Question 1

Can a bad relationship cause depression?

David Dozois · Accepted Answer

The link between relationship distress and depression is bidirectional, meaning that relationship difficulties can increase the risk of developing depression, and experiencing depression (or having a partner with depression) can increase relationship distress. In a comprehensive literature review, Dr Mark Whisman (professor of psychology and neuroscience at the University of Colorado Boulder) and his colleagues contend that a causal link exists between relationship distress and depression. Some possible mechanisms include poor communication, relationship stress (for example, learning that your partner is having an affair or threatening to end the relationship) and expressions of criticism, hostility, or emotional overinvolvement. It is important to point out that relationship problems are most likely to lead to depression in individuals with some pre-existing vulnerability to the disorder (what researchers call a diathesis-stress perspective). In other words, individuals with few or no predisposing factors for depression are probably far less likely to experience a depressive episode in the face of a relationship stressor. Depression also increases interpersonal difficulties and relationship distress, particularly in romantic relationships. For example, the interactions of couples in which one partner experiences depression tend to exhibit more negative communication patterns like blaming and withdrawal and fewer positive behaviors, such as working together to problem-solve, self-disclosure and eye contact. In longitudinal studies, relationship distress has predicted subsequent depressive symptoms and vice versa. Researchers are still trying to understand the specific mechanisms underlying this bidirectional link. More information is available at the following links: https://doi.org/10.1016/j.cpr.2007.04.007 https://doi.org/10.1037/0000332-008 https://doi.org/10.1146/annurev-clinpsy-081219-103323

Question 2

How do you tell someone when you’re feeling depressed and how it’s impacting you? How do you know when it’s impacting your relationships?

David Dozois · Accepted Answer

Depression is often termed as the common cold of mental disorders because it affects approximately 11 to 20 percent of the population over the course of the lifetime, depending on how it is assessed. This is quite an appropriate term in regard to how common depression is, but it is a misnomer given how devastating depression is to the individual and to their loved ones. Unlike the common cold, depression causes significant impairment in our emotions, thinking, behavior and social interactions. Depression is so often misunderstood. In everyday language, we often hear people state that they are “feeling depressed” or feeling “blue.” However, clinical depression is more than just low mood. Clinical depression is comprised of a cluster of symptoms that include: sadness; loss of interest; feelings of worthlessness or excessive guilt; suicidal thoughts; physical slowing or agitation; insomnia or hypersomnia; weight loss or weight gain (or significant appetite increase or decrease); impaired concentration; indecisiveness or difficulty thinking; and loss of energy or fatigue. There is nothing to be ashamed of in experiencing depression, but it can be difficult to share what you are going through with friends and loved ones. You might be nervous about how they will react or have mixed feelings about whether this is the right thing to do. This is totally understandable as mental health problems have historically not been discussed in ways that are sympathetic, accurate, or helpful. Fortunately, we seem to be better at talking about depression now and the stigma is starting to decline. Telling someone you are feeling depressed can be challenging, even if you have a close relationship with them. Although it is common to worry about being judged or misunderstood, opening up about your experiences can be really helpful. For example, telling someone about your depression can help increase support and reduce social isolation. It can also help you feel as though you are not alone in your struggles and can allow others to support you in the ways that are most important to you. When telling someone that you are feeling depressed, it is important to be clear with yourself about what you want or need. Do you want someone to give you advice, lend a listening ear, or provide tangible support? Knowing what you want to achieve from the conversation and being upfront about this will help make the conversation go more smoothly. It is quite possible that those close to you are already aware that something is happening and are ready to have this conversation and provide the support you need. Do not feel the need to talk about your depression until you feel ready. Once you are ready, you might begin by mentioning that you have something important that you want to share with them. At this point, you can express what you are hoping to achieve by sharing this information (for example, that you want them to listen; that you are hoping they will understand and support you with some of the household tasks; that you need some advice; or that you want them to understand why you have been interacting differently and that it is not a reflection of how you feel about the relationship or the person). It can also be helpful to acknowledge how this might impact your partner and encourage them to share how they feel. The person you are speaking with may not understand what depression is or how it makes you feel. It can be helpful to provide some specific examples of what you are experiencing. Remember, you don’t need to share everything. It might be worthwhile to jot down some thoughts on your phone or a piece of paper so that you are clear about what you want to share and what you need from the person you confide in. The second part of the question is how you know when it impacts your relationships. Depression can affect relationships in several ways. For example, you may notice that you withdraw from activities that you usually do together; have a lower sex drive; are not communicating openly; argue more; feel less satisfied with your relationship; seek reassurance from your partner more than usual; or spend more time isolated. You may also notice similar changes in your partner’s behavior. Having an open discussion about this can help your partner know it is not about them. It can also increase your sense of connection and support, prompt problem-solving and chart a path to recovery (for example, seeing a psychologist or other regulated health professional to treat your depression or perhaps working with someone in couples therapy). More information is available at the following links: https://www.guilford.com/books/Handbook-Assessment-Treatment-Planning-Psychological-Disorders/Antony-Barlow/9781462544882 https://doi.org/10.1001/jamapsychiatry.2017.4602 https://doi.org/10.1038/s41598-018-21243-x https://doi.org/10.1001/jamanetworkopen.2021.40202

Question 3

What is your opinion on the chemical imbalance theory of depression?

David Dozois · Accepted Answer

Many contemporary theorists have adopted the biopsychosocial framework to consider the risk for depression, which includes the formal recognition of biological, psychological and social risk factors and their interactions. The biopsychosocial framework permits the examination of unique variables but also implicitly encourages studies that examine the relationships and interactions among the range of variables in consideration. Biological factors related to depression could include genetic, epigenetic, biostructural, biochemical, neurotransmitter, dietary, sleep regulatory and even behavioral factors linked to physiological functions (such as exercise). Some examples of psychological factors include: negative thinking; pessimism; rumination; neuroticism; high negative affect and low positive affect; attentional and memory biases; cognitive control and so on. Finally, a plethora of social factors are associated with depression, including interpersonal interactions, social structure, class, ethnicity, discrimination and current and historical aspects of culture that could influence depression. When the range of potential biopsychosocial factors is considered, it becomes clear that the conceivable scope of complexity is enormous. The literature on risk factors in depression is vast and numerous biological, psychological and social variables have been identified. It is important to note, however, that the identification of a risk factor simply refers to an increased statistical likelihood of the onset or recurrence of depression and does not necessarily relay information about the causal mechanisms involved. For example, depression affects twice as many females as it does males. Knowing the odds ratio for sex differences in depression does not necessarily inform us about why this is the case (that is, vulnerability) or what mechanisms are involved. Kendler identified numerous variables that could be considered causes of depression. These included; genome-wide biological risks; fMRI resting state; reduced cortical brain volumes; genetic influences; abnormalities in the hypothalamic-pituitary-adrenal axis; immune activation; reduced serum brain-derived neurotrophic factor; poor diet; smoking; the post-partum period; affective processing biases; deficits in executive functioning; deficits in memory and attention; neuroticism; other psychiatric disorders (anxiety disorders, Borderline Personality Disorder, Alcohol Use Disorder); negative cognitive styles; rumination; stressful life events; long-term contextual threat; loss; humiliation; childhood sexual abuse; lack of exercise; low socioeconomic status; unemployment; low social support; intergenerational transmission; low parental warmth; parental death in childhood; and economic downturns. The biological, psychological and social risk factors associated with (and in some cases causally related to) depression are incredibly complex and interact in dynamic and reciprocal ways. Although isolated risk factors continue to be studied and add to our understanding of the development and maintenance of depression, the field is moving toward more sophisticated research strategies to test more complex mechanisms and processes that trigger depression onset and relapse. The “chemical imbalance theory of depression” suggests that excessive or insufficient neurotransmitters (for example, norepinephrine and serotonin) in the brain are responsible for depression. For many years, people have viewed depression as akin to diabetes (just as someone with diabetes needs to take insulin, someone with depression needs to take antidepressants). However, there is not a lot of support for this idea. This is not to say that neurotransmitters are unimportant in regulating emotion; however, just because taking Advil helps alleviate a headache does not mean that my headache is due to the lack of an anti-inflammatory. There is also important evidence that psychological treatments such as Cognitive Behavioral Therapy (CBT) are equally effective as antidepressant medication at treating a depressive episode and result in a lower risk of relapse. In general, research does not support the idea that any one risk factor is necessary and sufficient to cause depression. Instead, the variables that cause depression are characterized by equifinality (different risk factors can lead to the same disorder) and multifinality (the same risk factors can lead to various mental health problems). In addition, these risk factors interact in dynamic and complex ways. More information is available at the following links: https://doi.org/10.1002/wps.21069 https://www.elsevier.com/books/risk-factors-in-depression/dobson/978-0-08-045078-0 https://doi.org/10.1037/0000332-010 https://doi.org/10.1037/0000332-000 https://doi.org/10.1001/jamapsychiatry.2019.1200

Question 4

Do people go into relationships with preconceived ideas about what a relationship is or how their partner should be and then get disappointed or depressed if the actual reality is different?

David Dozois · Accepted Answer

The role that expectations play in relationship satisfaction is complex. Most research shows that having positive expectations about the relationship is associated with healthier relationship functioning. For example, people with positive expectations about their relationships often have positive overall evaluations of their relationships. They also tend to: persevere more in their relationships; have more positive thoughts about their partners; be more motivated to engage in relationship-building activities; be more forgiving and trusting; attribute more benign explanations to their partner’s behavior; and experience less contempt for their partners. These findings are congruent with “confirmation bias” (we tend to seek out or interpret our experiences in ways that confirm existing beliefs and expectations). However, some evidence suggests that positive expectations about relationships can sometimes have a negative impact. For instance, partners can be evaluated worse in response to positive expectations. If we have extremely high expectations, our partners will inevitably fall short. People can then start comparing their actual experiences in the relationship with what they expected to have. This “contrast effect” can make us feel worse about our partners or result in our circumstances appearing more negative than reality. Subsequently, this can lead to lowered investment and commitment in the relationship and increased perceptions that “the grass is greener on the other side.” In general, having high and even idealized expectations about our partners and the quality of our relationships is related to greater satisfaction. When our idealized romantic expectations are unmet, however, our commitment and investment in the relationship can waver and our satisfaction diminishes. For some individuals, disillusionment and dissatisfaction in their relationship may ultimately increase their risk of experiencing a depressed mood. More information is available at the following links: https://doi.org/10.1037/gpr0000066 https://doi.org/10.1037/0022-3514.70.1.79 https://doi.org/10.1177/0265407517703492

Question 5

What interventions are typically made in CBT to improve relationships?

David Dozois · Accepted Answer

There are several CBT approaches for couples that demonstrate high efficacy in clinical trials. Integrative Behavioral Couple Therapy, for example, involves an extension of traditional behavioral couple therapy with added components of acceptance. CBT draws heavily on behavioral couple therapy, cognitive therapy and basic cognitive and social psychology research on information processing. Some of the main change interventions have included: Behavioral exchange: aims to help couples increase positive behaviors and interactions that they experience in daily life. The therapist helps clients identify what each partner can do to increase satisfaction, increase the frequency of those behaviors and review the outcome. This intervention is based on behavior exchange theory which assumes that all relationships depend, at least to some extent, on one’s determination of the costs and benefits of the relationship (with the idea that we typically attempt to minimize costs and maximize gains). If the rewards of a relationship outweigh the costs, the person will decide to continue the relationship. If there are more costs than rewards, the interactions can become conflict-ridden, or someone might perceive that they have an empty relationship. Of course, this is overly simplistic since behavior is more complex and people are not always so cold and calculating. Communication training: helps the couple to discuss and resolve conflict without resorting to destructive techniques. The emphasis is on the process rather than the content per se. This involves instruction in the general approach to communication (for example, focus what you are saying on yourself, avoid blaming, talk about soft emotions, double-check for accuracy, paraphrase); the couple then practices these new communication strategies and applies them in session so that the psychologist or therapist can provide feedback to the couple. Eventually, this is assigned as homework. Couples learn how to express their thoughts and emotions clearly, listen to their partner’s messages, better understand their partner’s perspectives and emotions, use constructive rather than destructive messages, use “I feel” statements and focus on behaviors of their partner rather than their personality. Couples also learn to listen attentively and non-defensively, refrain from interrupting, clarify what they are hearing, reflect on what they have heard and summarize. Problem-solving training: used for more instrumental problems (not issues such as attitudes, feelings and desires). Couples learn to discuss only one issue at a time, paraphrase to understand their partner’s intent, avoid inferring malicious intent and avoid aversive behavior (both verbal and nonverbal). From there, they learn to work through the basic stages of problem-solving (define the problems in behaviorally specific terms; compare perceptions and agree on the description of the problem; generate possible solutions; evaluate the advantages and disadvantages of each solution; select a feasible solution; implement the solution; and evaluate its effectiveness). More recently, acceptance-based strategies have been included in the treatment paradigm and added to the efficacy of the intervention. In fact, the traditional change strategies are now used mainly as a backup if a therapist is not getting enough traction from the acceptance strategies. Some examples of acceptance strategies include: Empathic joining: stop blaming and learn to develop empathy for what your partner is experiencing (identify emotions, particularly the painful emotions that each partner experiences during an incident and then show how these emotions are understandable and motivate each partner’s behavior). Problems are reframed as stemming from common differences (not deficiencies) and emotional sensitivities. Unified detachment: the therapist encourages emotional detachment and helps the couple to use a more objective, distanced, intellectual analysis of the situation (for example, treating the problem as an “it” rather than blaming the other). Tolerance building: many couples try to change the other person, convinced this should improve the relationship. You can help them give up the struggle to change and help them see that much of the pain is because they are working so hard to change the other. More information is available at the following link: https://www.guilford.com/books/Clinical-Handbook-of-Psychological-Disorders/David-Barlow/9781462547043

Question 6

How do attachment styles (theory) fit with CBT models of depression? As a CBT therapist, how can I integrate attachment ideas in helping my clients with depressed mood who also struggle in their romantic relationships?

David Dozois · Accepted Answer

Bowlby’s attachment theory proposes that children with a secure attachment to their caregiver learn to self-reassure. In contrast, children who grow up with caregivers who are inconsistent in responding to their needs learn to seek assurances externally instead of internally. The basic idea is that we develop an “internalized working model” or interpersonal schema of self in relation to others. Research on adult attachment has demonstrated that individuals with an avoidant attachment style tend to minimize the expression of negative emotions and use deactivating strategies (such as avoidance of proximity) to deal with distress. On the other hand, individuals with an anxious attachment style tend to maximize the expression of negative emotions and use hyperactivating strategies such as proximity seeking or excessive reassurance seeking (ERS) to manage their distress. As a result of early childhood experiences, individuals develop a set of core beliefs or schemas that influence how they relate to others in adulthood, along with their attributions, perceptions and emotional understandings of close relationships. Related concepts from CBT include Dr Jeffrey Young’s abandonment/instability schema. Early core beliefs reflecting a high level of concern surrounding relationships (in particular, a fear of rejection and abandonment) are associated with behaviors such as ERS which may contribute to relationship distress and depression. There are a lot of similarities between internal working models proposed by attachment theory and core beliefs and schemas discussed in the CBT literature. As such, similar strategies used for targeting core beliefs and schemas (such as behavioral experiments) can be used for modifying attachment styles. Young’s schema therapy may also help to change a client’s internal working models. For couple therapy, basic behavioral communication skills training is instrumental in helping partners develop a more secure attachment to one another. Training can focus on effectively understanding and responding to a partner’s emotional needs. These principles could also be used in individual therapy to help clients communicate their attachment needs more effectively and increase the likelihood of them being met. More information is available at the following links: https://doi.org/10.1177/000306518403200125 https://doi.org/10.1037/0000332-010 https://doi.org/10.1016/j.cpr.2011.07.014 https://psycnet.apa.org/record/2009-02347-017 https://doi.org/10.1016/j.cpr.2019.03.003 https://www.guilford.com/books/Schema-Therapy/Young-Klosko-Weishaar/9781593853723 https://www.guilford.com/books/Clinical-Handbook-of-Psychological-Disorders/David-Barlow/9781462547043

Question 7

What does excessive reassurance seeking by one person do to the relationship? How can the other person respond in a helpful way?

David Dozois · Accepted Answer

As defined by Joiner et al. in 1999, ERS is “the relatively stable tendency to excessively and persistently seek assurances from others that one is lovable and worthy, regardless of whether such assurance has already been provided”. Although providing reassurance can help someone to feel better in the short term, it does not effectively deal with the problem and the person will likely increase this behavior over time (similar to how avoiding something you fear reduces anxiety in the short run but ultimately exacerbates anxiety long-term). ERS can sometimes lead to an intractable dilemma: the person both needs and doubts their partner’s reassurance. ERS is one of those interpersonal variables that can contribute to relationship stress and depression. Interpersonal models of depression, for example, posit that certain behaviors and characteristics associated with depression (such as ERS) lead to the generation of interpersonal stress that, in turn, maintains or exacerbates depression. ERS can also lead to relationship difficulties and disrupt feelings of connectedness with one’s partner. Continually asking questions about one’s lovability and self-worth that have already been answered often implies that one doubts the truthfulness of the responses (for example, “I just told you I am not angry, why do you keep asking?”). Our research has found that individuals are more likely to seek reassurance about relationship security when they possess early core beliefs reflecting insecurity in relationships rather than symptoms of depression per se. There are many ways that clients can learn to modify ERS. Firstly, it can be helpful to understand how the process works. An individual who seeks too much reassurance can learn how their own insecurity and abandonment fears lead to negative emotions and detrimental behaviors. For example, someone may have the thought “my partner does not really love me and will eventually leave me,” which leads them to feel sad and anxious and to seek reassurance that their partner truly loves them. Repeated reassurance seeking may cause the partner to withdraw from them and spend more time alone or with others, which may further fuel the client’s insecurity and contribute to sad feelings and beliefs of being unlovable and worthless. Helping the person to understand how their automatic thoughts influence subsequent emotions, behaviors and the responses of others may increase their motivation to apply more evidence-based thinking. It can also be helpful to monitor ERS behaviors. Often our behaviors improve when we become aware of them. Through self-monitoring, the person may realize that seeking reassurance is not a long-term solution but part of the problem. Moreover, it can be valuable to test the validity of their excessive need for acceptance and approval and develop more realistic thoughts (for example, no one can be universally liked and approved of). A number of behavioral interventions can also be helpful. For instance, you could encourage your partner to refrain from negative behaviors such as reassurance seeking for a predetermined amount of time and keep track of their thoughts and emotions and the responses of others throughout the experiment. Such behavioral experiments can demonstrate to your partner that changing how they interact with you can benefit your relationship and elicit more positive responses. You could also encourage your partner to engage in a strategy called exposure and response prevention. This is an effective treatment for Obsessive Compulsive Disorder. In depression, this involves reducing maladaptive ERS and shifting toward more adaptive expressions of dependency needs. The goal is to help your partner develop a more flexible, healthy balance of independence and connectedness/support seeking (not to remove dependency behaviors altogether). Cognitive behavioral interventions for ERS often encourage individuals to refrain from seeking any reassurance and preventing loved ones from providing it. However, a more effective approach might be to offer support without providing reassurance directly (it is helpful to discuss this with your partner and agree on how this will unfold). For example, instead of responding with “yes, I love you,” the partner could provide support to alleviate stress without answering the question directly (such as “I can tell that this is really difficult for you, but I know that you can handle this”; “we agreed that I will not answer that” or “you are seeking reassurance again”). Neal and Radomsky found that this kind of supportive feedback was more palatable to the person seeking reassurance and effectively disrupted the cycle of ERS. More information is available at the following links: https://doi.org/10.1016/j.cpr.2011.07.014 https://doi.org/10.5964/ejop.3059 https://doi.org/10.1521/jscp.2014.33.4.295 https://doi.org/10.1207/S15327965PLI1004_1 https://doi.org/10.1007/s10608-019-10007-0

Question 8

I have had depression for approximately 30 years. I have tried everything: exercise, antidepressants, retreats, St John's wort, prayer, being positive, sunshine, et cetera. What would you recommend?

David Dozois · Accepted Answer

I am so sorry to hear that you have struggled with depression for so long. It must be very difficult to have tried so many treatment options but not to feel as though you have found something that can help you overcome depression. Depression is a complicated problem. There are many pathways into depression – fortunately, there are also many pathways out. If you have not tried an evidence-based psychological treatment, that would be my first recommendation (either alone or in combination with antidepressant medications). The most evidence-based psychological treatments for depression include Behavioral Activation (BA), CBT and Interpersonal Psychotherapy (IPT). BA is based on a model which suggests that loss, reduction or persistently low levels of positive reinforcement contribute to the onset and maintenance of depression. By countering avoidance, withdrawal, rumination and inactivity, BA helps individuals with depression to re-engage fully in their lives. Specific strategies are used to help clients increase their functioning and ability to engage in behaviors that enhance sources of positive reinforcement (for example, pleasure- and mastery-oriented experiences), reduce activities that maintain or exacerbate depression (such as avoidance and rumination) and learn how to problem-solve effectively. Clients learn to act from the outside-in rather than inside-out. In other words, instead of permitting mood to dictate their behavior, clients are encouraged to commit to act in antidepressant ways despite how they are feeling – by doing so, mood, energy, motivation and life satisfaction improve. CBT aims to help individuals shift their cognitive appraisals and beliefs from unhealthy and maladaptive, to evidence-based and adaptive. CBT is a structured, collaborative process that helps individuals consider both the accuracy and usefulness of their thoughts through processes of exploration (determining one’s idiosyncratic meaning system and maladaptive beliefs), examination (reviewing the evidence for and against a particular belief and considering alternative interpretations or explanations) and experimentation (testing the validity of one’s belief system). Therapy typically begins with BA (especially for more severe depression) and moves toward helping clients identify, test and modify the thoughts and deeper beliefs contributing to their depression. The client and therapist work collaboratively throughout treatment. IPT is based on the idea that depression is the result of interpersonal problems and that if you can solve the life problem, depressive symptoms should also dissipate. IPT focuses on four main interpersonal problem areas: grief and loss; interpersonal disputes; role transitions; and interpersonal deficits or sensitivities. Each of these interventions has good empirical evidence that supports their use for the treatment of depression. More information is available at the following links: https://doi.org/10.1146/annurev-med-052209-100032 https://doi.org/10.1037/0000332-010 https://www.guilford.com/books/Behavioral-Activation-for-Depression/Martell-Dimidjian-Herman-Dunn/9781462548385 https://www.amazon.com/Current-Psychotherapies-Danny-Wedding/dp/1305865758

The Link Between Depression and Relationships

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