Depression

The Two Faces of Depression

Two different approaches to depression can work equally well. Learn why.

Posted May 17, 2020

 Image by MikesPhotos from Pixabay
Source: Image by MikesPhotos from Pixabay

Shakespeare defined Hamlet's depression in two contrasting ways in the following two quotes:

There is nothing either good or bad, but thinking makes it so
William Shakespeare, Hamlet, Act II, Scene 2

—And—

To be or not to be: That is the question: Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous fortune or to take arms against a sea of troubles, and by opposing end them…
William Shakespeare, Hamlet, Act III, Scene 1

Thinking Vs. Doing

The two quotes regarding William Shakespeare’s famous “Melancholy Dane,” Hamlet, represent the major themes of two of today’s prominent evidence-supported treatments for depression.

  • The first theme is that our thoughts have a major influence over our mood. Hamlet had consistently dark thoughts about himself, his situation, and his future.
  • The second theme is that interpersonal distress and relationship issues are the main cause of depression and thoughts of suicide. Certainly, Hamlet considered his own suicide in the face of his father’s death, and the loss of his mother’s attention to her new husband, who may have murdered Hamlet’s father.

As we might guess, the two leading treatments for depression, Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) focus their treatment on each of these two factors supposed to underlie depression—cognitions and relationships, respectively.

How CBT Explains Depression—Self-Fulfilling Prophecies

Aaron Beck’s cognitive model (Beck, et al., 1979) suggests three specific concepts to help explain depression. The combination of these three paints a picture of what becomes the self-fulfilling prophecy of depression for clients. The three areas are (1) the cognitive triad, (2) schemas, and (3) cognitive errors (faulty information processing).

  • The cognitive triad is composed of three patterns that draw the person into viewing herself, her future, and her experiences in a unique way.
  1. First, the client develops a negative view of themselves, assuming that because of their presumed deficits, they are undesirable and worthless.
  2. The second pattern is that the depressed person tends to interpret their ongoing experiences in a negative way, viewing situations as intolerable obstacles and confirmations of how bad things really are.
  3. The third component is that clients have negative views of the future, anticipating that their current difficulties or suffering will continue indefinitely.

The resulting symptoms of depression follow from the combination of these three client “distortions” of their reality. When clients are listless and withdraw to avoid their life demands, these actions are viewed as a result of clients’ pessimism and hopelessness given that they expect negative events and a negative outcome of their efforts. Clients become increasingly dependent on others because they view themselves as inept and helpless and they overestimate how difficult normal tasks will be and assume their efforts alone will only turn out badly. Apathy and low energy are seen as logical results of the client seeing that they are doomed to failure.

  •  Schemas are relatively stable cognitive patterns that serve as the basis for interpreting particular sets of situations. They help screen out, differentiate, and code stimuli into familiar, understandable, and predictable patterns that may then be responded to with an appropriate repertoire of reactions. Beck suggests that many of these schemas lie dormant until energized by specific environmental inputs (for example, stressful situations).

In the case of depression, these schemas are particularly negative, distorted, and dysfunctional. However, the more those schemas are used, the more they drive the self-fulfilling negative prophecy, and the more widely they are evoked and applied. Eventually, these schema-driven patterns are said to take on a life of their own, becoming autonomous.

The depressed person becomes less and less able to entertain the idea that their negative interpretations may be false. They may eventually become preoccupied with pervasive negative thoughts about themselves, their world, and their future, with all of the related symptoms of depression present.

  •  Cognitive Errors or faulty information processing is the final leg of the three-legged stool. These are a series of logical errors characteristic of depressive thinking which serve to maintain the person’s belief in the validity of his negative concepts. Beck’s list of thinking errors includes:

(a) Arbitrary inference, when a conclusion is drawn in the absence of evidence or in the face of evidence to the contrary;

(b) Selective abstraction, when a detail is taken out of context to characterize a whole experience, and ignoring other salient features of the situation;

(c) Overgeneralization, when one or more isolated incidents are used to draw a general rule or conclusion and apply it across broadly related and unrelated situations;

(d) Magnification and minimization, when perceived negative events or qualities are inflated and positive ones depreciated;

(e) Personalization, where a person relates external events to themselves when there is no basis for making such a connection; and

(f) Absolutistic, dichotomous thinking, where all experiences are cast into one of two opposite categories.

As might be imagined, each of these errors and their combination will tend to initiate and perpetuate their own vicious cycle of problems that characterize the depressed person’s experience.

Beck does note that the depressed person tends to have enough of an effect upon their environment and those around them to actually create situations that match their expectations. While they may isolate themselves from others, others may withdraw from them because he or she is not enjoyable to be with, and so on.

This can create an interpersonal self-fulfilling prophecy where what the person expects from their world eventually shapes their interactions to match those beliefs. While this gets very close to explaining depression in terms of relationships, as does the interpersonal approach, the CBT approach sticks to thinking errors as the main culprit for depression.

How IPT Explains Depression—Interpersonal Vicious Cycles

The interpersonal (IPT) approach to depression (Klerman, et al., 1984) locates depression in the interpersonal relationships of the depressed person. IPT suggests that psychotherapy should help the patient examine current interpersonal relationships and understand how they have developed from experiences with figures in childhood, adolescence, and adulthood.

This is an area that should sound vaguely similar to that of Beck's development of schemas discussed earlier. However, the interpersonal approach makes much more of the reciprocal vicious cycles that evolve in the relationships of depressed people and those who interact with them.

The interpersonal view suggests there are four main areas of interpersonal distress around which depression evolves. These interpersonal domains include:

(a) Grief, which focuses on the person’s reaction to the actual death of a person or people either now or in the past;

(b) Role disputes, which involves interpersonal disputes with friends, family, partners or co-workers;

(c) Transitions, which involve role-changing life events such as marrying, taking a new job, becoming a student, or becoming a parent and the like; and

(d) Interpersonal deficits, which relate mainly to interpersonal isolation and the poor quality and quantity of the depressed person’s interpersonal relationships.

The key element here is that the depressed person responds to each of these areas of interpersonal distress in a way that sets up a characteristic vicious cycle that eventually takes on a life of its own. The cycle eventually becomes an actual syndrome called clinical depression. One critical aspect of treatment is letting clients know that being depressed is no more their fault than having diabetes or a broken leg would be.

The interpersonal view suggests that the depressive symptoms are a natural result of failing to look at options to resolve critical areas of interpersonal distress and then take action to resolve them.

  • So, the CBT view sees the sad face of depression as caused by problems in thinking, and resolving depression involves changing problem thinking patterns.
  • Whereas the IPT view sees the sad face of depression as caused by problems in relationships, and thus depression involves taking action to change those relationship problems.

The amazing thing is that both of these therapies for depression, based on two different "faces" of depression, can be equally effective! It just depends upon which face we are looking at, or how we explain depression, as to which path we follow for resolutions. Both paths work. The key to which path to take is which path makes the most sense to those involved. We will turn to how these approaches and others end up breaking the same downward spiral of depression in the next post on Breaking Depression's Downward Cycle.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Fraser, J. S. (2018). Unifying effective psychotherapies: Tracing the process of change. Washington, DC: APA Books. This post was adapted from chapter 7, Depression.

Klerman, G., Weissman, M., Rounsaville, B., & Chevron, E. (1984). Interpersonal psychotherapy of depression. New York: Basic Books.