Christian Jonathan Haverkampf, M.D.
Depression is one of the most common medical conditions, which can interfere significantly with a person’s quality of life, relationships and ability to work. Several effective treatments are available, including psychotherapy and medication. This article contains a brief overview of both areas, while focusing on psychotherapy, particularly Communication-Focused Therapy® (CFT), as developed by the author.
Keywords: depression, treatment, psychotherapy, psychiatry
Depression affects a good size of the population. Although it is relatively common and the impact of the individual quality of life can be enormous, there is still a stigma attached to it. A common belief is that it is not treatable, which is in the vast majority of cases untrue. Another misconception is that it lowers a person’s intelligence or changes one’s personality, which is equally untrue. While someone suffers from depression, the ability to focus and concentrate may be reduced, it does not lower a person’s cognitive abilities when the person recovers from the depression. However, the most serious misconception must be the one that there are no effective treatments. In truth, there are many effective treatments available, but their effectiveness often depends on matching the correct treatment modality to the right patient.
The proportion of the global population living with depression is estimated to be 322 million people—4.4% of the world’s population—according to a new report, “Depression and Other Common Mental Disorders: Global Health Estimates,” released by the World Health Organization. The report also includes data on anxiety disorders, which affect more than 260 million people—3.6% of the global population. The prevalence of these common mental disorders is increasing, particularly in low- and middle-income countries, with many people experiencing both depression and anxiety disorders simultaneously. Depression is, in short, the leading cause of disability in the world (Friedrich, 2017).
Depression is also one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. (Gold et al., 2020)
Some possible pathophysiological mechanisms of depression include altered neurotransmission, HPA axis abnormalities involved in chronic stress, inflammation, reduced neuroplasticity, and network dysfunction. All of these proposed mechanisms are integrally related and interact bidirectionally. In addition, psychological factors have been shown to have a direct effect on neurodevelopment, causing a biological predisposition to depression, while biological factors can lead to psychological pathology as well. The authors suggest that while it is possible that there are several different endophenotypes of depression with distinct pathophysiological mechanisms, it may be helpful to think of depression as one united syndrome, in which these mechanisms interact as nodes in a matrix. Depressive disorders are considered in the context of the RDoC paradigm, identifying the pathological mechanisms at every translational level, with a focus on how these mechanisms interact. Finally, future directions of research are identified. (Dean & Keshavan, 2017)
To accommodate, they learn to censor themselves, to devalue their experience, to repress anger, to be silent. Examining moral themes in depressed women’s narratives, Jack demonstrates how internalized cultural expectations about feminine goodness affect women’s behavior in relationships and precipitate the plunge into depression. In a brilliant synthesis, Jack draws on myth and fairy tale for metaphors to further our understanding of women’s depression. (Jack, 1991)
Depressive disorders are frequently associated with significant and pervasive impairments in social functioning, often substantially worse than those experienced by patients with other chronic medical conditions. The enormous personal, social, and economic impact of depression, due in no small part to the associated impairments in social functioning, is often underappreciated. Both pharmacologic and psychotherapeutic approaches can improve social impairments, although there is a lack of extended, randomized controlled trials in this area using consistent assessment criteria. (Hirschfeld et al., 2000)
Many functions have been suggested for low mood or depression, including communicating a need for help, signalling yielding in a hierarchy conflict, fostering disengagement from commitments to unreachable goals, and regulating patterns of investment. A more comprehensive evolutionary explanation may emerge from attempts to identify how the characteristics of low mood increase an organism’s ability to cope with the adaptive challenges characteristic of unpropitious situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort. In such situations, pessimism and lack of motivation may give a fitness advantage by inhibiting certain actions, especially futile or dangerous challenges to dominant figures, actions in the absence of a crucial resource or a viable plan, efforts that would damage the body, and actions that would disrupt a currently unsatisfactory major life enterprise when it might recover, or the alternative is likely to be even worse. These hypotheses are consistent with considerable evidence and suggest specific tests. (Nesse, 2000)
Data are from 2,302 adolescent sibling pairs (mean age = 16 years) who were part of the National Longitudinal Study of Adolescent Health. Although genetic factors appeared to be important overall, model-fitting analyses revealed that the best-fitting model was a model that allowed for different parameters for male and female adolescents. Genetic contributions to variation in all 3 variables were greater among female adolescents than male adolescents, especially for depressed mood. Genetic factors also contributed to the correlations between family and school environment and adolescent depressed mood, although, again, these factors were stronger for female than for male adolescents. (Jacobson & Rowe, 1999)
There are many kinds of psychotherapy, but they all derive from the concept of the ‘talking cure’ developed by Freud and Breuer. Over time, various brands have been developed, but the interaction between the patient and therapist, insight, reflection, and learning are still the basic building blocks of psychotherapy or counselling.
Depression very often does not come ‘out of the blue’, and it is important to understand the factors that contribute to it. While some people have a greater predisposition for depression than others, psychological factors usually play a significant role. The three main schools of therapy are cognitive-behavioural, interpersonal, and psychodynamic therapies. Major differences are that the first one focuses more on learning and the last one more on insight and understanding, but many practitioners combine elements of each of them. I have developed a communication-focused approach, that works with both insight and learning, which is described in more detail below.
Depression comes with negative thoughts and feelings, where one influences the other. It can begin with difficulties and interpersonal problems, such as in a relationship or at the workplace. The more one doubts oneself, s self-critical or blames oneself, the more the spiral of depression reaches down. Communication patterns often change, both on the inside and the outside. Internally, ruminations, negative feelings, despair, hopelessness, and doubts can lead to increasing questioning of oneself to the point where one feels a physical pain or pressure. In severe cases of depression, the communication reaches a point where internal communication, feelings and thoughts flatten out. Depression does not necessarily mean that one feels sad all the time. In the more severe cases, it means that one feels less to the extent that one cannot cry anymore and feels a physical pain of emptiness. Thoughts about ending everything, as in self-harm, can occur quite frequently. They need to be taken seriously, and one should look for immediate help, which can also include a hospitalisation where a more intensive treatment and a secure environment are possible.
The outside communication reflects the internal communication to a large extent. And often it has become impossible on the inside to take a step back from the ruminations and circulating negative thoughts and watch what is happening from the outside. This step back would, however, be very important. Most often people then try even harder to run with their head against the invisible wall. The brain’s job is to think and to solve problems in the world by thinking through them. In a rumination the brain tries to ‘think its way out’. However, this usually just makes it worse. To get the view from the outside of what is happening and to find new strategies through changes in perspective are important steps in therapy.
Psychotherapy should address various factors, such as current stressors, unresolved conflicts, also internal emotional ones, past experiences, and patterns of relating with oneself and the world around. Identifying own needs, values, and aspirations in helpful in finding a life ath that is more aligned with what satisfies and makes happy.
Psychotherapy should be tailored to the individual needs of the patient. The main task of the therapist is understanding. All psychotherapeutic techniques are really a support towards this goal. As every patient is different, one begins in some ways from scratch. Being empathetic, mindful and aware of the other are crucial towards understanding the dynamics, needs, and suffering a patient is experiencing. Understanding can be accomplished in many different ways. Some focus more on the narrative, some on the interaction and communication patterns, others more on behavior patterns, or on past experiences. But all this is just to help the therapist understand in a way, that tools for healing can be applied/
Often in depression there is the sense that nothing is very helpful anymore. One feels alone with a situation where there does not seem to be a way out. One experiences feelings that are unpleasant, as mentioned to the extent of being painful. The internal communication revolves around questions that can lead deeper and deeper into depression. As our mind is programmed to solve problems, it pursues the questions as far as it can. However, if the questions are the wrong ones, this will not lead to a resolution.
Depression and risk for depression are characterized by the operation of negative biases, and often by a lack of positive biases, in self-referential processing, interpretation, attention, and memory, as well as the use of maladaptive cognitive emotion regulation strategies. (LeMoult & Gotlib, 2019) Depression is in that sense different from fear or anxiety in that one has negative thoughts about important attributes about oneself, such as personality, resources, strengths and weaknesses. At the same time, it is important to realize that this is I not directly about the innermost core sense of self. It is more about the facilities one has than about the feeling of self. Thus, one approach of the therapy is to connect with oneself on the level of the felling of self, which is below the surface of personality and skills (Haverkampf, 2010b). Straight forward mindfulness exercises in combination with any therapeutic approaches that also pay attention to communication can accomplish this. As the self is one’s perceptions of the internal flows of information (Haverkampf, 2010a, 2018a), the ability to take back a step and observing, while connecting with oneself is a key skill.
There is little doubt that medication is effective in depression. Increasingly, we also understand why it works, and how. The challenge can sometimes be to select the right antidepressant for a specific patient, but the miss rate usually declines with experience of the therapist. Generally, the side effects are low or non-existent and over a couple of weeks to a few months there is in about seventy percent of cases a marked improved in mood, motivation, focus and the energy to engage in activities. Sleep, appetite and other parameters can improve as well, depending on the medication selected. If a drug does not show an effect, or only an unsatisfactory one, after some time, it is often a good idea to switch the antidepressant, which frequently works.
When it comes to medication, it is important to understand that an antidepressant has usually other effects aside from its effect on mood. This also needs to be fitted to the patient. As mentioned, when psychotherapy was discussed, a depression is not the same for everyone. There are different types and flavours of it, which are unfortunately not capture adequately by the diagnostic systems we have. So, there can be a patient with severe mood lows and paralysis in life with a history of depression in the family, while another patient experiences anxiety and panic attacks with depression in the background after a relationship breakup, and a third one who does not feel that low, but who has severely disturbed sleep, libido and appetite in waves. In all those cases one would diagnose depression, but the treatment could be very different, both on the psychotherapy and the medication side. Understanding the patient, the individual history, the fear, needs, symptoms, aspirations, and more, is important not only to select and plan a course of psychotherapy, but also as regards the medication.
Good communicating is the foundation of good medicating. It not only indispensable in building compliance, but also in selecting the right medication. Too often the profile of a drug does not fit the patient. For example, a patient with insomnia may benefit more from an antidepressant that also has a sleep-inducing effect or another patient with anxiety may find it easier to gradually and slowly titrate up a softer serotonergic antidepressant. Potential or current pregnancy leads to its own unique considerations. Although randomised controlled trials on pregnant women are ethically impossible, we have a lot of data on women who took various antidepressants in pregnancy.
Even with medication one should not lose sight of the overall situation the patient is in, the patient’s past and desired future. The medication needs to fit in. For a patient to whom an active sexual life is a major factor in the level of quality of life, a medication that is very likely to impact libido negatively may be an inferior choice if there are other good alternatives.
A depression, if it is not primarily a reaction to a life event, is called in psychiatry a major depressive disorder (MDD). It is a condition characterized by at least two weeks of low mood that is present across most situations. (APA, 2013) It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and psychological pain without a clear cause. There may also be false beliefs and – in the more severe cases – acoustic or visual hallucinations. Major depression needs to be differentiated from sadness. Depression often actually means the subjective absence of feelings, such as sadness. Patients often cannot feel themselves anymore as before, which can cause additional anxiety.
Another form is the reactive depression, which occurs as part of several conditions, such as post-traumatic stress disorder (PTSD). These forms of depressions are discussed within the articles on these conditions. The following will focus on the depression, which is not primarily a part of these conditions, the major depression.
Some people have periods of depression separated by years in which they feel normal while others nearly always have symptoms present. The first line of treatment is a combination of psychotherapy and medication. Some common antidepressants are mentioned below. This combination has allowed most patients to live normal lives and in the clear majority leads to a significantly higher quality of life.
There is growing interest in moving away from unidirectional models of the stress-depression association, toward recognition of the effects of contexts and personal characteristics on the occurrence of stressors, and on the likelihood of progressive and dynamic relationships between stress and depression over time—including effects of childhood and lifetime stress exposure on later reactivity to stress. (Hammen, 2005)
Major depression significantly affects a person’s family and personal relationships, work or school life, sleeping and eating habits, and general health. Major depressive disorder can negatively affect a person’s family, work or school life, sleeping or eating habits, and general health. Between 2-7% of adults with major depression die by suicide (Richards & O’Hara, 2014) and up to 60% of people who die by suicide had depression or another mood disorder (Lynch & Duval, 2010). But depression has also been linked with several physical health conditions, such as cardiovascular and autoimmune illnesses. These conditions make up a large share of the costs society incurs when depression remains untreated. Depression causes the second most years lived with disability after low back pain. (Vos et al., 2015)
Depression can strike at any age, and the main tools we have, psychotherapy and medication as well as supportive therapies, mostly apply to all ages. However, the psychological issues for the different age groups can seem quite different. What may be an identity crisis in college aged adults can be a deeper crisis for meaning and purpose in the middle-age. The reason why I used the word ‘seems’ is because the underlying motives are not really age specific. Self-connectedness and connectedness with the world run like a thread through all these different manifestations. The identity crisis in young adults and the search for meaning in the middle-aged mean that one’s own basic parameters, the needs, values, and aspirations and information about the world feel insufficient. These feelings are a need for greater internal and external connectedness. It is important to keep in mind, however, that these two themes are just gross oversimplifications to cast the spotlight at the core theme of connectedness.
As mentioned, depression is common in older adults. (Kok & Reynolds, 2017) Efficacious psychotherapies for late-life depression exist, but are underutilized in part because of their complexity (Alexopoulos, 2019). Although antidepressants may effectively treat depression in older adults, they tend to pose greater risk for adverse events because of multiple medical comorbidities and drug-drug interactions in case of polypharmacy (Kok & Reynolds, 2017). They are also rather ineffective in treating depression of demented patients, but long-term use of antidepressants may reduce the risk of dementia. However, confirmation studies are needed. (Alexopoulos, 2019)
A diagnosis is only a tool in working out a treatment that offers a greater likelihood of success. It is important to keep this in mind because in medicine frequently a diagnosis seems to be an end in itself, but it should not be. Depression, a lowering of various feeling and cognitive states, is something that has been around for a very long time. However, increases in complexity and demands in the world quite often lead from stress and burnout to symptoms of depression. These demands can come from professional, personal and social areas of life.
There are many conditions, somatic, psychiatric or iatrogenic, which can induce symptoms similar to that of a depression. A host of other possibilities should thus be considered, and, if appropriate, be actively searched for. In most instances the situation is quite clear, especially in an outpatient setting, but even here it is advisable to explore alternative explanations aside from depression. At the same time, about 85% of patients with depression have significant anxiety, and 90% of patients with anxiety disorder have depression. (Tiller, 2013) In some cases, a patient may also suffer separately from a depression and another condition. In other cases, the full symptoms of depression occur as part of the condition, such as in a schizoaffective disorder, which combines both, the symptoms of a psychosis and a depression.
One should also not forget that medication can also induce depression-like symptoms, even though they do not match those of depression fully, such as the emotional flattening observed sometimes in several antipsychotics (Haverkampf, 2013b) In any case, a full list of the somatic and psychiatric medication the patient takes should always be scanned for anything that could lead to the symptoms the patient is experiencing.
Psychotherapy aims at changing how patients communicate and process information, and the important tool are information and communication. Helpful and meaningful information can be provided in many forms. Some people who suffer from depression, anxiety, or OCD work successfully with self-help books. This is essentially a one-way communication, and the hope is that the information presented changes a perspective, a way of thinking or acting, reflection and insight, and internal and external communication in general.
There are also internet-based treatment applications. While a book cannot provide feedback, a computer-based system can do so to some extent. However, a patient cannot assume or hope that the computer will offer real understanding similar to that of another human being. While programs that mimic therapists have been around for a long time, as one only needs to think of ‘Eliza’ from the late 1970s, they can hold the illusion only for a limited time. ‘Eliza’ was a very short program, by today’s standards, running on 8-bit computers with small memory even for the time, but it was ingenious. It would take sentence fragments and ask the user ‘How do you feel about …?’or ‘Tell me more about …’ and the like. The effect was really striking, which also illustrates how easy it can be to convey psychological support in real life.
A computer-based system also cannot replicate the many information channels that are usually available in human interactions. Still, internet-based systems have shown to be of some use in the treatment of depression. Josephine and colleagues conducted a systematic review of randomized controlled trials investigating internet- and mobile-based interventions targeting adults with diagnosed depression. They found that these interventions significantly reduced depression symptoms in adults with diagnosed depression at the end of treatment and at follow-up assessments when compared to waitlist conditions. (Josephine et al., 2017)
One should also not forget media that show human connection. The stereotypical image of the lovelorn on a couch self-soothing with ice cream and watching a film is not so far from the truth. Self-soothing is often underrated in working with depressed patients, and the movie temples of Hollywood’s golden age, where people could experience connectedness with themselves or others, have become the on-demand streaming services of today. My home is my cinema, where I can be distracted and feel connectedness. Good movies are those where one can feel connectedness between the characters of some kind, whether in the positive or in the negative. In the milder and more moderate forms of depression the withdrawal from others is usually accompanied with a greater need for connectedness. A greater need for connectedness, coupled with the negative thought and feelings about oneself, such as self-criticism, self-blame, and guilt, actually lead to greater withdrawal. The auto regulation seems to malfunction, which can be corrected through psychotherapy, for example. However, in some cases, a change in scenery, such as travelling abroad, or a provocative book brought about the needed change.
Doing things for oneself that make one feel better is vital in depression, because it helps regain a sense of control over the own feeling states. What makes depression worse is the sense of helplessness and powerlessness in ending the state. Often this is what prolongs or maintains it. Children self-sooth autonomously by, for example, using a finger, or by asking a caretake for help in the form of a hug, a pacifier, or something else that aligns with the present needs. In both cases, internal and external communication is important. In the former, it is the internal reading and processing of signals and the self-soothing activity, in the latter communication with the outside world is added. As both, internal and external communication are linked, they reflect each other.
Since communication is the main instrument we have for diagnosis and treatment, words play an important role. Sigmund Freud highlighted the importance of ‘mistakes’ people make in everyday language that reveal something about unconscious content, and the deeper meaning of jokes people make. The rich symbolism in myths and sacred texts often relies on the subtle meaning of words and word constellations. Depression does not create content, but it has an impact on content and on how content is processed. The shift in focus towards negative thoughts and feelings could have the function of pushing the individual towards the positive, but this becomes more difficult because of the disconnectedness one experiences internally and externally in depression. Thus, meaningful communication and connectedness can help to bridge the depression by enabling the move to the positive.
Communication is also important in identifying the type of depression. Communication patterns give away the fingerprint of the condition (Haverkampf, 2010c, 2013a). However, content can be helpful as well. The words individuals use in their communication can give us an insight into depression. Eichstaedt and colleagues showed in their study that the content shared by users on Facebook could predict a future occurrence of depression in their medical records. Language predictive of depression included references to typical symptoms, including sadness, loneliness, hostility, rumination, and increased self-reference. (Eichstaedt et al., 2018) As the world is becoming technologically more connected, more information is available on what and how one communicates. This could be used for good
Again, understanding and empathy are important in identifying where the depression affects the internal communication flows. Through its impact on information flows and processing a mental health condition can be identified. Depression has effects on the flow of cognitive information associated with thoughts, information associated with feelings, information associated with sensation, and so on. Psychosis, for example, also has distinct effects, one of which is the failure in separating whether a source of information is inside or outside the person. Connectedness is usually a good thing, but this really requires that we are all smart enough to make the most and best of it. This smartness in turn requires connectedness.
The communication patterns in the outside world and those on the inside are closely linked. So, the disconnectedness a patient with depression is experiencing can be felt on the outside and on the inside. Helping the patient to achieve greater connectedness in the outside world can so also transfer to better connectedness on the inside, while helping the patient to better connect with himself or herself also improves the connections the patient has with others. In Communication-Focused Therapy®, for example, awareness, reflection, insight, feedback, and experimenting with communication follows similar rules for the internal dialogues as well as for the outside dialogues (Haverkampf, 2010b, 2017b)
The feeling of connectedness with others is a powerful antidote to depression, anxiety and other mental health conditions (Haverkampf, 2020b). Important is that one feels connected in a meaningful way. One could feel lonely in a crowd of people or even when with family and friends. Meaningful connectedness means that one feels understood by others, that communication really works. The human touch is at its most powerful if one is in the presence of people where worlds can connect. A shared history can make connectedness easier in some cases, but by itself it is not enough. Connectedness between individuals requires interest and the effort to try to understand the other. However, it is effort well spent, as connectedness, both internally and externally, can decrease fear and other feelings, that often are at the foundations of the various conditions mentioned.
Why is connectedness so important? When we are connected, we lessen the effect of time and external circumstances. Connectedness happens in the present moment, and the feeling is about the now rather than the past and the future. Also, the more connected we are, the less will be our fears and anxieties. The fear of death is a fear of disconnect, and by feeling connectedness we reduce the sense of disconnect. Depression and anxiety, though in different ways, are also related to the internal sense of connectedness. This does not necessarily require the actual physical proximity of others, but the feeling of being connected into the world. Various mindfulness techniques and approaches that work with feeling at home in the body and in one’s environment can be helpful because they can increase the sense of connectedness.
Connectedness is different from mere social support. In a testing model in 272 college students, indirect paths to self–esteem and depression through the mediating variable of social connectedness were more strongly supported than direct pathways from social support or social competence to psychological outcomes. (Williams & Galliher, 2006) However, in a meta-review of fifty-one studies, the strongest and most consistent findings were significant protective effects of perceived emotional support, perceived instrumental support, and large, diverse social networks. Little evidence was found on whether social connectedness is related to depression, as was also the case for negative interactions. (Santini et al., 2015) A secondary analysis of a waitlist-controlled trial with 29 patients was conducted to evaluate treatment response and process of change in social connectedness within a 10-session positive activity intervention protocol—Amplification of Positivity (AMP)—designed to increase positive affect in individuals seeking treatment for anxiety or depression. The AMP group displayed significantly larger improvements in social connectedness from pre- to post-treatment compared to waitlist; improvements were maintained through 6-month follow-up. Within the AMP group, increases in positive affect and decreases in negative affect both uniquely predicted subsequent increases in connectedness throughout treatment. However, experiencing heightened negative affect throughout treatment attenuated the effect of changes in positive affect on connectedness. Improvements in connectedness predicted subsequent increases in positive affect, but not changes in negative affect. (Taylor et al., 2020) A convenience sample of rural residents in a western Colorado county. Self-reported survey data collection with hierarchical multiple regression analyses. The investigators found that the more socially connected a person felt, the better they perceived themselves as physically and mentally healthy. Additionally, the more socially connected the individual felt the less depressive symptoms they reported. Spiritual perspective was not found to correlate significantly with either self-reported depression or perceived health. (Galloway & Henry, 2014)
Cruwys and colleagues ran two studies. In Study 1 (N=52), participants at risk of depression joined a community recreation group; in Study 2 (N=92) adults with diagnosed depression joined a clinical psychotherapy group. In both the studies, social identification predicted recovery from depression after controlling for initial depression severity, frequency of attendance, and group type. In Study 2, benefits of social identification were larger for depression symptoms than for anxiety symptoms or quality of life. (Cruwys et al., 2014)
Trials with psylocybin for treatment-resistant depression also support the link between connectedness and depression. It has been argued that connectedness is key in understanding the effectiveness of psychedelic drugs against depression, and there is preliminary evidence to support this. (Carhart-Harris et al., 2018) In a study with twenty patients enrolled in an open-label trial of psilocybin for treatment-resistant depression, it was reported that medications and some short-term talking therapies tended to reinforce their sense of disconnection and avoidance, whereas treatment with psilocybin encouraged connection and acceptance. (Watts et al., 2017)
Much of the data on the association between depression and connectedness comes from school and college settings. Data from Waves I and II of the National Longitudinal Study of Adolescent Health (Add Health) indicated that higher school connectedness and getting along with teachers were significantly associated with fewer depressive symptoms. (Joyce & Early, 2014) In a study of students at an international university in Japan, a high prevalence of depression was associated with acculturation stress and social connectedness. (Nguyen et al., 2019) In an American study of 248 students aged between 15 and 20 years old showed that family ritual meaning was positively related to social connectedness and negatively related to depression. Social connectedness was negatively associated with anxiety and depression. Family ritual meaning was found to be negatively linked to both depression and anxiety symptoms via social connectedness. (Malaquias et al., 2015) However, recent literature suggests that school connectedness may be a key determinant of adolescent mental health. The relationship between social connectedness and low mood was reduced by the inclusion of self-esteem and peer attachment style. Peer attachment style was the largest predictor of low mood. (Millings et al., 2012) In a 2001 population-based sample of 4746 students in public schools, adolescents’ perceptions of low parental caring, difficulty talking to their parents about problems, and valuing their friends’ opinions for serious decisions were found to be significantly associated with compromised behavioral and emotional health. Interventions aimed at improving the parent–child relationship may provide an avenue toward preventing health risk behaviors in youth. (Ackard et al., 2006) In a longitudinal study of 142 youth recruited from an emergency department, who screened positive for elevated levels of bullying victimization, prospectively, family and school connectedness were negatively associated with depression and suicidal ideation. Across time points, community connectedness was negatively associated with suicidal ideation. The three subtypes of interpersonal connectedness among victimized youth (family, school, community) were associated with depression and suicidal ideation. (Arango et al., 2019)
a systematic review of recent research addressing the associations between adolescents’ sense of social connectedness and Internet technology use. Although Internet technology might provide additional opportunities for adolescents to seek emotional connection with friends and school, this study suggests that real-life social skills are still a necessary foundation for them to use technology in a beneficial way. (Wu et al., 2016) Hwang and colleagues investigated whether social connectedness on a support website protects older adults against depressive symptoms over the course of a year, above and beyond the protective effect of offline social connectedness. 197 adults aged 65 years or older. The more messages older adults read on the web-based forum for the first 6 months of the study, the less depressed they felt at the 1-year follow-up, above and beyond the availability of offline support networks at baseline. This pinpoints the substantial potential of web-based communication to combat depressive symptoms in this vulnerable population. (Hwang et al., 2021) Results from a study by Grieve and colleagues suggested that Facebook use may provide the opportunity to develop and maintain social connectedness in the online environment, and that Facebook connectedness is associated with lower depression and anxiety and greater satisfaction with life. Limitations and future directions are considered. It is concluded that Facebook may act as a separate social medium in which to develop and maintain relationships, providing an alternative social outlet associated with a range of positive psychological outcomes. (Grieve et al., 2013) A multidatabase search was performed. Papers published between January 2005 and June 2016 relevant to mental illness (depression and anxiety only) were extracted and reviewed. Results: Positive interactions, social support, and social connectedness on social networking sites (SNSs) were consistently related to lower levels of depression and anxiety, whereas negative interaction and social comparisons on SNSs were related to higher levels of depression and anxiety. SNS use related to less loneliness and greater self-esteem and life satisfaction. Findings were mixed for frequency of SNS use and number of SNS friends. Different patterns in the way individuals with depression and individuals with social anxiety engage with SNSs are beginning to emerge. (Seabrook et al., 2016)
The relationship between autonomy–connectedness, and depression and anxiety was investigated in 94 primary mental health care patients and 95 psychology students. All participants completed the Autonomy–Connectedness Scale–30 (ACS‐30), the Beck Depression Inventory (BDI), and the Symptom Checklist–90 (SCL‐90). Results indicated that the primary mental health care group compared with the control group scored lower in Self‐Awareness and Capacity for Managing New Situations, and higher in Sensitivity to Others. Women compared with men had higher levels of self‐reported Sensitivity to Others. Regression analyses showed that both (low) Self‐Awareness and (high) Sensitivity to Others predicted depression, as well as anxiety; also, (low) educational level had predictive value. These results indicate that low autonomy–connectedness might be a risk factor for depression and anxiety. (Bekker & Belt, 2006)
Relationship of loneliness and social connectedness with depression in elderly: A multicentric study under the aegis of Indian Association for Geriatric Mental Health. The study sample comprised 488 elderly patients (age ≥60 years) with depression recruited across 8 centers. About three-fourth of the elderly patients with depression also have associated loneliness. Loneliness is associated with higher severity of depression, anxiety, and somatic symptoms. Severity of depression is associated with loneliness but not with social connectedness. Lower social connectedness among elderly females with depression is associated with higher loneliness, but this is not true for elderly males with depression. (Grover et al., 2018)
In a further study, Kaniuka and colleagues examined depression and anxiety as mediators of the linkage between perceived stigma and suicidal behaviour, and the moderating role of LGBTQ community connectedness. Among their sample of 496 LGBTQ persons, psychopathology mediated the association between perceived stigma and suicidal behaviour. Connectedness moderated the relation between perceived stigma and depression, and between perceived stigma and suicidal behaviour in the anxiety model. (Kaniuka et al., 2019)
Its impact on functioning and well-being has been compared to that of other chronic medical conditions such as diabetes. The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing depression. The cause is believed to be a combination of genetic, environmental, and psychological factors. (APA, 2013) Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance abuse. (APA, 2013) About 40% of the risk appears to be related to genetic variations.
Lifetime rates are higher in the developed world compared to the developing world. Maybe a heightened stress level in a more complex living and working environment contributes to that, but it may also be a lower rate of diagnosing this condition in the developing world.
The monoamine hypothesis has been partially questioned, but it is still the leading, and also most coherent, hypothesis there is in providing a biological explanation for depression, as well as some anxiety disorders. Over time, its emphasis on particular neurotransmitters has shifted to a limited extent, while the focus on the neurotransmitter serotonin has endured. The monoamines are serotonin, norepinephrine, and dopamine. The antidepressants act on the neurotransmitter levels or on the receptors.
Serotonin is hypothesized to regulate other neurotransmitter systems; decreased serotonin activity may allow these systems to act differently and become less stable. According to this hypothesis, depression arises when low serotonin levels promote low levels of norepinephrine, another monoamine neurotransmitter. Some antidepressants enhance the levels of norepinephrine directly, whereas others raise the levels of dopamine, a third monoamine neurotransmitter. These observations gave rise to the monoamine hypothesis of depression.
In its contemporary formulation, the monoamine hypothesis postulates that a deficiency of certain neurotransmitters is responsible for the corresponding features of depression. The main effect is, however, believed to be due to changes in the receptor densities on the cell membrane rather than the changes in the neurotransmitter levels. This also explains why antidepressants can take a few weeks to work. This may be the time needed by the cell to change the receptor density and patterns in the cell membrane through recycling and protein synthesis.
Humans are constantly in a web of relations with other people. External communication from birth and even before influences how information is processed in the brain and how an individual communicates and interacts with others. The individual learns certain communication strategies and patterns that are shaped over time in response to the environment, internal communication and the biology underlying the neuronal network.
As children we pick up communication patterns from our parents or other important people in our lives which can then be internalized and also influence how we communicate with ourselves internally. And this process continues throughout or life, practically with every interaction we have with others. Our awareness of the flows of internal information then give rise to the sense of self.
Trauma committed by people can have such a devastating effect on individuals because of the communication it contains. Being exposed to someone who communicates that they negate our worth as a human being, our autonomy and integrity, traumatises and hurts us deeply. There need not be physical scars in a somatic medical sense. Our mind and our body form a union, however, and harm to one also harms the other. The body is the means that we can communicate with ourselves and others, while the mind connects us mentally with others. If that delicate fabric of connectedness between ourselves and others is torn or ruptured, we lose some of the safety and security it gives us. Trauma can be healed when we understand that its nature is in the communication that cause it. Awareness, insight, adapting communication patterns and learning new ones, as well as feedback are helpful in overcoming trauma (Haverkampf, 2016, 2020a) as they are in recuperating from depression.
A person having a major depressive episode usually exhibits a very low mood, which pervades all aspects of life, and anhedonia, the inability to experience pleasure in activities that were formerly enjoyed. Depressed people may be preoccupied with, or ruminate over, thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self-hatred.
Changes in the communication with oneself and others changes when an individual is depressed. This is a consequence of the symptoms of depression but often works also to deepen and prolong the condition. Loss of interest in things that were once enjoyable, seeing less meaning in activities and events and withdrawal from the world, and to an extent from oneself, are often the result and may worsen the depression, while more communication with oneself and others can help to reverse the depression.
In severe cases, depressed people may have symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually with negative and unpleasant content. A good indication that a psychotic symptom is maintained by a mood disorder is that the value of the content of any delusions or hallucinations is consistently in the direction of the mood disorders, such as negative content in a depression or alternating positive and negative content in bipolar disorder.
Other symptoms of depression, which are commonly observed, include
- poor concentration and memory
- withdrawal from social situations and activities
- reduced sex drive, irritability,
- and thoughts of death or suicide (which requires immediate professional help).
Insomnia is a common symptom. In the typical pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or oversleeping, can also happen. In an atypical form of depression, it is even possible that a patient experiences primarily insomnia, loss of concentration and poor memory retrieval, without a clear lowering in mood.
The physical symptoms of a depression are often underestimated. A depressed person may report multiple physical symptoms such as
- headaches, or
- digestive problems.
Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice that the person’s behaviour is either agitated or lethargic.
The two types of treatment, for which there exists broad empirical and conceptual support, are medication and psychotherapy. Generally, the best approach is to use both together. However, in very severe cases of depression only medication may be feasible, while in cases of mild depression psychotherapy may be sufficient.
There are various groups of antidepressants, often with regards to their function on neurotransmitters and neuroreceptors. The selective serotonin receptor inhibitors (SSRIs) are the ones most commonly used. They can also help against anxiety and panic attacks, as well as various other symptoms and conditions, such as emotional instability and eating disorder. Examples are escitalopram (Lexapro®) and sertraline (Zoloft®). The serotonin and norepinephrine reuptake inhibitors can also help against anxiety, but may be more activating, which can lead to increased nervousness and anxiety in the beginning. The best way to reduce an increase in anxiety in the first days, which can happen with most antidepressants, is to start the medication at a very low level and increase it in small increments in patients with anxiety, especially if there are also panic attacks.
As already mentioned, there are various brands of psychotherapy which are designed to help in the long run. Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT), as well as Gestalt therapy and others, are also focused at the short-term, while psychodynamic psychotherapy aims at a more permanent resolution of the depression in the long-run. (Haverkampf, 2017a) Communication-focused therapy (CFT), which was developed by the author to more closely work with the mechanism that underlies many forms of psychotherapy, communication. (Haverkampf, 2017f)
Psychotherapy should be targeted at the long-run. Short fixes for depression often do not work, and only in the short run. The reason is that a patient’s interaction patterns with herself and the environment often need to change, which requires some time. Good communication helps against a depression, but it often requires a change in perspective, as well as awareness and reflection, which ensures an enduring effect but requires time.
There is a significant amount of research which shows that the effect of psychotherapy may to a large extent be due to the personality and communication approach of the therapist, and there is a debate to what extent the specific viewpoint of a school of psychotherapy plays an actual role in the outcome of psychotherapy. This is one reason why communication-focused therapy (CFT) puts an emphasis on the communication patterns and dynamics that unfold, and are induced to unfold, in a psychotherapeutic session.
For any form of psychotherapy to work, it has to lead to some form of change. To achieve a lasting adaptive and helpful change, it has to come from the patient himself or herself, because if the change is not in sync with the patient’s basic parameters, any change will over time revert back, either to the state before the therapy or a state that is somewhere half-way between the pre-existing one and the desired state. If change is lasting nevertheless, it is often due to factors outside a manualized and structured therapy. One explanation could be that even a manualized approach contains elements that may help the patient to develop in a direction that correlates with the patient’s basic needs and aspirations on some level.
In many schools of psychotherapy there is unfortunately an almost complete separation between thoughts and emotions. However, from a communication perspective they both are signals, containing information. When a thought triggers and emotion, or an emotion leads to certain thoughts, it is in both cases some meaningful information which leads to new sets of information. This is also useful in the therapy, because communication patterns that apply to one kind of information also apply to the other.
The uncrossable dividing line between thoughts and emotions has largely contributed to a situation where we understand neither. We could arbitrarily categorise information, but it still does not bring us closer to understanding the dynamics in which the information, or the categories of information, flow. For example, a question as one of the most powerful communication tools can elicit an emotional signal in a person without a cognitive thought, because it is information which can under certain circumstances be retrieved directly.
Regarding both, emotions and thoughts, as bundles of information does not reduce their individual qualities, but these qualities are part of the information that makes up the thought or emotion. Whether a message is emotional or cognitive cannot be extrinsic to it. However, where a piece of information flows is in a sense intrinsic to it. Thus, the thought of pain and the feeling of pain can be quite similar in information content, but where the information flows in the neural network, and in what way, may be vastly different.
Focusing on the mind often neglects the wider dimensions of the body. In a study with a group of women with major depressive disorder, experiences of yoga were that it served as a self-care technique for the stress and ruminative aspects of depression and that it served as a relational technique, facilitating connectedness and shared experiences in a safe environment. (Kinser et al., 2013)
Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. (Haverkampf, 2010b, 2017b, 2017f, 2018b) The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy needs to lead to change in some form. (Haverkampf, 2010b)
register them as emotions; thus, severely depressed patients are as in-capable of experiencing sadness as of feeling joy. Their feelings are diffuse, are not registered as emotions, and are not properly identified. (Bucci & Freedman, 1981)
Change can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them.
There are various factors that may stand in the way. If fear inhibits the information retrieval from memory this will not fully work. However, this fear is again a signal, information that is transferred from one point to another and triggers certain information processing patterns. If these patterns are not helpful in supporting the larger goals of need fulfilment with respect to the internal and external world, they can lead into such stationary and change inhibiting dynamics as indefinite loops, or vicious cycles, in which a fear signal just leads to another fear signal, rather than inducing change. These dynamics include
- looping of information
- misdirected information
and many others. They are a consequence of inhibited change. To break out of these communication predicaments, changes in communication patterns are needed that compensate, interrupt, reconnect, or act in another positive way.
Michael feels a lump in his throat. His therapist looks at his with an encouraging trace of a benevolent smile. Michael is not helped much by it, he feels under even more pressure. The therapist than finally asks a question, while Michael is about to despair. “Described the lump.” At first Michael does not know what to do with this question. However, he begins describing the lump and develops increasing investigatory spirit in doing so. After he has been talking for a little while, Michael discovers that his narrative has actually shifted to talking about his feelings …
CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.
The goal is thus not to simply provide information, to communicate information from one point to another, but to understand the flows of information, to better use communication patterns and to recognise if something is not working. The objective is really to understand flows of information rather than to get caught in a specific content. Since change comes from the detection, decoding and processing of meaning in a message, a patient suffering from depression, and several other mental health conditions, will see a decline in symptoms over the time, the better he or she becomes in spotting meaning.
Many popular forms of psychotherapy, such as Cognitive-behavioural Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, communication constructs like transference and counter-transference have been formulated, which focuses on the outcome of communication processes. CFT in contrast attempts to focus on the process itself.
CFT attempts to analyse how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behaviour of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient.
The first important step in therapy is to create awareness for communication in general. Humans are sending and receiving countless of messages every minute, and most of this runs automatically. However, for messages that can be processed by higher brain functions, whether from internal and external sources, there is the option to make these communication processes conscious. Particularly in interactions with other living organisms, particularly humans, communication patterns have evolved that facilitate the exchange of meaningful information between one brain and another. While most of this communication is outside consciousness, there are processes that let some of it pass the filter and bring it into consciousness. Creating greater awareness means putting the focus on these flows of information by observing the observable. For example, if a patient focuses just on her right hand, for example, while she is talking or on the timber in her voice, this creates awareness for a small aspect of the information in her interaction with another. Becoming aware of a thought that is repeatedly coming back and is followed by a feeling of anxiety may lead to the observance of internal communication flows. While the majority of the information exchange in the human body, particularly on a cellular body, is not accessible to conscious awareness, the aggregate result is.
Paul is at home alone. It is close to midnight, he feels low and cannot sleep. He does not really know why. The day has been good overall, but sporadically a melancholic feeling strikes, as if out of nowhere. He looks at the clock in the living room, as the hands seem to stand still. Everything is still. It has been an intense week, and it is maybe the first time when everything seems to quiet down. In this stillness, he notices something new, a tension he cannot put his finger on. It seems as if from nowhere and he cannot identify it.
Rather than thinking about, he just sits there, experiences, is open and curious. The point of tensions takes on more detail, and he feels he can make out some context, bits of emotions and thoughts, faint signals that are becoming more defined. While he is curious about what they may grow into and become, he enjoys the changes that are taking place before his inner eye …
The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.
The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.
The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.
Communication patterns are basic units of communication dynamics which make spontaneous communication in everyday situations possible. A certain form of question may be such a communication pattern, which humans use instinctively without further thinking about the pattern they are using. Some basic communication patterns may be hardwired, but many are also learned. Since they all have to adhere to basic laws of information exchange, the patterns themselves adhere to certain rules. The author has focused more specifically on the origin and nature of communication patterns elsewhere. (Haverkampf, 2018c)
An awareness of communication structures and patterns begins with an inventory of what is there. An analysis reveals the constructivist nature of conversation, how the therapist uses rhetorical devices in an interactive manner to pursue his therapeutic agenda and how the dialogue is a systemic process. However, it goes deeper as the same laws of communication do not only apply in the external world but also in the inner realms of a person. This makes communication less constructivist, but as natural processes that follow universal laws.
Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. Communication has certain rules, and in a context communication patterns emerge that help the organism survive, evolve and prosper. A language can be seen as sets of symbols and signals that are used within communication patterns. We all communicate in patterns because they make communication more efficient within a given context, However, people spend little time observing and reflecting on their communication patterns on the inside and in the external world.
Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the communication patterns with oneself and the world do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. All these are modifications in external and internal communication patterns because they change which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.
Passive social media use (PSMU)—for example, scrolling through social media news feeds—has been associated with depression symptoms. More time spent on PSMU was associated with higher levels of interest loss, concentration problems, fatigue, and loneliness. (b) Fatigue and loneliness predicted PSMU across time, but PSMU predicted neither depression symptoms nor stress. (Aalbers et al., 2019)
Facebook depression is defined as feeling depressed upon too much exposure to Social networking sites (SNS). Researchers have argued that upward social comparisons made on SNS are the key to the Facebook depression phenomenon. Our literature search yielded 33 articles with a sample of 15,881 for time spent on SNS, 12 articles with a sample of 8041 for SNS checking frequency, and 5 articles with a sample of 1715 and 2298 for the general and the upward social comparison analyses, respectively. In both SNS-usage analyses, greater time spent on SNS and frequency of checking SNS were associated with higher levels of depression with a small effect size. Further, higher levels of depression were associated with greater general social comparisons on SNS with a small to medium effect, and greater upward social comparisons on SNS with a medium effect. Both social comparisons on SNS were more strongly related to depression than was time spent on SNS. (Yoon et al., 2019)
A search of PsycINFO, Medline, Embase, CINAHL and SSCI databases reaped 13 eligible studies, of which 12 were cross-sectional. Findings were classified into four domains of social media: time spent, activity, investment and addiction. All domains correlated with depression, anxiety and psychological distress. However, there are considerable caveats due to methodological limitations of cross-sectional design, sampling and measures. Mechanisms of the putative effects of social media on mental health should be explored further through qualitative enquiry and longitudinal cohort studies. (Keles et al., 2020)
There are growing concerns about the impact of digital technologies on children’s emotional well-being, particularly regarding fear, anxiety, and depression. A growing body of research confirms the relationship between digital media and depression. Although there is evidence that greater electronic media use is associated with depressive symptoms, there is also evidence that the social nature of digital communication may be harnessed in some situations to improve mood and to promote health-enhancing strategies. Much more research is needed to explore these possibilities. (Hoge et al., 2017)
Considerations of psychopathology and a greater understanding of child and developmental psychology provide a greater insight into the question how depression may be transferred from mother to child, for example. (Goodman, 2020) From a communication perspective this is easily understandable. The child’s first experiences of the world internally and externally is shaped through the communication with others, mainly the primary caretakers. Depressed parents have been found to interact with their children differently, in ways that affect child development. Depressed mothers have been found in some studies to use less emotion and expressivity in their language with their babies. Non-verbal communication is especially important at an early age, and depressed mothers tend to make less eye contact. Through withdrawal, depression can also lead to a wider social disconnect, which can then affect both, the mother and the child.
Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.
Information that contains meaning has the potential to bring about a change. This means it that it has to contain something that is not entirely predictable. If we were fully certain of that piece of information, it could not lead to change. Thus, any therapy that does not work with meaning and meaningful information must be quite useless and ineffective. Even a highly manualized and structured therapy contains some novel information, which can be relevant and meaningful to the patient. In fact, practically all interactions with other people contain some elements of novelty, relevance and meaning. If communication is all pervasive, chances are high that there will also be some meaningful communication.
By focusing more specifically on the communication process, it is possible to increase the density of helpful change, and thus to make therapy more effective. A positive effect is also that as the patient experiences the relevance and practical workings of the therapeutic process, motivation and optimism about the positive outcomes of therapy increase. These effects come through connectedness, but also increase connectedness in the future.
Meaning is here used in the sense of understanding the information behind information, its symbolic content. For example, even the simple sentence “How are you?” can have a broad range of meanings from “Hi!” to “Are you feeling better?” Our thoughts and feelings affect how we decode meaning. They affect the questions we ask about another’s comment and the context in which we understand it. This applies to our own internal communications, and external ones. Learning communication in different contexts is like learning foreign languages.
Important is also how we interpret our own thoughts, the meaning we give to them and to our feelings. How we interpret our own thoughts, the internal communication in general, influences how we see ourselves. Thus, by changing our internal communication strategies we can also affect how we feel about ourselves. Primarily cognitive and psychodynamic psychotherapies offer many strategies in this area, while the former tends to be more manualized and the latter organically growing out of the psychotherapeutic work.
To be able to help patients with depression it is important to understand the road from meaning to meaningfulness. While meaning is relevant content, meaningfulness is a measure of how much relevant content one sees in something. At the same time, meaningfulness can be a feeling, which imputes relevance to something, a relevance, which, as has been described above, contains hope for some change in emotional, cognitive or other state or process. The importance in getting patients to see more meaningfulness has been borne out in many studies. Carstens and colleagues, for example, administered in their study the Sense of Coherence scale and the Beck Depression Inventory to fifty patients diagnosed with major depressive disorder and to fifty control subjects. Significant negative correlations were found between scores on Depression and total scores on the Sense of Coherence scale as well as all three of its subscales (Comprehensibility, Manageability, and Meaningfulness). A significant positive correlation was found between scores on the Sense of Coherence scale and age. Of the three subscales, a low score on Meaningfulness was the best predictor of scores on Depression. (Carstens & Spangenberg, 1997)
How do we achieve the perception of more meaningfulness? That is linked to the ‘demands’ of our basic parameters, our needs, values, and aspirations. Identifying them through information we already have about ourselves from the past, in terms of situations that were fulfilling or unfulfilling, and through observation and reflection on our communication patterns can make it easier for us to find what is meaningful to us. Once things that are meaningful are identified, one not only gravitates more towards those things, but can also seem more of them in present activities and situations.
As an example, consider a social get together, a party, where people stand around and talk to each other.
Last year, Randy felt uncomfortable at Bob’s birthday party, particularly on a day where he does not feel his best. Bob always invites lots of people Randy does not know. He would stand there and do his best to mingle. Was that not the point of it to mingle? But Randy was not entirely sure what he was doing at the party? Yes, sure, he wanted to have a good time, had to have a good time, but it would be over after a couple of hours anyway, and then he would be by himself again.
Since last year, Randy had looked into Communication-Focused Therapy and several other therapeutic approaches, which seemed to help people. He also worked with a therapist. He found out that he likes being with people and is interested in them at a deeper level, rather than just pleasantries. He probably had learned at home not to look into things too deeply. Don’t scratch the surface. But that did not lead to very fulfilling relationships.
This year, Randy is at Bob’s birthday party again. He walked into the main room. He sees a woman looking at a photograph hanging at the wall. Since last year he has discovered his interest in other people’s lives, their perspectives and insights. He walks over to her and talks about the photograph, and asks what she thinks about it? How she feels about it? An hour later they were talking again about things that were important to them. This was a new experience for Randy.
What this everyday occurrence illustrates, that if one zooms in on the meaningful, such as talking with another human being about what they find important, it is less likely to get caught in the meaningless, small talk for the sake of small talk. While small talk fills an important role in building relationships, one needs to see it only as a transition phase, in which the focus should already be on the next phase in relationship building. Far too many people, particularly those with social anxiety or depression, stay in the small talk for its own purpose state. One reason may be, what we already discussed under the topic of connectedness, the longing for connectedness and, at the same time, the apprehensiveness about it. Ways to see more meaningfulness are powerful antidotes to this dilemma.
Meaningfulness is frequently something that is seen within the context of one’s life story, or part of the life story. However, it should not be dependent on the story, because the story in turn depends again on the individual needs, values, and aspirations, the basic parameters of the person. On the other hand, a story is a frame for communication that takes place within it. At the same time, the communication dynamics that develop within a story are meant to get the person closer to the fulfilment of the individual needs, values, and aspirations. Thus, identifying the latter can help to construct a story, in which more meaningfulness can be found. It is in the story where past present and future can come together and support one in the creation of more meaning and more meaningfulness. Stories, as long as they are flexible and align with oneself, can also speed up the decoding process of messages and facilitate communication.
Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.
Motivation often comes when one has already started on a task. This is even more true in depression. Once one is engaged in a task, the depression tends to become less of an issue. The thoughts and feelings we build up before engaging in a task can be coloured significantly by mood and other factors, so that depression can influence the motivation and initiative to begin on a task quite directly. Here it is again to zoom in on what is really important to oneself, and also to see the communication aspects when one engages in a task. Any task is an interaction with the environment and with oneself, and as we already discussed, our communication or interaction patterns with the environment shape the enjoyment and satisfaction we derive from it. One valuable task in therapy is to look at, reflect, and experiment with these patterns.
At the core of Communication-Focused Therapy® is interaction. Interacting with the world is an important pillar in moving away from depression. Anything that helps to interact with the world in a meaningful way can help to overcome negative thoughts, feelings, and ruminations, as well as to find energy, initiative and motivation again. But how to get back into the world if one cannot find the energy and initiative to do so, and the world seems bleak?
As already mentioned, an important part in reintegrating in the world is just to do things. Action. However, it is not mindless action we are looking for, but mindful action; the kind that gives one the feeling of progressing rather than regressing. The first steps are often the most difficult steps, and anything that helps us to get moving is usually leading one in the right direction. Important from a Communication-Focused Therapy® perspective is to examine the pattern one usually used to interact with the world and to see where changes can be helpful. One often also needs to develop new ones, either in combination with old ones or by themselves. Through experimentation one can then adjust them so that they fit and are effective in getting one’s needs, values, and aspirations met in the world.
The feeling of powerlessness is one of the hallmark features of depression, which often leads into a vicious cycle, which further paralyses the patient. This powerlessness often goes hand in hand with a sense of disconnectedness. After all, communication is how we can exert power by changing our environment and ourselves. As depression inhibits meaningful communication, the latter can help overcome the sense of powerlessness.
Particularly problematic can also be the feedback a depressed person receives from others, which can maintain the depression. Coyne tested the hypotheses that (a) normal Ss respond differentially to the behavior of depressed patients, (b) this differential response is due to the fact that the target individuals are depressed, and not that they are patients, and (c) this pattern can be related to the symptomatology of depression. Each of 45 normal female undergraduates conversed on the telephone with either a depressed patient ( n = 15), a nondepressed patient ( n = 15), or a normal control ( n = 15). It was found that following the phone conversation, Ss who had spoken to depressed patients were themselves significantly more depressed, anxious, hostile, and rejecting. Measures of activity, approval responses, hope statements, and genuineness did not distinguish between S groups or between target groups, but important differences were found in the Ss’ perception of the patients. It was proposed that environmental response may play an important role in the maintenance of depressed behavior. Furthermore, special skills may be required of the depressed person to cope with the environment his behavior creates. (Coyne, 1976)
In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:
- Selecting information for a message (e.g. I am not OK with our weekend plans because I rather stay in the city; I need to communicate this to my partner)
- Encoding the information in a message (I will say it to him verbally; I want to be clear but cautious because we had a fight yesterday and he is feeling low today)
- Sending the message through a communication channel (using the speech system to say the words)
- Receiving the message through a communication channel (using the auditory system)
- Decoding the message into information (my partner is unhappy)
- Processing the information further (is she unhappy with me? I better don’t go there.)
It is obvious from this example that communication has failed, as the feeling “I rather stay in the city” gets converted into “is she unhappy with me?” Some vital information is not transmitted even though both individuals have the capability to communicate anything they want. It is not difficult to imagine that person A could be an anxious person and person B a depressed person. The communication patterns they use may have served some function in the past, as they both seem to be protecting themselves from some negative emotional consequence. However, in the present they do not promote a more optimal outcome, which could take into account both their needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.
Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.
Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.
Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.
The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.
Resonance is when new information becomes meaningful because of the information the other person possesses, whether consciously or subconsciously. The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. This also means that the therapist, consciously or subconsciously, needs to have a good sense of the patient’s values, interests and aspirations, of what is relevant to the patient, which can also show in the symptoms and the situations in which the symptoms are triggered.
In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is saying and otherwise communicating, since it reflects the information the patient already has, and which represents the foundation for resonance.
Depression makes the own information, particularly the emotional information less accessible, which can also lower resonance. However, while in most depressed patients resonance may become narrower, it does not cease to exist. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.
Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.
Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout.
Relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.
Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.
In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.
Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the centre of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.
The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.
Experimenting with communication patterns is a central element of Communication-Focused Therapy®, which is shared by therapist and patient. As a therapist, one has to continually find new ways of doing things, mostly quite spontaneously in the situation. This is where creativity is an important skill of the therapist. At the same time, the patient needs to learn to also experiment with different ways of doing things, particularly in communicating and interacting with themselves and the world around them. Depression, anxiety, OCD, fears, psychosis, and many other conditions, lead to a narrowing of the breadth of communication and interaction patterns. The result is often a rigidity in these patterns also within oneself. Thoughts and feeling become more monotone and lead back to themselves in endless cycles. It seems as if there is no way out of them. A reset often can be helped by several techniques that bring the focus to new and potentially meaningful information, such as in mindfulness practices, for example, where one may focus on an object and investigate it mentally at deeper and deeper levels. One positive outcome is to prevent thoughts spirals triggered by irrelevant questions. Also, new information of any kind is like a ray of sunlight shining into the prison cell of depression. One at least has to grapple with the fact that there is a sun out there, which leads toa greater desire for change. Action for change may be much more difficult to accomplish in more severe cases of depression, but new meaningful information can contain a chance for change.
Core benefits of experimentation also include practice of great flexibility, which can break the rigidity in depression and lead to the openness, which lets through more meaningful information from more sources. This increases the perceived connectedness with oneself and the world, which is a powerful antidote against depression, fear and anxiety. Experimentation also helps to instil the connectedness with more life through constant change.
Observing is a skill that usually leads to many of the other skills. Important is the ability to observe without asking any specific questions. The communication patterns we use today have their origin in our past interaction and experiences on a bed of biology. Observing our own actions and those of others in various situations help to bring us insight into the underlying dynamics we repeat again and again in interactions with others, as well as the patterns we repeat within ourselves. Some of them work and some less so. An important and very basic question is whether they serve the aim of greater connectedness with ourselves and others, whether they help us to identify more closely our own needs, values, and aspirations, and whether they support us in achieving these basic parameters with others. Communication is how things are create, evolve, and are put into practice in the world, and the more one feels one understands and can make one’s communication patterns work for oneself and others, the less helpless, alone, and powerless one feels. Thus, working with them has a direct effect on the feelings that underlie and come with depression.
Observing one’s internal communication patterns has a similar effect on the feelings of depression from the inside.
As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost from exposing oneself to the right communication environment.
Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.
The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.
Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.
Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.
Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017b, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017g, 2017c, 2017e, 2017d, 2017h, 2017i). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.
The actual instrument of change are, however, the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.
If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy and counselling in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com. He is also a frequent guest on www.askdrjonathan.com.
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 Both terms, psychotherapy and counselling, are often used interchangeably. In academia and research ‘psychotherapy’ has been used traditionally more frequently. Many patients, however, find the term ‘counselling’ less stigmatizing and ‘pathological’. I will use the term psychotherapy as a matter of habit and convenience.