The following is a paper I wrote for an introduction to counseling course I recently completed through Athabasca University.
What is depression?
Major depressive disorder, commonly known as depression, is a medical condition that affects all aspects of an individual’s life. Unlike normal feelings of sadness that everyone experiences in life, depression lingers for at least two consecutive weeks and significantly interferes in daily functioning.
Symptoms of depression can include overwhelming feelings of sadness, despair, lack of energy and feelings of loneliness, worthlessness, and isolation (American Psychiatric Association, 2013). Petrohilos (2017) estimates that depression affects more than 300 million people worldwide, with women more likely to experience depression than men. If depression becomes severe enough, it may lead to suicide (Gladding & Alderson, 2012). However, not all suicide attempts are linked to depression, many other types of mental illnesses can contribute (Petrohilos, 2017). In Canada, suicide is the second leading cause of death in young people from 10 to 24 years old. Greenlee and Hyde (2014) found that the rate of suicide typically declines for women as they age, but increases amongst men. Older men are five times more likely to die by suicide than older women.
It takes on average 10 years for a depressed person to get the help they need. The delay in treatment is due to a variety of factors including stigma and confusion about mental health disorders. Discussing depression openly helps to reduce stigma and in turn, helps researchers and psychologists provide better and more specific treatment for the condition.
In order for a diagnosis to be made, a person must report feeling these symptoms consistently for at least two weeks. According to the American Psychiatric Association (2013) five or more of the following symptoms must be present in order for it to be diagnosed as clinical depression:
- Depressed mood most or nearly every day
- Loss of enjoyment and interest in the things that were previously enjoyable
- Significant weight loss or weight gain
- Incessant hypersomnia (sleeping too much) or insomnia (not being able to fall asleep)
- Feelings of constant restlessness or slow movements
- Fatigue, tiredness, or loss of energy nearly every day
- Feeling worthless or guilty nearly every day
- Feelings of indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideas without a specific plan, or a suicide attempt or a specific plan for dying by suicide.
The cause of depression is still not known. It is a complex disorder that combines many factors including genes, hormones, biology, family environment, and other socio-cultural factors (Bembnowska & Josko-Ochojska, 2015). This paper will examine three forms of psychological therapy treatments that have been proven to be effective in treating depression. These are: Dialectal Behavioural Therapy (DBT), Acceptance and Commitment Therapy (ACT) and Art Therapy.
Dialectal Behavioural Therapy
Dialectal Behavioural Therapy (DBT) was created in the 1900s by a Cognitive Behavioural Psychologist, Dr. Marsha Linehan. At that time, Dr. Lineham was treating severely suicidal women who had borderline personality disorder (Matta, 2016). She observed that using traditional Cognitive Behavioural Therapy (CBT) techniques only increased dropout and/or noncompliance (Shumlich, 2017). She began modifying CBT techniques in order to strengthen the therapeutic alliance with her clients, reduce dropout and increase compliance. The word “dialectal” describes the heart of this therapeutic technique which is balancing two opposing concepts: acceptance and change (Vinson, Felder, Ashby, Scott, Dean, & Dimidjian., 2017). DBT is now widely accepted as an effective treatment for many different types of mental illnesses, including depression (Shumlich, 2017).
Goals of Dialectal Behavioural Therapy
Shumlich (2017) explains that the goals of DBT are for the client to become a master of managing emotions, and enhance:
- Interpersonal effectiveness; learn how to manage healthy relationships with others
- Distress tolerance; learn how to cope with difficult situations
- Emotional regulation; discover how to manage emotions so that they are healthy and productive
- Increasing mindfulness; become more aware of the present moment and practice acceptance
DBT uses five functions that are delivered using a number of different therapeutic techniques and are conducted in either private or group counseling sessions. According to Feigenbaum (2008), the first function works to enhance the capabilities of the client through teaching new skills in group counseling or activating existing skills not used effectively. During these sessions, the therapist acts like a teacher and clients learn through exercise and homework assignments skills like mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation. The second function occurs during individual therapy where the client works to improve newly learned skills in different situations. The third function ensures that the new skills be applied to real-life situations and manage factors that impede their progress. The fourth function provides a structure to the environment that supports both the client and the therapist in the development and use of these newly acquired skills. The fifth function ensures that the therapists attend regular debriefs with the entire DBT consultation team to reduce burn-out and ensure they are providing the best possible service to their clients (Feigenbaum, 2008). The ability to find the best integration of both acceptance and change is an ongoing process, and challenge, of DBT (Vinson et al., 2017).
Process of treatment
According to DeCou, Comtois, and Landes (2018), the DBT treatment process is organized in a list of priority targets. The top priority is managing life-threatening behaviors, which include self-directed violence and/or violence toward others. The second target is therapy-interfering behaviors, which includes both client resistance as well as the therapist(s) not following the dialectal balance of acceptance and change. The third target is quality of life interference, which includes substance abuse, unemployment, interpersonal conflict, and any other behavior that reduce reasons for living. The fourth target is to increase the client’s ability to master DBT skills learned in therapy.
DBT is as an intensive, holistic therapeutic approach that involving many counselors and typically takes place over one year. It consists of one-hour individual therapy sessions every week, weekly skills training group, 24-hour access to phone coaching, and weekly consultation group for the therapists (DeCou et al., 2018). Due to DBT’s all-encompassing nature, it is the best technique for severely depressed clients who are on the verge of suicide or have previously made suicide attempts.
Strengths and limitations
According to Vinson Kleiber et al. (2017), DBT helps depressed clients learn effective coping skills that reinforce positive boundaries and enhance the ability to regulate strong and painful emotions. It is particularly effective for clients who are severely depressed and have planned, or have already attempted, suicide. However, according to Feigenbaum (2008) many claim that DBT lacks a firm evidence base. Additionally, Gladding and Alderson (2012) report that using DBT for highly depressive and suicidal adolescents remain inconclusive despite the positive results found in introductory trials.
Acceptance and Commitment Therapy
Acceptance and Commitment Therapy was created by psychologist Steven Hayes in 1982 and further developed by his colleagues (Kelson, Lam, Keep, & Campbell, 2017). Similar to DBT, Acceptance and Commitment Therapy (ACT) is a ‘third wave’ Cognitive Behavioural Therapeutic technique that uses mindfulness, acceptance and psychoeducational exercises to help a person live a more meaningful life (Gillard, Flaxman, & Hooper, 2018). ACT’s fundamental belief is that suffering is a basic characteristic of all human life and we suffer most during avoidance or when we become entangled in unproductive thoughts (Harris, 2007). ACT can be a helpful tool for treating depression because it works to develop flexibility within rigid, self-defeating thinking patterns.
Goals of Acceptance and Commitment Therapy
Harris (2007) describes the ultimate goal of ACT is to increase psychological flexibility and move towards a rich and meaningful life. The ACT therapist helps the clients understand the impact that thoughts, feelings, and behavior can have on their overall well-being.
The letters ACT can also be used as the acronym “A.C.T.” which describes what takes place in therapy: accept hardships, choose a values-based lifestyle, and take action (Kelson et al., 2017). Twohig (2012) explain that psychological flexibility is developed through six core principles: acceptance, defusion, being present, self as context, values, and behavioral commitments.
Process of treatment
The following lists a brief summary of the key principles used in ACT in order to develop psychological flexibility.
- Acceptance. Allowing thoughts, feelings, and urges to come and go without forcing them to be anything than what they are. This principle is meant to decreases the effort in trying to change or control the inner experiences by simply watching them enter in and out of consciousness (Twohig, 2012).
- Defusion. Cognitive defusion refers to the skill of perceiving thoughts, images, memories as nothing more than bits of language and images in our minds rather than threatening ideas or objective truths and facts. The opposite is cognitive fusion where one believes every thought they have is the truth and must be obeyed (Twohig, 2012).
- Being present. This involves a complete immersion into the current moment with openness, curiosity, and receptiveness. It is about anchoring the mind to the present moment of life and gently guiding it back each time it strays (Harris, 2006).
- Self as context. The “you” that has been constructed based on evaluations of the self and who we believe ourselves to be. Self as context is thought to be facilitated by cognitive defusion which creates the loss of perception between ourselves as the experiencer of life and the thoughts and stories that we tell ourselves (Gillard et al., 2018)
- Values. Individually chosen principles that guide and motivate one’s life. They create meaning and purpose and help clients work towards their goals (Twohig, 2012).
- Behavioral commitments. This uses behavioral therapy techniques to help the client commit to a desired action based on personal values (Twohig, 2012).
Strengths and limitations
ACT is can be effective for depression because it helps the client become aware of their coping strategies, such as withdrawal or substance use, and allows them to see how this causes even more suffering. It helps the client learn to let go of the eternal struggle to be happy and accept that suffering is a part of life (Gillard et al., 2018). Twohig (2012) and Harris (2006) note that ACT has empirical evidence for treating a variety of disorders that tend to accompany depression including: anxiety, substance abuse, eating disorders, and impulse control. Notable limitations include the fact that only a few studies have been formatted as randomized controlled trials and the theory has been criticized for its lack of empirically validated results (Gillard et al., 2018). It has also been criticized for using a very similar approach to Morita Therapy which was developed over 80 years ago (Gladding & Alderson, 2012).
Art Therapy emerged as a form of evidence-based psychotherapy in the 1940s (Blomdahl, Gunnarsson, Guregård, & Björklund, 2013). Art therapy is a versatile technique that integrates well with other therapeutic techniques to further enhance cognitive, social, emotional growth and healing (Shella, T. 2018). This form of therapy allows the depressed client to communicate without having to directly articulate their suffering (Blomdahl et al., 2013).
Goals, techniques and process
Art therapy utilizes a wide variety of creative activities from painting, drawing, dancing, sculpturing etc. (Rahmani et al., 2016). The most popular type of art therapy is painting (Blomdahl et al. 2013). The creative process of painting facilitates the expression of both unconscious and conscious thoughts and feelings. Clients will visually express a situation or idea as instructed by the therapist. After the client completes a painting, the therapist begins to ask questions to clarify and understand what the creation looks like to them. The therapist then supports the client in managing thoughts and emotions that come up during the process (Blomdahl et al. 2013).
Strengths and limitations
A strength of art therapy is that it is particularly useful for younger clients and children as well as the intellectually disabled (Rahmani et al., 2016). It is also a versatile form of therapy that can be used in conjunction with countless other cognitive behavioral therapies (Shella, 2018). This approach may also be useful for those who are creative by nature and may not believe they suffer from any psychological issues but are looking for support and understanding (Shella, 2018). Limitations described by Van Lith (2016) include the limited amount of studies using different research methods and small sample sizes. Additionally, many studies do not specify which exact form of art was used making it difficult to understand which elements of the artistic process lead to the best results.
In conclusion, the therapies explored in this paper match different degrees of depression and varying personality types. Dialectical Behavioural Therapy is the best choice for a client with debilitating depression who is actively considering suicide and/or has had a suicide attempt. Acceptance and Commitment Therapy would suit a client who is currently experiencing a troubling event that has led to depression and requires techniques and skills to pull them out. Art Therapy is best used for clients who are skeptical of other forms of psychotherapy and/or are unaware that what they are experiencing could be labeled as depression. It can be particularly effective for teens and adolescence.
While depression can be a debilitating disorder that drastically impacts one’s life, there are countless therapies available that can fit the personality and preference of almost anyone. As more research is made available, more forms of therapy will rise.
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- Bembnowska, M. & Josko-Ochojska, J. (2015). What causes depression in adults?. Polish Journal Of Public Health, 125(2), 116-120. doi:10.1515/pjph-2015-0037
- Blomdahl, C., Gunnarsson, B., Guregård, S., & Björklund, A. (2013). A realist review of art therapy for clients with depression. The Arts in Psychotherapy, 40(3), 322-330. doi: https://doi.org/10.1016/j.aip.2013.05.009
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- Shella, T. A. (2018). Art therapy improves mood, and reduces pain and anxiety when offered at bedside during acute hospital treatment. The Arts in Psychotherapy 57, 59–64.
- Shumlich, E. J. (2017). Dialectical Behaviour Therapy and Acceptance and Commitment Therapy for Eating Disorders: Mood Intolerance as a Common Treatment Target. Canadian Journal of Counselling & Psychotherapy, 51(3).
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