Compassion and Depression

What I want to cover:
1 If you have any particular interests in the subject
2 My background and interest in the subject.
3 Definitions of compassion.
4 Its importance
5 The body and compassion
6 The first few steps towards self compassion
7 Questions you may ask
8 Great podcasts and books etc

Have you any particular interests in the subject

2 My background and interest in the subject.
Current work
Work in the University on emotional intelligence
Failures as a therapist

3 Definitions of compassion.

Paul Gilbert and Kristin Neff are the two practitioners I think are most associated with compassion focused work.

Gilbert: Being sensitive to the suffering of self and others with a deep commitment to try and relieve it.

Differs from kindness: Kindness are acts – small or large – which are given to create pleasure or help suffering

Differs from sympathy: Appreciating the pain someone else is experiencing.

Differs from empathy: Understanding how another person feels or thinks whether it is a negative or positive feeling or thought but may not necessarily result in an attempt to alleviate suffering.
Emotional intelligence may or may not result in compassion. Emotional intelligence allows the recognition of distress in others and usually results in attempts to alleviate distress but not always. Emotional intelligence may help the individual regulate their own emotions when in an emotionally charged situation and may allow them to choose to help them in the best possible way.

Gilbert discusses how compassion often involves a turning towards suffering and not turning away from it.

4 Its importance

Mental ill health often involves self damage which can be physical or mental.

Self criticism can be regarded as a severe form of bullying – bullying of the worse kind as often we can eventually escape an external bully. For a great description of this listen to Brian Moore on desert Island Discs:

Many people with depression can not engage in CBT which require them to identify and work with their negative thoughts – why prod a sleeping Ogre?!

Gilbert’s sensitivity alerting him to the distress this caused his patients.

With the risk of me being insensitive can I ask if you identify with this?

5 The body and compassion

This part of Gilbert’s work interests the scientist- practitioner in me.
Gilbert observes how we are designed to be alert to threats and for those of us who have had the luck to have had supportive experiences in childhood or more recently can draw on these in times of threat. These may be in the shape of memories or current support available.

Compassion focused therapy aims to improve the person’s ability to self soothe by recreating or remembering memories of support. For some it may require an encounter with a compassionate practitioner as a reminder or maybe their first experience of compassion.

Compassion focused therapy involves balancing physiological systems in favour of those that physically soothe us – so that adrenaline systems and other stress body structures (amygdala etc) become less active and the person becomes better able to accept and give compassion including self compassion.targets

6 The first few steps towards self compassion

These are very important as people who are self critical may find kindness from others quite alien. To accept compassion requires “mega” trust and this is an issue for many with adverse backgrounds.

Being offered compassion can easily become part of the problem as people become defensive in the face of it. Compassion focused therapists may need to tread gently as “they may tread on their dreams”.

Steps may involve: building trust; helping a person identify the self critical voice; identifying the benefits and costs of self criticism in their lives; identifying and valuing a compassionate voice; how to respond when the critical voice starts up and gets louder.

Acceptance of the critical voice without going along with it can (paradoxically) make it quieter – listen to Brian Moore on this (below).

Gilbert in his podcast and in his books discusses how helping people take practical steps and behave compassionately towards themselves is often more tolerable to people who have strong habits of self criticism.

7 Questions

Questions worth considering after break in pairs or as a group (small or large)

1 You may want to look at the questions on the questionnaire and see whether these help you identify problem spots for you.

2 A good question to ask yourself is if you were less self critical what would you be doing that is different – this will give you ideas about doing things that may start you behaving more self compassionately;

3 What practical steps can you take to reduce your self critical voice?

Steve Lyon Fully accredited Cognitive Behavioural Therapist (email: PGDipCBT; Dip Couns: Dip Nurs; MSc; BEd (Hons); RMN; RGN; RNMH; FHEA

Do not judge, and you will not be judged. Do not condemn, and you will not be condemned. Forgive, and you will be forgiven. Give, and it will be given to you
LUKE 6:20-42

Great podcasts and books
Two Podcasts featuring Paul Gilbert:

Kristin Neff Podcast:

Compassionate Mind website:

Brown, B., Crawford, P., Gilbert, P., Gilbert, J., & Gale, C. (2014). Practical compassions: Repertoires of practice and compassion talk in acute mental healthcare. Sociology of Health & Illness, 36(3), 383-399. doi:10.1111/1467-9566.12065 Link
Crawford, P., Brown, B., Kvangarsnes, M., & Gilbert, P. (2014). The design of compassionate care. Journal of Clinical Nursing, 23(23-24), 3589-3599. doi:10.1111/jocn.12632 Link
Crawford, P., Gilbert, P., Gilbert, J., Gale, C., & Harvey, K. (2013). The language of compassion in acute mental health care. Qualitative Health Research, 23(6), 719-727.
Gilbert, P. (2005). Compassion: Conceptualisations, research and use in psychotherapy. London: Routledge. doi:10.4324/9780203003459 Link
Gilbert, P. (2007). Psychotherapy and counselling for depression. Los Angeles, Calif; London: SAGE. doi:10.4135/9781446279830 Link
Gilbert, P., & Choden. (2013). Mindful compassion. London: Robinson

Problem Solving for Rumination and Worry

woman working girl sitting
Photo by Alexander Dummer on

This talk will focus on problem solving and its role in helping people who worry and ruminate.
Problem solving important at all stages of life. Problem solving has been a process from dawn of time and evolution can be seen as a form of problem solving.
Problem solving useful in its own right but can be recognised as a process useful in tackling worry, rumination and anxiety.

Worry, rumination and anxiety
Let us first define what we mean by worry, rumination, and anxiety.
Worry: tends to be a process that interferes with attention and can be very unpleasant. It often involves vague targets and because of this can drift to other targets in a particularly unhelpful manner. Worry as a disorder can be measured using GAD7 or Penn State Questionnaire.
Rumination: Unhelpful preoccupation with past or current concerns, has an uncontrollable quality and person often describes it as being in a loop. It is frequently seen in depression and PTSD.
Anxiety is a strong emotional reaction to perceived threats in the future,
Worry and rumination are often described as BEHAVIOUR and that it can be strengthened if it results in a reward not dissimilar to doing something because it results in a reward. Examples of rewards: If I have a good meal in a restaurant I am likely to return there in future. If I watch a programme that makes me laugh or results in excitement ie “Bodyguard” then we are likely to tune into the programme again.
How then does worry or rumination result in a reward?
Worry and rumination is described as a process that involves vague concerns and therefore may be a form of avoidance.
Example: A young man has been seriously physically assaulted and the victim instead of recounting in detail the actual assault becomes drawn into thinking about how his personality, may have contributed to the assault.
Example: A depressed young lady ruminates over the reasons why her boyfriend left her and has not gone through a process of getting upset, angry and distraught by the incident.
The question then is what are the rewards for ruminating and worrying?
Answer: ruminating and worrying prevents the experience of strong emotion which may be avoided by particular people.

How does problem solving help?
You may have ideas of your own.
Problem solving at the simplest level may be regarded as an exposure strategy, That is people will approach a problem previously avoided and experience strong emotion but learn to cope with it. The fancy name for this is exposure.
Problem solving requires us to think about our problems and stay with them and not turn away from them and although this usually results in initial anxiety or low mood it will eventually work through. We are often overwhelmed not because we think about our problems but because we try and escape our problems. What then happens can be described as problem surfing = unsatisfactorily moving around problems in a perpetual game of ping pong.
But one of the most important reasons why problem solving works is that it helps people think in specifics and this is a real benefit. The research is there – rumination and worry is often reduced. When we start to think about our problems in specifics we get a real sense of what they are about – we experience the emotion associated with them and start to process them.
The treatment of PTSD is based on the need to get people to stay with images and feelings and not run from them – they are helped to recall their problems in considerable detail.
Worriers and ruminators often think in abstracts:
“Everyone hates me”
“My career will never happen”
“I was badly assaulted”
“I have always and will always be depressed”
These statements can be spoken with speed and without real depth of feeling and in a way that removes personal responsibility for challenging them and changing them. It’s a form of avoidance.
“I have always been depressed” can be seen as an unhelpful label that wrongly describes someone – “Depressed – well that’s just who I am so there is no need to try and change – so you can stuff your fancy ideas about therapy”. “I will always be depressed” – is a real block to recovery or growth.
Problem solutions

The problem is wonderfully and simply solved (or is it)?
A deep breath and plunge in – the water is freezing but we eventually warm up.
Getting started is a hard part and staying with the hard part is hard. We get anxious, we think we will fail, we believe it will confirm that we are a failure. Stay with it – embrace the anxiety. Let the “fail” words flit in and out again (mindfulness helps).
This is simply a form of exposure – learning that problem solving as an activity is initially scary but we become accustomed to it and more likely to do it in future.
Just the process of turning our vague ideas of what our problems are into clear and specific problems is beneficial.
I have known people recover just through the process of examining their feelings of being overwhelmed then turning them into a set of goals to be achieved.
This works because of the evidence that worriers and ruminators think about their experiences in abstract ways rather than in a more specific manner and this makes for sweeping and unhelpful generalisations.

Blocks to problem solving
Unhelpful self talk can stop us getting stuck into our problems “I wont be able to cope” – “I will fail” – “I would sooner do something else”.
Telling ourselves that we will do it later is a frequently used tactic that only helps in the short term.
Leaving it for somebody else to do is only helpful in the short term and we never learn to stand on our own feet.
Seeking reassurance for our solutions can be used as a delaying tactic.

Overcoming blocks
Just do it! If feeling overwhelmed break the problems into manageable lists. You can also weight each problem ie Importance and Difficulty.

Start with the most important and least difficult.
Don’t make creating the list the problem or a way of avoiding tackling the problem ie “I will sort it out when I have made my perfect list”.

Book that is useful: Watkins, E.R. (2016) Rumination-Focused Cognitive Behavioural Therapy. New York: Guilford.

Case Study: Polly Gets Stuck

Read this and suggest what advice/ideas you could give Polly

Polly has been very low in mood and frequently worries.

She lives with her Dad and older brother and has a boyfriend – they have been going out for 12 months. She met her boyfriend at school and he is to start university studying geography in Autumn.

Polly is studying for her A levels but at the same time is having arguments with her Dad and her boyfriend. Dad is not that keen on her boyfriend.

Her boyfriend wants her to spend less time studying and more time with him, Her Dad wants her to spend more time studying.

Dad expects her to spend her weekends helping him keep the house tidy and then studying in early evenings.

Polly has three assignments to complete: An English Lit essay; An essay on History; and an essay on Geography.

Polly loves doing the English Lit essay and spends a lot of her time on this and has nearly finished it. She hasn’t a clue what is expected of her in the History essay and dislikes the Geography essay because she doesn’t like the subject and is in danger of leaving it well alone.

Polly spends much of her time thinking how dumb she is for not being able to sort herself out but rarely voices her difficulties, but she in aplace where she would accept some advice.

Both Dad, her boyfriend, and her brother are caring and concerned and aware that Polly is struggling.


group of people sitting on white mat on grass field
Photo by Helena Lopes on

What this talk will focus on:
1 My own particular interest;
2 Why we should be interested in recruiting compassionate nurses;
3 What service users are looking for in nurses;
4 What other nurses admire in other nurses;
5 Recruitment processes for selecting nurses including emotional intelligence tests;
6 Recruiting service users – do they make the best nurses.
(see for additional views on this)
Additional notes appear on the mood-coach,com website for nurse applicants.

1 My own interests
I am a nurse who is committed to the ideas of sensitive and person centred care.
I recently watched a close relative during the end stages of their life and received excellent compassionate care but some care that was very distressing.
I was the champion of values based recruitment of student nurses in a Yorkshire University – this introduced ways of assessing for the most important values including compassion.
I am trained as an assessor of emotional intelligence and my pHd is looking at emotional intelligence and how it applies to nurses. My chapter in Clfton & Hemingways 2018 book is mostly about compassionate care.
(Further reading: Lyon, S.R (2018) Interpersonal Skills in A Clifton & S. Hemingway (eds.) Fundamentals of Mental Health Nursing. Wiley, Blackwell)

2 Why we should be interested in recruiting compassionate nurses
The Francis Inquiry identified some horrendous practices taking place in North Staffordshire and nurses were accused of lacking compassion. But its not the first inquiry and many have been conducted in “mental hospitals” ie Whittingham Inquiry in Lancashire.
The nursing profession is still reeling from the Francis Inquiry and on a weekly basis there are concerns that something similar to North Staffordshire may happen again.
These fears also surfaced through Nursing & Midwifery Council briefings to say that there are more nurses leaving nursing than are being recruited, many complaining about inability to nurse to a satisfactory standard. The Royal College of Nursing has also raised concerns about morale in the nursing workforce.
Nurses more than any other professional have more continuous direct contact than any other health profession so it is important that nurses are compassionate and treat people with respect and dignity.

3 What service users are looking for in nurses;
This is a question I would ask service users, although there is research that captures what service users have said previously.
Interestingly, service users value interpersonal skills over technical competence (Playle and Bee, 2009; Repper and Perkins, 2009)

Smith (2012) found that service users most valued commitment, making time available for them, helping them achieve things for themselves (giving them choices). Does this differ much from your views?

4 What I have found in my research
When interviewing third year nurses they valued other nurses who:
• showed commitment by going beyond their duties or seeing it as more than just a job,
• who were patient and helpful and willing to engage with difficult problems,
• had self control and managed their stress.
• who didn’t label people as difficult people if they presented a number of problems that were not instantly solvable.
The recruitment process is endeavouring to find people who have th potential to be caring, committed and compassionate.

5 The Recruitment process
Nurse recruitment has changed considerably based on research (see Health Education England, 2014 for detail). Interview panels are no longer the only process used to select people for nurse training.
Application forms: Application forms scrutinised for key words that demonstrate key values. Also make sure they have the right level of academic qualifications. Applicants can be deselected if the application is too brief or contain errors.
Workstations: Individual interviews via a workstation is a recommended practice. Structured and well designed Interviews have advantages over psychological tests and can help identify interpersonal skills (Mohammed & Mckay, 2017). Service users in charge of a workstation can be sensitive to which candidates relate well with service users and who have a good emotional understanding.
What would you do scenarios (Situational Judgement Tests): Individual interviews may be set up asking candidates for their views on particular situations. For example, “You are working as a first year student nurse and are told by another student not to spend time with a person who has a history of taking overdoses as this would reward this behaviour and we should be spending time with people who better deserve attention. What do you think and What would you do?

Emotional intelligence tests: Controversial tests not least because there is no agreement of what emotional intelligence is. Are we born with empathy (trait) or do we acquire empathy (ability). Because of this different tests exist with two examples given below (a trait and an ability test). Because of the controversy it is difficult to recommend its use and certainly as a stand alone recruitment test.

6 Do service users make the best mental health nurses?
This is a controversial area. People can profit from their experience as a service user and use this in a professional capacity. Service users need to be assured that they can use their experience to manage the stress that comes with the territory (just as most people applying for nursing should).There are additional notes below..

Additional Notes for Future Nurse Applicants
These notes aren’t written to give you an unfair advantage but to help you decide on whether nursing is right for you.
– Do considerable reading and research prior to applying for nursing. This will help you decide if nursing really is the career for you and will help you prepare for your written application and interview.
– Think through why you want to be a nurse and if you have the right qualities and desires to become a nurse. It is much better if you are able to select a career that is going to be satisfying and within your capability. There should be a good enough match up between nursing and your abilities/qualities but be careful not to dismiss some of your abilities.
– Nursing is more a career involving people than technical expertise although some nursing careers provides a nice balance of both. If you aren’t really ‘switched on’ by the thought of working with quite challenging people, then nursing may not be the best choice.
– If possible, get some real life accounts of what nursing is really like from people who do it.
Smith (2011) in her book about nursing points out that people who research nursing and find out the realities about this are more likely to make an informed choice to apply and better still are less likely to drop out of a nursing course.
The following resources may be of value:
For insight into health careers =
Youtube videos about different health careers =
About financial support =
About NHS Values including a self test:

Your application form. There are a lot of applicants for nursing but you can stand out from the rest. The basics must be right; with so many applicants if you can’t write without basic mistakes you will be rejected – check your application. Writing too brief can also be a switch off.
Have you decided what field of nursing you want to work in? Make sure the person reading your application knows from the outset you have decided on a particular field of nursing. Where you can give specific examples of how some of your past learning relates to this field especially if you have managed to get some experience that is not dissimilar to the field of nursing you are applying for.
Make sure your love of nursing comes over in passionate terms sometimes evidenced by the careful research you have done. Make sure you find space to discuss your qualities of empathy and compassion and respect for people.

Don’t write exclusively about how you looked after your Grandma or how you yourself were unwell. These are useful experiences but shouldn’t be at the expense of other material as you may come over as a little too focused on yourself and your family.
Attending for interview. Present yourself as if you are taking your application seriously. Chewing gum and attending far too casually dressed or in attitude, will switch off for some interviewers. Nervousness is natural and can make you appear animated and serious but don’t let it rob you of your ability to express yourself. Don’t let anxiety make you want to get it over so quickly that you give too short a response to questions. Have some questions to ask at the end.

The application process via UCAS:

Additional notes: service users as nurses
Compassion is an important but complex mental process. People who have a history of childhood trauma or even recent and severe psychological incidents can lead to difficulties in empathy and compassion. This is easy to understand, people in crisis naturally compensate by becoming more reserved. This is an intelligent response allowing a person to recover sufficiently before being able to give to others compassion and empathy. There is a link between lack of self compassion and lack of compassion for others. See Music’s readable book on these areas (Music, 2017).
But this need not be a hopeless position. With the right support and training people can recover from trauma sufficiently to be aware of triggers for a stress response and maintain an ability to be focused on others and less likely to become compassion fatigues.

Further reading:
Department of Health (2012) Compassion in Practice: Nursing, Midwifery and Care Staff – Our Vision and Strategy. Leeds, NHS Commissioning Board
Department of Health (2013). Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Robert Francis QC . (HC 947) Stationery Office
DHSS (1972)Report of the Committee of Inquiry into Whittingham Hospital, Cmnd 4861, HMSO
Health Education England., 2014b. Evaluation of Values Based Recruitment: Literature Review and Evaluation Criteria. HEE

MacCann, C., & Roberts, R. D. (2008). New paradigms for assessing emotional intelligence: Theory and data. Emotion, 8(4), 540-551. doi:10.1037/a0012746
Mohammed, S & McKay, A.S. (2017) Selection for team membership: complexity, contingency, and dynamism across multiple levels. In: JL Farr & NT Tippins (eds.). Handbook of Employee Selection: second edition. New York: Routledge.
Nursing and Midwifery Council (2017) Increasing number of nurses and midwives leaving profession ‘highlights major challenges faced by health and care sectors. (Accessed: 25.1.2018).

Playle, J. & Bee,P. (2009)Service user’s expectations and views of mental health nurses. In: P Callaghan, J. Playle and L. Cooper (eds.) Mental Health Nursing Skills. Oxford: OUP

Royal College of Nursing (2018) News: The RCN has called on the Government to lift the NHS out of the current “dangerous and downward” spiral. (accessed 24.1.2018)

Repper, J., & Perkins, R. (2003). Social inclusion and recovery: A model for mental health practice. London; Edinburgh: Baillière Tindall.
Waugh, A., Smith, D., Horsburgh, D., Gray, M., 2014. Towards a values-based person specification for recruitment of compassionate nursing and midwifery candidates: A study of registered and student nurses’ and midwives’ perceptions of prerequisite attributes and key skills. Nurse Education Today. (34) 1190-1195
Smith, P., & Smith, P. (2012;2011;2009;). The emotional labour of nursing revisited: Can nurses still care? (2nd;Second;2; ed.). Basingstoke: Palgrave Macmillan.

A Trait Test Example
1 = strongly disagree
2 = somewhat disagree
3 = neither agree or disagree
4 = somewhat agree
5 = strongly agree

1 I know when to speak about my personal problems to others 1 2 3 4 5
2 When I am faced with obstacles, I remember times I faced similar obstacles and overcame them 1 2 3 4 5
3 I expect that I will do well in most things that I try
1 2 3 4 5
4 Other people find it easy to confide in me
1 2 3 4 5
5 I find it hard to understand the non-verbal messages of other people 1 2 3 4 5

An Ability test example

1. Darren completes a difficult task on time and under
budget. Darren is most likely to feel?

(a) Surprise (b) Pride (c) Relief (d) Hope (e) Joy

2. An irritating neighbour of Eve’s moves to another
town. Eve is most likely to feel?

(a) Regret (b) Hope (c) Relief (d) Sadness (e) Joy

3. Edna’s workmate organizes a goodbye party for
Edna, who is going on holidays. Edna is most likely
to feel?

(a) Surprise (b) Gratitude (c) Pride (d) Hope

(e) Relief

4. Something unpleasant is happening. Neither the
person involved, nor anyone else can make it stop.
The person involved is most likely to feel?

(a) Guilty (b) Distressed (c) Sad (d) Scared

(e) Angry

5. If the current situation continues, Denise’s
employer will probably be able to move her job to a
location much closer to her home, which she really
wants. Denise is most likely to feel?

(a) Distress (b) Joy (c) Surprise (d) Hope (e) Fear

Talk on Depression – NICE draft guidelines on depression

What is depression?
The commonest mental health disorder with 4% of the population experiencing it. It is set to become the world leading disability and Kings Fund say by 2026 that 1.5 million people will be diagnosed with depression. Under-reported due to stigma with only just over 50% presenting to GPs and often GPs fail to recognise it.
A distressing disorder that is diagnosed if it both severe and persistent. Not just diagnosed using PHQ9. Low mood lasts regardless of circumstance (usually).
Main symptoms:
Feelings: feeling depressed for more than two weeks, tearfulness, loss of interest and enjoyment, No pleasure in doing things
Physical: loss of sleep very troubling (or increased sleep), tearfulness, poor appetite
Thinking: I am hopeless, I am to blame, I am helpless, I am useless and worthless, Things will never get better, Nothing I do is worthwhile, My thinking is stuck in a rut, My life is in a rut
Activity: Reduced, social withdrawal,

Triggers for depression
Usually starts age 20+ and although recovery often happens people can be left with symptoms and can have future attacks.
Difficult to isolate specific triggers. Predisposition through genes, links with low birth weight. Brain changes, increased interest in vascular depression. Life stressors including loss but also difficult living circumstances. Social isolation a strong factor and an interest in the social skills of people with depression. Although not described in NICE guidelines, my experience is bullying in childhood is commonly reported.

Treatment for depression
Feelings: Anti depressants – The Report appearing in April (2018) by Cipriana and colleagues reported the effectiveness of many anti-depressants like agomelatine, escitalopram, paroxetine, venlafaxine, amitriptyline. mirtazapine with the first two also being more acceptable to people.
All anti-depressants take time to work and should only be taken and stopped with medical advice – side effects particularly occurs in the early stages.
St Johns Wort does have ant-depressant effects but is best taken with advice, and some preparations may be better than others so get them from reputable shops.
Thoughts: Psychological therapies – These are very much supported by NICE Draft Guidelines as the first port of call. The use of therapy in groups are especially mentioned. Interpersonal Therapy and Cognitive Behavioural Therapy are identified as particularly effective. NICE Draft Guidelines have more emphasis on other psychological therapies such as therapies that explore inner workings of the mind. There is recognition for person centred counselling where there are relationship problems or work problems.
Various forms of psychological therapies are recommended and include the following:
Education, sessions like this alone is thought to be of value in that it can instil hope, reduce stigma and encourage people to seek help. Creative Living Centre and BIG both run sessions that provide education in mental health,
Self Help: Self help but with some professional support is the best mix. There are some excellent self help books available and mindfulness exercises may be available online and via mobile apps.

Physical Sleep: Agomelatine affects sleep/wakefulness cycles which are disrupted in depression especially winter depression. This is an expensive treatment and liver screening required.
Related – there is support in the NICE Draft Guidelines for sunlight therapy for winter depression (seasonal affective disorder).
Some support for physical therapies such as acupuncture.
Relaxation exercises may help if constant worry or tension present.
A lot of excitement regarding anti inflammatory drugs and depression. Research continues but appears as if 30% of depression may be down to viral infection.

Behaviour Exercise especially in conjunction with other therapies are considered as being beneficial. NICE Draft Guidelines make a case for this being as part of a planned programme in groups. I would expect being part of a pleasant walking group getting out in daylight/sunlight as being especially helpful for those who notice their moods get low in winter. One hour of exercise also seems to prevent depression.
Therapies to get you active which is called Behavioural Activation and which can be encouraged in groups is recommended. (Coping with Depression Course)

Useful follow up contacts
Creative Living Centre has good educational sessions and courses on negative thoughts and other relevant topics and also provide counselling

BIG in Bury have some excellent sessions on Tuesdays and Thursdays:
Recovery Group

Depression Drop In Group

The Recovery Academy also run courses that address many mental health issues:

Similarly, Bury College run courses to improve your mood:

Self Help Material
Some books help such as the “Overcoming Depression” series or “Overcoming low self esteem”
A few useful self help resources:

NHS Choices podcasts on mental health

Finding a therapist

NHS Choices lists local therapists

Find a counsellor

Preparing for CBT (see my website)

Videos on CBT

The 5 systems approach:

A longer video demonstrating what CBT is like:

The Five Systems Approach – a model for understanding depression and anxiety


The Five systems approach is a frequently used model employed by cognitive behavioral therapists. Best described by Padesky and later by Williams it is frequently used as an educational tool for people who are experiencing depression and anxiety. The terms used interchangeably with this are case formulation or case conceptualization.

The five systems consist of the triggering event or situation, the thoughts that are generated, the feelings or mood that are experienced, the physical sensations, and the things we avoid or do as a result of anxiety and depression.

Benefits 1

It is primarily an educational tool. It helps both therapist and person with depression and anxiety to understand the situation better.

It helps both of you make useful links between thoughts and mood, or behavior and moods, or physical sensations and thoughts etc.


I notice when I am feeling low that I stop going out

Whenever I feel my heart race I have the idea that I am going to collapse and this makes me feel worse

I keep on thinking and thinking and can’t break out of it and this makes me feel ten times worse

Not without some controversy, there are suggestions that using the five systems approach (or at least sharing an explanation for current problems) can lead to dramatic and sudden improvements. Thomas and Persons (2013) suggest that improvements can occur if we help a person understand the model being used in therapy and which can be applied to the person’s depression and anxiety. This model may not necessarily be the five systems model, but I would argue that its simplicity is helpful when people are depressed..

Kuyken, Padesky & Dudley (2009) bring our attention to research that implies that using such individualised models may not necessarily be as good as using a manual approach in therapy, but still write about the considerable benefit of working together with the person to write up an understanding pf the depression and anxiety.

Benefits are also presented through collecting information and presenting them under five columns. This is probably best illustrated by working with some examples.

Working with a short case study


Murray said he felt absolutely miserable he had recently lost his job and thought he was useless and that he deserved to be jobless. He thought he was a lousy husband and father and he had nothing to live for had thoughts of ending his life. He complained of having no interests and has led him to doing very little. He had no motivation and spent all morning in bed and the afternoons drinking cheap alcohol which made him feel worse and spent the evenings in criticising himself. His wife is losing patience with him and he takes himself off to bed rather than risk an argument. He often felt tired but could not sleep. He had broke off contact with his friends. Whenever friends ring him he feels extremely anxious and reluctant to answer phone.


Thoughts Feeling/Mood Physical Behaviour

There are additional examples to try at the end of this Document

A look at what you have written you may indicate where you have made most notes and this might indicate the target areas. What does this mean in practice?

Benefits 2

So far we have seen the benefits of helping people understand the links between situations and their reactions and also the systems which are most reactive. There are other benefits.

Seeing thoughts and feelings and ways of responding can start to help a person create a helpful distance and may start the process of changing habitual ways of responding.

Example: “When I make a mistake I start beating myself up pretty badly – does it really need me to be like that towards myself because I forgot to put the milk back in the fridge this morning?”.

Example: “I can see I have written down here that I am the worse husband in the world – why do I believe this so strongly, can it be right?”.

When general (big) statements are declared its great if you can start to break these down more.

Example: “I am stupid” becomes “Sometimes I forget to put the milk back in the fridge in the morning, and last month I locked the cat in the garage”.

Example: “”I am the worse husband in the world” becomes “I had to ask my wife when our anniversary was and she accused me of not caring, and that was despite that I had already bought her a suitable present and card but wasn’t sure exactly what date next week it was”.

You can see from the above examples how thoughts can sometimes be broken up and written into other parts of the five systems.

Breaking big statements up illustrates how it invites solutions. Can you suggest how… regarding the above examples?

Benefits 3

Considerable research into how therapy works has pointed towards the benefits of being more concrete and specific in the way we address our problems. Thinking in over-general and rather vague ways about ourselves invites us to bully ourselves or accuse ourselves without good reason “I’m the worse husband that has ever lived?”. We maintain our depression and anxiety because of the way we think about ourselves and our lives. The use of the five systems approach gives us an opportunity to be much more specific leading to a more balanced perspective and problem solving.

If you are interested in reading more on the thinking process read Ed Watkins work and his book on rumination.

Work with these Examples

Where in the Five systems would you place the following:

  • “I get butterflies on stage”
  • “People are staring at me”
  • “I am working less productively than anyone else in my team”
  • “I sleep for hours and hours”
  • “I am so jealous of other Mums”
  • “I’ve stopped playing with my children”

Looking at the above what feelings do you associate with each one of them?

What about other very common examples?

Are there any downsides to using a five systems approach?

  • People don’t operate in boxes – they are much more complex than this.
  • In therapy its use can interrupt the flow of conversation.
  • Some people can have quite a strong emotional reaction to seeing their thoughts written in black and white.

Where else can I learn about the five systems approach

Chris Williams’ books are a very useful read (see list at the end) and you can also read more about his work here:


Additional Case Studies

  • Margaret avoids going to the Library, she previously loved reading but now the thought of going into that Building fills her with dread. The only time she is now able to go to the Library is when she persuades her friend Rosey to come with her. Even so, she feels on the verge of panic most of the time and her heart races, she felt dizzy, she thought she was about to collapse. She often holds on to solid objects around the Library in case she falls over. Occasionally she asks Rosey if she looks alright and not pale. Her relationship with her partner is strained and there are frequent arguments with him. These were because she was reluctant to go into any public place because she thought she would panic.
  • Radoslaw has been in the UK for five years but has recently become depressed and highly anxious. He has isolated himself because he believes that his speech is not very clear. When he is talking he monitors his own conversation and looks for flaws in his speech. This makes him very hesitant. Because he listens to himself rather than others he loses track of what others are saying and he then blames this on his own stupidity. When he responds slowly he feels very awkward and this makes him more anxious and then he starts losing his train of thought and becomes even more hesitant. He has even stopped mixing with his Polish network because he anticipates the same thing happening when he talks to his friends. When he is talked into going out he has resorted to taking Dutch Courage – large glass of Vodka. What surprises you is that he talks quite well with you and is able to talk quite clearly about his difficulties.

Steve Lyon, Accredited CB Therapist (BABCP), MSc, BEd (Hons), Dip Couns, RMN. RGN, RNLD, FHEA

Committed to improving access to therapy (Offering limited places for limited fees)

Reading and References

  • Greenberger, D., & Padesky, C. A. (2016). Mind over mood: Change how you feel by changing the way you think (Second ed.). New York: The Guilford Press
  • Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York;London;: Guilford.
  • Strunk, D. R., Brotman, M. A., & DeRubeis, R. J. (2010). The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. Behaviour Research and Therapy, 48(7), 599-606. doi:10.1016/j.brat.2010.03.011
  • Thomas, C., & Persons, J. B. (2013). Sudden gains can occur in psychotherapy even when the pattern of change is gradual. Clinical Psychology: Science and Practice, 20(2), 127-142. doi:10.1111/cpsp.12029
  • Williams, C., Dr. (2008;2009;). Overcoming depression and low mood: A five areas approach (3rd;3; ed.). London: Hodder Arnold.
%d bloggers like this: