Psychotherapy and Counselling for Depression by Paul Gilbert – Third Edition pdf
Depression is a puzzling phenomenon – not only can it lead to extremely unpleasant states of mind, undermine our abilities to go about our everyday tasks, and fight off various infections and other illnesses, it can also induce people to want to kill themselves. So where should we begin the journey into the origins of depression? Has it been around for many millions of years or is it recent?
Does depression arise in other species? We can debate how animals ‘feel and experience their worlds’ and whether their feelings are anything like ours. In fact, many species seem capable of showing signs that their behaviour and positive emotion systems can become toned down and depressed-like, especially following threats and struggles they cannot resolve. Moreover, in the face of certain traumas, individuals of many species can show serious physical changes that significantly reduce their chances of survival, and at times they literally curl up, close down and die. So personally I believe that animals can and do suffer from depressed-like states.
This poses a question I was fascinated by when I started my PhD in 1975 – why, over the course of hundreds of millions of years of evolution, and in so many species, are depressed-like states possible? Is this positive selection – to the extent that animals that lacked a depressive response would be disadvantaged in some way (Keller and Nesse, 2006; Wilson, 1998)? If we could answer those questions would that give us clues to depression? Would it affect how we view depressions as diseases, deficits or adaptations? (Gilbert, 2001a, 2001b: McGuire and Troisi 1998a; Nesse and Jackson, 2006; Nesse and Williams, 1995; Wilson, 1998).
Considering these questions, I believe, would make a difference to how we think about depression – for as we will explore in the subsequent chapters, the potential for some symptoms of depression may have evolved as basic ways to cope with certain types of threat.
Does that mean that depression is adaptive then? Well much depends on how we define adaptive. If we mean ‘leaving genes’ behind, then frankly no one knows how depression affects gene replication rates. If we mean adaptive to the individual over their lifetime, then although some people do change and grow through a depression (Gut, 1989) for others depression does not seem very helpful.
There is another intriguing question here. Is it possible that one evolved adaptive process (e.g. getting depressed and shutting down in the face of overwhelming stress) and another evolved set of adaptive abilities (related to being able to think, imagine, plan and have sense of self and a self-identity) can interact in such a way as to accentuate depression, making it in some ways ‘worse’ for us humans and potentially highly maladaptive?
Or if we look at another process, is it possible that our vastly expanded primate and especially human needs (compared to other animals) for love and affection have come with the price that in socially hostile environments, our vulnerabilities to depression are greatly increased? I am going to answer ‘yes’ to both these propositions. Hence we can explore evolved adaptive mechanisms that underpin depression, that serve various protective functions, but also consider that in human minds, and human social and ecological contexts, these basic defensive protective mechanisms can come to operate highly maladaptively. This is because there are various ways dysfunctional feedback can be set up that accentuates and amplifies depressed states.
We know that depression has plagued our minds since recorded history. Over two thousand years ago the Greek physician Hippocrates labelled it melancholia. The Greeks believed depression arose from a disturbance of the body humours, specifically black bile. Early reports of depression can be found in numerous biblical texts. King Solomon is believed to have suffered from ‘an evil spirit’ and severe dark moods. The biblical book of Job, with ideas that God was purposely punishing him, is regarded by some as the work of a depressed person. Other sufferers from history include composers (Gustave Mahler, Tchaikovsky, Sibelius), politicians (Abraham Lincoln and Winston Churchill) and numerous writers, artists and poets (Edgar Allen Poe and Thomas Mann).
More recently, Lewis Wolpert, a well-known professor of biology, recently wrote of his own depression, efforts to understand it and made an excellent BBC television documentary series about it (Wolpert, 1999). Although depression is still stigmatised, increasing numbers of celebrities are acknowledging having problems with depression, and conveying what they are doing to try to help themselves. Whatever else we may say about depression, it has been with us for a very long time, is common, and can be severely disabling and life-threatening. Indeed, it is not even unique to humans, and various animal models of depression have been advanced and researched.
The nature of depression
Depression affects us in many different ways and symptoms are spread over different aspects of functioning These include:
Motivation: Apathy, loss of energy and interest. Things seem pointless and the future hopeless.
Emotional: The capacity for different types of positive emotion is reduced, and with moderate to severe depression a person may be anhedonic -meaning they lack the capacity to experience any pleasure. Depressed people may talk of feeling ‘empty’. However, negative feelings can increase and there can be heightened experiences of anger or resentment, anxiety, shame, envy and guilt.
Cognitive: Cognitive functioning may deteriorate and a person may have problems maintaining attention and concentration. Memory can also be affected and sometimes to such a degree that people worry that they are dementing. Cognitive contents – the focus of thoughts and ruminations – become negative with negative ideas about the self, the world and the future.
Behavioural: Depressed people often stop engaging in behaviours that have been enjoyable or pleasurable in the past. They may withdraw from social activities, stop going out or meeting with friends or seeking help from others. Some depressed people, on the other hand, become more demanding and cling to others – desperate for reassurance. In severer forms of the condition people may suffer from psychomotor agitation and restlessness, or retardation.
Biological: Depressed people commonly experience problems in sleeping, such
as waking up too early or sleeping too lightly. They may lose their appetite and interest in sex. There are many physiological changes, especially in stress hormones (e.g. cortisol) and important neurotransmitters such as serotonin and noradrenalin in depression.
Part I : Understanding the Nature of Depression with a Biopsychosocial Approach
1 Depression: The Basics
2 Multi-Level Systems in Depression
3 The Brain, Threats and Depression
4 Behavioural Approaches: Action Matters
5 Human Social Needs and Roles: Attachment, Social Connectedness and Defeat
6 Thinking, Self-Awareness, Social Goals and the Role of Shame in Depression
Part II : Processes for the Therapeutic Journey
7 The Therapeutic Relationship and Working Alliance
8 Beginning the Therapeutic Journey with the Depressed Person
9 Thoughts, Beliefs and Safety Strategies: Constructing Formulations
10 Helping People Engage and Change: Some Basic Principles
11 Developing Self-Compassion
12 Focusing Interventions with a Special Reference to Self-Criticism
13 Working with Specific Difficulties I: Approval, Achievement, Assertiveness and Rebellion
14 Working with Specific Difficulties II: Shame, Guilt, Ideal and Envy
15 Overview, Saying Goodbye and Personal Reflections
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