Análisis de Coherencia de las Alternativas

`I was so pleased and relieved to know what was wrong with me. I now know that I suffer from depression. I did not know what was going on inside my head. I was fearful that I was insane or would go mad. I felt low, down, tired, and tearful and found it dif®cult to concentrate and get out of bed. I lost interest in going out to see people and socialise and could not go to work . . . It was terrible and scary,' said Caroline.

It is understandable that Caroline (and other clients) was relieved to know what was wrong with her. She now had a certainty in the form of a psychiatric

diagnosis for these symptoms, although she did not know why these symp- toms had developed and what made them worse. She was also hopeful that the drug treatment being prescribed would cure her depression, in a way similar to that for physical illness. Her psychiatrist told her that the cause of her depression was likely to be a chemical imbalance in her brain and also genetic, since her mother and her uncle also suffered from it, and that she was likely to take medication for a long time or even for the rest of her life. This was another `bonus' for her as it indicated that her depression was not her fault and she was not psychologically weak. She was just the victim of an inherited disease.

Caroline was referred to cognitive behaviour therapy for depression and low self-esteem. `I have been depressed all my life and medication hasn't been as helpful as I would have hoped for,' said Caroline. She was a 36-year-old mother of three young children, aged 10, 7 and 5. She had graduated with a ®rst-class honours degree from a prestigious university, and then quali®ed as a chartered accountant. She was now a full-time mother. However, looking after her children was a struggle as she needed to be a perfect wife and mother. Her husband was a businessman and was supportive of her, but he couldn't understand her problem. He found it dif®cult to give her emotional support and did not understand depression and the nature of it, saying, `We have everything we want in life: a big house, a holiday home, a yacht, cars, expensive holidays all over the world, and no ®nancial worry.' `What is she depressed about?' was the question he kept asking. He came to accept that depression was part of her and it was a genetic and biological condition. After all, her mother and an uncle suffered from depression and her psychiatrist and general practitioner all said that biological and genetic factors were the likely cause of her depression. In the last ten years or so, she had been hospitalised on three occasions, ranging from a couple of weeks to a month and had been on a range of drugs of various dosages. She was also given a course of electro-convulsive therapy (ECT) which had little or no long-term bene®t.

Although she had the help of an au-pair, she just felt everything was on top of her. She had to organise and do everything perfectly. Otherwise, she would feel guilty and criticise herself for being lazy and useless. She had to be on the run or doing things all the time and found it dif®cult to relax. She admitted that she was a perfectionist and saw nothing wrong with needing to be perfect. `I will feel guilty for not doing things. I can't just sit down and watch television, read the newspaper, or listen to music, even for a short time,' said Caroline. She saw this as being part of her personality, something that couldn't be changed: `I was born like this and my mother was also that kind of person,' said

Caroline. Saying `no' to requests from friends and relatives was particularly dif®cult for her, although she would have liked to have been able to do so in some circumstances. Not only did she need to be perfect in what she did, but she also needed people's approval and recognition. Otherwise, the fear of being disliked or rejected made her feel less worthy as a person. Admittedly, her self-worth was conditional on people liking and accepting her, and on not being criticised. She was a perfectionist as well as a workaholic, working hard to be a perfect wife and mother and to please people around her.

When Caroline was referred to CBT for the ®rst time, she was not sure whether this type of therapy could help her depression, saying that `it is not a matter of thinking the right things and feeling the right way and all will be well'. She was hoping that a `right' drug or a combination of drugs could be found to cure her depression, despite having been on medication for a long time. Her previous experiences with psychotherapy had been disappointing. Biological and genetic explanations for her depression became more compelling as a result.

Slowly and surely, she started to respond to CBT and felt more optimistic about her recovery from depression. She could see that her perfectionism, self-criticism, approval-seeking behaviour (see Part III of this book), and fear of rejection and criticism (see Part IV) all contributed to the ups and downs of her moods, and to the development of her depression. However, the fear of the depression coming back was always at the back of her mind, despite the progress being made with CBT and a gradual reduction in her medi- cation. `While I am well now, I wonder how long it will last. I just feel that I do not have control over whether or not I am depressed or well,' said Caroline in an anxious and worried tone of voice. Her experience or feelings were not unusual as the idea of `mental illness' being a disease of the brain had not only had a profound adverse effect on her (and other clients') fear, but also affected her con®dence to reduce or stop taking medication. The desire to stop taking medication was there and not just because of its side effects; she said that she did not want to depend on it for the rest of her life. However, the notion of `a diseased brain, chemical imbalance or genetic factor' was in the way of her taking a `risk' and therefore making a full recovery: to be able to `stay' better.

`My depression is coming back. Can I come to see you now?' Caroline phoned at eight one evening and was in a terrible state when she arrived. She was tearful and shaking, saying that she was fearful of the depression coming back. She couldn't go to sleep, despite feeling very tired. Not being able to go to sleep, to her, was a symptom of depression and was an indication of the imminent recurrence of her depression. This symptom was present prior to

her becoming depressed in her last three bouts of depression. Another similar episode happened again a few months later. She called to say that her `depression is coming back' with the same rationale as before. This time the symptoms were that she was feeling tired and drained and could not con- centrate. Her psychiatrist warned her to watch out for these symptoms of depression.

She put her learning into practice at every available opportunity and started to have a better understanding of the way in which her emotional upset occurred (see Chapter 4 on `CBT theory of emotional upset'). She accepted that her emotional upset had little or nothing to do with it being biological, and that it was more to do with the way she thought about the situation or other people and with her own reaction. As a result, she made steady progress in the two years of CBT therapy, which started with a weekly session for ten weeks, then once every month for three months, and then once every three months. On our ®nal session, she said that she now had the con®dence and a tool to deal with adversity. She also said that had she not been able to think in a more realistic and adaptive way, she would have gone down with depression a few times in the past two years. Her con®dence had improved and her fear of the depression coming back was greatly reduced; this had changed her perception of `mental illness' being a disease of the brain.

Cognitive behaviour therapy approach to causal