Psychotherapy for Depression

There are many different approaches to treat depression with psychotherapy. I, of course, have my own thoughts about what works best. But first I need to outline three of the most common psychotherapy approaches:

  1. Cognitive-Behavioral Therapy – Focuses on identifying and changing unhealthy thoughts and patterns of behavior. Cognitive techniques focus on changing irrational thought patterns, which are assumed to contribute to depression. The idea is that if you work on changing these thought patterns, your emotional distress and depression are lessened. Behavioral activation techniques focus on changing behavior by adding more pleasure producing activities, reducing stress, and problem-solving situational factors that may be contributing to depressed mood.
  2. Interpersonal Therapy – Focuses on the depressed person’s relationships or relationship patterns, which are assumed to be a contributing factor in terms of their depression symptoms. The idea is that by learning how to improve relationships and working on these issues, the depressed person will feel better overall.
  3. Psychodynamic Therapy – This approach, more than the others, tends to focus on how the person’s unconscious conflicts, childhood and family issues, and attachment patterns may contribute to depression. Many different versions of this approach are employed, and it is probably the least well defined of all the options.

There are certainly other approaches, and I am not claiming to be an expert in any of them. It is important to understand that in the field of mental health treatment, researchers and clinicians often debate the issue of what it is about psychotherapy that actually helps people. Some will say it is the particular set of techniques that are used, and will argue strongly that their specific approach is best. In fact, there is a whole movement in the field toward what are called “Evidence-Based Practices,” where “manualized” approaches of a certain number of sessions, with certain techniques, are used. Proponents of these approaches will point to the fact that research shows that they help…at least for the period of time that the research studies are measuring.

I am not disparaging any technique or approach that helps people feel better. But, there is a whole group of researchers and professionals in the mental health field who strongly believe that it is actually the quality of the relationship between the therapist and the client that makes the biggest difference. I am very much in this camp. I believe that in order to benefit most from any therapeutic technique, the client must feel comfortable with the therapist. He or she must feel able to talk openly, and feel supported and understood. Obviously, the therapist has to be well trained and experienced enough to know when to use what techniques. But, in my opinion, without the foundation of a strong therapeutic alliance, therapy is much less likely to be of benefit.

My advice for people wanting to try psychotherapy is to talk to a potential therapist on the phone prior to scheduling an appointment. If they aren’t willing to do this, they aren’t the right person. Ask about their approach to treating depression. Trust your gut about whether you feel comfortable with their responses. If so, see them for a few sessions. If it isn’t the right match, try someone else. Don’t settle! A good therapeutic alliance is invaluable, and a bad match between therapist and client can actually make things worse!

Next Month:  My Approach to Psychotherapy for Depression

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Effective Treatment for Depression – Is Medication Necessary?

As I said last month, research shows the best treatment for depression, in general, involves a combination of medication and psychotherapy. There are many therapy approaches, and I will address the most widely used ones in future posts. First though, it is important to address whether medication is a necessary part of treatment.

Some people require antidepressant medication to feel better, and some do not. In my experience as a psychologist, I’ve learned that depression symptoms fall on a continuum from mild to severe. Mild depression does not usually require medication. It tends to be related to situational factors, and talking through different ways to approach the situation usually helps. When depression is severe, the biological symptoms make it impossible to function normally, and medication is clearly required. The confusion comes when depression falls in the moderate range. At this point on the continuum people can function, but it takes effort. They sometimes go long periods of time without knowing how depressed they actually are.

Many people are reluctant to take these medicines for various reasons. Some are afraid of side effects. Some do not want to acknowledge they might need medication due to the stigma. Others simply feel they want to try other options before taking this step. It is important to know that these medications tend to have few side effects. There are many different options if any negative effects happen. It is relatively safe to give it a try.

The best way to know whether medication is needed is to try psychotherapy first, and/or to work on doing the things that would normally help depression…particularly exercise. If you are unable to motivate yourself to do things differently, or if you force yourself and it doesn’t help, there is a good chance you are biologically depressed enough that you will need medication to alleviate the symptoms.

On the continuum of depression symptoms, I think there is a threshold (somewhere between moderate and severe depression) at which no amount of psychotherapy, or exercise, or any other behavioral changes will help. At some point, people are biologically depressed enough that their brain just needs medication, at least for a while.

So, if you have many depression symptoms (see my May post) and are not sure if you are at that threshold where you need medication, listen to that nagging voice inside about what would make you feel better. Are you beating yourself up for not exercising or eating healthier? Are you letting things around the house go undone? Or are you avoiding activities or people you usually care about? Start trying to address these issues. If you can’t get motivated to do things different consistently, or if you do and still feel down, apathetic or unmotivated, consider talking to a psychotherapist. And, to your doctor about antidepressant medication!

Next month:  Psychotherapy for Depression

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Robin Settles in Florida–Conclusion

One issue I haven’t touched on yet that I probably should is tanning. People may wonder why someone like me, with my tanning OCD issues and history of basal cell carcinoma, would move to Florida. I did though, and I’m trying to be smart about it. This is one of the ways in which being unemployed for a year in the transition hurt me, as I didn’t have anything to do but lay in the sun every day. Since I’m able to be outside year-round here, no tanning bed usage is necessary to maintain my color.

The sun is so much stronger here than in the Midwest, I can lay out for less time and still get more color because the UV index is higher. This allows me to spend less time in the sun, which is nice, because in the summer it is horrible to be in the sun for very long unless I’m at the pool. The humidity and heat are unbearable most afternoons, with heat indices around one hundred degrees. Our initial summer here I just laid out on our patio, but last summer I started going to our community’s pool. I’m much cooler there, and I was able to meet quite a few people. They are all older than me, but not too old to still be fun to hang out with at the pool. I now use sun screen on my face to protect it from the intense sun.

Unfortunately, using sun screen hasn’t kept me from having ongoing skin cancer concerns. I recently had a spot on the side of my nose for about five months, and finally decided to go to a dermatologist. She’s a young doctor, but I liked her. She’s from northern Indiana where I’m from, her parents still live there, and she got her undergrad degree from the same university I did. This gave us something to chat about.

The doctor didn’t lecture me about my tan or about being in the sun, which was a relief. We discussed it, obviously, and she said to apply sun screen to my face more often, but she didn’t harp on it, thankfully. Anyway, she biopsied the spot on my nose. The biopsy showed that I had basal cell carcinoma, again. The following week I went in for a Mohs procedure, which is the surgical procedure often used to remove cancer from the face.

In this procedure, they cut out a small area and then biopsy it. If it shows cancer on the edges of the area they go back and cut out more. They continue this process until they are sure they have removed it all. It’s a rather time consuming process (I was there about five hours). First, I was given shots in the nose and cheek area to numb it. This is the worst part of the process, as the shots to the face are painful and I have a needle phobia. The doctor then removes a chunk of flesh to be biopsied, cauterizes the wound, and puts a temporary bandage on my nose while we await biopsy results.

I joined four other people in a small waiting room. This was a comical scene…four of us with bandages on our noses, and one with a bandage on his ear. It was awkward at first, as we were strangers. I read my e-mail and Facebook for awhile to kill time. It didn’t take long though for a chatty senior woman to start conversation with everyone. By the end of the day we were all chatting and laughing together. The same doctor was working on all of us, so we were called back in one at a time to find out whether the first part of the process got all the cancer. Unfortunately, they didn’t get all of it the first time, so I had to go through it a second time (more shots to the face and cauterization then more time in the waiting room). The third time the nurse called me back, I got the good news that they had removed all the cancer. I got more shots to the face to numb the area to receive stitches. I had to wear a large pressure bandage for 24 hours, then I covered it with a large Bandaid for a couple weeks to keep it clean at work. I couldn’t go into the pool for a couple of weeks, but I still went to the pool to lay in the sun (yes, I laid in the sun even after having skin cancer removed. The OCD urges are relentless).

My social life is different in Florida than it was in Indiana. In Indiana I socialized with my age peer group, while in Florida I mostly do things with my mom’s peer group. I’m just as socially active as I was before and have just as much fun. I go out to eat, go to movies, go see live bands, go to arts and crafts festivals, and of course we go to some of the Florida attractions (the beach, Disney, going to see the manatees, for example). I socialize with my mom, Betty, and newer friends Diane and Denny (who Betty has been friends with for many years). In January I went on a 6- day Caribbean cruise with my mom, Betty and Diane and had a great time. We stopped at two ports in the Bahamas, and in the Dominican Republic and Grand Turk. I have fun regularly with the many people at the pool, even though most of them are twenty years older than I am. I actually know more people who live in our community than my mom does, through the relationships I’ve made at the pool.

As I said in our book, prior to moving to Florida I was settled into a job that worked for me. I had friends, and was having fun socializing. I had doctors in place who I trusted and felt supported by. When I decided to move, I gave up all of this. In hindsight, I understand why Sharon was concerned about the possibility that I would be psychiatrically destabilized by the stress of the transition. It certainly was a big change! But two years later, I can confidently say I have managed to make this transition quite successfully. I have the right job, an active social life, and doctors who I trust. I have no regrets. I remain stable and content.

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Effective Treatment for Depression

Last month I discussed the symptoms of depression. So, what if you’ve accepted you may be “depressed” in the clinical sense, which means you need to pursue treatment for it? For most people, this is a scary step. When you have depression it’s hard to get motivated to do things. To do something new which involves making yourself very vulnerable, feels impossible. But, going forward without doing something different, feels even more impossible. You are ready to “suck it up” and talk to a professional about your symptoms. Good for you!

People have varying opinions about what type of provider to see first. Research has repeatedly concluded that the most effective treatment for depression usually involves a combination of both psychotherapy and medication. Some people are more afraid to talk about their feelings and prefer to start by taking medication. Others want no part of this, and would prefer just talking to someone.

In my opinion, where you start is less important than making sure you take a positive step forward to get help…from anyone. If you want to try medication first, most primary care physicians are willing to prescribe meds for depression and do so frequently. If you want to go straight to an expert, psychiatrists are the physicians who specialize in treating mental health issues with medications.

There is relatively little risk involved in trying one of the newer antidepressants. If there are any side effects that become intolerable, gradually decreasing and stopping the medicine will almost always resolve them. Most importantly, these meds tend to be quite effective in alleviating both depression and anxiety symptoms, although it takes several weeks for them to work.

If you prefer to try overcoming your depression symptoms without medication, the best option is to find a good psychotherapist. There are psychologists, social workers, counselors, and marriage and family therapists among others who practice psychotherapy. Lots of people will say one or the other of these professions is superior to the other. In my experience, whether someone is an effective psychotherapist has less to do with their degree and more to do with their experience and about who they are as a person. It helps to find someone who has a license in their given profession, as this means they have had at least a minimum amount of supervised experience. It helps to get referrals from other people about who the good therapists are. If you don’t want to tell friends or family you are looking, ask your primary care physician for a referral. They usually have therapists in their community who they collaborate with (and if they don’t, they should).

The advantage to starting with psychotherapy is that your therapist can help to figure out whether medication is likely to be a necessary step for you, or not, depending on your individual symptoms and issues. Depression is usually caused by a combination of biological factors and psychological or situational factors, which is why treatment often (but not always) needs to involve a combination of approaches. A good psychotherapist should be able to help sort this out. Next month, I will give my opinion about the best way to sort out these issues.

Next Month:  Effective Treatment For Depression–Is Medication Necessary?

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Robin Settles in Florida–Part Two

In August of last year, I finally got a new job after nearly a year of looking. I was hired as a cashier at a local Goodwill store. I’ve never been a retail cashier, but I have worked at Goodwill and I think that helped me get the job. Not surprisingly, this was a stressful position for me. Having lots of people waiting in line, staring at me and sometimes getting frustrated with the wait, on top of having to be friendly and social while stressed, was difficult. Goodwill gets very busy at times, and it was made worse by the fact that we were short several cashiers due to firings and transfers to another store.

To add to the stress, the staff shortage meant I was being scheduled for too many hours, which resulted in me earning too much money. I can only make a certain amount each month and still retain my disability benefits. When I am job hunting, it is always a dilemma for me in terms of whether to disclose this issue during the interview process. While Goodwill is very supportive of hiring people with disabilities, the stigma still exists and I’m hesitant to broadcast that I’m mentally ill before people get to know me. In this case, I had followed this strategy. So, the managers did not know I could only work a certain number of hours. They just thought I preferred part-time work, and that scheduling me for more hours temporarily wouldn’t be an issue. Worrying about losing my disability benefits just added to the already intolerable stress of being a cashier.

I was at a point where I was clear I couldn’t continue in this situation. I was quite relieved when, three months after starting the job, an opening came up for a “store clerk” in the same store. I told my manager about my disability, and that I was making too much money. I used this to justify my need to change jobs, rather than saying I couldn’t handle the stress. The store clerk position pays fifty cents an hour less than the cashiers earn. She was supportive, made it clear she didn’t want to lose me as an employee, and agreed to give me this position and limit my hours to twenty-six per week.

The role of store clerk is to stock the clothing on the racks, assist customers at the jewelry counter, clear the clothing from the fitting rooms, and keep the store looking nice (I spend a lot of time picking clothing off the floor and re-hanging it). It’s an active job. I’m constantly moving around. I used to wear my Fitbit activity tracker to work, and it was common for me to walk five miles on the concrete floors during my shift. Early on, when I left work I could barely walk because my feet hurt so badly. I’ve gotten used to it since then and my feet only hurt a little when I leave work.

So, about a year and a half after our big move to Florida, I finally felt settled into a job that works for me. It was a long haul, but I am relieved and glad to not have to worry about this anymore. It is helpful to have structure, social contact, and most importantly more income.

Soon after I began working at Goodwill, in September 2017, we had our first major hurricane since we had moved to central Florida. The weather people start following potential storms way early, so we had plenty of time to prepare. About six days before the actual hurricane was supposed to hit, all the stores in town were out of bottled water and other supplies. Hurricane Irma was predicted to hit our town sometime on Sunday, so my mom and I spent Saturday moving her plants from the yard to the carport area, under a roof. That afternoon we packed some clothes and our dog, Otis, and went to our friend Betty’s house.

We added Otis to our family in December 2017. He’s a young Maltese and Yorkshire Terrier mix. He’s very cute and energetic. Anyway, we went to stay at Betty’s house because her home is more secure in the event of tornadoes. Betty has a dog also, a year older than Otis, named Jojo. Jojo and Otis did well together while we were there, considering Otis is very playful with other dogs and Jojo is, not so much.

We started following Hurricane Irma’s progress on Sunday, as it moved toward Florida and changed in intensity. It was very windy and rained heavily all day and evening. At one point we got a tornado warning for our area and had to huddle in the hallway, which was scary for a bit. Of course, with two dogs, we had the joy of taking them outside in the storm to go to the bathroom. Both dogs hate rain, so our trips outside were brief. It was cute though, that Betty had two little doggie rain jackets which we put on them. At about three a.m. or so Irma came through central Florida as a Category 3 hurricane. Betty and I were both still up at that point, but my mom had gone to bed. I think the stress and tension had drained her, and she just needed a break.

I didn’t have to work on Sunday or Monday, as Goodwill closed due to the hurricane. On Monday we went home to assess the damage. We had learned from a neighbor who stayed home through the storm that our neighborhood had lost power on Sunday. We saw why when we got close to home. There were trees down along the street next to our entrance, and electrical wires were down. The only entrance to our community was flooded and impassable, so we had to drive through an empty lot to get into the community. We finally got near our home, passing several others that had roofs ripped off. My mom cried with relief when she saw that our home had only minimal damage to some trim around the roof. We were very fortunate!

Our neighborhood was without electricity for a week after the storm, so we stayed with Betty during that time. I think we got through the whole experience well, all things considered. It was stressful and scary at times, but we were lucky (again) to have Betty. It would have been worse had we come home the day after the hurricane and had no power for a week. We were very glad to have someplace cool to go…our neighbors had to deal with the heat and humidity of September in Florida without air conditioning. I was quite happy to get through our initiation to Florida hurricanes. It was something I had been nervous about when we made the decision to move.

(Continued in Part Three)

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You May Have Depression and Not Know It

For people who are unfamiliar with mental illness, the term “depression” usually applies to someone else. The stigma about mental illness causes people to be uncomfortable identifying with this concept. They may not even think about it, but amazingly, they could have it but not know it.

What is depression? It is a change in the biochemistry of the brain caused by stress. It is consistently estimated that 20-25% of people become clinically depressed at some point in their life. That’s one out of every four or five people. Think about how many people that is!

I worked as an outpatient psychotherapist at a large mental health center for almost 20 years. It was not an infrequent occurrence to have people arrive for treatment after having waited for their depression symptoms to get bad enough to seriously impact their functioning. They would present with issues including insomnia, relationship problems, job-related difficulties, or physical symptoms that had no medical explanation.

Once I identified that a client was depressed, I would say to them:

“Many people walk around with a moderate level of depression without knowing it. They drag themselves out of bed and go to work, because that’s what they need to do. They are able to ‘fake it’ and do okay through the day, but it takes an enormous amount of energy to do this. By the time they get home, they are exhausted from using all their energy to fake it through the day, and they collapse and don’t get done what they want to get done in the evening. Things pile up. Because they aren’t getting things done, they beat themselves up. They may or may not be able to sleep at night, but regardless they are exhausted. They may do things they would normally enjoy to try to cheer themselves up, but they have difficulty enjoying anything. They start to feel like things will never get better, and if it goes on long enough they don’t even remember that this isn’t the way life is supposed to be. It feels normal to them.”

More often than not, the depressed client could completely relate to this description. For the first time in a long time they became hopeful that things could get better. After appropriate treatment, they would often come back and say “Sharon, I can’t believe how much better I feel. I must have been depressed for years without knowing it. I should have sought help a long time ago.”

Unfortunately, for many of these people the next focus of treatment became working through their grief over the years they wasted due to living with depression unnecessarily.

The symptoms of clinical depression include sadness or irritability, lack of interest in activities, sleep or appetite increases or decreases, weight changes, low energy, feelings of restlessness, difficulty concentrating or making decisions, increased feelings of guilt or worthlessness, and feelings of hopelessness. Suicidal thoughts may be present if depression is particularly severe.

If you or anyone you know is experiencing some of these symptoms, please get help. Talk to your primary care physician, and ask for a referral for a psychotherapist.

Next month: Effective Treatments for Depression


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Check it Out…

When our book was first published, I spent quite a bit of time trying to promote it on-line. One of the methods I used was to contact book reviewers and ask them to review our book.

One of the reviewers who kindly agreed to do so, was Jeyran Main, whose blog “Review Tales” is wonderful. Here’s a link to her review of our book on her website:

Jeyran Main’s Review of Our Book on Review Tales

Robin and I were thrilled with her review, and grateful to her for taking the time to write it, and to post it on Amazon. But, as I have said, promoting the book has not been a recent focus as I am working on new ways of getting the word out about it.

So imagine my surprise and delight when, about a month ago, Jeyran Main contacted me and asked if I wanted to be a guest host on her website on a monthly basis! I jumped at the chance. I will be writing short blog posts about topics related to mental illness. Here is the link to the first of these posts, which was just published on “Review Tales:”

You May Have Depression and Not Know It

I am going to publish the articles on our blog as well. I’m happy to be able to continue to help decrease the stigma!


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