The Hypothetical Client

I do not post information about my actual clients on this blog because therapy is a strictly confidential. This is as it should be.

And yet I also think it's helpful for people who are thinking about trying to therapy to get a feel for how therapy works and what we talk about.

Enter the HYPOTHETICAL client.

He could be young, old, male or female. He could be white, black, latino. He could be you, me, or your neighbor.

Our Hypothetical Client is depressed. Over the course of my practice, I've seen hundreds of depressed persons. Though I do not subscribe to the notion of putting people in categories (every client's depression is, in some ways, unique), depression tends to have universal symptoms. Our hypothetical client is struggling with depressed mood, low energy, loss of hope, and sleep problems. His concentration is not what it was and, perhaps more than anything, he just can't get going -- the depression is weighing him down. Maybe he spends too much time inert, sitting in a chair or on a couch, or maybe he forces himself to go work, but it's exhausting. Our hypothetical depressed person finds himself thinking that maybe he should just end it all...

If I were to work with our Hypothetical Client, here are three things I'd want to know:

1. What are the sources of his depression? Not the causes; causes are an entirely different matter, and they are complicated. But the sources. Most people who become depressed ruminate over certain aspects of their lives. Job, family, kids, failures, whatever. What I'd want to know is where does the rumination take him? First we follow the problems.

2. How can we make the problems solvable? Frequently when people become depressed, they become overwhelmed. Problems become mountains to climb and oceans to swim. In a depressed state, problems often seem impossible. As first step, however, we need to break the problems into solvable parts to make them more manageable. Therapy isn't just about talking out your feelings, it's about finding new actions to take.

3. Can we take a close look at his thinking patterns? Depression is a sad emotional state, true, but it is also a kind of thinking disorder. In the throes of depression, thinking gets muddled and distorted. Has our Hypothetical Client fallen into the trap of black or white thinking? (e.g., either I'm a success or a failure. Either I can do it right, or I can't do it at all. Hint: where is grey?) Or has he become a master of extracting negative information from all situations, while ignoring or dismissing the positive? We're not always aware of our own thinking patterns. We just think the way we think, and it feels natural to us. This is where I come in. I've spent countless hours helping people identify ways their own thinking is making problems worse.

This isn't the full story of what treatment for our Hypothetical Depressed Person would look like. Therapy is a complex business that is tailored to a specific individual (or couple). But maybe this gives you a taste of how a therapy for a depressed person might start.

For more information, check out these related posts: The Downward Spiral of Depression. And Tip for Coping with Depression.

The Consumer Reports Survey on Anxiety and Depression

A recent article in the July 2010 Consumer Reports presents the results of a survey they did with their readers about getting help for Anxiety and Depression.

Conclusion: their sample of readers felt both that both “talk therapy” (psychotherapy) and medication were each effective, but combining the two yielded the best results.

No surprise, here. These findings are very much in line with the behavioral research on the topic. (True clinical studies typically measure outcomes and employ appropriate control groups.)

I often see people in my practice who do not want to go on medication, largely because of side effects. I’m not against medication; I just happen to provide therapy. If my patients want medication I will happily refer them and let them come to their own conclusions about the value medicine in their lives, which I think is the best way to do it. On occasion, I will also see a patient who does not want talk therapy, but only wants the pills. I have no objection to this, either.

What I do find, however, is that often medication treatment alone is good so long as one stays on the medication. If the medication is discontinued -- without psychotherapy -- the symptoms may relapse. This, too, is in line with current research.

A different view of antidepressants was discussed in this post: Antidepressants Don’t Work...Can this be true?

Tip for Coping with Depression

The Cut-it-in Half rule.

Usually when people are depressed they struggle with motivation, fatigue, low energy, or inertia. It’s so tempting just to sit in a chair for hours, go to bed, or come to a complete stop. Why bother doing anything?

But this only makes depression worse. Curiously enough, the human body makes energy by exerting energy. Whereas more stopped-ness makes more inertia.

The cut-it-in-half rule says, If you can’t go what you usually do, cut your efforts in half. Don’t succumb to all-or-nothing. (Either I worked to my usual capacity, or I didn’t. EIther I succeeded, or I failed.) If you can’t manage your usual effort, try cutting it in half. When it comes to depression, some effort is always better than no effort.

Related post: The Downward Spiral of Depression.

Antidepressants Don't Work...Can this be True?

According to research published last month in THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, antidepressants are being challenged as an effective treatment for depression.

The cover story for NEWSWEEK (Feb 8, 2010) gives an excellent report on these new findings.

For mild, moderate, and severe depression, antidepressants are virtually no better than a placebo. However, antidepressants have been found to be effective for very severe depression.

These conclusions were reached using meta-analysis, a statistical technique that allows researchers to put the effects of any given study on a common metric so that an overall effect size can be calculated. (Don't let the jargon bog you down. Meta-analysis simply puts separate studies on the same yardstick so they can be compared.)

In this case, Irving Hirsh used 48 studies, taking pains to gather all of the studies he could find. He went so far as to use the Freedom of Information Act to obtain unpublished studies by drug companies that were available through the Food and Drug Administration.

The end result? For the most part, antidepressants are no better than a dummy pill.


The drug companies have some explaining to do. Incidentally, they are not disputing the findings of their own studies, but they are trying to point out the depression is an individualized illness and that patient responses may vary. Still, we're talking about a multi-billion dollar industry here. We're talking about big news.

No doubt, we're bound to here more on this story in the comming months. In the mean time, if you are taking an antidepressant, do not stop abruptly. This can be dangerous. Consult the person who prescribes them to talk over what's best for you.

One last point: psychotherapy has been show to effective in treating depression. And compared to antidepressants, the relapse rate is lower, too.

The Downward Spiral of Depression

Major Depression. Chronic depression. Situational depression. Depressions vary in kind and severity, but what they have in common, at their core, is negativity and despair.

Depressed persons see the glass as half-full. They have a perceptual bias toward extracting negative information from situations while minimizing or ignoring positive information. They have negative views of self, other, world. And they don’t just perceive negativity, they recall it. Their memories are consistent with their moods. It’s not necessarily that they had more negative experiences to begin with, it’s that their minds filter out the positive memories to match their depressed state of mind.

Unfortunately, negative thinking leads to negative actions which turn often result in negative results. In this way, negativity is self-reinforcing. If you act on your negative perceptions, and get back negative results, your views are confirmed. And then despair sets in. Despair is when we believe there is no hope that things will get better. This mood, this pain, this self, this world, this life––there is hope that any of it will ever be different.

This is how the spiral starts.

Depression is exhausting, mind-numbing, painful. The depressed person struggles to function. It’s just too tempting to sit in the chair, lay on the bed, or hide out from the world. Or use some substance to help numb the pain. Unfortunately, our bodies restore energy by expending energy. They are not like batteries. We must move to get energy. But movement and effort are generally the last things the depressed person wants to do.

So down the spiral we go, slipping deeper and deeper into the mood, the negativity, the despair. Is it any wonder that most truly depressed persons start thinking seriously about suicide?

But wait! We can interrupt the spiral.

The secret lies in getting inside of the negativity. Negative thinking is fraught with distortion. In therapy, we call these negative thoughts out into the open and examine them. Some perceptions may indeed be accurate (losing your job is tough no matter how you cut it), but frequently the depressed person distorts reality without realizing they’re doing it, or without realizing how much they do it. Once we restore balance in thinking patterns, the spiral starts to work in reverse.

Depression can be overcome. Don’t let despair convince you otherwise.

(Photo by Dhammza)

Copyright 2008-2016 John Gibson. All rights reserved.