Partial Hospitalization: How do you actually treat depression?
So you're depressed and you find yourself in therapy. What does that actually look like?
Imagine you’ve broken your leg. You can’t really cure a broken leg - you put it in a cast to keep it from getting worse and maybe you take some tylenol or something to help a bit with the pain but for the most part you just have to wait.
But in the meantime, you can’t just go on as if nothing was wrong. You need certain skills to cope with your broken leg - things like using crutches and hopping on one leg for short distances and how to sit down when you can’t put weight on one of your feet.
Depression is like that, except that you can’t see what’s hurting or why, so it’s not as obvious which skills you need to use. If you were some sort of superstar neuroscientist you could maybe make observations like “neuron 372 isn’t firing correctly so I’m going to adjust my thought patterns to avoid it”, but for us mere mortals it’s a little more hit-or-miss. It's as if you had no way of knowing which bone was broken: maybe crutches are a good tool, or maybe you need to learn to write with your opposite hand, or maybe you need a neck brace - you'd just have to try and see. Therapy is (I think) the art of figuring out which skills will help you cope with whatever your brain is doing.
I want to give two examples of skills I’m learning and practicing as part of my program that seem like they’re the most helpful to my depression. There are literally pages and pages of skills out there, so this certainly doesn’t generalize and I would advise anyone with depression to seek help from a skilled CBT- or DBT-trained therapist.
Problem 1: Distress Intolerance
For as long as I can remember, I’ve been really sensitive to rejection and other romance-related problems. (Yay Valentine's Day!) Through the "therapy modules" I'm working through, I've learned that this is an example of distress intolerance: the inability to correctly process negative emotions.
A standard way this plays out is that something (say, rejection) will trigger negative emotions. Then, instead of naturally working through and coming to terms with the emotion, a distress intolerant person will have an additional negative reaction to the negative emotion itself, which sort of compounds itself into either unhealthy coping mechanisms or a chain reaction of sadness.
Skill: Cognitive Defusion
The central assumption of cognitive defusion is that your natural thoughts and emotions are not the problem, your response to them is.
More specifically, cognitive fusion is when you believe your thoughts are the truth. This is generally okay if your brain is working properly - you might have a few wrong beliefs and some mixed-up values, but you can still be a functioning human being because your everyday thoughts generally match the outside world.
But this is a huge problem if you're depressed, because suddenly your thoughts are horrible and awful - nobody likes me or nothing I do will ever matter or I should just kill myself.
For a long time, I thought the point of depression treatment was to get rid of these thoughts and the associated emotions --- after all, that would certainly fix my depression. But I've been learning recently that this is simply an unreasonable goal --- we as a species have no idea how to change thoughts, especially automatic thoughts, or to get rid of unwanted negative emotions.
So instead of trying to suppress the thoughts or counteract them, cognitive defusion asks us simply take the role of an interested observer: what does the thought feel like? Does it have a physical presence? How long does it last? This lets us put some space between our thoughts and reality - instead of the above thoughts, we have something like - I am having the thought nobody likes me or I am having a sensation of hopelessness or my brain wants to kill itself.
What stood out the most to me is that we aren't asking whether a thought is true or not. Cognitive Behavioral Therapy, which focuses on rationally interrogating our thoughts, has never worked well for me because there's always that lingering doubt - if nobody did like me, would I really know? I can't discount the possibility there really is no hope. (perhaps doing math has given me unreasonably high standards of proof)
Instead, the only question we ask thoughts is whether or not they're helpful. When I observe the thought I will never get over this, the first step is to immediately transform it into my mind is telling me I will never get over this. Then, instead of trying to disprove the thought (which for me, makes it come back even stronger because MAYBE IT IS TRUE MAYBE MAYBE), I just have to ask whether or not it's helpful. If it's helpful, I can transform it back into a belief. Since in this case it's not, I can remain content to simply observe its existence.
Of course, this is all easier said than done. There are various techniques to practice the skill, and actually learning it properly should involve an actual therapist and not just secondhand information. But I want to draw attention to it because it's super cool and is the first technique I've found that's actually helped me effectively deal with suicidal thoughts!
Problem 2: Shortened Attention Span
When I’m depressed, my attention span drops from a reasonable level to more-or-less instant distraction or boredom, even when I’m doing things or hanging out with people I ordinarily enjoy. I'm not entirely sure why this is, but I think it stems from being stuck in my head: when I'm focused on my thoughts, I require constant stimulation, whereas when I'm focused on the task at hand I have more focus.
Potential Skill: Mindfulness
My least favorite part of every day at PHP is mindfulness. I would say I’m terrible at it, but my therapist says I’m not allowed to, so instead I’ll say that mindfulness is challenging for me.
Mindfulness is the art of staying focused on the present moment, or what my seventh-grade teacher used to call "the here and now." This is an important skill for fighting various problems with depression - rumination, self-criticism, perfectionism, attention span, etc. etc. etc. It's so important that half an hour of every day at my PHP is devoted to some sort of mindfulness activity.
There are various ways to build mindfulness, including meditation, breathing exercises, adult coloring books, etc. (Some people put prayer on this list, but I think that's misleading - the goal of mindfulness is to have your focus on the present moment, whereas the goal of prayer is to have your focus on God.)
But my favorite mindfulness tool is called 5-4-3-2-1. Briefly put, from where you are, you have to observe:
5 things you can see
4 things you can touch (and touch them!)
3 things you can hear
2 things you can smell
1 thing you can taste
Repeat as necessary until you're focused on what's around you instead of your thoughts!