- Patients consider their depression due to external sources of stress or conflict. These include: conflict with work colleagues, or family, chronic illness, events in childhood, material disadvantages and racism. Doctors mostly think of depression in terms of presence of symptoms, in terms of illness. Being unable to cope and disturbances in everyday functioning and social roles (e.g. husband or wife, caretaker, breadwinner)is what depressed patients perceive
- Seeking help from general practitioners or other health professionals by depressed patients is problematic. Mostly done as an option of last resort, rather than through a specific expectation. Doctors mostly think patients visit them with a specific expectation that assessing the service will be helpful. Patients visit their GP because inaction was leading to negative consequences for other family members, complicated by feelings of guilt, or shame and lack of legitimacy. Asking for help is probably also perceived as a threat to an already weakened sense of self. There might be fear for treatment options that a patient might find unacceptable. Covert presentation of psychological problems is another obstacle in diagnosing depression.
- Seeking help and treatment is primarily associated with failure of strategies to cope by patients. These failing coping strategies are mostly seeking distraction or the use of particular locations associated with feelings of safety and control. Seeking help is not associated by patients with negative feelings or symptoms of depression. Taking medication e.g. is mostly not a measure for patients to feel in control and recovering a sense of self and social functioning.
- Stigma associated with treatment due to feelings of loss of control, lack of legitimacy in seeking help for a non-physical problem. Lack of control especially due to taking medication (antidepressants). Taking medication is related to a moral discourse about personal responsibility, the fear of loss of function in everyday life and a need to accept help for the sake of others. What to tell others that they were taking antidepressants, taking medication was perceived as somehow deficient, afraid of long term changes to their personality.
- Understanding of self-help is difficult when suffering from low self-esteem and lack of motivation.
How can these insights help guided self-help?
- Patients description of their problems differs from the biomedical model such as used by doctors. The subjective experience of depression with the need to restore social functioning should be prioritized over symptoms. Maximize the resources the patients already bring with them. Be aware of the patients' own constructions of depression and their current coping mechanism.
- Promote primary care as an appropriate place for mental health problems, not only physical symptoms. Primary care as a suitable location for mental health care
- Patients develop individual strategies for controlling feelings. Guided self-help is largely based on cognitive behavioral therapy. It may not be optimal to replace every day strategies with evidence-based strategies. Accept the individual strategies as important and built the self-help on them.
- Provide means of management of depression wider than medication. Make it more acceptable to them and others around them.
- Promote the feelings of strength to overcome negative feelings and depression. The self as mechanism of change of taking control. Support the active role of the patients. Control and social functioning are important to patients.
Now these mutterings are the interpretation by yours truly of a recent article. What do you think? Do these differences and advise regarding self help sound reasonable? Or are they just another misconception by a good willing professional?
Br J Psychiatry. 2007 Sep;191:206-11.
Guided self-help in primary care mental health: meta-synthesis of qualitative
studies of patient experience.
Khan N, Bower P, Rogers A.