Seeing What Others Don't

The remarkable ways we gain insights

Clinical Causality

How to use the Causal Landscape with clinically depressed clients.

The Causal Landscape is a way to display the range of causes that account for why an event happened. The Causal Landscape portrays the relevant causes but also uses a simple 2-step strategy to highlight the few causes worth taking action about. The strategy is to rate each cause for the impact it had on the effect and then rate each one again for the ease of eliminating it. The causes that have the strongest impact and are the easiest to get rid of are the ones to act on. 

The Causal Landscape helps people move out of a shallow mindset that there is only one cause. It shows a wide array of causes but keeps the attention on action by emphasizing the most important and actionable causes. 

That earlier piece, Causal Landscape 2.0, used the example of a client seeking relief from anxiety. I am not a clinical psychologist, and so I relied on guidance from two highly skilled and experienced therapists, Mitchell Klein, Ph.D. (my brother), and Bob Barcus, Ph.D. 

In this piece I will explain why I think that the Causal Landscape can also be used for clients seeking relief from depression. The causal field might include some or many of the following:

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Lifestyle issues (irregular sleep, poor diet, lack of exercise, smoking, obesity, poverty, lack of friends and family connections, alcohol abuse, poor stress management skills).

Life events (e.g., childbirth, menopause, financial problems, job problems, adverse medical diagnosis, bullying, loss of a loved one, a natural disaster, physical injury, being neglected as a child).

Physical conditions (e.g., seasonal affect disorder, vitamin B6 deficiency, post-concussive symptoms, endocrine disorder, chronic fatigue syndrome), including illness  (e.g., neurological condition, chronic pain, HIV/AIDS, stroke, diabetes, PTSD, sleep apnea, Alzheimers, cardiovascular disease, hypertension) and medical treatments, including some drug therapies. Heredity might fit in this bucket as well.

Some patients may want a simple diagnosis, such as “you are depressed because you didn’t get enough affection as a child.” Such diagnoses are obviously naïve; they are also non-actionable. Childhood neglect cannot be undone. Brooding about childhood neglect can be addressed but it is only one of a large number of possible causes. The Causal Landscape might help therapists, and some of their patients, see how to tackle several of the primary problems.

I sent a draft of this piece to a few therapists, and they agreed that the factors I identified. One of them, Sandie Johnson, explained that “these factors may be and often are threads within the same tapestry; one size never fits all.”  In working with a client, she tries to learn about the variables I’ve listed. She also examines the self-soothing strategies the person uses and will usually teach some additional methods. And she assesses the possible use of medications.  

Sandie explained to me that the depressed patient who wants immediate relief from psychological pain is sufficiently motivated to make life-style changes that will affect health and social connections, and to learn techniques for reducing stress and anxiety. Treatment with anti-depressive medication might solve the immediate problem but fail to take advantage of this opportunity. (And I appreciate that skilled therapists would not be content with just putting the patient on an anti-depressive medication regimen, even if that’s all the patient wants.)

For the Causal Landscape ease-of-change ratings, we can use a 4-point rating scale:

4 = Impossible to change. For the depressive, wanting to understand how he/she got into this state, causes such as childhood neglect, heredity, loss of a loved one, all play a role but can’t be undone.

3 = Very difficult to change. For the depressive, it might include financial problems and chronic pain.

2 = Changeable with some effort. Strategies to help a depressive cope with frustrations and anxiety could have broad value, such as learning better coping skills so that they don’t feel so out of control, and teaching these coping skills to their children so that they are breaking the cycle instead of modeling depressive ways of being and thinking.

1 = Simple to change. Treating the depressed patient with anti-depressive medication is easy to implement but addresses only the immediate symptom.

As I noted in the previous piece, Causal Landscape 2.0, interventions can address both (1) and (2) above, not just the easiest to change but also behaviors that are changeable with some effort, yielding greater impact. 

 

Gary Klein is Senior Scientist at MacroCognition LLC; his most recent book is Seeing What Others Don't: The remarkable ways we gain insights.

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