The Palo Alto approach, brief, systemic and strategic therapy in depression

by Béatrice Giraudeau - Therapist and life coach / LACT research partner

Blog: Sculpt your life - 

Set the scene 

Depression is a bit like an abandoned house, where you can only contemplate, powerless, the spectacle of your life in ruins... It's extreme suffering, caused in particular by the loss of desire. The will to live is gone and existence is collapsing like a house of cards. Days and nights pass, immutable in sadness and despair, insomnia sets in and ruminations around an announced end, gradually nibble at the brain. The painter's palette focused on grays and black, like an intolerance to light. No way out, except that of renunciation. There's no way out when the future is seen through the eyes of the present, those who are only feeling black. Rideau, move on, there's nothing more to see!

"He is tired the handsome prince charming" as sang the late Michel Delpech , himself struck down at one point in his life by a terrible depression.

Philippe Labro , a multifaceted man, journalist, writer, filmmaker, recounts his depression in Falling seven times, getting up eight . It evokes this sadness without tears and the effects of the grinder that gnaws at your belly. Here is an excerpt that masterfully describes this crossing into another world:

"It happened surreptitiously, slyly, without warning, a real mess, a slow and insidious penetration. I am the slave of an indefinable thing which is destroying me and I obey it without any resistance... Something thing has changed."

I could also quote Guy Birenbaum Le Monde titled after the publication of his book: You missed me.
History of a French depression. Extract:

"I'm French, I observe, I comment, I share my country's great conversation on the radio, on the web, on a daily basis. It's
my job. I tweet, I facebook, I blog, I instagram. I think I'm strong. Stronger than the others. I brag. I'm wrong. Everything is in place for the big slide....
I have no idea when it caught up with me. I remember "a great weariness, tears that flow as if inadvertently. Then nights soaked in sweats, back and stomach pains; heart racing. One morning, I was unable to get up. Depression left me I was bedridden. I didn't want to see anyone. I was afraid of everything...."

State of play

The number of people with depression is staggering; thus more than 300 million people in the world suffer from this mood disorder with a clear female predominance (I would have made the polls lie by quoting 3 men), and France is the first prescriber of antidepressants . Not to mention that depression is the number one cause of suicide . And to give weight to a self-fulfilling prophecy, studies conducted in the United States announce that in 2020, depression will be the second cause of disability behind heart disease.

Faced with the seriousness of this mood disorder and this very debilitating suffering, it is essential to take stock of the symptoms in order to clarify everyone's minds; being depressed can remain a difficult part of your life, without falling into depression. This one is not a simple blow of blues. It is part of the long term, paralyzes the taste for life.

According to the DSM 5, Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association , the diagnostic criteria for depression are as follows, knowing that among the 9 symptoms mentioned, at least 5 must have existed for 2 weeks and the one of the first two must be present:

• Almost permanent sadness, sometimes with tears
• Loss of interest and pleasure in all daily activities, even the usually pleasant ones
• Excessive or inappropriate feelings of worthlessness and guilt
• Recurrent thoughts of death or suicide
• psychomotor retardation
• Fatigue (asthenia) often in the morning
• An appetite disorder (increase or reduction) with weight gain or loss
• Sleep disturbances (insomnia or hypersomnia)
• Attentional difficulties of concentration and memorization

Note that all ages are affected by depression;
children and teenagers are no exception, nor are the elderly. Societal pressure and loneliness are activators of depression. In the very front line, general practitioners do not have an easy task faced with the considerable mass of these patients struggling to live, not to mention the current avalanche of burnout;
they lack time, and they find themselves faced with a double constraint: Detect and diagnose as quickly as possible for early treatment, and not psychiatrize existential and social problems which would lead to an abusive prescription of psychotropic drugs.

The Systemic and Strategic Therapy Approach to Depression

NB: It does not replace a medical diagnosis, but offers effective therapeutic support, in close collaboration with doctors and psychiatrists. Each case of depression is unique, because it is intrinsically linked to the person interacting with those around them, and to the context in which they live.

All attempts at a solution, aggravating and counterproductive, will be stopped and replaced by the famous 180° approach of the Palo Alto school. Prescriptions will be given to the patient. Note that in depression, we only start with observation tasks, because the strategic movement is to brake. The strategic and reframing reformulation of the problem is essential to lead the patient towards a small seed of change, a different look, "a difference that makes the difference".

1) The first step of the therapist is to "join" the patient in his suffering , without judgment and a priori. Go into his vision of the world , built and invested with his own feelings, sensations and emotions, his beliefs and the context in which he lives. Help him identify and clarify his symptoms in a strategic and metaphorical approach, because the patient is in the eye of the storm and no longer sees anything:

• Do you feel like your future is blocked? That you're stuck in quicksand?
• Have you given up in your actions, but not in your mind, or have you given up totally?
• Are you disappointed in yourself, in others, or in society?
• What hurts you the most? The loss of all desire, or the fear of never being able to get out of the tunnel?
• How will you know you are getting better? What is the first thing that should change? Etc.

It is a question in our therapeutic jargon of "problematizing" the situation, by looking for the functioning of the depression, and not the why . The search for "how depression was built" , gives the workings of the problem and what maintains it, even aggravates it.
(We will see this later with the attempted solutions). Moreover, giving meaning to the depressive state of the patient is an essential reframing which makes it possible to relieve him of guilt;
guilt that pushes him to exhort himself, to push himself to do, to get back in motion to assume his responsibilities (of parents, spouse, within his work, at school, within society... ), and respond to the injunctions of those around you and the dictates of society. Which exhausts him even more. For this reframing, the therapist presents his patient with another level of reading. Indeed, if the patient slows down and brakes with four irons, it is because he has good reasons, unconscious of course, but vital for him. From the point of view of archaic survival programs, the reptilian brain, which ensures the survival of the species, has found nothing better than to say stop! Slowing down allows you not to hit the wall, not to lose yourself more... The therapist uses metaphors to get the message across:

•  "Your brain has found the circuit breaker, it has pressed stop, you will finally be able to breathe and recover"

This disguised injunction is equivalent to slowing down the patient even more, which already represents a 180° and impacts a strategic change.

2) A second phase, very characteristic of the systemic, is to consider the patient in his interaction with his entourage , in order to identify and stop the attempts at solution : who says what, who does what, who intervenes in the expression and the collateral damage of depression? This also involves working with those around you (parents, spouse, family and company, etc.)

• When you tend to compare yourself to others or to before, does it improve you or degrade you?
• Are you doing something to get out of the problem or have you given up?
• Do you ask for help or do you expect those around you to comfort you?
• Who is your close entourage who intervenes daily?
• What does or says those around you to help you?
• And when those around you help and comfort you, does that improve or worsen your inability to do things?
• Do you tend to avoid every situation that scares you, or do you push yourself to go for it? (I must, if I want I can)

....
Attempts at a solution, including reassurance and help from relatives, only aggravate the problem.
Indeed the 1st message delivered is: "I love you, I am here to help you"
the second implicit message is: "You are not capable of.... " and the circle is closed.
The advice of those around you is legion: "shake yourself up, make an effort, take it upon yourself, you have everything to be happy, stop hanging around, change your mind, get out! ..." To stop these attempts
to solution, the strategic dialogue will constitute to provoke a greater fear vis-à-vis the requested or given help: "Every time you reassure him, push him to do, you send him the message that he (she) does not is not capable of...., that his depression has no meaning, and he (she) collapses even more, even more desperate.
A word about the entourage who also suffers from this state, sees his life turned upside down by the depression of one of his family and intervenes to help him get out of the suffering, with a great feeling of helplessness which makes him suffer, provokes anger and weariness in the face of the complaint the depressive person.
Imagine the life of a clan, organized around the place and the function of each one; the survival of this clan passes by the maint much of the balance of this organization that I could call homeostasis , principle of internal regulation, specific to any living system (organism, family, company, society, caste...) Which sheds light on what urges the entourage to push, encourage and get the person out of their impasse as quickly as possible.

Everyone is in danger! Joining the entourage will allow him to be better reframed to stop his attempts at a solution. 3) A third step will close the session and prepare the patient's inter-session.
After "softening up" the system, the therapist gives prescriptions and observation tasks that will further identify attempted solutions as well as any aggravating factors. It is deliberately that I do not give them to you, because I cannot post these prescriptions and strategies which would not be there any more. It would be a bit like selling the skin of the bear before killing it... These three steps are reductive and simplified, but it is useful to remember that "too much information kills information". Gregory Bateson

Before you leave...

To conclude, and if you are interested in the subject, as well as brief systemic and strategic therapy, I can only recommend the next free LACT web conference, entitled Dealing with depression (in the workplace) on Tuesday March 22 from 11 a.m. to 12 p.m.
LACT is an intervention and research firm, specialized in the systemic and strategic regulation of individual or collective psychological and relational disorders. In its vocation to raise awareness and recognition of systemic and strategic brief therapy scientifically and methodologically, LACT currently brings together 50 research partners, therapists (including myself), psychologists, doctors and stakeholders in systemic regulation in the company.