CBT for depression and perfectionism

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Understanding depression

Symptoms of depression:
– Depressed mood: feeling hopeless/miserable/irritable/numb/empty.
– Losing interest and enjoyment in previously enjoyed activities.
– Self-criticism and guilt.
– Pessimism.
– Hopelessness.
– Loss of energy.
– Reduced activity.
– Withdrawal from social activities.
– Difficulty concentrating.
– Memory difficulties.
– Changes in sleep patterns.
– Changes in appetite and weight.
– Loss of interest in sex.
– Thoughts of death (If you are having thoughts about suicide, get professional help as soon as possible)

Myths about depression:
‘Nothing bad has happened to me, there’s no reason I should feel depressed. It must be my fault’.
Reality: It can be hard to understand why you feel depressed but a psychologist can help. Depression is not your fault.

‘Depression is biological – there’s nothing you can do about it. Only pills can make a difference’.
Reality: Depression does appear to have biological factors and medication helps many people. However, therapy can also be very beneficial by helping you make changes in the way you think and behave.

‘Other people can cope with worse things happening to them without getting depressed. I must be weak’
Reality: A lot of people may appear to be coping, when really they’re struggling too. Also, it is important to remember that feeling you cannot cope is a symptom of depression.

‘I should be able to just snap out of it’
Reality: If it were this simple, no one would ever be depressed. Vast amounts of money is poured into mental health resources because it is recognised that people can’t just snap out of it. Talking in a constructive way has been shown to help a lot of people.

‘Why should I take medication? It won’t help change the things that make me depressed’.
Reality: Medication can help improve your mood and help you cope with your problems in a different way.

Links between thoughts, emotions and behaviour

Your thoughts and evaluative judgements mediate between experiences and emotions/behaviour.

Situation: Lose job
Certain life experiences can make people more likely to develop depression. However, not all people with these problems get depressed- it depends on their evaluative judgements of the event.
Thoughts: ‘I’ve failed. I’ve let my family down. I won’t get another job now’
Even if something bad happens, there are a number of different ways of thinking about it. John could have thought ‘well, that was unfair but I’m sure I’ll find another job- maybe even something I like more’. People with depression tend to see things in a way which is harsh, self-critical, unfair and unrealistic. With thoughts like ‘I’m a failure’ it is understandable that John should feel low.
Physical changes: Can’t sleep. Poor concentration. Loss of appetite. Fatigue.
Depression has many physical symptoms, which can in turn have a big impact on people’s behaviour.
Emotions: Sad. Disappointed. Depressed.
Once people start to think in a negative way, their feelings naturally follow. Once the negative emotions start, they make it more likely that people’s thinking will become negative, leading to a vicious circle.
Behaviour: Withdraws from friends and family. Stops doing hobbies. Stays in bed.
Often people with depression are withdrawn, stop caring for themselves, have problems with everyday tasks and have less involvement in rewarding activities.

All of these are connected and influence each other, often leading to vicious circles. It can be difficult to manage but it can also mean that making positive changes in one area, can lead to changes in others.

Steps to start tackling your depression.

Get going again.

When people feel depressed they often start doing less, including stopping activities they previously enjoyed. This can then make them feel worse.
Step 1: See what you’re actually doing by keeping a diary or using an activity monitoring sheet. Rate each activity in terms of achievement and enjoyment.
Step 2: Make a list for yourself including involvement with family and friends, Self-care, Personally rewarding activities and Small duties (eg paying bills).
Step 3: Pick your goals: Pick 2 of the activities (preferably from different areas) that you listed that are the most practical for you to start doing now.
Step 4: Make SMART goals: They should be Specific, Measurable, Achieveable, Realistic and Time specific.
Eg instead of ‘I want to eat more healthily’ you could say ‘I want to eat 2 pieces of fruit every day for 2 weeks’
Step 5: Carry out your goals: Keep a record of how you’re doing and reward yourself. This can be hard because when people are depressed, they tend to focus on the things they haven’t done and ignore or downplay their achievmenets. Deliberatiely remind yourself of what you’ve done.
Step 6: Review your progress: Are these activities having a positive impact? Do you want to increase your goals slightly?
Are you struggling with them? Do they need to be more specific or manageable?

As your energy starts to come back you will be able to do more and more. The most important thing is to start moving, no matter how slowly. When you feel ready start adding another smart goal.

Negative thinking and depression.

Our evaluative judgements of an lead to low mood, rather than the event itself. For example, if someone walks past you without saying hello, the evaluative judgement ‘they must be angry with me’ would leave you feeling bad, whereas the evaluative judgement ‘they must be really busy’ wouldn’t. Either judgement could be true but people with depression tend to focus on the most negative one.
The first step is to start becoming aware of these thoughts. Try to note down the situation, negative thought and emotions (rate each one in terms of intensity).
Find alternatives: For each negative thought, try to note down a more adaptive one. Then rate your emotions again. It is important to do this repeatedly if you want to see change. It is not enough to do it once or twice if you want to start breaking the habit of negative thinking. Here are some questions that might help you come up with some more fair and realistic thoughts:
– What evidence do I have for this thought?
– Is there any alternative way of looking at this?
– How would someone else think about this situation?
– Am I thinking in all-or-nothing terms?
– Am I forgetting relevant facts?
– How will things be in X months time?
Preparing for trigger situations: There will be situations in your life which make it more likely for negative thinking to occur. Look back over your thought records and try to make a list of the top 3 situations. In future when you find yourself in these situations try to be aware of any negative thoughts and think of alternatives.

Recognising the positive

People with depression often ignore positive events and focus on negative things that happen.

Step 1: Keep track of good things that happen. Make a record of everything, no matter how small. Even if it’s just that you got out of bed today.
Step 2: Reward yourself for things you do manage. Eg go for a walk in the sunshine or spend 30 minutes watching your favourite program.
Step 3: Get a more positive view of yourself:
Make a list of as many positive characteristics you can think of.
If you’re struggling then ask friends and family to make a list for you.
Or think about what bad characteristics you don’t have eg I’m not rude.
Try to carry the list with you and look at it when you’re feeling low.

Also remember

Physical activity can help. Frequency is more important than duration. Pick activities you enjoy.
Sleep is important for mood. Try to have a set bedtime and rising time.

Perfectionism

Identifying Over-evaluation of achieving
Most people evaluate their self-worth based on a variety of things, such as their relationships, hobbies, leisure activities, achievements at work, and other abilities. Their self worth pie chart could include 11% social life, 15% money, 21% family, 6% body shape, 8% job, 6% travel, 11% sport and fitness, 11% future goals, 6% partner and 5% community.

Perfectionists tend to judge their self-worth based almost entirely on achieving their unrelenting standards. They overvalue achieving and achievement. They may have other interests, but over time these seem to take a lesser place in their lives. This system of self-evaluation may have developed through particular life experiences and/or positive reinforcement from people around them. People who try hard and are successful are often rewarded by others so achieving can become equated with being hard-working, conscientious and intelligent- in short, being of worth.

Perfectionists come to believe that they are only of worth if they are pursuing or achieving the high standards they set for themselves. Activities involving achievement take up a very large part of their pie chart, and become overly important in their lives. They begin to judge their self-worth largely on their ability to achieve. Their self worth pie chart could include 9% sport and fitness, 9% studies, 7% friends, 11% family and 64% achieving at work.

They often focus on one area of their life giving them all of their self-worth. This is very risky as any problems in this area will then lead to the person judging themselves negatively and think they are of no value. They are therefore putting a huge amount of pressure on themselves to make sure that it works out. That’s why it’s not surprising that perfectionists tend to be very focused on achieving the high standards they set themselves. It is also not surprising that they often feel stressed, irritable, depressed, anxious and guilty, and think negatively about themselves. When a goal is achieved they may feel relieved but they don’t tend to feel happy for very long. In fact, perfectionists tend to dismiss their success (‘I was just lucky’) or conclude that the standard set was too low (‘anyone could have done that’) and re-set the standard higher for next time.

Work and education use to take up most of my pie chart. Try drawing your own one and see if it’s balanced or unbalanced.

To expand your self-evaluation across different life areas. For each of these areas, think ‘Who do you want to be in these areas? What do you want to do in these areas?’

My social life
My work/education
My finances
My emotional health
My relationship with my partner
My relationship with my children
My relationships with my close friends
My relationship with my parents/siblings
My contribution to the community
My spiritual life
My valued pastimes and hobbies
My fitness and physical and nutritional health
Etc

Then identify goals for some of these areas by looking at
The changes I want to make:
The most important reasons I want to make these changes are:
The steps I plan to take are:
I will know the plan is working if:
Things that might interfere with my plan and how I will overcome them are:

4 thoughts on “CBT for depression and perfectionism

  1. Thanks for sharing this. Even though I’ve done quite a bit of CBT, there were some new insights for me here – so I very much appreciated reading it! Thanks again 🙂

  2. I feel I should mention, your blogs come to my inbox and I always read them.
    This one is particularly useful to me, as although I’ve done a lot of therapy no one has ever suggested making up a pie chart for the perfectionism. It sounds like a great idea for me! Thanks for continuing to write these informative posts about mental health and well being 🙂

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