Some therapists don’t talk much about diagnosis, but it is essential they think about diagnosis. Proper treatment depends on the correct classification.
In the case of longstanding depression, here’s why:
- Effective therapy for Persistent Depressive Disorder (PDD) differs from approaches to other types.
- Persistent Depressive Disorder consists of a distinct set of symptoms not typical of the broad range of mood problems.
How is PDD different from other periods of unusual sorrow? Duration is emphasized.*
The syndrome lasts longer (at least two years) and often starts early. Symptom-free periods, if they happen, last no more than two months. More comorbidities are present: that is, other diagnosable conditions.
Among additional distinguishing characteristics, traumatic and abusive childhood experiences are frequently a part of the individual’s back story. In general, the younger the patient was at onset, the more limited his problem-solving skills are today.
Though the above list may be daunting, the evidence supporting the effectiveness of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is impressive. Indeed, an extensive review of the scientific literature endorsed by the European Psychiatric Association recommended it as a top-line psychotherapeutic procedure for people with PDD.**
Perhaps not surprisingly, significant improvement tends to demand an extended therapeutic regime. More than a year would not be uncommon, with an indefinite but lengthy course of less frequent follow-up sessions to maintain gains.
The prescription of psychotropic medication in combination with the “talking cure” is customary, as well.
One of the most notable features of CBASP is its focus on fragile self-esteem. The client views himself as unable to produce satisfying encounters with acquaintances, coworkers, and friends. Nor does he realize the degree to which his words and deeds (or their absence) cause some of his unhappiness.
While his pain is acknowledged as genuine, CBASP views the new client as someone with chronic and pessimistic expectations of the world: self-fulfilling prophecies.
History informs him of how his life has worked out and, he believes, will work out. The evaluation of the patient, therefore, seeks to uncover the ways he contributes (without intention) to the repetition of disappointments characteristic of his past.
Moreover, the practitioner expects such counterproductive social interactions not to be restricted to life outside the consulting room. Comparable events are predicted in-session. The provider of treatment discusses this prospect with the sufferer.
Together they analyze what the depressed individual forecasts will happen between them, along with the actual effects of his behavioral choices. The atmosphere of the conversation must ensure a feeling of safety, not judgement.
An enlargement of the patient’s self-awareness develops as his anticipation of the psychotherapist’s behavior is explored. The Socratic dialogue with the healer should lead him to conclusions he comes to on his own.
This enlightenment is also fostered when the therapist tells him of his own internal reactions to what the client is doing: the feelings or thoughts emerging inside himself (the analyst) in-the-moment. In this way, the patient begins to become aware of his impact on others.
When the process works as designed, the outpatient starts to try out what are novel efforts to accomplish the kind of responses he desires. This begins in the office and extends to people he encounters elsewhere.
Thus, the transference relationship with the counselor is key. The system builds toward recognition of the healer as somebody who responds differently from those in his pretreatment life who caused harm or neglect.
Just as he comes to grasp he was mistaken in many of his beliefs about the adviser, so he begins to recognize routine errors in expecting the worst from much of the rest of the human world.
Progress relies, in part, on the subject’s growing ability to sense his own power to affect how people react to him. Another marker of improvement is his expanding understanding of how failed actions and inactions have added to his fixed sense of helplessness and hopelessness. Increased flexibility in both cognitive and emotional domains is a goal.
The therapeutic conversation includes a step-wise analysis of how troublesome situations in the client’s life developed – what happened at the start, in the middle, and at the end of them. Questions include, for example, “How did you interpret what occurred?” “What did you do?” “What did you want” and “Did you get what you wanted?”
A successful course of CBASP empowers the patient to gain insight through the emotions and thoughts evoked by inquiries like this. The ease of performing similar analyses on his own expands. He reaches the point of engaging the interpersonal world with an enhanced belief in what is possible.
Hopefulness comes to occupy an enlarged place in the client’s vision of what lies ahead. As a result, he risks letting go of passive-aggressive, hostile, submissive, and avoidant strategies. Friendly and assertive advances toward society increase.
Put simply, while there are no guarantees, the news is encouraging for those long-depressed souls who have yet to find a satisfying route to the alleviation of their unhappiness.
*The complete diagnostic criteria for Persistent Depressive Disorder can be found here: https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_PersistentDepressiveDisorder.pdf
**Jobst, A., Brakemeier, E. L.., Buchheim, A., Caspar, F., Cuijpers, P., Ebmeier, K. P., … Padberg, F. (2016). European Psychiatric Association guidance on psychotherapy in chronic depression across Europe. European Psychiatry, 33, 18-36. http://doi.org/10.1016/j.eurpsy.2015.12.003
The bottom photo is Central Utah in Late Summer at Sunset by Laura Hedien, with her kind permission: https://laura-hedien.pixels.com/