31. 辅导因抑郁而困扰的人

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31 Counselling those troubled by depression When do you get depressed? Why do you get depressed? We all get depressed from time to time. Being depressed some of the time is a normal human condition and as counsellors we are sure to meet with people who are depressed. Depression only becomes a serious problem when it is either very deep or very7 prolonged, it is then dangerous and requires specialist treatment, so counsellors need to be aware of this and refer people for appropriate professional help when necessary. There can be many reasons for depression. Some people become depressed as a consequence of what they see as overwhelming pressure in their lives. Others are depressed as a direct result of sickness. People who are unable to meet their own expectations of themselves are usually depressed. Then there are those people whose depression is due to their inability to accept that other people do not live up to their expectations. There are people who are depressed because they are grieving as a consequence of loss, and our guess is that you can think of a range of other circumstances that are likely to produce depression. It is also important to recognise that there may be organic reasons for depression; problems with body chemistry, organic problems in the brain and other medical conditions can cause depression. USE OF THE NORMAL COUNSELLING PROCESSES For many people the normal counselling processes previously described will produce changes in emotional feelings and thought patterns so that depression lifts. So why are we writing a special chapter on depression if the normal counselling processes are usually sufficient? We are doing this because for some people who suffer from prolonged depression, a heavy7 emphasis on the reflective counselling techniques described in the early chapters of this book will not be useful, and may even have a detrimental effect. This is particularly so in cases where the depression does not seem to be related to recent or specific causes. Generally, when depression can be directly related to a person’s personal life and can be attributed to specific life events, a personal situation or an identifiable crisis, it is appropriate to use the counselling techniques previously described. While doing this, it is useful to remember that depression can often be understood in terms of blocked anger.

DEPRESSION AS BLOCKED ANGER When a person suppresses or is unable to recognise anger towards someone else, it is quite likely that they will become depressed. Can you imagine yourself being very angry with someone but being unable to express that anger? You might be unable to give vent to your anger for a variety of reasons. Maybe you care so much about the person who is the target of your anger that you do not want to hurt them by expressing anger. Perhaps you recognise that really your anger is unjustified, although real. Possibly you have been taught not to blame others or not to express angry feelings. After all, how many times do parents say to children, ‘Don't be angry7’? Sometimes parents will do this at times when it is appropriate for their children to be angry, and by doing so we encourage them to block or suppress their legitimate feelings with inevitable negative consequences for themselves. How are you going to feel if you suppress angry feelings? You 're probably going to feel frustrated. If you are not able to deal with your frustration by letting that anger out, then you are likely to experience feelings of helplessness and depression. EXPLORING THE POSSIBILITY OF BLOCKED ANGER During the counselling process it is often sensible to confront a person who is suffering from depression with the possibility of anger underpinning the depression. A variety of counsellor responses can be used for raising awareness of underlying anger. Here are some examples: When you think about what has happened to you, who are you most angry with? If you weren't depressed, who would you be angry with? If instead of feeling depressed you felt angry, what would that anger be about? Sometimes, a person’s response to one of these questions will be to deny that they are angry with anyone or anything, and this may be true. However, it may be that they are unable to get in touch with their anger, if it exists, or that for some reason they don’t want to own it. If a counsellor suspects that anger is blocked then it may be useful to give the person a message that implies that it is OK to be angry in the person’s particular situation. A counsellor might say, ‘If I had experienced what you have experienced, 1 think that 1 would feel vew angry.' I his may enable the person to recognise and access anger. If it does, then dialoguing and the empty chair technique described in Chapters 27 and 30 can be used so that the nerson is given the opportunity to express anger verbally in the safety of the counselling environment. We recommend, however, that you make sure the person understands that there are appropriate and inappropriate ways of expressing anger.

Sometimes people who have learnt to disown angry feelings will tell you that they are not angry, but instead are just frustrated. There is a thin dividing line between frustration and anger. If a person is frustrated, the approach used for the expression of anger may be equally appropriate in dealing with the frustration. Often when a person who was troubled by depression expresses anger, there will be a change in their demeanour, with the lethargy caused by the depression being replaced by an energised state in which the person becomes more active and looks more in control. People suffering from depression due to the loss of a relationship are often angry with the person they have lost. Appropriate expression of that anger in the therapeutic environment may enable them to deal with it in a constructive way. However, remember that some people have the potential to be dangerous to others (see Chapter 30). These people need to learn to control their anger and should be referred for appropriate professional help for your protection and the protection of others. THOSE WHO NEED REFERRAL Counsellors need to be able to identify those people who need referral for specialist counselling or medical or psychiatric assessment and treatment. Included in this group are people who: • are so troubled by depression that they are a danger to themselves or others • are unable to function satisfactorily in their daily lives due to depression • have suffered from depression for long periods • have no clearly identifiable cause for the depression. If you are in doubt regarding referral to a suitable professional, we suggest that you talk with your Supervisor. Regardless of the need for referral in cases such as those described above, counsellors working in crisis counselling agencies will frequently become involved in counselling people who are chronically depressed. Many of them may be either unwilling to seek specialist treatment or engaged in long-term psychiatric treatment with little positive effect. We believe that it is appropriate for such people to talk to counsellors from time to time, provided that any other professionals involved are comfortable with that. Certainly, counselling by a skilled counsellor will, at the very least, enable the person to feel that someone cares enough to listen, and there may be other beneficial effects. COUNSELLING PEOPLE WHO SUFFER FROM CHRONIC DEPRESSION When counsellors are working with a person who is experiencing long-term depression, the effect of continually reflecting back depressed feelings is likely to do little more than heighten their experience of feeling depressed. Unfortunately, this may result in the person feeling that they are hopelessly and chronically depressed and beyond help. Clearly, this approach is unhelpful! When seeking to help a person who is suffering from chronic depression we therefore need to limit our use of reflection and to use a different emphasis in our counselling. This does not mean that we should discard our ideas about the counselling relationship or forget the basic micro-skills. We need all that has previously been learnt, but with a change in emphasis. We suggest that you might like to refer to the 'Stages of the counselling process’ chart (figure 16.1 on page 135). The difference in dealing with a person who is suffering from chronic depression is that we need to move forward more quickly and decisively from the emphasis on emotions stage into the emphasis on thoughts and behaviour stages (see the right-hand side of the chart). By doing this, the emphasis is taken off emotions and replaced by an emphasis on thoughts and behaviours. Rather than accompanying the person on a journey down into depression by reflecting feelings, invite them to join you on a journey of exploration where together you will explore the influence of thoughts and behaviours on the depression, with some limited but positive goals in mind. In this process the counsellor needs to be more active and confronting than might be the case with those who do not suffer from chronic depression. We suggest that when counselling chronically depressed people, the counsellor may wish to start by attending carefully to the person using active listening to allow the counselling relationship to develop. However, once the feelings of depression have been validated by reflection, then, as mentioned earlier, it is not wise to continue by reflecting feelings of depression as this will merely accentuate the depressed feelings. Instead the counsellor mayr begin to refer to the depression as something to be dealt with, rather like a piece of baggage that can be picked up or put to one side. When doing this the counsellor is using a process similar to externalising (see Chapter 21). COUNSELLING GOALS FOR PEOPLE WHO SUFFER FROM CHRONIC DEPRESSION When counselling someone who is troubled by chronic depression, it’s necessary to make a decision about what are realistic counselling goals and what are unrealistic goals. New counsellors sometimes believe that it should be possible, with skill, to help every person who is sufl'ering from chronic depression to feel better. Unfortunately this is unrealistic. However, if counsellors choose suitable goals, many people who are suffering from depression can be helped to enjoy a better quality7 of life. You might like to try to think of some realistic goals yourself before reading our suggestions: • To help the person to identify what makes them feel better and what makes them feel worse. • To help the person to recognise that they have choice regarding their current behaviour at any time. For example, they could choose to do what makes them feel better or what makes them feel worse. They could choose to sit around and do nothing, or they could choose to do something active. To encourage the person to focus their mind on what they are actively doing instead of focusing on depression. • To enable the person to take action. • To enable the person to make a decision to seek appropriate specialist or psychiatric help. • To enable the person to come to a decision with regard to one of the practical problems in their life. • To help the person to challenge a self-destructive belief that is making them feel worse. • To help the person feel a sense of importance because you are listening. (Note that some people who are suffering from depression will deny that the counsellor cares because there is a limit to a counsellor’s caring. However, as a counsellor you do care enough to listen and you can say that. Be specific though. A statement such as ll care about you’ is likely to be challenged, whereas a statement such as ‘I care about you enough to want to listen to you’ can’t be sensibly challenged.) • To give the person a positive message about themselves at the end of the counselling session. For example, ‘I’m impressed by the way you were able to clearly identify what makes you feel better and what makes you feel worse’- If you decide that the goals described above might be too difficult to achieve, you could set an easier goal such as: • My goal will be to listen to this person so that for a time they are not alone but will have my company. (In this case, you are really offering company rather than counselling so you may end up chatting together rather than using counselling skills.) Even if the previous goals listed are not attainable, this last goal is definitely achievable and therefore realistic. If you decide to try to achieve one of the earlier goals mentioned, we suggest that you may wish to set one goal only, because it will be hard for someone who is suffering from a high level of depression to find the motivation required to make several choices and take action to carry’ them out. The nature of depression leads to loss of motivation and consequent inactivity. Unfortunately, inactivity7 reinforces depression, making it hard for the person concerned to make changes.

USING A DIFFERENT APPROACH If, as a counsellor, you are to achieve a selected goal, once you have secured a warm and trusting relationship with the person by using active listening and problem identification, you will need to make amendments to the counselling strategies you have previously learnt. Although you will be walking alongside the person at times, at other times it will be advantageous for you to take control of the direction of counselling intervention. It may also be advantageous at times to change your counselling style so that you are more confronting, but in a friendly, caring and non-threatening way. As explained, a person who is suffering from chronic depression will find it difficult to be motivated and consequently will find it hard to change. They will find it hard to identify ways to reduce their pain. However, by confronting with care you may enable them to explore options and take some positive action. ENCOURAGING ACTION It can be useful for a person suffering from depression to be able to recognise those behaviours and situations that make them feel less depressed. If they can discover what they need to do or where they need to go in order to feel less depressed, they may be able to escape from the intensity of the depression for a time. A good approach is to ask the person, ‘Was there ever a time when you weren't depressed?’ (see Chapter 22 regarding looking for exceptions). Most people can identify some times in their lives when they enjoyed themselves. If you can find out when those times were for the person you are seeking to help, then you may be able to help them discover some way of partially regaining some pleasant experiences. When we are suffering from depression we all tend to think negatively, so remember how difficult it will be for a person troubled by depression to try to think positively. However, if you are to help such a person, you will need to try to help them discover some positive ways of thinking and behaving. Let us consider an example: imagine that a person says, ‘1 was only happy while Judith was alive. She’s dead now and so my life is meaningless.’ In order to help this person you would need to use your ingenuity to try to discover what it was that Judith did, apart from being present, that helped the person to feel good. You might ask the question ‘What sort of things did you do when Judith was around?’ and this might lead to the answer 'We used to go for long walks in the bush’. You could then explore whether, at the present time, a long walk in the bush would be more or less depressing than not going for a walk. 1 he question ‘Would that be more or less depressing than doing what you are doing now?’ is a smart way of avoiding a 'Yes but ...’ answer. Even so, you might get the answer ‘Yes, but 1 would still be depressed? You can agree and say: 'Yes, you would still be depressed but would you be more depressed or less depressed?' Of course you might get the answer ‘I’d be just the same, miserably depressed’. In this case, seek a less ambitious goal for the session, but do not give up. Remember that this person is in pain and deserves respect and help. THE USE OF ACTIVITY Research over many years has shown that generally people who suffer from depression tend to be less depressed when they are active. This is why occupational therapy is used in psychiatric settings to help those who suffer from severe depression. Even a simple action such as going to have a shower or take a bath can be a useful activity that might temporarily ease the depressed feeling. SETTING TIME LIMITS There may be limited value in talking for lengthy periods with people who suffer from chronic depression. Generally, short interventions tend to be more useful, particularly if they encourage the person to undertake some activity. To encourage activity, remember to reward a person with praise when they do engage in meaningful activity and when they succeed, for a time, in feeling less depressed. Because people who suffer from depression are often bored and preoccupied with negative thoughts, they may wish to talk at length without purpose and to travel the same road in their thoughts, over and over again. In turn, counsellors may need to use good termination skills. A useful way to terminate a counselling session is for the counsellor to be directive in suggesting that the person go to perform a task. For example, the counsellor may say, 'I would like to finish our conversation now and suggest that you might like to go home and prepare a meal for yourself right away. Next time we meet I would like you to tell me whether you felt more or less depressed when you made and ate the meal.’ Once again, the suggestion is action-oriented and includes the goal of identifying the usefulness of activity. DEBRIEFING If counsellors join empathic ally with people who are depressed, they may pick up negative and depressed feelings themselves. It is therefore important to debrief and to look after your own needs (see Chapter 42).

Learning summary ft is normal for people to suffer from depression as a result of personal stress or as a consequence of a troubling situation. For many people who suffer from depression as a consequence of a troubling personal situation, the normal counselling processes may be sufficient. Sometimes depression results from blocked anger. Depression calls for specialist treatment when it is either very deep or prolonged. For people who suffer from chronic depression: » referral to a specialist is required (after consultation with your supervisor) » continual reflection of feelings can be counterproductive » set goals for the session and take control of the counselling process » be confronting » encourage activity » keep counselling sessions short and energised. Further reading Gilbert, P.R, 2009, Overcoming Depression: A Self-help (ini de Using Cognitive Behavioural techniques, 3rd edn, Robinson, London. Massey, A, 2005, Beat Depression and Reclaim Your Life, Virgin, London.