5 Proven Behavioural Interventions for Depression

Help clients detach from the negative rumination weighing them down

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“Whatever you can do, or dream you can, begin it; boldness has genius, power, and magic in it.”

– W. H. Murray in The Scottish Himalayan Expedition, 1951

More people than ever, especially young people and children, are unhappy.¹ Rates of depression, suicide attempts and actual suicides (particularly among men) continue to rise.²

It’s important we understand this widespread and increasing misery. But I’ve noticed, and maybe you have too, a curious reaction among some people when you try to describe depression.

Sometimes when you try to pin down depression or even describe what might be done about it, people say, “ah, but you’re not talking about real depression!” Or if they don’t say “real”, maybe they say “clinical”. Real depression becomes a slippery fish, impossible to cling onto for more than a moment.

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The idea that real depression is some kind of God-given, immutable chemical disease that can at best be managed, but will always be there, is an extremely pervasive and pessimistic one. It’s a depressing idea about depression.

So where might such an idea come from?

“You can’t possibly know my lived experience!”

I think the reason for the “ah, but you’re not talking about real depression” reaction, apart from it being a bit of a meme repeated by those who’ve heard others say it, is that when depression is described it’s as if the depth of suffering it produces is somehow negated or misunderstood.

Something so soul sapping and paralysing surely can’t be explained in straightforward terms. But we should all, I think, understand the nature of the beast – because it seems to be affecting more of us each year, and it may not go away any time soon.

The more you know it, the more you can help your clients, your loved ones, and yourself.

The value of clear understanding and rapport

Actually, acute and profound experiences can often be described in quite simple terms. We can describe fairly simply what is happening to light during a Caribbean sunset, for instance. It’s just that the experience of it cannot be contained so easily.

But that’s not to say the description of what is happening is wrong. Only that a simple outer description of a phenomenon is of a totally different order to the inner experience of it.

But I’ve found that many depressed people really do like to have a clear idea as to what has been happening to them, rather than just a diagnosis.

The reassurance of knowledge

Many of my depressed clients seem to really love a commonsensical explanation of depression.

They tend to relate when I describe how depression has people spending too much time in their heads ruminating³ without hope.⁴

They often connect to the explanation that over-rumination tends to load the REM mechanism in the brain, which is why people dream more when depressed (whether they recall those dreams or not).⁵ But beyond that, they tend to relate to the explanation that over-dreaming leads to morning exhaustion and loss of motivation. The classic ‘cycle of depression‘.

So depressed clients tend to know they are over-ruminating, know their sleep is making them more not less tired, and know they have been viewing their world through all-or-nothing, extremist (or, in the words of the psychologists, ‘absolutist’) ways.

It can be reassuring for clients to see there are clear explanations, above and beyond the simplistic, medicalized ‘your chemicals are all wrong‘ myths that are so often trotted out.

So what can we do to help depressed people?

A multi-pronged approach

Depression is an emotional condition which produces, but then is partly fuelled by, absolutist (including perfectionistic), catastrophic and, of course, pessimistic thinking.

Because it’s a stress condition, we need to do relaxation training with the client. Because the emotion produces thinking biases, we need to work on that level too. And, of course, we need to help our clients meet all their primal emotional needs in sustainable ways so life feels meaningful and enjoyable for them.

So we can use a multifaceted approach to depression.

There are some things we have to do, such as decrease stress, limit rumination (in order to improve the sleep cycle) and help the client meet their emotional and physical needs in balance while seeing and challenging their own depressive thinking biases.

But we are not just what we feel and think. We are also what we do.

Behavioural interventions for depression

As terrible as depression is, some simple interventions can be surprisingly effective in relieving symptoms. For example, depriving depressed people of REM sleep can lift symptoms rapidly for many people.⁶

I’m not suggesting we can or should do this of course, but it does show two things quite clearly: first, that depression is strongly linked to over-REMming, and second, that changing behaviour can directly change emotional state.

I’ve often written about working with depressed people, and I offer an online course in the treatment of depression. But here I want to exclusively focus on behavioural interventions that can really help start to lift depression and get the ball rolling.

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But what’s the point? I hear your depressed client think.

Overcoming “but what’s the point?”

The depressive mindset tends to all-or-nothing, according to research as well as common observation. So if we suggest a behavioural task to a depressed person they may feel or say, “How will that cure my depression?” Or “What’s the point of that?” These are absolutist statements. How will adding pepper make the meal? It won’t on its own. But it’s a smaller part of a bigger composite.

When we are thinking in terms of all-or-nothing we can’t see things like incremental possibilities, or shades of meaning and nuance.

The point is there is no one point unless we see reality in limited terms. Life is complex, and there can be multiple benefits and effects from what seem like quite simple interventions when treating depression.

So how might we sidestep depressive ‘whatsthepointism’?

Pre-empting the objection

I sometimes describe this ‘what’s the point’ thinking as being part of a common depressive mindset before offering a client a behavioural task. In this way I give them an opportunity to check any depressive thinking that might pollute their willingness to adopt the task.

Doing one thing won’t necessarily lift the depression, but chaos theory posits that whole systems of reality can be influenced by small changes.

Anyway, in the ideas presented below I will include a list of all the basic primal needs each behavioural task can meet, at least as far as I can see. You might see more.

Okay, so with that out of the way, what can I suggest in the way of behavioural interventions?

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Intervention one: Tell and show them they don’t have to ruminate

This sounds so simple as to be frankly insulting, but bear with me. We know that the fuel of depression seems to be rumination without hope. Without negative rumination depression falls apart pretty fast.

Some recent research found that simply realizing that you don’t have to ruminate can be liberating.⁷ So liberating in fact that six months after commencing metacognitive therapy aimed at helping patients avoid such negative thought patterns, 80% of formerly depressed participants were no longer depressed.

We don’t want our clients to suppress rumination, but rather detach from it. Then, when they see depressive rumination operating (and remember, you’ve already described it to them), it no longer feels like a genuine reflection of reality, but simply a depressive take on it. This is hugely liberating.

I will often ask clients to make a diary of when they spot themselves using all-or-nothing thinking, and specifically all the typical explanatory styles so common to depression.

Needs met:

Sense of autonomy and control
Meaning (fighting back against the depression)
Sense of safety and security (they can see beyond the depression)

Next we can help them do what depressed people don’t generally do. Resolve enjoyable “problems.”

Intervention two: Give them an intrinsically satisfying task

We human beings are intrinsically problem-solving creatures. We find meaning through solving problems.

Sometimes our drive to solve problems goes awry. For instance, we may unconsciously try to solve the problem of loneliness or shyness with excessive alcohol consumption. We might try to meet the need for healthy attention exchange though attention-seeking behaviours that actually drive others away from us.

But the common denominator is the drive to solve problems.

Depressed people stop trying to solve problems either because they feel overwhelmed or because they’ve stopped feeling they can solve problems – they have learned helplessness. Or maybe they never learned they could solve problems in the first place.

We are unhappy when we don’t have problems to solve and unhappy until we solve them. It might seem counterintuitive to set a depressed client a ‘problem’.

After all, surely they have more than enough! But what we can do is ask them to engage in an activity which can be completed satisfactorily. Something they are good at that has a beginning, a middle, and an end, such as baking a cake, mowing the grass, or doing some satisfying chore. Or maybe something they’ve been putting off doing.

If we see depression in part as a series of emotional unfinished threads in the mind then giving the client a ‘thread’ they can actually resolve can be surprisingly satisfying for them. If the activity is absorbing enough it will also help them cut down on ruminating.

The activity can also re-acquaint them with the sensation of actually solving problems.

Motivational Tip: To make it more likely your depressed client will actually carry out a task, relax them deeply and have them visualize seeing themselves (from a third-person perspective) carrying out the task. Research has found that people who visualize seeing themselves doing a task are more likely to actually carry it out than those who visualize doing it from a first-person position.⁸

Needs met:

Sense of autonomy and control
Sense of connection to others (if the activity relates to others in any way)
Self-esteem and feelings of competence
Stimulation and challenge

Depressed people often find it hard to get things done but then worry about their procrastination. Actually, I do that too sometimes, so when I find myself not doing what I should be doing I’ll use the next technique.

Intervention three: Aim to do just five minutes

Completion or resolution of expectations is important for us because we evolved to act in the world. But the absolutist thinking of depression has people feeling they have to do all of something or none at all.

The depressed person may have fallen into the trap of having stopped breaking tasks down into steps.

It seems we are hardwired to feel compelled to complete things we’ve started. So even just starting something with the intention of only spending a couple of minutes on it can make you feel compelled to continue with it. Even if you hadn’t felt compelled at all beforehand.

If you have something to do, whether it’s working out at home, writing a blog or an email or tackling a pile of ironing, deciding to do just two minutes of the activity can take the pressure off.

Interestingly, you’ll almost certainly find that once you’ve done two minutes of dish washing, or writing, or working out, you’ll suddenly feel you want to do more. This happens because of the universal need for completion.

Cristine, a depressed client, told me her tax returns were hanging over her “like the sword of Damocles”.

I got her to agree to “only do five minutes and no more!” Could she do that? Yes, she said, she could. I asked her to set the alarm on her phone to go off five minutes after starting. And no matter how laborious it was, she was to remind herself it was only five minutes.

The following week she said she had sat down to do the first five minutes and been pleased with even that. “At least I’ll have at last done some”, she’d thought. But when the alarm went off she had carried on and done it all!

This is a win-win technique. If you only do five minutes, you’ve still done something. If you do more, great!

Needs met:

Sense of autonomy and control
Self-esteem and feelings of competence
Stimulation and challenge

This next one is particularly important.

Intervention four: Help them get some real face time

When people depress they often isolate themselves. But isolating ourselves too much for too long can also make us depress, it seems.

Some research from 2015 found that as face-to-face contact declined, the likelihood of developing major depression increased.⁹ That’s right – face-to-face contact. The same thing isn’t true for email or phone contact. We need to be with people.

Well, actually, maybe not just people! It seems even face-to-face time with animals (maybe not wild crocodiles!) can help improve mental health.¹⁰

Some more research found that cell phone usage can worsen depression in those already depressed, but face-to-face contact can ameliorate depressive symptoms.¹¹

Just this week I asked a depressed young man to meet up with some friends he hadn’t seen in a long while. “Can you do that, do you think?” I asked him. He thought about it and said he could. I encouraged him to relax deeply and see himself (from a third-person observer position) contacting them and fixing a time, date and meeting point. I then had him imagine relaxing with these friends.

He texted me later to tell me he’d had a really good time, “forgotten the depression” and in fact felt better since.

Isolation means we spend more time in our heads – making stuff up, but not testing our imaginings against actual reality.

Get your client to get some real face time.

Needs met:

Giving and receiving attention.
Connection to the community (or at least being in it!)
Stimulation (hopefully!)

We are meant to act in the world, not just live in our heads. Which means we need to get our clients moving.

Intervention five: They’ve got to move it move it!

Depression is a stress condition. We experience stress to make us stronger and faster so we can move. If we feel stress but don’t get moving then the all-or-nothing fight-or-flight response can filter through into the way we think and talk:

“Nothing ever works out!”
“I’ll always be alone!”
“The world is totally terrible!”

But completing the arousal loop by actually moving (and sometimes as fast as possible) has been shown to reduce the chances of developing depression by 44%.¹² The research found all it took was an hour of exercise a week, no matter what the intensity.

Not only that, but another study showed that for older people who were already clinically depressed, a brisk walk three times a week actually alleviated their symptoms more effectively than antidepressant drugs.¹³ (That said, it did take some time for the symptoms to start to lift.)

Being outside in nature also has its own benefits for the mind, decreasing both hostility and depression scores.¹⁴

Personally, I like to encourage clients to move in such a way that they don’t have the time or spare capacity to ruminate. Going as fast as you can, sprinting, has been shown to improve mood (after you’ve recovered!) but also promote neurogenesis – the formation of new brain cells – which may ward off depression, not to mention degenerative brain diseases.¹⁵

Sprinting can take any number of forms. Sure, it can be full-out running. But for some people maybe it means walking as fast as they can up 25 steps five times in a row (with a short rest in between), or pedalling as fast as they can on a bike. ‘Sprinting’ just means going as fast as you can go. And if that’s just fast walking, it will still benefit the brain and body.

Don’t underestimate the power of getting your depressed clients to simply move more.

I encouraged one client, who was extremely inactive, to simply walk up her staircase five times in a row twice a day. She said she was exhausted after the first time but then felt good. She started looking forward to it and found she wanted to get outside, to act in the world more fully.

In order to meet our needs we have to act in the world. Depression promotes in activity. We dwell on problems but don’t act in the world to solve them. This becomes a self-paralysing habit that causes dependence but not in dependence.

These are just some of the behavioural shifts we can help our depressed clients adopt.

The word ‘rumination’ comes, of course, from the cow’s cycle of chewing food, digesting it, regurgitating, then chewing and digesting again. It’s not hard to see the parallels!

Ruminating on problems has its limits. And after those limits have been reached, it has its own kind of toxins, which cause the misery and ‘paralysis by analysis’ of depression.

As Albert Einstein said, “We can not solve our problems with the same level of thinking that created them.”

Helping a therapist overcome imposter syndrome

This UPTV client achieved his hypnotherapy diploma a couple of years back. Although he feels supremely confident helping people one to one he feels like an imposter when it comes to actually promoting himself as a therapist to even get into the position of seeing clients.

He is 62 and doesn’t want to set the world alight or earn millions. He just wants some way of augmenting his retirement and fulfilling his sense of wanting to contribute to his community. He has a strong need for meaning, loves helping others, and feels he is good at it.

Mark helps him construct a four-step plan to get where needs to be, and uses lots of reframing throughout the session as well as an extremely straightforward hypnotic induction. Click here to be notified when UPTV is open for booking.

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

You can get my book FREE when you subscribe to my therapy techniques newsletter. Click here to subscribe free now.

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First published on: 2nd July 2018

Notes:

5 Proven Behavioural Interventions for Depression