The Depression Notebook – continued

In the morning she scuffed her way to the kitchen and sat down with a fresh cup of coffee. It took a while for her to feel awake enough to look around, to survey the disaster. Somehow she’d cleaned up the sink full of dishes yesterday. Finally. It looked nicer. Her memory of the day was hazy, as usual. Brain fog, or something, she said under her breath.
She glanced at the table and saw the notebook, still sitting there under the damp towel. Only then did she remember — she’d written that list, the “what’s wrong?” list, the day before. What a slog through my collection of hells, she thought. She did not want to read it through, or think about the problems for a while.
She sipped the coffee and stared off into the distance. All the things going wrong…quite a list. Seemed a bit — just a bit — more manageable, at least, after doing that brain dump.
Then she remembered, there was another question. One was about what was wrong. What was the other one?
She refilled her coffee mug and sat back down. She opened the notebook to a new page. A fresh start. And again, as if a voice within whispered the words, she wrote at the top of the clean sheet, “What’s going well?”
She stared at the sheet for a long time. This was harder. Finally she wrote, “well, the coffee is hot.”
Smiled a bit. That was stupid.
“…and the dishes are done. The kitchen looks a bit cleaner.”
She sat a while longer, nothing else coming to mind. Then something did. Just a little thing. She wrote it down.
And another came to mind.
After a while she stopped. She’d filled half the page. There was a list there, which came from…somewhere. Things going well.
The stupid smile came back to her face. She decided to get up and shower and finish the cleaning. Something felt a bit better, anyway. Maybe not hugely better. But a bit.

Getting the mind out of the depressive track
Depression tends to involve a cycle of thinking and mood symptoms. They tend to fuel each other, much like a cat chasing, but then catching and biting on his own tail.
When you are depressed, you tend to filter out the good stuff. You are less able to remember the positives, the pleasant experiences. It’s harder to remember the many things that are going right, because you get so focused on what is going wrong.
It’s a form of tunnel vision. Only focusing on the bad parts.
I like to think of this as a sort of survival reflex gone rogue. In primitive times, we probably needed a way to cope with emergencies that involved laser-like focus on whatever was going wrong. You want to survive in a stone-age environment, you need to be aware of the falling tree, the attacking animal, the noise in the bushes. Everything else should be put on hold.
Which is fine for coping with an immediate, short-term emergency. It keeps you alive.
The problem is that in most of our lives, the sources of danger are not short term, and not physical threats that require an immediate response. Rather, they are simmering problems: a relationship under strain. A bill that you can’t pay this month. A chronic physical condition. Loneliness. Loss of a love.
Those problems are not acute, fix-it-this-second-or-die emergencies. Yet our brains treat them as if they were.
Meaning, we automatically focus only on these negative things. And so we forget about the rest of life. The good parts.
In short, our conscious awareness gets stuck in a toxic groove. All we see is the negative.
This in turn triggers our biology, and nasty things happen. Stress hormones, brain chemistry, a cascade of ick.
The advantage of making yourself shift focus
Several decades of research in depression has confirmed what some of the ancient philosophers taught about the healing effects of shifting your focus away from the ick. Often, the simple act of listing what is going well, of writing down things you are thinkful for, or even just forcing yourself to smile, can actually, believe it or now, help you feel better.
In effect, what you think and what you do to feel less depressed can be as effective (or even more effective) than taking a pill to treat your depression. These things literally do change your brain chemistry as effectively at times as antidepressants.

Thoughts and acts are medicine

Try this exercise a few times. It’s one of many ways of doing this. Just do it and see if it helps at all:

Write down a list of “things going right in my life today.”

Little things count. The coffee you like. Someone smiled at you. The sun came up.
Just see what happens. Not promising it will work. Just worth a try.

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How to do psychological first-aid on a desert island

You’ve probably never had it THIS bad. Nearly killed in a shipwreck, stranded alone on an island, no hope of rescue. The temptation to give in to despair must have been nearly overwhelming. Many would have become immobilized, maybe even considered taking a long, cold walk back into the ocean to end it all.

message in a bottle

But Robinson Crusoe didn’t. And the reason he didn’t, the psychological “first aid” that he rendered unto himself, still stands nearly 300 years later as perhaps one of the simplest, yet best example of what would later be called “cognitive behavior therapy.”

How Crusoe did it

Here’s the key passage* from Daniel Defoe’s 1719 classic:

I now began to consider seriously my condition, and the circumstances I was reduced to; and I drew up the state of my affairs in writing, not so much to leave them to any that were to come after me—for I was likely to have but few heirs—as to deliver my thoughts from daily poring over them, and afflicting my mind; and as my reason began now to master my despondency, I began to comfort myself as well as I could, and to set the good against the evil, that I might have something to distinguish my case from worse; and I stated very impartially, like debtor and creditor, the comforts I enjoyed against the miseries I suffered, thus:—

At that, Crusoe write down a list of negatives in one column, and responses in the other:

             _Evil_.                             _Good_.
I am cast upon a horrible,          But I am alive; and not drowned,
desolate island, void of all hope   as all my ship’s company were.
of recovery.

I am singled out and separated,     But I am singled out, too, from
as it were, from all the world,     all the ship’s crew, to be spared
to be miserable.                    from death; and He that
                                    miraculously saved me from death
                                    can deliver me from this
                                    condition.

I am divided from mankind—a         But I am not starved, and
solitaire; one banished from        perishing on a barren place,
human society.                      affording no sustenance.

I have no clothes to cover me.      But I am in a hot climate, where,
                                    if I had clothes, I could hardly
                                    wear them.

I am without any defence, or        But I am cast on an island where
means to resist any violence of     I see no wild beasts to hurt me,
man or beast.                       as I saw on the coast of Africa;
                                    and what if I had been
                                    shipwrecked there?

I have no soul to speak to or       But God wonderfully sent the ship
relieve me.                         in near enough to the shore, that
                                    I have got out as many necessary
                                    things as will either supply my
                                    wants or enable me to supply
                                    myself, even as long as I live.

His conclusion from the exercise:

Upon the whole, here was an undoubted testimony that there was scarce any condition in the world so miserable but there was something negative or something positive to be thankful for in it; and let this stand as a direction from the experience of the most miserable of all conditions in this world: that we may always find in it something to comfort ourselves from, and to set, in the description of good and evil, on the credit side of the account.

Useful lessons from a shipwrecked man

Reading the above passage, there are a few really good examples of effective self-treatment for depression or despair.  You can probably see how effective this exercise might have been in reducing some of the despair and fear he was feeling.

Here are a few of the most notable things Crusoe does:

1. Writes his concerns down

First, Crusoe makes the point that it’s better to not let your concerns just rattle around loose in your head:

“I drew up the state of my affairs in writing…to deliver my thoughts from daily poring over them, and afflicting my mind.”

Continuously “poring over”,  ruminating about your worries, overthinking things, is a sure way to go crazy — at every turn, these things will pop up and nag at you.

“Free range terrors,” left to run amok in your mind, are the most damaging. Tweet this

You’ll often see this key principle of writing things down happening if and when you talk to a therapist. Forget your troubles for a second and just watch how they work, and how this works for you:

Generally, they start jotting down the sixteen things you rattle off that are bothering you. And at the end of their high-priced session, they look up over their spectacles, smile, and in that kindly and wise seeming way, say, “so… it seems to me that your main worries are…” and they glance down at their pad, and like a genius, they read back to you the three or four main “worry clumps” that pretty much summarize your last hour’s worth of fretting and whining. Then they sit back, let that soak in, and send you a bill.

It seems too simple. But odds are, you’ll feel like your head is a bit clearer, things seem less chaotic, just for having had your concerns summarized back to you. This kind of summary lets us get a bit of psychological distance from things, and that seems to help.

Like Crusoe, stuck on an island that has no managed care clinic nearby, you can jot down your worries and fears yourself, pick out the main “themes,” and get about $150 dollars’ worth of therapeutic help from that simple step. (Plus, write down one more in the “Good” column: you will have saved $150.) Writing your concerns down tends to give you a bit of psychological “distance” from them. Seeing  beasts on the ground from helicopter height, instead of down on the ground where the big scary rhino is breathing in your face, you tend to feel a bit more able to think clearly about things.

2. Examines his thoughts and asks critical questions

The second thing Crusoe does, is to start coming up with responses to his fears. This is almost exactly the same process that later became the hallmark of “Rational Emotive Therapy” founder Albert Ellis, and still later, the “Cognitive Therapy” of Aaron Beck.

It’s not a hard thing to master. Having written his worst fears down, Crusoe then has a bit of psychological “breathing room” in which he can think logically about these concerns. He is then able to think of a specific, focused responses to each concern, a sort of “on the other hand” response.

It’s important to notice that this is not a vague, overly general “always look on the bright side of life” cure. He is not just staring up at the blue sky and whispering “everything is peachy keen today!” Because that would not work. It would not deal with the very real, and very specific, raging fears and concerns that are tormenting him.

Rather, he gets each individual concern down on paper. He then comes up with a SPECIFIC “on the other hand” kind of response to each concern.

The standard Cognitive Therapy way to work with such a list would involve taking  each concern on your list, and asking yourself a few simple questions:

– Is this concern valid? How do I know? (Could I be misinterpreting the evidence? Am I being selective in what I am paying attention to, filtering out the good news and only paying attention to the scary clues? Was that scary bump a burglar, or just the cat…again?)

– Are there other ways of thinking about this that might be more helpful, or calming? (e.g., the response to “God must hate me to have stranded me” can be countered with, “Well, but he DROWNED all the other guys and kept me alive! Maybe I’m the favorite!”)

– So what? So what if this is true? What’s the worst that can happen? How, specifically, can I manage if this fear is true? What, for instance, might be the realistic, long term results of this situation? (e.g.: “I’ll just live and learn.” “Pay the fine and move on.” “I’ll make sure my next brownies aren’t burned.” “I’ll make sure my next husband isn’t such a jerk.”)

This kind of thing takes a bit of practice, and I would imagine that Defoe had to struggle a bit, tapping his head with his inky quill, to get this nifty example down on parchment. It will take you a bit of time to learn, as well. But we know from decades of psychological research in treatments such as cognitive-behavior therapy, that when you learn this technique, it practically becomes your superpower. Your mind, and your life, will thank you for learning it.

3. He gets busy

Crusoe finishes the exercise thus:

Having now brought my mind a little to relish my condition, and given over looking out to sea, to see if I could spy a ship—I say, giving over these things, I began to apply myself to arrange my way of living, and to make things as easy to me as I could.

When we are depressed and scared, we tend to be paralyzed. We may be agitated, tired, unable to get moving. Breaking out of the worried, ruminative state tends to release a great deal of physical and mental energy. Crusoe felt better and so his energy was freed up to get busy, building his island home.

Another advantage of getting going, doing things, is that you can start to deal with the “real world” situations that have been triggering all that worry. After Crusoe spends some time and effort getting his situation organized, he’s going to be in a much better position to cope with the disaster that has occurred. He may still be stuck on an island, but he will at least have managed to find safety, food, water, shelter, and protection for himself. The only way he could have done all that, was by shaking off the paralyzing depression and fear that threatened to overwhelm him.

Practice exercise

Sit down and write out three of your current concerns or worries. Do a Robinson Crusoe on them: next to each one, try to come up with a different, less catastrophic way of thinking about the situation. If it’s not easy at first, remember that you will get better at this kind of thing with practice. Devoting a bit of time to mastering this skill will change your life.

___

* Excerpt from Robinson Crusoe, a public domain book, courtesy of Project Gutenberg. You can find the whole book here.

A Self-help Program For Curing Depression

There are at least a hundred things you can do — completely on your own, that will cost you nothing but a few minutes of your time — to reduce or even eliminate a depression.

The fact is that we know more about the causes and treatment of depression than ever before in history.

I know this for two reasons. I’ve been a psychologist for over 30 years, have treated hundreds of people, and I read the research on depression. I’ve also had my own struggles, at several points in my life, with depression. I’ll be sharing just a bit about that in the posts and books that follow.  (Not everything, not a lot of gory details. I think there is a value for all of us in expecting and protecting privacy.)

Over time, combining some trial-and-error and what I understood when I was young about the newly developing research on depression, I stumbled on a very simple way of managing my own depressed moods. It was, in fact, so simple to do and so effective that I felt depression free within a short period of time. After which, being busy with grad school and life, I pretty much forgot about this technique for several years. But in looking back, now that so much more is known about the effective treatment of depression than was known years ago, I have come to realize that my simple “five stroke cure” was a great example of an effective depression treatment.

And it’s this understanding of how depression works and can be managed, that I’m going to be sharing.

depressed

 Signs of depression

Depression is generally defined as a mental health condition in which one experiences a sad or empty mood (though one can also have other feelings mixed in, such as anger, hopelessness, or anxiety.) Depression symptoms can include crying spells, sleep disturbance, loss of appetite (or “comfort eating”), loss of motivation or energy, loss of interest in things, poor concentration or memory, and thoughts of suicide. Many other symptoms are possible. Depression can last for a few days, a few weeks, or through one’s entire life.

 More facts about depression

  • Depression is one of the most common psychological and medical problems. It can also be one of the most painful and life-damaging conditions on earth. Studies suggest that between six and seven out of every 100 persons will have a clinically significant level of depression in a given year.
  • Depression can affect children, adolescents, adults and the elderly.
  • Twice as many women as men tend to develop depression.
  • Depression tends to co-occur with a number of other mental or physical health conditions, ranging from anxiety problems to drug and alcohol addictions to cancer.
  • In a kind of cosmically unfair-seeming way, if you’re depressed you’re also statistically more likely to have a heart attack, stroke, or other difficulties (not to mention the fact that you’re more likely to get depressed if you do develop a heart attack, stroke, cancer, etc.)
  • Depression tends to jeopardize and wreck relationships. Depressed people pull back from close relationships, and tend to “wear out their welcome” as relatives’ and friends’ to help them feel better fail time and time again. Which, of course, the depressed person senses but feels helpless to prevent…further deepening their sense of being unlovable, unwanted, and isolated.
  • Depression is the leading cause of workplace disability worldwide, and it is estimated that it costs US businesses $70 billion annually, when medical expenses, productivity loss and other costs are factored in. About $12 billion in lost workdays due to depression occur annually, in addition to nearly the same amount due to lost productivity.

 Why it’s hard to get help for a depression

  • When you are depressed, it is sometimes hard to get yourself to do anything. Showering, eating, getting to work, caring for your kids, may all suffer. So it can be a thousand times harder to find the energy to start down the path of finding some kind of help for yourself.
  • But many people who do manage to get to the phone, or to tell someone about their desire for mental health assistance, find that it’s even harder than they expected to actually get the help they need. This can be for a number of reasons:
  • Therapy is expensive. If you have insurance, you may find that it’s still hard to locate “providers” who can help you, and your insurance carrier (who I can guarantee you is more interested in their profits than your well-being) may not authorize enough, or any, treatment.
  • Most people get help from their physicians, but physicians most often provide minimal assistance besides prescribing antidepressants. Which may be quite useful for many people, but not always. But physicians seldom have the time or the training to help you develop a wider range of effective self-treatment skills.
  • It’s also hard for many depressed persons to stick to the medication program once it’s started. Side effects, not being sure the meds are helping, anxiety about calling the doctor back for help, may all interfere.
  • If you do find a therapist, many may expect you to endure a long period of getting “insight” before you will feel even a bit of relief. (This can fuel the problem of “overthinking” that I mentioned in the last post.)
  • Persons living in isolated or rural areas may find it difficult or even impossible to find qualified helpers.
  • Many people simply are too scared or uncomfortable to want to share much about their depression with anyone, even a professional.

 A self-help program for curing depression

We know this from research:

Self-help approaches to treating depression can be as effective as professional treatment. (tweet this)

In some cases, they can be every bit as effective as professional interventions. This may depend on the type of self-help approach used. (I’ll summarize some of the research on self-help and depression in a later post.)

In the posts that follow, I’ll be sharing excerpts from my upcoming book on self-help for depression. My hope is that if I can share some things I’ve learned both as a patient and a psychologist about depression and its treatment, that at least some people will find this helpful.

The program I’ll be sharing is a skill based model for treating depression. That means it relies less on older notions of “insight” into things like “childhood causes” or “hidden underlying psychological dynamics” of depression (not that those things are not true and valid. They just aren’t the first things you need to attend to in order to get some relief, and focusing on them can even slow up your progress…or make you feel worse!)

Neither does my program require medications.

In saying these things, I do NOT mean to say that people should not use medications, or work with good therapists on insight or whatever they and their therapists feel is important. This program is not meant to be a substitute for needed medical or other professional care. You can use it alone, or WITH all those other treatments. You can use some of the techniques I suggest while you are a patient on a psychiatric ward, while you are taking meds, or while actively working with your psychotherapist or psychoanalyst or other health care professional. This program will not interfere with any of those treatment approaches.

Or you can just try this approach first, and see if it’s enough.

The program is research based. It collects ideas from the most up to date cognitive behavioral, positive psychology and mindfulness approaches (Google those terms if you want to have some idea what I mean, or hang on and I’ll get to them.)

Since the program is a SKILLS based approach, the techniques are often going to work best if you practice them a bit.

General approach

The basics of the stuff I’ll be sharing can be summarized simply:

First, see depression as in part as a problem that is caused or maintained by patterns in your thinking or ways of acting. For instance, people with depression tend to focus more on negative than positive events. This tends to make the depression worse instead of better. (Be careful about the rather passive idea of seeing it all as some kind of a “chemical imbalance.” Your chemistry can get “unbalanced” in large part because of your thinking patterns!) To fix the depressed mood, then, you need to make some changes in your thinking and behavior patterns.

Second, see these techniques as skills that you can learn, try out, but that may work best with some regular practice.

Third, go for what I call “incremental improvement.” This means, try to develop some “two percent solutions,” simple things that you can do that give you at least a “two percent improvement” in your mood when you do them. I’ll share at least a hundred techniques that you can try, to see which ones give you the biggest percentage of improvement in your mood.

Finally, again, this is a skills based approach. That means you can practice and the idea is to get better at the approach over time. Eventually, the new “habits of thougth” can become pretty automatic — things you do that are just a natural part of “who you are.”

And again, you can use this approach along with other approaches that you are already using: talking to a therapist, taking medications, and so on.

A quick example

There are lots of things you can do that might improve your mood a bit. Some general ideas of things you might try are below:

First, get a general sense of how depressed you’re feeling right now. RATE IT on a 1-100 point scale, where one end of the scale is anchored at a “positive” or neutral end (e.g., “feeling fine”) and the other end is the most severe depression level you can imagine. Write the number down

Next, pick one of the following actions and do it, right now. Just get up and do it:

  1. Make a mental list of five things you’ve gotten the most pleasure or enjoyment from today. Simple things: the cat in your lap, seeing the sunrise, the taste of your breakfast toast. Remember each thing on the list for just a few moments, but try to remember the pleasure you experienced as vividly as you can. Go through each of the five experiences and do that memory exercise.
  2. Call someone you feel good talking to, just to say hi. Don’t mention that you’re doing it to feel less depressed; don’t mention depression at all. Just make it a five minute or less hello call. Be sure to ask them how THEY are doing.
  3. Put on a favorite piece of music, something you think is beautiful, encouraging, that energizes you. Relax and just enjoy it for a few minutes.
  4. Go outside and stretch, take five or ten nice deep breaths. Stretch or go for a short walk.

As soon as you are done with the activity, rate your depression again. Notice any difference in the before and after ratings. It may be a big difference, but even a two point improvement is excellent. Write this second 1 to 100 rating down. If you did get at least a two percent change, do the exercise again today, at least two but no more than four more times. See if it helps.

If it did not help, try another of the exercises. Again, be sure to rate your “before” and “after” score.

If none of them help, that’s fine. Remember, this program will have over 100 suggestions, and much more information on the treatment of depression. It only takes one successful “two percent solution” to get the mood to start shifting.

More resources

That’s just a start. Much to follow. Hope this promises to be helpful!

Meanwhile, here are Amazon links to a few other excellent resources for some self-help:

Feeling Good: The New Mood Therapy – David Burns

Women Who Think Too Much – Susan Nolen-Hoeksema

Talk to me

I can’t necessarily respond to particular requests for information, but I am very interested in your reactions to this blog and to the suggestions and ideas I’ll be sharing. As time goes on, I’ll be setting up some surveys to determine which techniques are most helpful to readers. Talk to me in comments and I’ll get back to you with general responses (meaning, I can’t address your particular clinical needs. Sorry.)

Here is the usual disclaimer

I dislike having to mention this, but it is kind of important to remind you that a blog or book are not therapy, and I am not able to provide individual consultation to any readers. This material is here for educational and/or entertainment purposes; I hope it proves useful to readers, but I cannot be held responsible for anything that does or does not occur as a result of reading this material. Sorry, but it would be professionally unethical to attempt to provide actual psychological treatment to a readers of this blog. Please contact your own therapist, physician or other licensed helping professional if you feel that you are in need of personal assistance.

Overthinking Depression

Women Who Think Too Much

by Susan Nolen-Hoeksema, Ph.D.

(Book review)Image

Dr. Susan Nolen-Hoeksema, who recently passed away, has left us a lasting gift in this excellent book on the causes and effective ways to treat depression.

Women Who Think Too Much explains how one major cause of depression is likely to be “overthinking.” She defined this as “getting caught in torrents of negative thoughts and emotions that overwhelm us and interfere with our functioning and well-being.” (p. 3) She describes how such thinking patterns tend to develop and gives lots of examples that will probably ring bells of recognition in many readers.

For instance, she describes how a woman who reacts to a boss’s sarcastic comment may come to spend days going over the remark, expanding her worries to include her boss’s opinion of her work, her own self-doubts about her work, and on and on… triggering more feelings of guilt, shame, and other negative emotions.

The more we overthink, the more likely we are to get depressed. click to tweet

Special risks for women

While both men and women, boys and girls, are vulnerable to this kind of psychological wound-picking, Nolen-Hoeksema highlights the ways in which women may be more prone than men to engage in depressive thinking patterns. Her chapter on “women’s unique vulnerabilities” shows how this occurs.

Stressful roles at work and in the family, lower status and pay, unequal power, sexual abuse and harassment, can all contribute to overthinking.

Managing your thinking patterns

 Most useful to many readers, she has a very clear, well-written set of strategies for breaking unhealthy thought patterns. One of her first suggestions is that one should understand how overthinking is “not your friend,” that ruminating endlessly on one’s faults and even your past history of injuries and errors, may be quite self-destructive. (This is no doubt the dark side of “navel gazing” that seems so much like “insight” when we are doing it, or even sometimes when our well-meaning counselors or therapists encourage it in less than productive ways.)

Some other suggestions she makes include:

  • Distracting yourself from overthinking, especially with positive diversions
  • Getting into healthy activities such as exercise
  • Immersing yourself in hobbies, reading, etc.
  • Avoiding unhealthy ways of distracting yourself (especially things like alcohol)

Decide to change your outlook by saying to yourself, “I have the right to choose how I look upon this situation, and I am going to exercise that right.”

Dr. Nolen-Hoeksema was a respected researcher at Stanford and Yale, trained in the “positive psychology” tradition of her teacher, Martin Seligman. Her book is essentially a readable primer in many of the cognitive-behavioral and positive psychology concepts that have been proven to be highly effective in the treatment of depression, anxiety and related conditions.

Letting your light shine

In addition to helping persons, women and men, with depression, this book can be a useful guide to simply living a better life. For instance, parents, especially parents of girls, may find it helpful in learning both to teach their kids, and to be good models for their kids, of healthy ways of thinking.

A favorite Bible quote of many psychologists should really be Matthew 5:15: “Don’t hide your light under a basket.” Whatever one’s religious beliefs, each of us needs all the encouragement we can get to remember that in a sometimes scary and guilt-producing world, “letting our inner light cut through the darkness” is good for ourselves and others. Being fully alive means, as a first step, not letting ourselves get chronically caught up in waves of self-doubt and overthinking. The late Dr. Nolen-Hoeksema’s book is a valuable source of light for use in our journeys. The book is highly recommended.