Other than relationship problems, anxiety and depression symptoms are the leading reasons why people seek out therapy. And of course, relationship issues are often accompanied by anxious or depressed feelings.
Anxiety and depression, like most other psychological issues, run on a spectrum, ranging from mild to severe, feeling fairly manageable, to feeling “out of control”. It’s important to remember that all people experience anxiety and/or depression symptoms at some point in life, and this hardly means that they have a psychological disorder. Often the most natural, and healthiest response to a stressor or life circumstance may be anxiety or depression symptoms.
That being said, on the severe end of the spectrum, people are dealing with a true psychological disorder, are acutely suffering, and are living a small fraction of the life they’d be living without the symptoms. There are many factors that come together to create these issue: genes, physiology, family upbringing, life circumstances, lifestyle, health, social support, etc. Because all people are in some ways effected by depression, anxiety, or both (either personally or second hand), a lot of research has been focused on understand and helping people suffering from them. It should also be noted, that although there are many similarities between depression and anxiety, and there is almost always some overlap, there are also many important ways that they are very different. Indeed, they are distinct disorders.
When one is experiencing depression or anxiety, it can feel overwhelming, exhausting, hopeless. People often go through phases of how they handle their symptoms, and most people try many things before they even consider therapy. Unfortunately, often the symptoms themselves make reaching out very difficult. With depression, people’s energy is often very low and depressive thoughts such as “nothing will help”, or “I’d be too humiliated to talk to anyone” stand in the way of setting up therapy. For anxiety, there is often a strong feeling of wanting to avoid things that feel uncomfortable. This avoidance alone is often strong enough to prevent people from reaching out, and there are also common anxious thoughts and worries that also stand in the way.
If you relate to the above paragraph, first of all, know that what you are experiencing is very common. But also, keep in mind, that by reaching out for help, you are taking the first step in fighting back against the depression or anxiety symptoms that you may be experiencing.
It can also help people to have a sense of what they might experience if they were to start therapy to address these types of issues. I like to start with Cognitive-Behavioral Therapy (CBT) when working with people who are experiencing depression or anxiety symptoms. I incorporate other approaches as well, including positive psychology, and other acceptance and mindfulness-based practices. This entry will be focused on CBT and how it works.
The basic premise of CBT is that our thoughts about ourselves, others, and our circumstances effect the way we feel, the choices we perceive, and therefore, our behaviors. Our behaviors, in turn, slowly but surely, shape our lives. CBT believes that our thoughts, feelings, behaviors, and outside circumstances/stressors, are engaged in a feedback loop, and that intervention at any point has the potential to change the pattern, hopefully for the better. However, it is felt that certain factors are easier to influence then others. For example, CBT focuses on trying to change thoughts and behaviors, because they are thought to be easier (though not necessary easy) to change then moods, emotions, outside circumstances, and other people.
When using CBT to work with a client, therapists might do a number of things, depending on how strictly they are adhering to CBT protocol and if they are incorporating other types of therapy, as well. Also, different presenting issues will influence the type of interventions that are used. And of course, everyone is different, and some people prefer other types of interventions.
CBT interventions can be thought of as targeting cognitive symptoms, behavioral symptoms, or both. Cognitive interventions target thoughts. All of us have thoughts that help us through difficult situations, as well as thoughts that stand in our way. Sometimes these thoughts are clearly, explicitly, stated to ourselves, while other times, they are unarticulated assumptions that lay the foundation of how we live. The first step to working with these thoughts is to notice them, and to start tracking them. When do they arise, how do they make us feel, how do we act when we believe them? Once we feel like we have a good understanding of the types of thoughts that are standing in our way, making us feel worse, etc, we can start to challenge them. This is called cognitive restructuring, and includes many potential CBT interventions that are designed to create more flexibility around these thoughts so that they are less influential and harmful to our mood.
Here is a common example. A depressed person might have a foundational belief (in CBT, called a core belief) that he or she is a failure. Perhaps, they don’t really feel this way when they’re not feeling depressed, but when something happens, like getting fired from a job, or getting a bad grade in a class, then this belief is triggered. If 100 people were fired from their jobs, all 100 of them could have slightly different interpretations of why. If you are the person who believes deep down that the reason for getting fired is because you are a failure, doomed to fail, etc, then you are going to feel much worse about yourself, possibly be overcome with a sense of hopelessness, self-loathing, shame, and therefore, withdraw from friends or family, not jump into job searching, etc. If this person is prone to depression, then this alone can get the ball rolling in having a depressive mood or episode.
Cognitively, there may be many things that this person is telling himself or herself on a daily (or hourly) basis that is adding fuel to the fire of depression. CBT would try to identify these thoughts, and work at changing them, or at least, lessening their grip on the person’s mood and behavior.
This takes us to the importance of using behavioral interventions as well. As mentioned, our thoughts and behaviors almost always go hand in hand. If you are telling yourself that it was your fault you were fired, because you are a failure, and you are feeling worthless, ashamed, hopeless, then you are likely to withdraw, shut down, or lapse into bad habits. Although we often want to wait until we feel better to do a certain behavior (like jump into job searching), we do not have to feel better to engage in proactive, healthy behaviors. Going to the gym is a perfect example of this. Many people would never go to the gym is they waited until they felt like it.
In our example, we would encourage our fictional person to behave as if they were not depressed. In this example, we might encourage them to get out of the house, exercise, interact with friends and family, and actively job search. Behavioral interventions would be aimed at encouraging breaking the behavioral aspect of the depression cycle.
Behavioral interventions are especially important for anxiety symptoms, which can only persist with behavioral avoidance. In other words, if something makes you anxious, and you know that the anxiety is not helpful (some anxiety keeps us safe from dangerous situations), the anxiety cannot go away unless you do the feared behavior. If you have a flying phobia, it does not matter how much you may intellectually understand that flying is safe, you will still be scared the first (few) times you fly, but then gradually, the anxiety will reduce, if your thoughts are also supporting your new belief that flying is safe. If you’re considering therapy for anxiety but are concerned about being forced to do behaviors that you don’t want to do, rest assured that therapy is done at your pace.
You can probably see how cognitive and behavioral interventions can work to benefit each other. For instance, if I start to break down the belief that I am a failure, it will be easier to be pro-active, gather support for myself, and try again after a loss. Conversely, if I am putting myself out there, and start having little successes, and have a little more energy because I am being active, then I will have more evidence to fight my unhelpful beliefs.
If you do a quick Google-scholar search you will see thousands of articles reflecting countless studies about CBT having great success in treating depression, and anxiety (including panic). If you are experiencing these symptoms, consider if therapy could be a helpful next step. Do not hesitate to contact me if you’d like to discuss a consultation to see if therapy is a good fit for you, or if you have other questions about this issue.
-Dr. Megan Goodwin