Dear Anonymous

Thank you for your comments. I understand your scepticism about this approach having spent many years talking and providing treatment with a large number of people with depression. It is understandable to be unconvinced about any treatment approach when stuck in depression and the idea of changing thinking can feel very challenging when depressed. Of course, we also recognise that it is very easy, as you describe, for thinking to tend back to negative self-criticism focused on deficiencies and inadequacies.

You raise a number of important issues that bear clarification, so thank you for highlighting these issues.

First, you describe a tendency to ruminate and relive negative experiences. As noted in a previous blog, this is a common tendency in depression. Our research suggests that reliving these moments in different ways does have different effects on how people feel.

Second, it is helpful to clarify the difference between what I mean by asking "How?" versus asking "Why?". These terms are short-hand for a wider distinction between thinking in a more abstract versus more concrete way (see the next blog on Becoming More Specific for more detail). What you are describing re focusing on defciences reflects a tendency to think in an abstract and general way about past difficulties - for example to blame events on unchangeable deficiencies, on fixed traits in yourself, and on global flaws in character. As you recognise, this is an unhelpful way to look at the world as it makes you feel inadequate. We know that such overgeneralization and negative self-blame is common in depression. When we talk about being more concrete and asking "how?", we are encouraging people to try and focus on the details of situations so that they can pay attention to the specific and unique circumstances and details and notice what about the circumstances and their and others behaviours influenced what happened. This concrete processing is intended to help people to move away from abstract judgements about the self to explanations for events that are grounded in what happened, e.g, it was unhelpful for me to say that or for him to do that. By describing events in terms of actual behaviours or aspects of the environment, this often moves away from blaming the self in terms of a fixed deficiency and helps to think about what could be done different. Staying at the concrete level of representing events provides an opportunity for alternative explanations and interpretations of situations to emerge - for example, I did not do well because I was tired or because the task was difficult, or that way of speaking may not have been helpful. We find it is much more useful to consider what happened in terms of behaviour -which people can change, rather than in terms of personal traits.

Third, it is important to emphasise that the approach to doing this is not simply asking "How?" -although this is a useful shorthand for one set of the questions. I have provided a more detailed account of what this involves in the next blog. It involves paying attention to the world, thinking about next steps to take and summarising the sequence of events, all to help get perspective on situations and make better plans. It is probably also important to clarify that we dont't deliberately ask people to relive major upsetting events -because that would obviously carry the risk of making people feel worse. Rather we encourage people to practise being concrete for everyday minor upsets on a regular basis to improve problem-solving and to prevent these spiralling out to further negative thinking, as well as to get into the habit of being concrete to upsetting events. As this habit gets stronger, then it more naturally occurs for past upsetting events that come to mind, and can help to reduce the upset that occurs when these events are relived over time. It is important to note that in our treatments, a therapist works closely with a patient to guide and support them into being more concrete, as we recognise that this can be quite hard to do.

Fourth, you highlight a key issue we have experienced when working with patients with depression - which is how hard it is for people with depression to achieve more specific and concrete thinking about events. There is a strong tendency when depressed to move to more abstract, general, and global judgements particularly about the self ("It is all my fault", "I am flawed"), as you describe, even when asking questions like "How?" that usually focus people on the concrete details of what happened. Your description of this process suggests that you are still focusing on more abstract meanings and implications of events, rather than focusing on the specific experience because you infer that what happened is a result of unchangeable deficiencies. This is not uncommon - we have found that people have to repeatedly practice quite hard to spot that they are being abstract about situations, and then deliberately focus on paying attention to specific details that may be unique to the situation. It is like trying to change a habit - it requires repeated work to shift the thinking style away from being abstract.

Our experience with over a hundred patients with depression is that on average repeated practice at becoming more concrete is helpful at reducing symptoms of depression, relative to control treatments. We know that with practice, this approach can be helpful. We also know that it changes how people with depression think about themselves, so that they become less negative and tend to blame themselves less for the negative things that happen to them. Of course, not all approaches work equally well for all people - and different individuals need to find the treatment approach that best suits them.

I hope these are useful clarifications to your questions.

All the best

Ed Watkins