The depression of Joris
His mother sat in my waiting room while Joris told his story. Joris was 15 at the time. School had not been going well for several months. He could no longer focus. He was worrying all day or was absentminded. Joris no longer saw the use of anything. Joris was unmistakably depressed.
I listened to his story, asked what he did in school and what he was doing. After half an hour of listening I heard a small spark. Something in his voice let me know that this was important information. Joris talked about his grandfather, who had recently passed away. He looked up to his grandfather. His grandfather had survived the concentration camps and Joris had received the diary from his mother which his grandfather secretly kept during the war in the concentration camp.
Not the passing away, but rather the diary had gotten my attention. Only solution focused information is important to help people. Maybe the magic formula to healing Joris was found in this diary?
−Joris, your grandfather must be a hero to you, I said.
− Yes, my grandfather was a great man. I miss him.
−You look up to him, right? - Yes, Joris nodded, with an emotion-filled look.
−He must indeed have been a strong man. That mus have been a difficult period for him.
I let Joris speak for a few minutes about all the qualities which he admired in his grandfather. Time was ticking and my next patient was already waiting in the waiting room. Time to give him a 'therapeutic task'.
−You told me that you received his diary?
− Yes, he nodded (I saw a spark in his eyes).
− Could you do something for me, Joris? - Yes. - Could you pick up the diary from your grandfather some time during the coming week? I would like you to read some parts about his difficult times in the concentration camp. And I am interested in knowing how your grandfather took his through these difficult moments. I would like to hear from you, next week, where he got the energy to keep going and to survive. I am also interested in knowing how he managed to get rid of his negative thoughts and hopelessness at the times in which these overwhelmed him. Could you do that for me?
− Yes, Joris nodded.
The sparks in his eyes told me that we were on the right track. The body language of a patient can tell one second my second which intervention will work and which one will not. When we, as therapists or doctors are 'right', one can literally see the levels of energy in the patient increase. When our 'guess' is wrong, his body language lets us know in a fraction of a second. There is no need to spend several sessions on this. This is something which is usually felt already in the first session.
The next week, Joris came to tell me how his grandfather had gotten through the war. As per usual it was all about the normal things in life: the thought that he would once again see his fiancée and having children with her and creating a family, his wish to help other people as a doctor in the future, the dream of buying a house for her, the content feeling of having helped someone int he concentration camp today, ...
Grandfather did not do any mindfulness, no yoga, no special relaxation exercises. It were the little things in life which gave him the courage and energy to survive and overcome the improbable.
Joris was feeling much better already. I saw him a third and final time, three weeks later. Joris was smiling again, once again played with his friends on the playground. His mother also came with him for five minutes and confirmed that he had gone 'back to normal'. We decided that he would take the free self-test on 15Minutes4Me.com for another year, once every month, and that he would call me if his scores were to end up in the red area again.
Relapse prevention means that you preventively measure when you are falling back into bad habits. Then you can intervene before you actually relapse. Joris has not relapsed. Joris did not need any pills to get rid of his depression. He simply needed to focus his attention on the little things in life. I could have told him about these, because after years of experience in my practise I know what type of solutions people look for. But I could never communicate these in his language, which was something which his grandfather could do much more easily.
That is why it is good to never give solutions or advice to someone with a depression. It is better to ask the right questions, so that the patient themselves can reach a solution. Did not the Greek philosopher Socrates teach us this, over 2000 years ago? Joris was helped because I asked him the right questions.
The psychobiological theory behind this depression
In our article on self-confidence, we described the mechanism of 'learned helplessness' by Martin Seligman in his publication regarding 'Learned Helplessness' in the year 1967. This same mechanism also explains why our brain at some points ends up in a 'depression'. By feeling learned helplessness for an extended period of time in a situation, the production of the stress hormone cortisol in the adrenocortical is increased, which was shown by Robert Sapolsky from Stanford University during his seminar at Washington State University on the 10th of October 2001.
This mechanism is strongly analog with the mechanism which we described in Psyche&Brain number 5 regarding burnout, with the difference that, in a burnout stage, an exhaustion of the cortisol production will take place and blood levels measured will have lowered, while they are often still high during a depression.
Cortisol will damage about 25 percent of te cells in the hippocampus, and especially those 25 percent of neurones in the hippocampus which contain cortisol receptors. As the hippocampus is responsible for the functions memory and focus, these are the first to be damaged.
In a later stage, the left prefrontal cortex (positive thoughts and feelings) will also be damaged, and if the depression then continues even further, even the right prefrontal cortex (negative thoughts and feelings) will be affected. In this last stage, the patient becomes apathetic and hardly feels anything anymore. All future focused thoughts will then have as good as disappeared. Joris did have issues focusing and problems with memory, and in later weeks his optimism was also reducing.
We know that learned helplessness is one of the main causes of this type of depression. That is the reason why the therapist chooses to look for an intervention where the patient once again discovers that they can help themselves. We want to build up 'learned optimism' - as written about inMartinSeligman's eponymous book 'Learned Optimism', which was published in 1990.
Solution focused therapy
As a therapist I chose to make use of 2 sources of help:
the first was the admiration which Joris had for his grandfather and his great loyalty to him.
the second source of help was the war diary, which was a source of solution strategies when it came to dealing with difficulties.
My empathetic relation with Joris was what motivated him to do this task. The real therapy for his depression then took place at home, when reading the diary. My empathetic relation was only the tool I used to motivate him to start this process. While he was reading, his loyalty toward his grandfather became is biggest motivator. Slowly but surely he integrated the solutions by a man whom he admired in his life, and Joris cured himself from his depression.
The American psychiatrist Milton H. Erickson shaped the idea in the 1930s that a patient heals when a doctor uses the sources of help found in the world of the patient and his environment, rather than giving external solutions to their depressed patient.
In the seventies, the American sociologist steveDeShazer and hiswifeInsoo Kim Berg systemized this approach into a systematically learnable type of therapy: the solution focused therapy. The intervention to let Joris solve his own depression by, himself, breaking out of his learned helplessness - reading about how his own grandfather overcame difficulties - is a beautiful example of a solution focused intervention by the therapist.
Inthe following caseofEvelien we see a different way of using the same solution focused approach to treat a 'reactive depression'. Solution focused therapy helps the patient to, themselves, discover their own solutions and work on these.
The depression of Evelien
I have never met Evelien. She called me after having followed the online self-help program on 15inutes4Me.com, to thank me. She told me her story over the phone.
In her case there had not been an empathetic relationship with a therapist. Evelien had decided by herself that it could not continue like this and that she wanted to help herself. She did not want to accept help from others, just because she was feeling so hopeless. She worried that she might get to hear that help was not possible for her.
Her feeling of self-worth (learned helplessness) was so deep, that she did not want to speak to anyone about it. One night she got an anxiety attack on top of her depressed feelings, and that was the proverbial last straw. She took herself to her computer and started googling to find a solution. She found an online self-test and her fear was confirmed: she had poor scores on depression as well as on anxiety. She was scared that she would no longer have the courage to call a doctor the next day, so she signed up for the online self-help program and did her first session.
The next day Evelien was not feeling good and she did not have the courage to continue with the program. It would not help anyway. Several hours later, so she said, she felt guilty because she had paid for something which she was not going to use. This is something she kept worrying about and in the end she opened her computer and found an e-mail, inviting her to her second online session.
She found it very difficult to answer the solution focused questions, but the film clip about depression had gotten her attention, and she slowly realized that she could teach herself to overcome her learned helplessness by looking at herself in a different way. With trial and error she kept going. The third week, her husband noticed that she did a bit more housework and that she even smiled sometimes, even though these moments only lasted a short time.
This gave her courage. She was surprised that the difference could already be seen by the outside world. She confided in her husband and two days later she asked him if he would become her 'buddy' in the program. This way he could provide solution focused feedback via the program, which was focused on further breaking down her learned helplessness.
Slowly but surely she found her own energy again, started doing sports again and did more housework. A week later she went to her doctor to tell him what had happened and to show him her evolution graphs. Together they decided how she would continue, step by step. He wold from then on see her every other month to see how she was doing and to follow-up.
For Evelien it was her own decision to look for a solution which suited her and which saved her. Talking was something she did not want to do during her depression, so she picked a type of help where this was not necessary.
Empathy versus engagement as a lever for change
Often, people believe that an empathetic talk with a doctor or therapist is the only way to get rid of a depression. This was something which was believed in scientific circles for a long time, too, because all studies were focused on highlighting the role of empathy in therapy.
The American researcher Scott Miller, co-author of ‘The Heart & Soul of Change: What Works in Therapy’ does a lot of research regarding what does and does not work in therapy. During our last conversation he confirmed for me that he is more and more convinced that the role of empathy mainly is to gain 'commitment' from a patient to, themselves, change something about their situation.
As soon as this decision is taken, he patient has to be guided by being asked the correct questions. But whether this guidance is done by a person or by a computer, is not as important. What is important, however, is to talk to your doctor in order to get a proper diagnosis and to evaluate whether tools other than therapy or self-help are necessary.
Evelien first started with the program, and only after having started went to her doctor. This was her own choice. She chose herself for the engagement to look for a solution in online guidance. The program itself recommends the patient to talk to a doctor, but she chose her timing herself. Taking someone's freedom of choice seriously is the first step in breaking out of learned helplessness through the authentic message: 'We take your seriously. You choose your own path. We only help you by making some tools more readily available to you or by helping you to find these tools more easily.'
This approach is the basis for the therapy for most normal depressions, also sometimes called reactive depressions: taking the freedom of choice of the patient seriously is the first step in breaking out of learned helplessness, as this is something which often occurs as a reaction to a stressful period in life.
Certain deep depressions of the endogenous type, and also bipolar disorder, require a combination of therapy with antidepressants or other more biological treatment forms. These will form the theme for a future article.
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Paul Koeck, MD
