By the turn of the 20th century, the terms depression and melancholia had become synonymous. In 1917, Freud likened melancholia to a period of mourning. Kurt Schneider, a German psychiatrist, first coined the terms endogenous depression and reactive depression in 1920, thereby proposing a binary theory of depression. In his model, the term reactive referred to a reactivity in the patient’s mood, not a reaction to external events. This theory was widely accepted in the USA, while the United Kingdom largely continued to follow the unitarian model for depression, which theorizes that there is just one cause for depression.
When I was a psychiatry resident in 1974/75 in Manchester, England, we used the Schneider model for depression, except that the term reactive had by then come to be interpreted as a reaction to external stressful events. The concept has continued to this day with the term adjustment disorder. We identified a sub-type of endogenous depression, when symptoms included anxiety, restlessness, insomnia and worry, as agitated depression. I was also using the diagnostic term neurotic depression, which today would probably fall within the various categories of Personality Disorder.
We treated endogenous depression with tricyclic antidepressant medications and reactive depression with supportive psychotherapy and motivational interviewing techniques. If endogenous depression included biological symptoms, lack of energy and withdrawal from relationships, we prescribed imipramine. If those symptoms were severe and included depressive delusions and suicidality, we diagnosed melancholia and prescribed electroconvulsive therapy (ECT), which was remarkably effective. For agitated depression, we prescribed amitriptyline. For neurotic depression, the treatment was monoamine oxidase inhibitor (MAOI) antidepressant medication, which was usually ineffective, and supportive psychotherapy. Psychotherapy treatment was an integral component of the treatment of all categories of depression.
Dr. David Murphy
The syndrome that is now described as depression was first described by the ancient Greeks, including Hippocrates, as melancholia. Melancholia translates to black bile in English. The ancient Greeks believed that symptoms of melancholia were caused by an excess of black bile, one of the four humors in the body, the others being yellow bile, blood and phlegm. Melancholia continued to be recognized by the Romans and, in the 10th to 12th centuries, by Persian physicians. Various theories about the causes of melancholia were proposed by Western physicians throughout the 17th to 19th centuries. The exact etiology of depression continues to remain elusive and multi-factorial.
The term depression appeared in the 17th and 18th centuries, firstly in Richard Baker’s Chronicle of the Kings of England (1665) and later in the writings of the English essayist Samuel Johnson (1753). Johnson, in his Dictionary of the English Language (1785), defines depression as ‘The act of humbling; debasement’.
Depression became a psychiatric symptom in 1856, when a French Psychiatrist Louis Delasiauve used the term. At about this time, melancholia started to be referred to as a ‘depressive state’. Maudsley, an English psychiatrist, proposed the term Affective Disorder, to describe both melancholy and depression. Maudsley believed that all mental disorders were nervous diseases with predominantly mental symptoms. He proposed that insanity was a hereditary disorder. Descriptions of Maudsley’s negative and agnostic beliefs would suggest that he may have suffered from depression himself. By the turn of the 20th century, the terms depression and melancholia had become synonymous.
Dr. David Murphy
Neuro-Linguistic Programming for Depression
David Murphy M.B., Ch.B., CGPP
Neuro-Linguistic Programming (NLP) is a model of psychotherapy, developed by Richard Bandler and John Grinder (1975a, 1975b), in which it is postulated that humans create language patterns within the nervous system to process sensory information and form psychological programs that drive our behaviour. Using the NLP model, symptoms of depression can be considered as dysfunctional, maladaptive psychological programs that can be modified, through psychotherapy treatment, into functional, constructive programs. In this article, I will expand on the description of NLP from my previous article in this journal (Murphy, 2016) and highlight some of the NLP techniques that can be applied to the treatment of symptoms of depression.
NLP postulates that humans encode their sensory (neurological) experiences using language in order to create a reality. That reality is then stored in memory, in the form of a map, and that memory becomes a part of our personal knowledge, experience and wisdom. An example of that coding is the difference between whether or not we like or dislike an individual. We encode if we like someone differently than how we encode if we dislike someone. The encoding is both a physical (neurological) and an emotional experience and is associated with a language pattern. Whether or not we choose to like an individual is governed by complex psychological programs that involve personal beliefs, values, previous life experiences and generalizations about people and the world around us.
The primary human senses are sight, sound and touch (visual, auditory and kinesthetic). We all tend to rely on one sense more than the other two. Approximately two-thirds of individuals are primarily visual. About twenty percent of individuals rely on their auditory sense. Perhaps 10% of individuals are kinesthetic. Each group will use specific language patterns that reveal that preference. Individuals who are visual may use the phrase, “I see what you mean,” to indicate that they understand. Someone who is primarily auditory will say “I hear you.” Someone who relies on their kinesthetic senses will say “I’ve got it.” If we are receiving conflicting information from a different sense, we will tend to rely on the information coming from our primary sense. For instance, if I am primarily visual, then I am more likely to rely on the information from other people’s body language than on the information from their spoken words.
The psychological programs that govern how we process sensory information and drive our behaviour can be simplified into two categories: towards pleasure and away from pain. Ideally, we have a balance between those two programs. However, individuals who are driven only by pleasure may have a tendency towards addictions, thrill-seeking, eating disorders, instant gratification and egotistical behaviours. Individuals who are driven only by avoidance of pain may exhibit avoidant behaviour, repetitive breakdown of relationships, addictions, symptoms of depression and symptoms of anxiety.
NLP and Depression
Patients presenting with symptoms of depression who are primarily kinesthetic will use kinesthetic terminology to describe their symptoms. They use expressions such as, “I have this heavy weight on my shoulders” and may present with psychosomatic symptoms such as chronic pain or gastrointestinal symptoms. The patient who is primarily visual may describe the future as “gloomy” and have a pessimistic or hopeless/helpless outlook on life. A patient who relies on the auditory system may hear negative parental messages from the past, such as “you’re useless” and have a low self-esteem.
There are many psychological programs that can result in sensory information being encoded as symptoms of depression. For example, negative generalizations about oneself that are part of our sense of identity, such as “I’m a loser” will inevitably lead to repeated failure in life. Events in which the patient has been successful will be deleted from memory or distorted into and encoded as perceived failures. Any success will be demeaned and discarded as unreal or meaningless. The patient may never move out of entry-level jobs. Relationships may break down. Any sensory information which challenges that belief will be deleted or distorted.
A patient who lives life by setting negative outcomes and describing reality in negative terms will present with constant symptoms of depression. Such a patient, when asked to set outcomes for therapy, may respond by saying, “I don’t want to feel miserable anymore; I don’t like my job; I don’t feel appreciated by my spouse.” When asked to describe their state of mind, the same patient may respond with, “I’m not happy—I don’t know—my partner is not supportive; I don’t feel important.” This patient will present with symptoms of depression and derealisation, because he or she is unable to describe or live in a real world.
Growing up, we are all exposed to various role models. In our very young years, our primary role models are our parents. Role modelling from our parents and other important individuals in our life results in beliefs about ourselves and our sense of identity; beliefs about values, beliefs about our capabilities and beliefs about emotional behaviours. We learnt what to feel happy about, what to feel sad about, what to be afraid of, what to be ashamed of and what to be angry about. These programs become encoded psychologically and drive our behaviour, in response to sensory information about our outside world. If our parents are alcoholics, we will be more likely to become involved in an addiction in our adult years. If a parent presents to us a hopeless/helpless view of the world, then we are more likely to feel depressed ourselves as adults.
The NLP Treatment Paradigm
NLP offers an optimistic viewpoint on the treatment of symptoms of depression. The NLP model postulates that depression is caused by learned psychological programs, which result in maladaptive, depressive behaviours. The beliefs that are associated with those psychological programs both distort and delete sensory information, resulting in the patient’s reality being encoded with symptoms of depression. Therefore, it is possible to change those psychological programs through psychotherapy treatment, encouraging constructive coping skills and a positive, resourceful, empowered outlook on life. This may result in an improved self-worth and a sense of contentedness.
The NLP model is patient-centred. The therapist is not there to fix the patient. It is up to the patient to set their own specific, positive-focused outcomes for therapy and develop sensory criteria for knowing when those outcomes have been achieved. In other words, what will the patient be able to see, hear and touch/feel when the outcomes for therapy have been achieved? I often use the analogy of an Olympic champion, who will realize that he or she has achieved their dream, when they feel the sensation of someone draping a gold disc on a ribbon around their neck; they see their nation’s flag being raised up the middle of three flagpoles; and they hear their national anthem being played. I tell my patients that I am not there to fix them or to tell them what is wrong with them. I will not tell them how to live their life or to tell them what is right or wrong for them. My only role as their therapist is to help them understand what it is that they want and need in life, help them to access their own internal, untapped resources and offer them some tools and resources to help them achieve those outcomes.
NLP makes a number of presuppositions that can be important in the management of symptoms of depression (1975a, 1975b):
1. Behind every behaviour, no matter how destructive it may be, there is a positive intention.
2. Every behaviour is useful in some context.
3. People already have all the resources they need.
4. There is no such thing as failure. There is only feedback.
5. If you aren’t getting the response you want, try something different.
6. No one is wrong or broken. People function perfectly to accomplish what they are currently accomplishing. 7. The map is not the territory.
Some Strategies for Treating Depression with the NLP Model
Because of Milton Erickson’s (1979) influence, hypnotherapy is an NLP tool that is used for treating symptoms of depression. Hypnotherapy can be used for bypassing the part of the mind, the critical faculty, that generates the generalizations/distortions/deletions that are contributing to depression. Regression exercises, through hypnotherapy, can help the patient access positive resources from past memories and bring those emotional resources into the present to be incorporated into daily life. If, for instance, symptoms of depression are encoded in the kinesthetic system, then hypnosis can be used to access positive emotional coping skills that have been encoded in the visual or auditory systems. A patient who feels useless can be encouraged to see times in their lives when they have been productive or hear words of praise from a co-worker or employer for a job well done.
B. Timeline Imaging Exercises
We encode our past memories and our future imagination differently. We can all tell the difference between a past memory and an imaginary future, but would be unable to describe how we do that. Usually, there is a difference in how we visualize those experiences. Images of the past may appear to be behind us and images of an imaginary future may appear to be in front of us. That is where the expression “putting the past behind me” comes from.
One of my patients, a 30-year-old man who had been depressed for many years, encoded his past memories behind him and his imaginary future in front of him. However, there was a period in his mid-teens when he was involved in drugs and gangs. He was deeply ashamed of those events. Those memories had been encoded so that they appeared to be right in front of his face. Unconsciously, he was viewing his future through the filter of these shameful times. He was able to imagine putting the teen memories behind him, filing them away within the chronological order of his past experiences. As he did so, he started to smile for the first time. He continues to smile, his mood improved, and he concluded his psychotherapy treatment shortly after that.
C. Resolving Depressive Identities
Who we are includes many different identities. We are all sons or daughters. Some of us are parents. We may be doctors or psychotherapists. Each identity has a set of guiding beliefs and values that have been encoded over time. Those beliefs influence our capabilities. We will not be able to do something if we do not believe that we are capable. Therefore, beliefs can limit our capabilities. Our capabilities affect the behaviours that we are able to carry out. Those behaviours are carried out in a particular environment.
If symptoms of depression have been encoded as an identity—“I am useless, I’m a loser, I’m a failure, I am an alcoholic, I am a victim, and I am depressed”—then the associated beliefs will limit capabilities and affect behaviour. In this context, mood is a behaviour. Lack of motivation, low energy, hypersomnia, anorexia, and anhedonia are all physical/mental/emotional states that have a strong behavioural component. Changing an identity can be difficult. It can take a long time to create an identity. For example, it takes years of training to become a doctor. Therefore, it is much easier to treat symptoms of depression that are associated with an identity by encouraging change at a different level. An alcoholic can be encouraged to attend Alcoholics Anonymous. A failure can be encouraged to set up achievable outcomes. A victim can be taught to be empowered. It is much easier to treat symptoms of depression than to challenge the belief and identity that I am depressed. As the behaviours are practiced, then capabilities change, distorted beliefs are challenged and the identity evolves into something constructive.
NLP is a useful psychotherapeutic model for effecting change in patients who present with symptoms of depression. Many of the NLP treatment strategies are similar to CognitiveBehavioural Therapy. Both techniques challenge the patient’s language that is creating symptoms of depression and offer to teach constructive language patterns. Because NLP was developed by role-modelling Fritz Perls and Milton Erickson, many NLP techniques bear similarity to Gestalt Therapy and include hypnotherapy techniques.
A downside is that NLP has its own jargon, which can sometimes be difficult to comprehend for the patient and for clinicians who are unfamiliar with the model. Criticism has been levelled at the NLP model, because it is also applied by non-medical practitioners in non-clinical scenarios, such as personal growth and business. Despite these concerns, I believe NLP is a helpful therapeutic model. It is capable of quickly challenging core beliefs that have created longstanding symptoms of depression, particularly when hypnotherapy techniques are also applied.
Conflict of interest: none
Bandler, R. & Grinder, J. (1975a). The Structure of Magic I: A Book about Language and Therapy. Palo Alto, CA: Science and Behavior Books.
Bandler, R. & Grinder, J. (1975b). The Structure of Magic II: A Book about Communication and Change. Palo Alto, CA: Science and Behaviour books.
Erickson, M. & Rossi, I. (1979). Hypnotherapy—An Exploratory Casebook. Stratford NH: Irvington Publishers.
Murphy, D. (2016). Neuro-Linguistic Programming for Depression. GP Psychotherapist, 23(2), 8-10.
Dr. David Murphy
David Murphy is a graduate of the University of Manchester Medical School (1973). He is a Medical Psychotherapist, Master Practitioner of Neuro-linguistic Programming and Certified Anesthesiologist, whose medical practice is focused on the management of chronic pain, psychological trauma, anger and stress. He provides forensic psychotherapy and pre-sentence reports for sexual and other offenders.