Preamble

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As part of my Master degree in Social Work I took part in an eight month internship at a community health center close to where I live. There I did one on one counselling with individuals who were experiencing a wide range of mental health issues, one of which was depression. This article discusses some of my understanding of depression and introduces a client case study to convey how an individual’s thoughts can contribute to the symptoms associated with the mental health concern.

Note: My clients name has been changed and some of the details of their situation have been altered to protect their confidentiality.

Client Session Case Study

During my internship a young man who I will call Sam was referred to me by his primary health care provider because he had been experiencing feelings of depression for the past several months. During our sessions Sam explained to me that he rarely had an appetite and that he rarely (if ever) got a good night sleep. He explained that his thoughts prevented him from falling asleep until the early hours of the morning.

Through our work together Sam revealed that he often compared himself to others, that he felt that he was never good enough and that he often felt unloved by his parents. When he spoke about the world he only ever discussed the negative occurrences that were taking place and he also mentioned that his school was a toxic environment where nobody cared about anything or anyone. On several occasions Sam mentioned that he wanted to feel “normal” and happy but that things were hopeless for him and that he often wished that he had never been born.

One session with Sam was particularly challenging for me and even though it has been several months since I last saw him, I still often think about it.

At the beginning of the session Sam’s mood state appeared to be normal in that he appeared to be relatively happy and in good spirits. However, that quickly changed as Sam began to discuss the events that took place over the past week that had been troubling him.

I listened to Sam without interruption and after a short while I began to notice that Sam’s speech was gaining a sort of momentum as he discussed how bad things were for him and the world in general. Sam jumped from topic to topic painting a bleak picture of his reality and several times Sam stated that things were hopeless, that they would always be this way and that there was nothing he or anyone could do to change them.

During Sam’s speech one topic lead into the next and then the next in an endless spiraling stream of negative consciousness. It began to seem as though reality for Sam was nothing more than a series of negative interactions and injustices and each example that he provided built upon this overall idea that the world is a horrible place and that he is un-loveable. I listened as Sam’s negative thoughts seemed to be spiraling him into a pit of darkness – a sort of black abyss that would be difficult if not impossible to get him out of.

In witnessing this whole thing take place I began to feel mortified by my own incompetence. I didn’t know what to say to make Sam feel better and I soon realized that I wouldn’t be able to pull him out of the darkness. Like Sam, I myself began to feel hopeless and helpless which was amplified at the end of the session when Sam informed me that he actually felt worse off than when he had originally come in to see me. He had a look in his eye that said “aren’t you going to say something to help me?”

The session ended soon after with me feeling like a failure.

Though all that I did during the session was listen to Sam and allow him to speak freely the session was nonetheless a bit of a disaster on my part. However, in reflecting on the experience I’ve come to realize that I actually learned a lot from the session and about the symptoms of depression in general. The way Sam discussed his issues gave me insight into how the human mind operates and in a way, I saw firsthand what I had learned in many of the books that I had read during my degree.

For the remainder of the post I will share how my experience with Sam relates to some of what I learned about depression.

Core Beliefs

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At their most basic level core beliefs are the fundamental assumptions that people have about themselves, others, and the world around them. They influence the individual’s thoughts and also their behaviors.

Core beliefs develop over time during key life events and circumstances and often begin to be formulated in the early stages of childhood. This tends to make core beliefs highly ingrained within the individual as well as being strongly held, ridged and inflexible. This is also why individuals tend to have a difficult time recognizing their own core beliefs and why they tend to accept them without questioning their validity or where they come from. This can also have the effect of making one’s core beliefs act as a sort of filter through which the individual perceives themselves and the world round them.

Part of what makes an individual’s core beliefs so strong is that once they are formulated they tend to be reinforced and maintained by any information that confirms the belief while information that dis-confirms the belief tends to be ignored. This phenomenon is referred to as “confirmation bias,” which is a common behavior among all people not only those individuals with depression.

A core belief could be about anything, but a few examples of core beliefs that tend to be associated with depression are as follows:

1. “Nobody cares about me,” and/or “I am unlovable.”
2. “I am no good, stupid, inferior, and/or incompetent.”
3. “People are cruel.”
4. “The world is dangerous and/or unfair.”
5. “Things are hopeless and/or things will never change.”

From the list above we can see that the core beliefs themselves tend to be very one dimensional, simplistic and somewhat “matter of fact.”

One of the challenges of altering ones core beliefs is that there will always be evidence in the world that the individual can use to prove their belief. As such, the task of altering an individual’s core beliefs involves helping them recognize and identify their core beliefs along with any evidence that contradicts the belief. In doing so, over time the individual’s core beliefs will hopefully begin to shift, allowing the individual to take on a more balanced outlook of themselves and the world around them. Something to keep in mind however, is that this process can take a lot of time and that it is often much easier said than done.

Automatic Thoughts

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As the name suggests, automatic thoughts are uncontrolled and spontaneous thoughts or images that occur in an individual’s mind in response to a particular circumstance or event. Automatic thoughts can be helpful or unhelpful and they can be positive or negative in nature. Not surprisingly, negative automatic thoughts tend to be highly associated with depression.

Automatic thoughts are generally considered to be unhelpful if they lead to low self-esteem or negative affect in the individual and/or if they generally do not benefit the individual in some way. For instance, a negative automatic thought is not helpful if it leads to the individual feeling depressed, especially if the circumstance is beyond the individual’s control. If the individual is unable or unwilling to change the situation that caused the thought that lead to the negative feeling, then the thought itself serves no purpose other than to increase the individual’s negative emotions. On the other hand, a negative thought and/or feeling could be helpful if it leads the individual to make a change that improves the situation.

A common example of a negative automatic thought that is unhelpful is as follows:

A person is walking down the street and sees a friend across the way. The individual waves to the friend and the friend looks in their direction but keeps walking without waving back. The individual then automatically thinks to themselves “my friend hates me.”

This particular automatic thought is unhelpful because it can activate the individual’s core belief of being disliked and/or unloved which may lead them to feeling down on themselves. However, the thought itself is not necessarily even a reality. It is possible that the friend was in a hurry and they just didn’t see their friend across the street and that is why they did not wave back. In such a situation the thought, “my friend hates me” is completely unjustified and really serves no purpose other than to lower the individual’s self-esteem.

Since automatic thoughts tend to spontaneous and uncontrolled it can be very challenging to recognize them occurring. However, recognizing our automatic thoughts is the first step to recognizing alternative explanations to any given situation. So recognizing ones automatic thoughts becomes an important practice in reducing thoughts that lead to feelings of depression.

How Thoughts Lead to Feelings of Depression

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I am not an expert on the human brain or on depression so I would like to emphasize that the following is just my understanding of how an individual’s thoughts may contribute to their feelings of depression.

Firstly, the brain is made up of cells called neurons which communicate with one another through electrical impulses and through the transmission of chemicals called neurotransmitters. The individual neurons within the brain, connect with other neurons and form vast networks among themselves that essentially formulate an individual’s thought patterns. These networks essentially become the basis of the individual’s thoughts, ideas and beliefs.

Thoughts within the individual occur when an electrical impulse travels down a neural network. When the individual experiences the same thought repeatedly over time, that particular network becomes more and more hardwired together until it eventually becomes ingrained within the individuals psyche. Once it is ingrained within the individual it basically acts as one of their core beliefs.

Similarly, when a highly ingrained neural network is exercised repeatedly, the network becomes more and more sensitive to information that will trigger it, and the overall thought process occurs more and more rapidly. In this way, events that are even remotely related to the individuals underlying core belief system essentially trigger their automatic thought processes. Once the automatic thought occurs this signals the electrical impulse to travel down the neural network to the cluster of neurons that make up the individuals core belief. Once that core belief is stimulated, the individual concludes that the triggering event is another example that proves their belief.

I’ve created a picture analogy to demonstrate this idea. It’s not perfect but hopefully it demonstrates my point. In the image above the magnolia flowers represent the individual neurons within the brain which are clumped together in complex networks. These networks represent the individual’s core beliefs which are connected by a vast series of branches. Notice that some core belief networks contain many individual flowers which are densely packed together while others have fewer flowers that are farther apart. The dense networks represent the individual’s oldest and most ingrained beliefs whereas the less compact networks represent newer more flexible beliefs systems. The flowers outside of the colored line represent the neurons not associated with any specific network.

As neurons are activated by a triggering event, an electrical impulse begins to travel down the branches of the tree to other neurons and the individual begins to formulate automatic thoughts about the event. At some point enough neurons in the network become activated to stimulate the individual’s core belief. Note that some of the core beliefs overlap and that there are many different pathways for the electrical impulse to travel. This is similar to the brain in that often an individual’s core beliefs are closely tied to other core beliefs. Similarly, when an individual has one thought, often other thoughts are also stimulated until many of the individual’s core beliefs are activated. In this way one seemingly minor event often triggers a cascade of negative thoughts until the individual arrives at the overall belief that – no one cares about them, they are stupid and un-loveable, people are cruel and that everything is hopeless.

Conclusion

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The process outlined above appears to be what I witnessed in my client Sam. Sam came in feeling relatively okay at the beginning of the session, but as the session progressed he began to feel worse and worse. Because I allowed Sam to speak uninhibited without interruption, each thought that he had appeared to activate another which created a sort of chain reaction that spiraled him into a place of complete and utter negative emotion. Eventually Sam got to the point where many of his negative core beliefs about himself and the world around him had been activated, which is what likely also happens to him at night while he is lying in bed unable to sleep.

Unfortunately, at that point of the session there was no time left for us to address any one of those circumstances, so Sam was forced to leave the session with a very bleak and dismal outlook on himself and the world around him. As a result he undoubtedly left the office feeling even more depressed then when he came in.

In hindsight, I now realize that I probably should not have allowed Sam to speak uninhibited for the entire session. Rather, I should have re-directed the focus to only one of the issues that was most important for Sam to work on in our time together. From there we could have explored how the situation related to his core beliefs about himself and the world and possibly moved on to strategies that would allow him to cope with these seemingly unhelpful thoughts.

At the end of my internship Sam was referred to a senior therapist at the health center. Though I have not stayed in touch with Sam or the health center, I am confident that he got the help that I failed to provide.

Thanks For Reading