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"Sad is How I Am!" Treating Dysthymia in Children and Adults
Dysthymia continuing education MFT CEUs

Section 2
Decision Making Task

CEU Question 2 | CEU Test | Table of Contents | Depression
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On the previous track, 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 of depression.

As I describe three Cognitive Behavior Therapy interventions for you to consider using with a depressed client who has problems making decisions, think of a client expressing depression you are currently treating and decide whether any of these three interventions would be appropriate with you client. The three interventions are, Alphabet Action, Coin Toss, and A Consequences List

Three CBT Interventions for a Depressed Client Who has Problems Making Decisions

#1 Alphabet Action
First, consider Alphabet Action. Here's an example of how, Cheryl, a colleague of mine described her use of the Alphabet Action Method. Cheryl's client was a twenty-five-year-old flight attendant, Alison. Alison was suffering from chronic depression. Alison had great difficulty in deciding what clothes to pack. Since she was a flight attendant, this problem confronted her frequently. She frequently would be up all night prior to a flight.

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.

After Alison thought for a moment about what Cheryl said, she seemed to get very sad. Cheryl asked Alison what she was thinking. "As trivial as this may sound," Alison stated, "I was thinking I'll never get to wear my Wellington boots again." Cheryl clarified this further to Alison that she only had to use the alphabet method when she couldn't make a decision. She could decide to wear her Wellingtons any time she wanted to.

Obviously, the idea here is to make a decision and take action on it. Cheryl explained to Alison that ruminating over simple decisions would perpetuate her freeze in decision-making. At the same time, Cheryl told Alison to keep in mind the following five principles. As I read these five principles to you, evaluate if any of these principles might be appropriate for you to include in your next session with a depressed, indecisive client.

5 Principles for Making a Decision
1. Since there's
no absolute certainty in life, there's no guarantee that any decision will be the best.
2. In minor matters, a decision is better than no decision.
3. You can increase your chances of a good outcome if you research or explore alternatives.
4. Most of the time choices are neither right nor wrong; they're simply different.

Each has different consequences and even partial solutions will keep adding up until the whole problem is solved. Cheryl advised Alison to be prepared to work on feelings of guilt or regret that may come after making difficult decisions, and also, not to set her decisions as no-win propositions because that will make her feel like she lost, no matter what she decided.

Think of a client you are currently treating that has a dysthymic disorder and is frozen in indecision. Would action through the alphabet method be a technique you might consider suggesting to facilitate your client's lack of decision making? If not, perhaps their lack of ability to make a decision or handcuffed depression might be facilitated by the concept of "wants" versus "shoulds," as I will outline next as they relate to the Coin Toss technique.

#2 The Coin Toss
Here's a second CBT technique for treating "Handcuffed Depression." As you know, patients suffering from depression are not only faced with minor decisions, but major ones as well. These minor decisions may confuse and overwhelm your depressed client. Obviously, since depression distorts your client's view of life, major decisions should usually be postponed until some of the symptoms have been relieved in order to make a rational choice. However, think of a client that has an important decision to make that just can't wait.

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
--Principle #1.
Taking Action. Because Kyle is experiencing what Evans calls Handcuffed Depression, the act of making a decision is more important than the actual decision.

--Principle #2.
The Absolute certainty myth. A symptom of Kyle's Handcuffed Depression is obsessive thinking. His obsessiveness occurs because he is demanding absolute certainty that his choice will be right. In turn, his anxiety stems from this demand. I reminded him that there is no absolute guarantee that any choice is right.

--Principle #3.
Unanticipated consequences. No one can realistically expect absolute certainty or "correctness." No one can predict the future. Unanticipated consequences, both positive and negative, will occur no matter what Kyle chooses even if it's a "wrong" decision. A "wrong" decision is usually only the long way around to the same goal

--Principle #4.
Buyer's Remorse. Kyle still experienced regret for a week or so after his decision to attend the smaller college. I helped Kyle to put his feelings into perspective by telling him that sales people call predictable regret after making a decision "buyer's or seller's remorse." Regret is one of the normal inconveniences of life that many people experience after making a decision.

#3 Advantages, Disadvantages, and Consequences:
The third intervention to assist your indecisive depressed client, who is experiencing Handcuffed Depression, is the Make a List Technique. As I describe this basic CBT intervention, decide whether it is appropriate for a client you are currently treating.

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.

This track 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 track will provide you with specific interventions to assist your depressed client's concentration and memory.

Peer-Reviewed Journal Article References:
Delgadillo, J., & Gonzalez Salas Duhne, P. (2020). Targeted prescription of cognitive–behavioral therapy versus person-centered counseling for depression using a machine learning approach. Journal of Consulting and Clinical Psychology, 88(1), 14–24.

Fernández-Theoduloz, G., Paz, V., Nicolaisen-Sobesky, E., Pérez, A., Buunk, A. P., Cabana, Á., & Gradin, V. B. (2019). Social avoidance in depression: A study using a social decision-making task. Journal of Abnormal Psychology, 128(3), 234–244.

Geschwind, N., Bosgraaf, E., Bannink, F., & Peeters, F. (2020). Positivity pays off: Clients’ perspectives on positive compared with traditional cognitive behavioral therapy for depression. Psychotherapy, 57(3), 366–378.

Ljótsson, B., Hedman, E., Mattsson, S., & Andersson, E. (2017). The effects of cognitive–behavioral therapy for depression are not falling: A re-analysis of Johnsen and Friborg (2015). Psychological Bulletin, 143(3), 321–325.

Online Continuing Education QUESTION 2
What are four principles in client decision making? To select and enter your answer go to CEU Test.

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