Depression is ubiquitous among therapy clients, so here’s my two cents on what it can be like to treat clients with depression and some quality approaches to it. Depression is covered extensively by specialists, so I’ll be brief and you can dig into what seems interesting.

Keep in mind that with therapy for any issue, the therapeutic alliance is more important than any ‘perfect’ theory. As I discussed in my article on theoretical orientations, I listen for and ask about my client’s worldview and how they think change occurs, which helps me tailor my approach to their existing ideological foundations, and the intervention needs to be stage-matched, which tracking can help.

A Specialist

• Michael Yapko has written well about this, particularly in “The Discriminating Therapist: Asking How Questions, Making Distinctions, and Finding Direction in Therapy”. I highly recommend at least reading the first half. He’s got lots of videos online to get an idea of his work.

  • Yapko focuses a lot on ‘how’ we decide things. He suggests it’s common for people to make important decisions often without really knowing how they decided—what process or values informed the choice. It relates to Socratic questioning as well. This book teaches therapists how to listen for and ask about these ‘how’ questions. He wrote that ‘how’ questions can reveal:

• The client’s discrimination criteria for making a decision (“How did you decide this was important to do?”)
• The client’s cognitive style (global/linear)
• The client’s strategy for pursuing some desirable outcome (“Here’s how I approached the goal”)
• The client’s experiential deficit (what’s either incorrect, misrepresented, or missing altogether)

Existentialism

My bias here is toward an existential approach to depression. As in, people feel lousy and unmotivated when the way they spend their time is out of alignment with their values. Why would I feel happy or satisfied if I endlessly toil doing things I think are unimportant, when the task itself is tedious and even its outcomes don’t seem connected to a larger purpose? So, a common approach would be to ensure the person knows what they value in life (e.g., values clarification) then have them map how their values connect to their long and short term goals, and how that connects to their day to day actions.

Motivation is a strange word, because it doesn’t really mean what we think it means. We think it means that we’re fired up to do something, eager and passionate to make something happen (this might more accurately be called the sudden and inexplicable strike of ‘inspiration’). We think we should somehow simply be able to turn this eagerness and passion ‘on’ any time—but we can’t! Motivate doesn’t mean to yell, scream, or encourage; to motivate means to provide a motive, a reason ‘why’. So to motivate someone is to explain to them why they’re doing the task, how it will help them, why this persistence in the face of struggle is worth it. ~Jocko Willink

In therapy, we don’t explain a client’s unique motivation to them but rather help them explore what their own reasons are. I think adults are responsible for generating their own meaning in life and to live purposefully. To do otherwise and expect fulfillment and happiness seems unwise. Some books I commonly suggest, depending on the client are Frankl’s Man’s Search for Meaning, Jocko Willink’s Extreme Ownership, and Mark Manson’s “Book about Hope”.

CBT

It’s become a cliche, but I do draw upon CBT fairly often with depression. “The mind is like a bad neighbourhood, I try not to go there alone”, and CBT is a companion I think most of us can benefit from. Before going too deeply into interventions, I’ll hand clients a sheet of ‘unhelpful thinking styles (i.e., cognitive distortions) and ask if any seem familiar to them. This typically generates valuable process discussion, and we go from there. It’s not my style to suggest formal thought logs very often, but some variation of their application is useful, depending on how much structure a client prefers.

Behavioural activation fits in here as well—“nothing changes til you change it”. I focus on stage-matched interventions, particularly pre-contemplative ones involving motivational interviewing.

Mindfulness

Meditation can be a beautiful avenue to improving people’s mental health, as well as helping them relate differently to their experience of suffering. While it can help to practice an intervention in session to help clients feel more comfortable as well as help correct their technique, I tend not to do guided meditations in session because time in therapy is so limited already. Sam Harris’s app Waking Up is my top suggestion to clients because it’s very high quality, well organized, and free to access if you ask. Insight Timer is another common app that I find quite good, though some of the content is paid. I like Jon Kabat-Zinn’s writing, though he’s very longwinded at times. There are many guided meditations on YouTube as well, which can get fairly specific in subject. Kristin Neff’s book and website Self-Compassion are exceptional, focusing on fostering a supportive stance toward yourself via mindfulness. A genuine and regular practice of gratitude can be of value as well—and I often suggest Shawn Achor’s TED talk on happiness. Sam Harris’s discussions of ‘the last time’ you do something and on regaining deep gratitude are poignant as well.

Miscellanea

Depression can sometimes be thought of as ‘merely’ a symptom of something else: a behavior, belief, or experience. Oftentimes unhealthy relational beliefs or approaches lead to a lot of suffering and depression. Keep an eye out for possible biological causes of depression as well, and don’t hesitate to suggest a client discuss that part of the issue with a doctor if it seems relevant. Trauma can cause depression symptoms certainly, as can experiencing abuse, and so on. People pleasing, rescuing everyone, victim stances, and so on come to mind as other sources. I didn’t mention this anywhere else, but risk assessing is important with depression, especially when you’re seeing hopelessness.

Additionally, if other relevant factors seem indicated, doing a screening test for autism can be of use. There are a shocking number of adults who don’t realize they are autistic until they are in their 30s, 40s, 50s etc, and it’s often life changing to figure this out.

Having clients with more severe, ‘heavy’ depression can be draining for some therapists, and those folks usually learn not to book heavier clients back to back, or too many in one day when possible. Vicarious trauma and burnout can leave therapists feeling their own symptoms of depression (as can any other number of life experiences, especially graduate school) which can lead to possible countertransference in these sessions.

Conclusion

I find that treating clients with moderate depression is enjoyable. We root things out together, gain insights, build alliance; it’s a frequent occurrence and an opportunity to do good therapy. I love group therapy, and while depression groups can be heavy, a good structure and homework with the accountability, camaraderie, and group processing is frequently rewarding. Depression is a great area to create and modify interventions, and to build your ‘toolbox’. Be sure to ask peers or supervisors what interventions they most often reach for with depression.

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