Communication-Focused Therapy® (CFT) for Depression
Christian Jonathan Haverkampf, M.D.
Depression is a mental health condition that affects a large part of the population at least once over their life span, significantly reducing life quality and impairing work and relationships. Psychotherapy and medication are the main treatments for the condition. Communication-Focused Therapy® (CFT) is a therapy developed by the author, focusing on communication processes to treat depression. Improvements in internal and external communication and awareness for a patient’s needs, values and aspirations appear to be effective against several symptoms of depression and increase motivation and compliance for therapy. This article provides an overview of a conceptual framework from a communication perspective and several approaches for treating depression with psychotherapy.
Keywords: depression, communication-focused therapy, CFT, communication, psychotherapy, psychiatry, treatment
Table of Contents
Depression is a general lowering of emotional experiences, while in the lighter forms, it may just be a reduction of positive emotional experiences. A dialling down of internal and external communication, such as thoughts, feelings and activities, usually accompanies it. Loss of energy, motivation, and initiative, loss of enjoyment and interest in pleasurable activities, and loss of concentration are just some of the possible attributes of depression.
All explanations for depression seem to depend on the framework of the school of thought that produced them. An early answer from ego psychology was that depression is the emotional expression of a state of ego-helplessness and ego-powerlessness to live up to certain strongly maintained narcissistic aspirations. (Bibring, 1953) This explanation is in some ways not so far from what we can observe in depression in every clinical practice, even if we rarely use the terminology anymore. Patients who are depressed indeed mostly feel helpless and powerless, which are practically requirements of the sense of feeling depressed. When we find ourselves in a situation where there seems no escape or where we have to decide quite literally between a rock and a hard place, we are more likely to feel depressed, unless we develop a new alternative and open a door we have not seen before. Unfortunately, depression makes it seem harder to innovate and be creative. One of the techniques of Communication-Focused Therapy® (CFT) is to restore the ability to see a broad range of options and innovate in depression. The path there is through work on communication patterns, as communication is how we all get our needs, values and aspirations satisfied.
Depression usually impairs the emotional communication one has with oneself and with others. (Haverkampf, 2017e) Experimental data has been showing quite consistently that depressive subjects exhibit disrupted emotional processing. (Delle-Vigne et al., 2014) This emotional disconnect from oneself leads to a less complete sense of self and lower confidence in oneself and the world. (Haverkampf, 2012) The disconnect then leads to significant secondary impairments in everyday life. It affects the interaction patterns one has with other people and oneself, leading to various relationship and workplace problems, and from here to further depression and anxiety. Thus, a neverending vicious cycle can pull the individual suffering from depression ever further down. Fortunately, in most people, depressive episodes are self-limiting as self-regulatory mechanisms usually kick in once it has reached a level where the quality of life is severely compromised. What then happens is that a shift or change in the internal and external communication happens that pulls the individual out of the depression. This latter process is what Communication-Focused Therapy® aims to bring about in patients where these auto-regulatory processes are absent or maladaptive. (Haverkampf, 2010b)
The symptoms of depression are the result of maladaptive internal and external communication patterns. A disturbance in the flows of meaningful information flows within the nervous system and between the nervous system and the outside world leads to a disconnect, resulting in less perceived meaning in the world and worse decisions because there is less available information. The informational deficit about oneself and the world leads to depression and anxiety, which causes even more withdrawal in a vicious cycle.
The link between communication patterns and mental well-being is an essential insight for its enormous ramifications on understanding and treating depression. However, one needs to view it as a large puzzle, where the pieces all fit in in the end. These puzzle pieces can come from many areas of an individual’s everyday life. In a study on monogamous romantic relationships, for example, mutual constructive communication was associated with decreases in depressive symptoms for males. In contrast, demand-withdraw communication correlated with increases in attachment avoidance and depressive symptoms. (Givertz & Safford, 2011)
An essential step in overcoming depression is becoming curious about how one communicates with oneself and others. Using constructive inquisitive communication patterns can have a healing effect (Haverkampf, 2017i). In therapy, the therapist can encourage observing the communication patterns a client operates and the assumptions made in them about intentions, wishes and needs, values, and other factors that determine the quality, quantity and future of human interactions. Since all psychotherapies to date, use human interaction as the main instrument in the healing process, even if they do not focus on it, most therapies can have a beneficial effect. Unfortunately, the focus is often not on communication patterns, which can, at least from a theoretical perspective, render them less efficient. While it is true that learned behaviour and past experiences influence the severity of the symptoms, they do so via internal and external patterns of communication. In any instance where therapy works, it is a change in information flows and communication behaviours that brings about changes in symptoms and quality of life. (Haverkampf, 2010b, 2017a)
Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behaviour, feelings, and sense of well-being. A depressed mood can be a normal temporary reaction to life events such as loss of a loved one, a job loss, but also ‘positive’ ones, such as winning in a lottery or having sudden and spectacular success. All these events represent changes globally, requiring internal modifications to adjust internal and external communication systems to the new reality. A job that is now suddenly more practical requires a different internal dialogue, such as less analysis and more exploration. It may also require different external communication patterns with colleagues rather than work in front of a computer screen. If these changes have only occurred partially or not, the information exchange patterns do not fit the situation. This lack of fit can lead to feelings of being overwhelmed, withdrawal, emptiness and feelings of depression, or in some cases (hypo)manic states.
The sum of the basic patterns of external and internal communication, an individual’s personality, remains relatively stable over time. (Haverkampf, 2010a) This also applies if a mental health condition, such as depression, improves. In a sample of depressed outpatients receiving a 5-week trial of pharmacotherapy, changes in neuroticism and extraversion scores were modestly or not accounted for by changes in depression scores. (Santor et al., 1997) However, how individual communication elements and patterns are used in given situations can be subjected to change, leading to significant changes in personal satisfaction, contentment and happiness.
Depression leads to a disconnect. A patient is no longer able to access positive emotions to the same extent as before. However, at the same time he or she may also become disconnected to a varying degree from ‘negative’ emotions, such as sadness. In all cases, the individual suffers from missing out on important information about the own person. This then leads to negative feelings, possibly also fears and anxiety, because meaningful information is missing. To some degree it is possible to counteract this with activities that are meaningful to oneself. One may even say that in the best a depression weeds out thoughts and activities that are less meaningful. And in most cases short and especially the reactive depressive episodes are self-limiting. But in the more severe and longer lasting depression the disconnectedness from emotional signals accelerates the downward spiral of decreasing emotional connectedness and increasing ability to correctly send and receive meaningful messages. (Haverkampf, 2010c, 2013)
Reconnecting with emotional signals can be helpful in depression. This should not add to the pressure on the patient ‘to feel better’. In Communication-Focused Therapy®, this is usually done by using the communication patterns in the session or memories of past interactions and experiences in the world to inquire into the feelings that were associated with them. However, the main technique is concerned less with individual emotional episodes, but with enabling a patient to become more aware of and influence communication processes and information, which lead to particular emotional signals. (Haverkampf, 2017a)
Elevated levels of repetitive negative thinking are present across a large range of Axis I disorders and appear to be causally involved in the maintenance of emotional problems. It has also been argued that repetitive negative thinking is characterised by the same process across disorders due to the inherent similarities (Ehring & Watkins, 2008). A depression leads to more negative interpretations of messages from the environment and from within oneself. As one attributes the cause of negative experiences to oneself and engages in self-blame, feelings of guilt, failure and incompetence emerge. At the same time, the own person, others and the world as a whole appear to be less meaningful and less relevant. This loss of meaning can potentially lead to dangerous situations of self-harm or even suicide. To prevent this requires an insightful and caring use of communication between therapist and patient.
It is important to realise that it can be the same information which reaches the patient, but which is associated with more negative emotions and thus more hypotheses of negative consequences. A depressed affect can so lead to an increased selection of information associated with negative emotions, which can then lead to an even more depressed affect. This vicious cycle usually does not pose a problem because positive information becomes more appealing, which pulls the individual out of the negative affective state. In a depression where emotional and other communication is inhibited already, it is more difficult for the autoregulatory mechanisms to work, making a spiralling into an increasingly depressed affect more likely. This can also lead to distortions how one thinks about other people’s thoughts about oneself, causing even more withdrawl. It has been suggested that low level of social functioning associated with depression can also be ascribed partially to a theory of mind deficit. (Wolkenstein et al., 2011)
Analytical internal communication patterns can be helpful in many areas of life. However, in depression they are often used for the wrong purpose, possibly in the attempt to extricate oneself from the symptoms of depression. In a study by Rimes and Watkins, thirty depressed participants and thirty never-depressed participants were randomly allocated to ‘analytic’ (high analysis) or ‘experiential’ (low analysis) self-focused manipulations. As predicted, in depressed participants, the analytical self-focus condition increased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the experiential self-focus condition resulted in no significant change in such judgements. (Rimes & Watkins, 2005)
Negative thinking can often be triggered by some internal or external information, frequently an intrusive, which may be easier to shrug off for a non-depressed person. In this instance, it is as if the depressed person tries to preempt any disappoints or possible negative emotions from an adverse outcome, by already realising them intracranially and fighting them with compensating emotions. However, this only leads to further negative thoughts and downward spiraling ruminations. One solution is to identify thoughts as mere thoughts and not real, another to build a sense of oneself as being able to deal with whatever may be coming one’s way, particularly the own emotions.
Repetitive negative thinking can, on the other hand, be distinguished from other forms of recurrent cognitions, such as obsessions, intrusive memories or functional forms of repeated thinking. (Ehring & Watkins, 2008) This illustrated how certain symptoms of a mental health condition can be grouped along the internal and external communication patterns they are associated with, and that they can be categorised into a moderate number of sets.
Communication-Focused Therapy® (CFT®) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy has to lead to change. This can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them. If fear inhibits the information retrieval from memory this will not fully work. CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.
Many popular forms of psychotherapy, such as Cognitive-behavioral Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, there is the concept of transference and counter-transference which focuses on the result of communication processes. CFT in contrast attempts to focus on the process itself. (Haverkampf, 2017a)
CFT attempts to analyse how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behavior of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient. Working with and analysing patterns of internal and external communication helps to make the exchange of meaningful information work more effectively, reducing anxiety, emotional, mood, psychotic and other disorder in the long-run. (Haverkampf, 2018b) This does not mean that medication and other forms of therapy do not have their places in treatment, it does not change that at all. However, CFT provides a theoretical and empirical framework that can enrich these other therapeutic approaches, while also being used on its own.
Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. The reason why certain patterns have to be used is so that the other person can understand the message. A language can be seen as a form of communication patterns on a more complex level. We all communicate in patterns. However, unlike learning a language, people spend little time observing and reflecting on the other communication patterns they use all the time.
In biology, an emerging picture of interconnected networks has replaced the earlier view of discrete linear pathways that relate extracellular signals to specific genes, raising questions about the specificity of signal-response events (Kholodenko, 2006). In synthetic biology, researchers integrate basic elements and modules to create systems-level circuitry (Purnick & Weiss, 2009). The communication of the cells with each other and with the environment determines how effective they are in, for example, eliminating tumor cells. The important basic material is ‘information’, which is then activated and given influence over other factors through meaning, whether that is meaning in in an intracellular or an interpersonal context. Communication patterns and structures facilitate this process. (Haverkampf, 2018c)
Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the internal and external communication patterns do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. Changes in communication patterns means modifications in which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.
As has been pointed out by the author already elsewhere, questions are powerful communication patterns in effecting change in other communication patterns (Haverkampf, 2017i). In depression, they can mobilise resources and redirect thinking towards a different focus, and they can also help end ruminations and looping thoughts. Over time, the patient should become a personal expert in asking the right questions.
Questions represent a large group of communication patterns with very diverse combinations of communication elements. One needs to fine-tune questions to the present communication dynamics and the aim of the questioning. Using them is to cause a branching off in the communication dynamics, which then brings about change in everyone in the session. One should not forget that a question can also change the one asking it, even if one has used a particular type of question hundreds or thousands of times. Questions are so embedded in the social and interactional everyday life that we mostly are not aware of them more than the microtasks we carry out when driving a car. The author has written elsewhere much more in-depth about the question as a communication pattern that can be a potent therapy tool. (Haverkampf, 2017i)
Patients with depression often spend a considerable amount of time ruminating about the past. Those who also suffer from anxiety may also ruminate about the future. What frequently gets lost is thinking about the present, even though that is the point-like interval of time which is the only one that is ever real. To avoid the reality of the present can be due to various reasons. The depression can make existence so unbearable that one escapes into a different ‘time zone’, and that it is not real may even be wished for in the hope that this also makes the pain less real.
The use of observations, feedback and questions can help the patient to stay in the patient. Several other communication patterns can also achieve this goal. Whenever a communication pattern leads to greater internal and external connectedness, it helps to anchor the patient more firmly in the now. However, this does not lead to more intense suffering because it is the disconnectedness that usually causes suffering. Patients with severe depression do not feel sadder, but they often feel nothing. Truly experiencing an emotion like sadness, when one feels ready for it and while being connected with others and oneself, can be an essential step in dealing with and overcoming a loss or other saddening event. And nothing can be as connectivity promoting as communication itself.
As a slowing down of the internal clock in depressive participants has been observed (Gil & Droit-Volet, 2009), this can also change a person’s subjective experience of the world, particularly when one dips out and into a depression. Changes in how one experiences the world in terms of time can further reduce the sense of groundedness in the world. The interactions in a therapeutic session can counteract this. As the patient experiences that the own communication and the therapist’s understanding of it do not depend on the patent’s state, it adds to the feeling of being grounded in a world that may have seemed unstable due to the fluctuations of the depression.
Questions help the patient in changing communication patterns. Still, they can also produce information, which lowers uncertainty, brings new insight or leads to something new in the world, which is enjoyable and improves the overall mood. Often, patients with depression return to the same thoughts or situations because they do not see alternative actions or ideas, which may be enjoyable and lead to a better mood. Ruminations result not from too much but too little useful information, yet finding the right information again depends on communication patterns.
When things look at their darkest, and everything around seems empty like a desert, it helps be aware of all the meaningful information that is already easily accessible. Connecting within oneself and others can lead to insights that help in countering the depressed rumination. A therapist’s task is to help the patient build communication patterns that are more effective towards connecting with oneself and others. Doing so allows a patient to find more meaningful information in places such as the own life experiences, which are a treasure trove of information. If I ask what is important to me and what I value, I just have to look at situations in the past and probe how I felt, what I thought and whether my actions and interactions in these situations benefitted me. One only has to be more open to information that can be helpful, and one aim in therapy is to help patients become better at this without fear.
Communication patterns that help the therapist and patient connect in the session can also help the patient connect with others and with themselves. As already pointed out, the internal and external communication is a reflection of the other. The ability to communicate with the outer world also increases the ability to communicate better on the inside. Communication-Focused Therapy® supports patients in becoming more aware of, reflecting on, and experimenting with communication, which leads to the flexibility and openness in communication that is very effective against many forms of depression.
Communication patterns that increase connectedness include questions and other communication patterns that enable the flows of meaningful information. The latter may consist of repeating a modified message, providing information about a feeling or thought triggered in response to the patient’s communication, making an observation that offers a new perspective, and so forth. It is more than small talk because therapeutic communication patterns provide the patient with the sense that they can build relationships, stemming from the greater awareness and insight into how communication works.
By talking about the communication between patient and therapist, it is possible to help the patient see how communication can be influenced and shaped to lead to new insights and make new connections between pieces of information. This integration of different strands of information flows is vital in helping the patient feel more integrated. For example, talking about communication can help the patient associate an image with emotions and connect with their memories. However, this integration requires that it is first possible to speak of these thoughts and feelings, and then talk about communication in ways that help the patient make associations between the different flows of information.
Whenever the perception of how the world works and individual experiences in everyday situations do not align, there is room for apprehensiveness, fear and discontent. Even if something bad happens, the experience of it is often not as unpleasant, if it fits into one’s view of how the world works. This can even go so far that people lower their expectations by adopting a more pessimistic world view to avoid disappointment and reduce unpleasant feelings when something negative happens. In depression, this can be part of a vicious cycle where fear leads to the adoption of a more negative belief system, which then causes more withdrawal and suffering. In the end, it does not feel good living in a harsh world, even if it is of one’s own making. Communication-Focused Therapy® aims at accepting that there is uncertainty in the world, while recognising that internal and external communication provides us with the tools to live well with uncertainty.
The first important step in therapy is to create awareness for the flows of information and their patterns. (Haverkampf, 2018c) These dynamics happen primarily outside of consciousness, but they are not random. Instead, they result from biology and the internal and external communication experiences of an individual over time. Complex organisms receive, combine, and send millions of bits of information in the smallest fraction of a microsecond. To navigate within this sea of information successfully is the primary objective of every organism, humans included. Health impairments result if these processes no longer work adequately. Mental health conditions often also have a significant impairment in external communication between a person and the environment.
The human brain processes information within its network of neurons. One objective of therapy should be to help it work better with information, whether from emotional signals, sensory organs, or retrieved from within the neural network itself. Communication processes and information can be made conscious. Important is to understand that the information contained in a neuron, which can be stored in any of the cell properties, only makes sense within the network of other neurons. Information is, in a sense, held everywhere and nowhere at the same time. Communication changes it, and therapy works with external communication. However, since internal communication reflects external communication to a large extent, awareness and reflection on communication patterns in the interaction with therapist and patient can lead to changes on the inside.
Particularly in interactions with other humans and other living organisms, communication patterns have evolved that facilitate the exchange of meaningful information in an efficient way. They need to be largely automatic, such as a gesture in response or a change of voice, and it may be even more distracting to follow them all, but it is possible to discern and work with some universal patterns. For example, the sequence of a specific type of question and a specific type of answer can be universal, such as the nod of a waiter signaling attention, followed by a guest using the palm of her hand and finger to scribble in mid-air, which indicates that she wants the bill. However, a complex business negotiation would also use the basic communication element of question and answer and build it into more complex patterns. Spiralling negative thoughts in depression, on the other hand, also use otherwise adaptive communication elements; however, they do so in unhelpful communication patterns. The problem is not the ability to worry and think, but how this is done, the pattern, which is not constructive and unhelpful.
Even tiny bits of information can be analysed in therapy when they do not seem to fit in with other information. Discrepancies in information are usually helpful in producing new meaning and positive change. Depression makes most forms of awareness, reflection and insight more difficult because the internal communication patterns can become maladaptive and freeze any positive change. However, this does not apply to any depressive dip. Many mild depressive episodes may also benefit us when they lead to some withdrawal, inside focus, and deliver the push for a constructive push. But suppose this is not the case, and the internal communication patterns do not terminate the depressive episode and lead to positive change. In that case, external communication with the therapist can help the inner communication processes fulfil their autoregulatory mission.
An emotion contains a lot of information that can become even more useful if one becomes aware of and reflects on it. The brain integrates many information flows into an emotion. A feeling of sadness, for example, can derive from a present physical and emotional state, the information that a relationship has ended, the information about the relationship itself, past relationships, individual interactions with others, one’s parents, and so forth. In a therapeutic setting, all this information can help adapt strategies, design new ones, and help the patient integrate all this information into their lives.
The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is mostly determined by own needs and wants, but also by past experiences. When the patient begins to form new communication patterns or adapts old ones, it helps identify ways that have worked well for them in the past. Sometimes new ones have to be constructed from scratch, when a patient has been socially isolated for some time, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation, this may be necessary, but also essential to maintain the patient’s motivation for the therapeutic work.
The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight, which cannot be manualised. Communication has, however, universal rules which can be understood and worked with.
Decreased motivation is a core symptom of depression which often makes therapy more difficult. It is no different in a communication-focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin treatment and make it through the early stages. A communication-focused approach may have the advantage here that it works from the moment the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication-focused approach emphasises the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.
A communication-focused approach aims to provide patients with more autonomy and control over their recovery and healing process. As they become more fluent in how communication can work for them, they also gain more self-confidence and greater optimism about the future. They are essentially more motivated to continue the process. But a communication-focused interaction model provides the patient already at the beginning of therapy with a greater sense that they already have what will help them over time, their innate abilities to interact and communicate. The feeling that a therapy supports me in something I want for myself is more motivating than another person telling me what they feel is best for me. Autonomous motivation (Deci & Ryan, 2000) was in an empirical study a stronger predictor of outcome than therapeutic alliance, predicting a higher probability of achieving remission and lower posttreatment depression severity across all three treatments. Patients who perceived their therapists as more autonomy supportive reported higher autonomous motivation. (Zuroff et al., 2007)
In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This knowledge is practically very relevant in everyday life and in planning for the future. Observing communication patterns and trying out new ones is an integral part of the therapeutic process. Since communication has different components, one can focus on its ingredients:
- Selecting information for a message
- Encoding the information in a message
- Sending the message through a communication channel (e.g. using the speech system to say the words)
- Receiving the message through a communication channel (e.g. using the auditory system)
- Decoding the message into information
- Processing the information further
One will observe quite often that a message is not received accurately. For example, one may say “the weather is nice today”, and the other person may interpret this as a signal that one wants to go on a hiking tour. Of course, the easiest way is to ask the other person again if one is in doubt. However, patients with depression or anxiety are less likely to take this step.
Communication and depression can be viewed as a chicken and egg problem if one overlooks that depression itself is a communication structure. Depression comes with internal and external communication patterns, which are predictable. That it arises at the intersection between biology, psychology, and the social environment is secondary. It primarily is a communication structure with its own communication patterns. Internal information processing plays a role. It has been argued, for example, that depression is characterized by increased elaboration of negative information, by difficulties disengaging from negative material, and by deficits in cognitive control when processing negative information. (Gotlib & Joormann, 2010)
The interaction between communication and depression has been well documented. For example, social skills play an important role in students experience of loneliness as well as depression and anxiety. (Moeller & Seehuus, 2019) Another research group has used artificial intelligence to identify depression from speech. (He & Cao, 2018) Poor social skills as a cause of depression, depression as a cause of poor social skills, and poor social skills as a vulnerability factor in the development of depression all seem to play a role. (Segrin, 2000) There is also evidence for modulating processes associated with ‘expression decoding’ but not ‘structural encoding’ when serotonin is enhanced, such as in the case of a selective serotonin reuptake inhibitor (antidepressant). The enhanced cortical response to perception of moderately intense sad facial expressions following citalopram administration may relate to the cognitive processing of the social relevance or significance of such ambiguous stimuli. (Labuschagne et al., 2010)
Emotional processing impairment in depression is not confined to interpersonal stimuli (faces and voices), but also present in the ability to feel music accurately. (Naranjo et al., 2011) In another study, investigators used signal detection theory to determine whether any perceptual biases exist in depression aside from decisional biases. They found lower sensitivity to happiness in general and lower sensitivity to both happiness and sadness with ambiguous stimuli. They showed that the overall pattern of results can be explained by a neurocomputational model in which neural populations encoding positive expressions are selectively suppressed. (Soto et al., 2019) However, they found no systematic effect of depression on the perceptual interactions between facial expression and identity.
The communication patterns a depressed patient uses may have served some function in the past, as they could have protected from some negative emotional consequence. One may speculate that withdrawal and a greater focus on the own person could have had a protective effect in some circumstances. And still today some episodes of reactive depression can have a benefit. For example, if one is in the wrong job or the wrong relationship, a depressive episode may force one to reflect and make a change. In other words, a significant reason for prolonged depression is how one deals with it. On the other hand, it is also easy to see how awareness, reflection, and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A, and lift B’s mood. That is what a communication-oriented therapy should do.
Maladaptive communication patterns can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit. The latter often follow from the former in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations that can facilitate better communication patterns as the communication patterns one uses depend on the communication patterns of the people one interacts with. Suppose a person is continuously exposed to other people who are stressed, anxious or depressed. In that case, one may adopt more communication patterns, internally and externally, leading to greater stress, anxiety and depression. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on the existing set of helpful communication patterns and autoregulatory processes’ effectiveness, the child may adopt more or less maladaptive communication patterns.
Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. Thus, there is a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression. Engaging with the world can make the inner sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes themselves to be more outgoing in a social situation often feels worse in the end.
Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.
The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.
Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.
Meaning requires that one can decode a message and extract some novel information form it which can potentially lead to change within oneself, a new thought, state or emotional signal, for example, which can then also lead to a change in the world. Helping patients to reassess and readjust communication patterns can be particularly helpful in therapy because the resulting change in perceiving and thinking usually also leads to a change in perspective (Haverkampf, 2018d), which then in turn also lead to changes in thinking, feeling, acting and interacting.
Resonance is when synchronicity or similarity leads to a potentiation of a signal or piece of information. In a therapeutic setting, resonance can be important because it identifies information that may be important or relevant. A depressed patient who has lost a grasp of what is potentially enjoyable and meaningful can rediscover it when resonance is detected. When the therapist becomes aware of resonance in how a patient is communicating about something, it is often helpful to point that out. If there is true resonance, the patient will usually acknowledge it quite quickly. In other cases, the therapist may also identify it as a projection of something that is important to the therapist only. But if the patient sees a resonance, it can be helpful in getting more insight into the own needs, values and aspirations.
Resonance is when new piece of information becomes more meaningful because of the information that is already present (Haverkampf, 2018a). The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. In therapy, often the technique of the ‘fishhook’ (Haverkampf, 2010b) may be used. One asks the patient to describe life in general, such as the events of the weekend. The more the patient learns to work with resonance, the easier it will be for her to find insight in these everyday events by using an increasing volume of information effectively, including emotional signals, perceptions, cognitive thoughts and more.
In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is communicating, since it reflects the information the patient already has, and which represents the foundation for resonance. The question “how was life yesterday?” or “what did you do yesterday?” can be more powerful than a complex intervention, because it can serve as the starting point to greater insight if one is aware of information resonance.
Depression makes old and new information, particularly emotional information, less accessible, which lowers any potential resonance. However, in many patients suffering from mild or moderate forms of depression accessibility may not be greatly reduced. Rather, it is a question of whether a patient can still believe there is ‘something’ below the unpleasant state. Resonance can help to rebuild a connection with interests, needs, values and aspiration, whose pursuit can be enjoyable, below a surface of depressed feelings. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalisation of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.
Depression makes everything seem less relevant as it reduces the spectrum of available information, including emotional signals. Less available information leads to less resonance, and thus less meaning is extracted from messages from internal and external sources. The world as a whole becomes less meaningful, including one’s place in it. There will also be less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore, even though one is an enthusiastic arborist (tree expert). The visual information about the tree still arrives in the brain as it always did, but the information associated in memory with trees, including the good feelings, is less accessible. The actual tress has not changed, but it has become less relevant to the person because of the depression, which illustrates that how information is exchanged internally and externally determines how we perceive the world and feel about it.
Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not be feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Instead, a typical response to stress is often to work even harder, which can lead to burnout. However, the more one thinks about relevance on a smaller level, the easier it becomes to adjust larger constructs, such as ‘one’s job’. As mentioned before, it is the details that help identify one’s needs, values and aspirations. On a smaller scale, the brain reorients the focus towards task-relevant stimulus information. Egner and Hirsch showed that, in response to high conflict, cognitive control mechanisms enhance performance by transiently amplifying cortical responses to task-relevant information rather than inhibiting responses to task-irrelevant information (Egner & Hirsch, 2005). This also shows that the brain focuses on picking out potentially relevant information rather than suppressing non-relevant ones. Of course, what is relevant is subjective to the individual, but it must be based on existing information about the one’s needs, internal states, and the state of the world.
From a broader and more long-term perspective, relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values, or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns, leading to better information, and exposure to meaningful communication.
Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.
In therapy, rebuilding relevance through new communication patterns that bring a different focus, and more useful information changes how the person and the world are seen. It also directs the focus towards better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him what the other group members have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, can be very effective in treating depression and other mental health conditions. It lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.
Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the center of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.
The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.
As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost from exposing oneself to the right communication environment.
Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.
The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.
Exploring interests, values, needs, and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.
Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.
Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017a, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017f, 2017b, 2017d, 2017c, 2017g, 2017h). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.
The actual instrument of change are the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.
If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. You can reach author by email at firstname.lastname@example.org or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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