The Power of Client Engagement: “Contextual Healing” Research and Implications for Treatment of Depression

The pervasive incidence of depression is predicted to increase even more exponentially over the next 2 decades; by 2030, depression will likely be among the most common causes of disability (Mathers & Loncar, 2006). Although efficacious interventions for depression have been established, these treatments are, paradoxically, accessed by and/or available to only a small percentage of affected individuals. Furthermore, the most frequently used interventions-traditional psychotherapy and antidepressant medications-are conceptually based within an external control model as opposed to a holistic model of care. Interventions are reactive as opposed to proactive, and they highlight the role of agents external to the individual. This conceptualization opposes a more expansive approach that incorporates medical, psychological, and social factors as equivalent contributors to health. An alternative lens through which prevention and management of depression can be viewed emphasizing the influence of client participation is described. Citing results from research in which outcomes from use of antidepressant medications only slightly exceeded the influence of placebos (Kirsch, 2010), an often overlooked intervention resource, the influence of the patient himself/herself and the "contextual healing" suggested through placebo research is highlighted. Presenting literature on hope models (Jacoby, 2003) and positive psychology (Seligman & Csikszentmihalyi, 2000), the role of the individual as a powerful resource for depression intervention, is emphasized. Examples of therapeutic strategies that capitalize on this resource are described along with a discussion regarding the ethical responsibility of health care providers to include such strategies in practice.Depression represents a major cause of disability affecting approximately 121 million individuals worldwide (World Health Organization, 2012). This already substantial prevalence is predicted to steadily increase with unipolar depression projected to be one of the leading contributors to disability by the year 2030 along with HIV/AIDS and ischemic heart disease (Mathers & Loncar, 2006). Although two interventions-psychotherapy and pharmacotherapy-are considered efficacious in the treatment of depression and both are recommended practices outlined in guidelines from the American Psychiatric Association (2010), large-scale reports have indicated that these interventions are accessed by only one-third to onehalf of those with symptoms (Kessler et al., 2003; Pratt & Brody, 2008). Factors associated with more limited access include perceived stigma associated with mental illness and absence of health care coverage (Pratt & Brody, 2008), minority ethnic status (Gonzales et al., 2010), and lower educational level (Young, Klap, Sherbourne, & Wells, 2001). Furthermore, based on analysis of data from the National Comorbidity Survey, Young et al. (2001) indicated that quality of care for most individuals with depressive disorders who sought treatment via their primary care provider, the most commonly accessed source, was not consistent with treatment guidelines that recommend a comprehensive intervention plan.In addition to the complexities associated with access to care, treatment efficacy related to the use of antidepressant medication has become increasingly scrutinized ( Breggin, 2008; Kramer, 1993; Valenstein, 2002). One major limitation is that effectiveness is restricted to the timeframe of active treatment; thus, when antidepressants are discontinued, recurrence of depressive symptoms is often reported to occur (Williams, Teasdale, Segal, & Kabat-Zinn, 2007). In addition to these results from shorter term trials, efficacy from long-term treatment with antidepressants has been questioned based on extensive meta-analytic review of published studies (Hughes & Cohen, 2009). Moreover, analysis of clinical trial data has raised questions regarding the reported magnitude of effects from antidepressant medication usage (Healy, 2007; Kirsch, 2010). …