Healthcare Training Institute - Quality Education since 1979
CE for Psychologist, Social Worker, Counselor, & MFT!!
the previous section, I talked about how depression can cause a client to be frozen
or handcuffed, so to speak, in relationship to their ability to make decisions.
As you know, difficulty concentrating, making decisions, or remembering are symptoms
Three CBT Interventions for a Depressed Client Who has Problems Making Decisions
For example, Alison would agonize over whether to pack her blue top or her green top. Cheryl, Alison's therapist, suggested Alison might try using the "Alphabet Method" to help her to take action. In this case, she would pack the blue top because it came first in the alphabet. If Alison was undecided regarding whether to take the black coat or the white coat, she would take the black coat because it was first in the Alphabetical Order. Most normally, when clients are not suffering from depression, they would have the energy to create a preference in their mind whether they wanted to take a blue or a green top, or, a black or a white coat.
However, due to the feeling of overwhelm, Alison felt relieved to have a system to facilitate the choice making process. After trying this method Alison seemed relieved stating,
"That's a good method. It seems stupid at first, but when I force myself
to choose the blue one, I can see I really want to pack the green one." Cheryl
then pointed out that this wasn't the way to use this method. She told Alison
that she must stick with her decision. If she didn't, she would soon be back in
the same position: vacillating from one choice to another.
The Coin Toss
Kyle, age 19, experienced depression throughout high school. Kyle couldn't decide whether to go to a small or large college. The large university offered a scholarship, but the small college he felt was better academically. Kyle had placed himself, in one respect, in a no-lose situation because either school was good. However, because of his indecisiveness, he created a no-win situation as well. Here's how...If Kyle chose the small college, he would lose the scholarship; if he chose the large university, he'd miss the academic excellence he felt he would gain by attending the smaller school.
Over several sessions, Kyle kept changing his mind. Finally, his session with me fell on the deadline date to make a decision on which school he would attend. Unable to decide, Kyle experienced waves of panic during the session. I've seen similar problems when I worked in a college counseling center. At the start of each term, anxious students had to decide immediately what courses to take. I developed a technique to help them decide quickly on wants, in other words, what they really wanted, and not base a decision upon "shoulds" or fear of consequences.
I took out a coin and flipped it. I told Kyle, "Heads is the small college, and tails is the larger university." But before showing him which side came up, I asked him what he hoped the coin showed. Once he told me what he hoped it would be, he asked to see if it was head or tails. I then put the coin back in my pocket without showing it to him. Flipping the coin forced Kyle to voice his preference without taking time to ruminate. Kyle made his decision, and at that point he contacted the school and confirmed his choice. Thus, he made an immediate choice based on his "wants" rather than his "shoulds" or fear of consequences.
Here are four principles in Kyle's decision making. See if any are appropriate for a future session you may have with a dysthymic client who is frozen in his or her inability to make a decision.
4 Principles in Kyle's Decision Making
♦ #3 Advantages,
Disadvantages, and Consequences:
When your depressed client is faced with a dilemma, have him or her draw a line down the middle of two sheets of paper. At the top of the left hand column of the first sheet of paper write advantages and at the top of the right hand column write consequences. Sound familiar? At the top of the left hand column of the second sheet of paper write disadvantages and at the top of the right hand column of the second sheet of paper write consequences. So that's two sheets of paper... advantages and consequences at the top of one and disadvantages and consequences at the top of the other.
Vicky, a 29 year-old mother and housewife, was experiencing depression due to money problems. Vicky couldn't decide whether or not to take a part-time job. Two advantages were, one, she would have a chance to get out of the house. The consequence of this advantage, which she wrote on the first paper, was guilt feelings regarding spending less time with her children. And two, she would have the opportunity to talk to someone besides the children. The disadvantage was the cost of hiring a sitter for the time she was at work. The consequence was less total income per hour once the sitter expenses were deducted. As you know, with depressed clients, guilt feelings often play a role in making decisions. Vicky's Handcuffed Depression about the decision to work was fueled by guilt.
A challenge regarding implementing this intervention of Advantages, Disadvantages, and Consequences is to assess if your client is listing the disadvantages of either choice and ask yourself, is she distorting the situation? Here's what I mean. Vicky had at first listed her guilty feelings as a disadvantage, rather than a consequence. However, she came to realize that guilt wasn't a real disadvantage, because it was not a statement of fact. She could choose to not feel guilty; thus, her feelings of guilt were really a consequence. After writing these advantages, disadvantage, and consequences down on paper, she felt that the advantages outweighed the disadvantages, so she decided to take the job.
section provided you with the three intervention techniques of the Alphabet Method,
the Coin Toss, and Listing Advantages, Disadvantages and Consequences to assist
your depressed client in decision making. As depression hinders decision-making,
it can also create problems in concentration and memory. The next section will provide
you with specific interventions to assist your depressed client's concentration