When clients can’t see the path forward, explore the path backward

By Randy J. Paterson, PhD

Clients who have been suffering from depression or dysthymia for a long time often have difficulty believing that doing things differently will have a positive impact on their mood. This makes it hard to commit to the work of therapy.

You can cite the research, tell stories of other people’s successes, and invite them to treat therapy as an experiment—“let’s try it and see.” But many still won’t think that anything they do will have a positive impact on their mood.

In such cases, you can turn the exercise around. Invite them to imagine that the task was to feel worse rather than better. I often propose a hypothetical fortune that hinges on their ability to feel particularly awful next Tuesday. How would they go about this?

Conduct a brief brainstorming exercise, prompting both for things they might do and ways they might think in order to lower their mood. After a brief pause, many clients can come up with a substantial list: don’t exercise, stay at home, isolate, eat junk food, inventory past failures, imagine future catastrophes, listen to hurtin’ songs, and so on.

This has two effects:

1. Clients realize that they really do have at least some control over their mental state: they could make it even worse if they wanted to do so. Perhaps if the way downward is at least partially under their control, the path upward might be as well.

2. They realize that they are already doing at least some of the items on the list, even though they don’t want to feel any worse. Perhaps if they could stop some of these things, substitute them with other behaviors, or just do the opposite—things might be better.

Some clients take it a step further, realizing that depression can be, at least in part, something one does as much as something one has. Whether they arrive at this latter conclusion or not, the exercise can open the door to behavioral activation, lifestyle change, and a contemplation of the validity of the depressive thinking.

Randy J. Paterson, PhD, is director of Changeways Clinic, a private psychology practice in Vancouver, BC, Canada. He is author of The Assertiveness Workbook and Your Depression Map, and conducts training programs for professionals on evidence-based treatment. His forthcoming book, How to Be Miserable, is available May 1.