Section XIV: Depression

Challenging Depressive Illusions

Goals of the Exercise

1. Verbally identify, if possible, the source of depressed mood.

2. Alleviate depressed mood and return to previous level of effective functioning.

3. Develop healthy cognitive patterns and beliefs about self and the world that lead to alleviation of depression and help prevent relapse into depressive symptoms.

4. Identify and replace cognitive self-talk that is engaged to support depression.

5. Verbalize more hopeful and positive statements regarding self, others, and the future.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Challenging Depressive Illusions” activity teaches veterans/service members to reality-test depressive perceptions and correct those that are not accurate. This activity is oriented toward Cognitive-Behavioral Therapy (CBT) or Cognitive Processing Therapy (CPT). In addition to therapeutic homework, this activity is suitable for discussion and use in individual or group therapy sessions. Follow-up concurrent treatment can include bibliotherapy using books listed for this issue in Appendix A of TheVeterans and Active Duty Military Psychotherapy Treatment Planner and/or videotherapy using films suggested for “Emotional and Affective Disorders” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, published by John Wiley & Sons.

EXERCISE XIV.A Challenging Depressive Illusions

When we suffer from depression, our views of ourselves, other people, our situations, and our futures usually become systematically distorted in ways that feed into the depression, until we are living in a world of negative illusions instead of seeing the world as it really is. This exercise will help you learn to catch these illusions when they creep into your thinking and replace them with more accurate ways of seeing things.

There are several kinds of depressive illusions. Let's look at how they work, ask how you may see them in your life, and what more accurate kinds of beliefs we can replace them with.

1. All or nothing thinking. We see things as completely good or bad (usually bad when we're depressed) or perfect or awful—perfectionism fits into this kind of illusionary thinking. When we make mistakes we see ourselves as idiots; with the self-talk inside our minds, we are far meaner to ourselves than we would be to anyone else.

One way I see this in my life:

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Corrective thought: Life is never all good or bad, nor are we or anything we do. Look for exceptions to this illusion and write one or two here:

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2. Predicting negative outcomes for uncertain situations. We leap to conclusions about the future, usually in a negative way. We put definite and negative interpretations on events or actions that don't have clear meanings, such as thinking people are mad at us when they don't act happy. We don't check to see whether our inter-pretations are right before we accept them as true.

One way I see this in my life:

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Corrective thought: The future is uncertain, and lots of things could happen. Let me focus my energy on what I can do to raise the chances of a good outcome. One action is:

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3. Emotional reasoning. We assume that our emotions or suspicions reflect the way things really are: “If I feel it, it must be true.”

One way I see this in my life:

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Corrective thought: When I'm upset, I know I can misinterpret things—the sky is probably not really falling; I need to get some feedback from a level-headed person I trust, namely:

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4. Lots of “should” statements. We guide our actions by what we think we should or shouldn't do, and beat ourselves up with guilt and shame whenever we fail to meet those standards (which are usually impossible). We may also do this to other people, getting angry and judgmental when they don't do what we think they should, even if we have no business demanding anything from them or we never told them what our expectations were.

One way I see this in my life:

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Corrective thought: Says who? Is that “should” reasonable?

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5. Judgment and labeling. We use negative outcomes or actions as a basis to judge ourselves and others instead of judging just the outcomes or actions. If we lose at something, we call ourselves losers; if another person fails at something, we see him or her as a failure.

One way I see this in my life:

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Corrective thought: We all have many successes and many failures in our lives—to judge myself or anyone else on the basis of one success or failure is unreasonable and oversimplified. For the negative label I just listed, here's a piece of evidence that points to the opposite conclusion about myself or someone else:

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6. Taking things personally. We see other people's actions as being aimed at us, and we feel responsible for things we can't control.

One way I see this in my life:

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Corrective thought: Whatever other people choose to do is under their control, not mine, and is about them, not me.

7. Another strategy to correct distorted thinking is to check it out with someone you trust. When you're upset about a situation, talk with someone wise and trusted who isn't emotionally involved. Tell them what happened—only what you actually saw and heard, not what you believe others were thinking or feeling. Ask this person what he or she thinks, and share your thoughts and feelings. Ask them if it seems as if you're making one of the mistakes listed above. Please try this and describe what happens:

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Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.

From Acceptance to Appreciation

Goals of the Exercise

1. Identify and replace cognitive self-talk that supports depression.

2. Use behavioral strategies to overcome depression.

3. Recognize and verbalize ways in which your situation has improved and elements in your life situation for which you are grateful.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “From Acceptance to Appreciation” activity is designed to help veterans/service members who have already achieved at least a moderate degree of acceptance of the challenges in their lives. The purpose of this activity is to help these veterans/service members make further progress to alleviate depression by appreciating the positive aspects of their life situations and by seeing ways in which their problems are less difficult than those of some other people. Follow-up or concurrent treatment activities can include encouragement to engage in volunteer work in community programs assisting others; bibliotherapy using one or more of the books listed for this issue in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner; and/or videotherapy using films suggested for the topic “Emotional and Affective Disorders” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, also published by John Wiley & Sons.

EXERCISE XIV.B From Acceptance to Appreciation

In working to overcome depression and other challenges in your life, you may have come to a point where you are able to clearly see the sources of your problems, the resources and methods you can use to cope with those problems, and to accept those facts as they are, rather than engaging in denial or wishful thinking. You may have reached an understanding of the meaning of acceptance as simply acknowledging the way things are and not as necessarily liking those realities, and as seeing that accepted reality as a starting point for change rather than as the way things will stay. This is a great deal of progress and insight, more than many people ever achieve. If you've reached this point you may have more awareness of your power to solve problems and attain goals and have greater hope than you had in the past, and thus have good reason to feel hope and optimism. However, at this point—one of insight, acceptance, and empowerment—happiness and satisfaction with life may still appear to be more hope than reality. The purpose of this exercise is to guide you in continuing your progress and finding greater happiness by seeing more of the positive aspects of your current situation in comparison to the past, in terms of the possibilities it offers, and by comparison to the problems some other people live with.

1. There's an old story about the nature of good and bad luck which you may have heard. In the story, a farmer's horse escapes from its stable and runs away.

A neighbor felt bad for him and said, “I'm sorry your horse is gone—that was an unlucky event for you,” to which the farmer replied, “Oh, I don't know, it might not be so bad.”

The following week the horse returned, and following it were three more horses in the prime of health. The farmer's neighbor congratulated him on this stroke of luck, but the farmer said, “I don't know, it might not be such good fortune—we'll see.”

The farmer's son really liked one of the new horses, so the farmer gave it to him, but when the son saddled the horse and set out for a ride, the horse threw him and he broke his leg. The neighbor shook his head and offered the farmer (and the farmer's son) consolation over this injury, but the farmer shrugged and said, “Well, it might not be such a bad thing.”

The following week, the emperor sent officials to the village to draft all the young men into the army, but the farmer's son was excused because of his broken leg. Not long after, the village got word that all the young men that had been drafted had died in a battle.

The farmer's neighbor stopped jumping to conclusions about whether events were lucky or unlucky, seeing that the future is unknown and what seems like mis-fortune may turn out to be good luck and vice versa.

After reading this, what is an example from your life, or that of someone you know, of an event that seemed unlucky but turned out in time to be a blessing, or the other way around?

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2. The message of this assignment is not that anyone's challenges and losses are not real and difficult; that would be insulting and also untrue. However, there's a reason for clichés like “a blessing in disguise” and “every cloud has a silver lining.” One way this is shown is in the benefits we gain from the work our problems force us to do, such as better understanding of other people and ourselves, problem-solving skills, and confidence in our ability to cope with whatever life throws at us. Please list some benefits like this that you appreciate most:

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3. Another result of experiencing trying situations is that it can “stretch your yardstick.” By this we mean that everyone has a sort of mental yardstick they use to measure how good or bad something is by comparing events to others they've experienced. When we've gone through genuine crises, lesser problems don't cause us as much stress and anxiety as they would if we'd never dealt with serious problems. Please list a couple of events or situations that stretched your yardstick:

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4. It is also true that regardless of what problems we have, we can almost always think of someone else whose troubles look worse to us, someone we wouldn't want to trade places with. For example, in a recent conversation with a veteran whose body is paralyzed from the chest down, he expressed gratitude that he has the use of his arms and hands, and mentioned another patient in the same VA hospital who is paralyzed from the neck down. Are there problems that you see others struggle with that you are grateful not to have? If so, can you provide some examples?

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5. A good way to get a more rounded viewpoint on life is to find ways we can help other people coping with their own challenges. Doing good things for other people benefits us in many ways including lifting our moods, improving self-image, and relieving pain. But in relation to this exercise, we're focusing on two main benefits: the first is allowing us to see ways other people may be successfully overcoming their problems, and the second is giving us a chance to see that there are a lot of people in this world dealing with hardships of all kinds. What kind of volunteer work would you be interested in doing?

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Once again, we want to say as clearly as we can that the message of this exercise is not to imply that your challenges, or anyone's, are not real, serious, and difficult, or to sound as if the work you're doing to overcome them is not tough and sometimes painful. But every situation looks better from some viewpoints than from others. Our goal is to help you look at your situation from some different angles, with the idea of sharing a tool you can use to avoid discouragement and depression and gain a better quality of life.

Be sure to bring this handout with you to your next therapy session, and be prepared to discuss your thoughts and feelings about this exercise.