Treating Depression –  A Mindful Approach

The following approach does not represent a complete intervention sequence in clinical depression; however, the steps noted may be helpful if/when clinicians find their typical interventions are not working.  The approach noted here assumes that formal assessment of depression has taken place (objective measure), and that the clinician has a way to repeat it to see if treatment is improving the client’s depression. Here we are talking about treatment of depression as it is that lacks clear effectiveness in outcomes.

1. Medication/s: If the client has been taking anti-depressant medications, the first step is to evaluate their effectiveness.  Generally, behavioral health specialists are not in a position to advise medical professional about how they prescribe medications.  In this case, however, the selected medication and/or dosage, and/or compliance do not appear to be effective. A simple way to measure effectiveness is to have the client complete two SUDs scores a day. I prefer 0 to 100 rather than the standard 0 to 10 scale. The numerical space between, say,  50 and 60 allows clinicians more latitude is assessing and addressing emotionally-focused scores.  Always obtain more descriptive details about what the score means to the client in actual experiences. The higher the score, the more serious the subjective experience of depression is. Simply request that the client note formally (in writing) their scores on the Subjective Units of Distress/Discomfort Scale twice daily (Am and PM). If after a couple weeks, it seems clear from this data and verbal self-reports that relief is inadequate, the client should report that information to the medical professional monitoring their medication and request a review.
2. Cognitive Therapy: From cognitive therapy, ask the client for ONE dominant and recurring automatic negative thought they experience.  I like to refer to these troubling thoughts as “Red Ants.”  Red automatic negative thoughts are one important thing to deal with in treating depression. Many common repeating negative thoughts can be identified as types of “distorted” or “irrational” thinking in older forms of cognitive therapy.  Best to use the terms like “unhelpful thought” or “unwanted thought” to remain respectful of the client. If success happens with the recommended interventions with one thought, continue with other thoughts.
3. Cognitive Therapy/Rational Emotive Behavior Therapy: Refutation or disputation techniques are often helpful in weakening, even dislodging, unhelpful and repeating negative thoughts in clients suffering from depression. One I like a lot is “Where is the evidence?” that the thought is true. If true, from 1 to 100 how true does the client believe the thought is?  Work gently and respectfully with the client to “work through” the thought (collection of evidence) with intention to weaken its impact. Sometimes the client will discover a more moderate thought similar to the Red Ant.  If the new thought is accepted by the client, request that each time the old Red Ant enters consciousness the client is to replace it with the new more moderate thought. Check on this skill in later sessions.
4. Behavior Therapy/Mindfulness: From behavior therapy implement behavioral activation.  Research support on the effect of  behavioral activation on depression is quite positive.  Despite this fact, too few clinicians use it. When the client works very hard to overcome fatigue and lack of motivation – to in fact DO SOMETHING with their body – it often improves their level of depression. Various things can be done: walking, social interaction, exercise, etc. Research support on regular exercise shows that this form of behavioral activation has strong positive effects on depression. I recommend teaching the client rough forms of tai chi, qi gong, and/or yoga stretches IN THE OFFICE as part of their skills training. Be sure you do not misrepresent yourself as a specialized trainer in these areas – unless you happen to be one.  So here imperfect form may reduce the effects; however, if such interventions are done regularly and practiced by the client on their own – expect positive results. To simply request that the client does these things as homework will NOT work.  To do this well, clinicians have to practice these movement meditations on their own.
5. Mindfulness-Based Treatments: Teaching clients how to use mindfulness about depressive symptoms and conditions can be helpful.  Mindfulness-Based Cognitive Therapy has proven in repeated studies to be a potent treatment for depression. The details of this therapy are too involved to review here. In some studies MBCT reduced depressive relapses 50% – better than various other treatments for depression and medications.  Clinicians need to practice MBCT skills on their own: various meditative/yogic breathing techniques; thoughts as simply neural activation of consciousness; you are NOT your thoughts; using friendly awareness of unhelpful thoughts and feelings; shifting attention; recognizing impermanence of unhelpful thoughts and feelings; and, especially, decentering skills. If unfamiliar with MBCT, best to obtain formal training and supervision.

Hopefully, this eclectic and scientific therapy format will help to improve your client’s depression and your own effectiveness.

Hang in there!

By Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness  

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