One of my favorite activities during the week is consultation with individual and small groups of therapists. Consultations help me refine my understanding and teaching of the connections between CBT theory, methods, and clinical practice. Questions asked often prompt new creative ideas.
Over the past few months I have been consulting with one group on depression and suicide interventions, drawing on ideas from my new workshop, Best Practices: CBT for Depression & Suicide. Recently we talked about clients who have had particularly harsh lives and are now embedded in very difficult life circumstances. When these clients are depressed and suicidal, it sometimes is very difficult to find areas of their life in which they experience pleasure or to get them to agree to do pleasurable activities. Sometimes they try to engage in pleasurable activities but experience nothing positive.
When this was brought up in the consultation session, I invited group members to stand up and walk around the office in which they were sitting. I asked them to take two minutes and find something in the office that brought them at least a little pleasure. It might be something they see, hear, taste, touch or remember. When everyone sat down, I invited several people to say what they found.
One woman said she found pleasure looking at the tree outside the window and also the plant inside the office. Another found pleasure in looking at the coffee cups on the floor because they reminded her of the smell and taste of coffee which she loves. We then discussed how these individual experiences could be used to fine tune homework assignments regarding pleasurable activities. The first woman might have better success experiencing pleasure during the week if she could be in nature. She might even go to a nursery and buy a small plant to tend at home. If the second woman had trouble getting out of bed in the morning, her therapist has learned that she would be motivated by coffee. Getting her to linger with each cup of coffee, savoring the smell and taste, could be the best first pleasurable experience during her difficult days.
If a client did not find anything in the office pleasurable, I might invite him or her to look for pleasure while I coached the experience. We might look together at a piece of artwork and choose colors, textures, meanings we each prefer in it. Next we could listen to some music, open the window and look outside, or feel the texture on the sofa. Such sensory experiences can help clients learn that pleasure involves engagement and also openness to attending to very small experiences. Sometimes these experiences will evoke interfering assumptions, “It is wrong (or impossible) to experience something positive when I am going through such a terrible time” or “Feeling better for one minute means nothing when the depression just crashes in on my again.” These thoughts can be discussed, weighing the pros and cons of living according to such beliefs.
When clients struggle with homework tasks outside of session, I think it is wise to begin to do those tasks in session. A two minute in-office experiment often can be very helpful in locating pathways to help nonresponsive clients. In session practice, role plays and experiments help us assess what strengths a client has and offer opportunities to help our clients develop additional skills.