Today we consider the very first principle of Stoicism as defined by Epictetus in his handbook, The Enchiridion. What can we control and what can’t we control?
This means understanding the difference between problems and facts.
Stoics choose not to waste energy or emotional effort on facts that they cannot change – it’s pointless. Instead they work on things they can change, control or influence. That means they work on (and worry about) surprisingly little.
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Sometimes the easiest way to make sense of a topic is to put it into story format.
Jamie and Janice don’t really exist but their experiences are typical of many who do. Their stories, fictional though they are, illustrate the non-chemical aspect of delusion formation as a way to boost self-esteem and save us from despair – even if that ‘salvation’ comes at a very high price.
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The cognitive or psychological symptoms of depression (what we think about) are just as important as the physiological ones. Some people believe that psychological symptoms are more important but this is not necessarily true. After all there is no such thing as the ‘mind/body split’.
Depressed people tend to think in a particular way. They tell themselves the same sort of gloomy, pessimistic things over and over again. This is what psychologists call negative thinking. After a while this pattern of thinking becomes a habit. When that happens it is described as automatic negative thinking. This habit formation is one of the most damaging aspects of depression as it locks the sufferer into a downward spiral which drags them deeper and deeper into despair.
General thinking errors
There are three ‘general’ thinking errors that are important to understand not only for depression but many forms of mental ill health. The three ‘general thinking errors’ are…
Ignoring the positive
People seem much more likely to focus upon bad things that happen to them than they are upon the good.
Exaggerating the negative
Having focussed upon bad stuff many people then seem to blow it out of all proportion until it overwhelms them.
Overgeneralisation
One swallow doesn’t make a summer. One difficult conversation doesn’t mean it’s going to be one of those days and a couple of frustrations this week don’t mean you’ll never succeed at anything.
Let’s look at some more precise forms of depressed thinking.
Things will never get any better
If we believe this then we also believe that there’s no point in trying to improve things. This one thought stops depressed people from joining in with their treatment plans. These people become lethargic and apathetic. Not the most helpful start to recovery.
People would be better off without me
It’s not difficult to see where this thought pattern is leading. Many depressed people are so convinced of their own worthlessness that they come to see themselves as nothing more than a burden to others. This idea can lead to withdrawal, social isolation, shame and even self-harm or suicide. Once again this is not a helpful way to think about oneself.
I can’t help being depressed after what I’ve been through
This is a remarkably common depressive thought. It also seems quite reasonable at first glance. People who’ve been through difficult times are almost expected to become depressed. The problem is that such a belief system takes away the individual’s choices. If you believe depression is inevitable you won’t really struggle against it and so you won’t change it until you believe you’ve suffered enough. It’s often interesting to ask people how much suffering will be enough.
Some people ‘wear’ their depression like a badge. It’s as though they think they’ve earned it and no one’s going to take it away from them. Of course it’s true that they have a perfect right to feel as depressed as they like for as long as they like. The question is – why would they want to?
Depression runs in my family – it’s genetic
This attitude is called determinism. That’s the idea that people are helpless victims of fate. They believe that because their parents suffered from depression they also must. Of course it’s true that depressive illness does often run in families but that’s not always because of genetics. Sometimes it’s simply because of the coping skills we learn from our parents. Skills which can be unlearned or altered – often with surprisingly little effort. Even those people whose depression does appear to be genetic can be helped considerably once they let go of their deterministic attitudes. Any thought that implies helplessness is deterministic and extremely damaging.
What can depressed people do to help themselves?
Avoid alcohol – particularly in excess;
Don’t smoke – it starves the tissues and brain of oxygen and causes lethargy;
Eat a healthy diet designed to provide plenty of energy;
Take regular aerobic exercise. A brisk walk is usually sufficient;
Stop talking/thinking about depression and concentrate on doing things instead. Get involved in a worthwhile project of some kind;
Keep mentally active;
Write goals, even little ones to keep motivated;
Resolve to make the best of every situation;
Adopt happy physiology – stand straight, move quickly, smile;
Become an ‘inverse paranoid’. Expect good things to happen every day. This doesn’t necessarily mean the world will treat anyone better – but it does mean that people notice good things when they do happen and won’t waste time ruminating about or getting paranoid over the little inconveniences that happen to us all.
The simple truth is that if depressed people wait around for someone else to make things better for them it just won’t happen. However since one of the symptoms of depression is lack of motivation the big danger is that they will do just that. Your job as support worker is to motivate service users to take responsibility for their mood and circumstances while still giving assistance as needed.
This can be a difficult balance to strike. The general rule of thumb is to intervene less and less over time as the service user is encouraged to do more and more for themselves. But be careful. This isn’t an excuse to abandon people who really need our help – simply an awareness that they need to work toward greater independence as time goes on.
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If anxiety is a call to action that is there to help us solve a problem (how to be safe) depression is the opposite. Depression is a form of physiological de-arousal. This is about giving up. Very broadly speaking depressed people are no longer interested in finding a solution. They have decided that there is nothing to be done and so they give up. Of course there are degrees of this ‘giving up’ and it’s not really as ‘cut and dry’ as all that but none the less depression does have an element of giving up about it. That’s not to suggest that it’s a voluntary ‘submission’ to depression but it is fair to say that depressed people are generally less determined to sort out their problems than anxious people are.
This may seem strange but it actually links very well to the stress and vulnerability model we mentioned in an earlier episode. As people’s stress levels increase they become anxious and try to solve their problems. However if they are unable to solve their problems and the stress increases they give up trying to sort things out and so their anxiety (a call to action) subsides. At this point they move up the scale of mental disorder into depression.
Biological (physical) signs of depression include sleep disturbance (too much or too little), appetite disturbance, apathy and lethargy, tearfulness, slowing down of physical movement and passivity (the opposite of assertiveness).
The service user who never seems to cause any problems or demand anything from the staff might not be content – they are just as likely to be depressed. Be aware of the risk of suicide. According to the Beck Suicide Scale (BSS) the best indicators of impending suicide apart from past behaviour are ‘helplessness’ and ‘hopelessness’. Both of these things are features of depression.
Clinical depression is different from sadness. We all have bad days and the occasional low mood is just part and parcel of normal mood variation. Clinical depression includes the biological symptoms mentioned earlier and is thought to result from a reduction in the levels of various brain chemicals such as serotonin. However, as we noted in a previous episode on physiology there is a ‘chicken and egg’ situation here. Low serotonin levels can cause depression but inactivity (a major symptom of depression) also reduces serotonin levels still further. It’s not always terribly important to worry whether the depression came first or the inactivity was the cause. As is often the case dealing with current problems may well be far more important than trying to understand the history of the disorder. Sometimes ‘here and now’ is all we need to work on – at least in the beginning.
For example ensure that people’s current behaviour doesn’t undermine recovery. Many people turn to alcohol when they’re down but that simply makes things worse. Alcohol depletes serotonin levels which not only deepens depression it also prevents anti-depressant medication from working properly.
However as the depression begins to lift that sort of historical information can be extremely useful – but only if we know how to use it and what to do with it. That’s where diagnosis falls down – it’s only really interested in current symptoms. Formulation is more comprehensive and takes account of the many factors that led people into depression as well as the aspects of their thoughts and behaviours that kept them there. If diagnosis helps us to know what the problem is, formulation helps us to ensure people overcome it and then have at least a fighting chance of avoiding relapse in the future.
All that fancy stuff aside (we’ll get to it later) the basic trick with depression is positive action. Get people active again and give them a reason to continue to take an interest. This is more than mere distraction – it involves purpose. Clearly purpose can be difficult to achieve with some people but it’s worth working at none the less. Purpose and security also make it much less likely that people will present with challenging behaviours too. They have no reason to so long as their needs are being met.
There is, of course, much more to depression than we’ve covered in this little introduction. In particular we need to consider the specific thoughts and behaviours that both create and maintain the disorder. We’ll get to those as the series progresses. For now it’s enough to describe in broad terms what depression is. How it is assessed and what we do about it will come later.
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In this video I discuss the evolutionary roots of anxiety, its purpose as a call to action and the way to manage it in the modern world. Beginning with broad principles of freeze, flight and fight we consider the role of the brain’s primitive limbic system (reprile brain) in anxiety, the Freudian concept of appropriate and inappropriate anxiety and ways to help people to overcome it. We consider the basics of relaxation, of anxiety management and the ‘3 stage test’ to help people regain perspective.
We consider reassurance and the folly of offering reassurances we can’t back up with facts – that just demonstrates us to be untrustworthy or ill-informed, causing the anxious person to reject our attempts to help them altogether.
Finally we consider the role of gradual desensitisation (exposure therapy) as opposed to ‘flooding’ in a quest to help people to build up positive memories of facing the thing they fear.
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“Don’t blame people with mental disorders for behaving like people with mental disorders”
Too often mental health workers expect far more from their service-users than they are currently able to give. Then they blame them for having the very problems that brought them into mental health services in the first place. This is a fundamental misunderstanding of mental illness, of the process of recovery and of the role of mental health workers themselves.
It’s true that people are just people and there really is no ‘us and them’. But when people are struggling it’s not fair to expect them to perform at their best. Instead we should practice ‘therapeutic optimism’… Accept the person’s current difficulties but continue to expect them to overcome those difficulties with a succession of little steps.
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I’m a great believer in process. That doesn’t mean pigeon-holing the people we work with. It means having a process, a system that’s clear enough to keep us on track and flexible enough to allow truly collaborative and individualised working. That’s why I developed 2016-the-social-care-recovery-model-final. Designed around existing keyworking processes this model allows mental health care providers, housing association support workers and residential care workers to pinpoint exactly what their service-user needs and plan with them to meet their needs in a straightforward but effective way.
The Social care recovery model is simple to understand. It involves 9 domains that come together to create a cohesive system of care provision based upon skills development and recovery in an efficient and enabling environment.
The first 6 domains (the support domains) focus upon direct work with service users. They are developed through regular keyworking sessions and tools are provided to help service users and keyworkers to develop and plan for a range of situations as required.
As they progress through the 6 support domains, staff and service-users work collaboratively to address not only immediate needs but also the longer term issues that form the basis of recovery. The underlying assumption is that meaningful recovery is achieved via a succession of little steps, each of which is manageable and achievable. We always aim to take the next little step.
The 6 support domains are supported by 3 ‘process’ domains that govern the organisation’s own internal processes and the values and philosophy that make up the enabling environment.
If the support domains are about what we do, the process domains are concerned with how we do it. The process domains direct staff attention to key areas of work and the systems the organisation uses.
The first two process domains, ‘Focus on recovery’ and ‘Creating the right atmosphere’ relate entirely to the values and philosophies that govern social care work. They are based upon established recovery principles such as therapeutic optimism, expressed emotion and the self-fulfilling prophecy. All 9 domains should be supported by the appropriate training to ensure that staff understand how to help people recover most effectively.
The final domain concerns itself with the administrative and duty of care aspects of social care work and again, training and guidance is provided to ensure that both these vital activities are maintained.
To get more information about the Social care recovery model and how it can help your staff click here. Go on – you know you want to!
General thinking errors
As they progress through the 6 support domains, staff and service-users work collaboratively to address not only immediate needs but also the longer term issues that form the basis of recovery. The underlying assumption is that meaningful recovery is achieved via a succession of little steps, each of which is manageable and achievable. We always aim to take the next little step.
The first two process domains, ‘Focus on recovery’ and ‘Creating the right atmosphere’ relate entirely to the values and philosophies that govern social care work. They are based upon established recovery principles such as therapeutic optimism, expressed emotion and the self-fulfilling prophecy. All 9 domains should be supported by the appropriate training to ensure that staff understand how to help people recover most effectively.
Mind The Care Training 