A mighty oak will not fall in one swing of the ax; a formidable foe will not fall after a single punch; a powerful army will not raise the white flag after one shot fired; and a chess master will not resign after the very first move. In that same regard, depression will not be quelled following a single application of a therapeutic intervention – not a fact I like very much, but a fact nonetheless.
As a therapist who specializes in treating intense and unrelenting depression and anxiety often associated with chronic mental illness and personality disorders, I spend my days teaching clients how to use skills like deep breathing, distraction, positive activity scheduling, thought restructuring, and mindfulness to reduce tough symptoms of depression. One day, one of those same clients taught me a valuable lesson — it’s not about the individual skills, it’s about what they can do in combination.
Meet Elena: My Teacher
Elena was 35 when she first sought treatment for her PTSD and depression. She had endured years of childhood neglect followed by more relationship abuse intermittently throughout her adult life. Sure, she had her reasons to be sad and resentful about where life had taken her, but she would suffer from bouts of depression that far outweighed the levels of feeling justified by her current circumstances. She was, after all, now gainfully employed, surrounded by friends and family who loved her and did not abuse her, and had left those who had treated her poorly in her dust. Her bills were paid. She had a boss who had absolute faith in her and a new relationship with someone who absolutely adored her. So, how then could she regularly fall victim to episodes of depression that would steal her will to get out of bed, much less to go on living at all?
Together, we searched for the answer to that question – how could a woman so resourced when not depressed, completely fall apart when depression got its grip on her? How could she go week after week functioning (and sometimes over-functioning), but one day wake up and not have the motivation or energy to make it to work, take a shower or return a text message. She would spend days in bed, sometimes not even able to get up to use the bathroom. Yes – she could do nothing but lay in her own filth.
Exploring: From Antecedents to Behavioral Reactions
We explored every facet of the spiral that lead down, down, down to the depths of darkness that would result in someone becoming essentially catatonic with despair.
First, we discovered the typical antecedents to these conditions – things like perceived criticism at work, an unreturned phone call from a friend, or an annoyed look from her partner.
Second, we identified her interpretations of these events. She was able to recall many of her automatic thoughts, all of which began with “DANGER!” — “DANGER! I’m going to lose my job.” “DANGER! I’m being blackballed by my friends.” “DANGER! I am about to be abused again . . .”
Third, she uncovered the feelings resulting from those thoughts – she would immediately feel sad and scared, anticipating the grief she would feel at loosing these positive relationships.
Finally, we looked at Elena’s physical sensations, urges and behavioral reactions. Instinctually, she fell into a freeze response to her fears which lead to behaviors of withdrawal and avoidance. The more she avoided her job, friends, and partner, the more disconnected she got, thus, reinforcing her fears that she was losing them all. Without those connections, she had no identity left other than the poor abused child who could not take care of herself. Without an identity, she had no life left… and down, down, down she went into the darkness.
Learning New Skills
Our treatment plan was full of skills meant to address the problem at each step in her plunge. We worked on problem-solving the initial events by practicing asking others for clarification of their remarks, actions or expressions. She learned a skill called “Check the Facts” which calls for opening up your view and accounting for all possible interpretations of available evidence. She learned to respond to her negative thoughts with a simple, “Maybe it’s NOT all about me.” We reviewed skills for regulating intense emotions by staying active physically and mentally. In total she learned 52 skills for tolerating distress and staving off depression and despair.
For 6 months she learned and practiced and role-played and prepared for the next episode. For 6 months she stuck to the program, attended skills groups and came to weekly individual therapy sessions. In that 6 months she experienced no less than 5 recurrences of her depression. I shared in her frustrations at the lack of abatement in her condition despite her valiant efforts to learn and practice each of those 52 skills.
Thoughtful Combinations (aka the One-Two Punch)
Thankfully, one day Elena came to skills group with a glorious announcement – she was able to put the brakes on another “near-death spiral”!
“I finally figured it out!” she exclaimed. “I have been trying this one skill at a time. When one skill didn’t do the trick, I might move one to another and another, but eventually I would write them all off as failures and give in to the slide. Not this week! This week, I realized I needed to give that depression a combo punch. I needed to breathe AND say my mantra. Then I needed to engage in mindful activity AND distract from my unhelpful thoughts. Then, I needed to deal a final blow – instead of avoiding a friend who did not return a text, I asked another friend out to a movie despite wanting more than anything to just hibernate in my apartment for the weekend. That means I did the ‘Opposite Action’ skill while at the same time doing a ‘Positive Events’ skill AND the ‘Radical Acceptance’ and ‘Willingness’ skills.”
Everyone in group regarded Elena with awe, myself included. She had discovered the secret to therapy skills – they are more effective in tandem than as a single, stand-alone solution. She figured out that to win a fight, one must bob and weave in addition to throwing a punch or two (or three or four…). And so it goes when depression is the opponent – throw everything you’ve got in thoughtful combinations. Each combo builds your momentum to spiral OUT of the darkness, and, eventually, to stay out.
Casey Limmer, LMSW, LCSW, is founder and owner of St. Louis DBT, LLC. Casey has become an authority on DBT in the St. Louis area, using DBT in her practice since 2002 and training directly with its creator, Marsha Linehan, Ph.D. Casey teaches courses in Applied Behavior Therapy, Cognitive Behavior Therapy (CBT) and DBT at Washington University’s Brown School of Social Work. She is one of only a handful of clinicians to achieve certification in DBT with the Lineman Board of Certification. She trains and supervises therapists in the practice. Learn more about St. Louis DBT