Out of the Blue: Six Non-Medication Ways to Relieve Depression (Norton Professional Books) (7 page)

But the reason I tell you this story is that now, more than thirty years later, I can’t remember one of the nice comments, but that critical comment is lodged in my mind. Perhaps we have minds that latch on to and remember the negative. And people who are depressed tend to over-notice and over-remember the negative. Their attention is focused on some specific incident or, more generally, what’s wrong with themselves, with others, or with the world.

In this area, our task is to notice which patterns of attention and meaning happen when the client is depressed or is getting depressed and then to shift those patterns in any respectful and effective ways we can to discover.

Assessing The Viewing in depression involves asking and noticing. Some patterns may emerge spontaneously, so all we have to do is take note of them. Others can be elicited by questioning.

Here are some questions that can illuminate The Viewing:

“Where does your mind go when you’re depressed?”

“Where does your mind go when you’re just beginning to feel depressed?”

“What are you paying attention to when you’re depressed?”

“What kinds of ideas do you have about yourself and your depression?”

“What kinds of thoughts are more prevalent when you’re depressed?”

“What do you make of your depression?”

“What kind of person do you think you are?”

“What do you think causes you to be depressed?”

“How do you think you’re different from others?”

“Do you spend more time thinking about the present, the past, or the future?”

“When you think about the past, how do you view it?”

“When you think about the future, what do you think will happen?”

“What thoughts does depression seem to bring to your mind? Do you always believe those thoughts are true, or do you sometimes challenge or doubt them?”

“What captures your attention when you’re depressed?”

“What do you spend a lot of time focusing on these days?”

Here is a sample dialogue in which the therapist tries to change The Viewing of a client who is depressed:

Client:
I’m such a loser. I can’t seem to get it together.

Therapist:
Is that how you thought of yourself before depression happened, or does that idea of yourself as a loser come as a package deal with depression?

Client:
I guess I thought of myself as pretty competent and okay before I got depressed, but I wonder if I was just deluding myself. Maybe I was a loser all along.

Therapist:
I don’t really know, but I’ve noticed that you’re not the first person to have that recurrent idea while you’re depressed. It’s common, so I tend to think it’s one of the features of depression rather than a true idea about your life. Let’s look at the evidence. Have you ever accomplished something you were proud of and that would dispute this idea that you’re a loser?

Client:
I ran three marathons. I got two raises and promotions at work, and my boss was talking about sending me to the West Coast to open a new branch office before I got depressed.

Therapist:
Okay, not sounding loser-like to me.

Client:
You’re right. I think that is a depression idea. But it’s hard to fight it while I’m feeling so low.

Therapist:
How about this? The next time that idea comes along, since you’re not sure it’s true, just move to “I don’t know” rather than thinking well of yourself or proud of what you’ve accomplished, if that’s too much of a stretch. Just get to neutral. Think of it something like this: “Hmm, this may be depression talking or it may be true. I just don’t know. I don’t know if I’m a loser or not.”

Client:
Yeah, I could do that. Get to neutral. That would work. Positive is too much, as you say, but neutral feels doable.

The Context of Depression

The Context involves anything around but not directly involved in the depression. Context includes things like family background and patterns, cultural background and patterns, biochemical and neurological patterns, spiritual background and beliefs, physical or spatial orientations and locations, social relationships and connections (or isolation), sexual orientation, gender training and propensities, connection or alienation from nature, and nutritional influences and sensitivities.

Here are some questions to get at The Context for your client in relation to his depression:

“Can you tell me something about your family background? How do you think it influenced who you are and how you look at or handle things today?”

“How do people in your family view or handle difficulties?”

“What kinds of things in your life come from your ethnic background? How does or did that culture play into who you are today?”

“What have you noticed or learned about how your body or brain works?”

“What is your connection to others or to your community, neighbors, friends, family members, spiritual community, or other groups?”

“How much time do you spend alone versus with other people?”

“What did growing up male [or female] teach you? How do you think that shaped you?”

“What do you think being inducted into the ‘male [or female] culture’ had to do with making you who you are today?”

“What kinds of responses have you noticed to different foods you eat?”

“Have you noticed any correlation between how or what you eat and your level of depression?”

“Where do you usually spend time when you’re depressed?”

“What part of your house or apartment is your ‘depression place’?”

“What kinds of religious or spiritual backgrounds do you have? How might those play into how you think about what you’ve been going through?”

“How much time have you been spending alone these days as opposed to being with another person or a group of people?”

“How often do you go outside these days?”

Let’s examine some sample dialogues investigating The Context with a client who is depressed.

Client:
I’m such a loser. I can’t seem to get it together.

Therapist:
Where have you heard those words before, and how did you come to incorporate them into how you think about yourself?

Client:
I guess now that you mention it, my dad used to say those exact words to me: “You’re such a loser.”

Therapist:
And did you believe him?

Client:
No, I used to get so mad when he would say that. I told him he was wrong about me.

Therapist:
And what did your dad tell you that ran counter to the idea that you were a loser?

Client:
He often told me that I could do anything I put my mind to and that I was one of the most stubborn people he had ever met. He told me one thing that would take me far is that I would never give up.

Therapist:
Ah, yes, we often get both unhelpful and helpful legacies from our families. So how do you think that other idea about you never giving up might be helpful for you right now?

Client:
I feel like I’m totally alone in the universe.

Therapist:
I’m curious. Do you have any religious or spiritual beliefs or practices?

Client:
Yes, I’m a Christian. I was born again ten years ago. It really changed my life. I was so messed up at the time.

Therapist:
What does your understanding and experience of Christianity tell you about this being alone in the universe?

Client:
We’re never alone. Even if we don’t realize it, Christ is always here with us. He became a human and suffered like we did so he could be closer to us.

Therapist:
And how does articulating and perhaps remembering that help at this moment?

Client:
It actually does help. I know that deeply, and somehow, until you just asked me, I had forgotten it. I feel comforted remembering that and bringing it back to my heart.

OKAY, NOW WHAT?

As the sample dialogues have indicated, once you’ve discerned the patterns related to depression in any of the three areas mentioned above (The Doing, The Viewing, and The Context), your next task is to intervene in two ways: (a) Help the person challenge and change these depression patterns by doing anything that is not associated with the patterns, and (b) find and substitute solution patterns in place of the unhelpful patterns. That’s why this chapter is called “Undoing Depression.” If we think of depression as a process, or as a pattern or set of patterns rather than a fixed biochemical state or diagnostic entity, it can be changed. (Note here that I am not claiming that depression
is
a process—although I suspect it may be—only that thinking about it this way makes it more available to intervention. That is, I make no claim to know the true nature or cause of depression; as you have read, I don’t think anyone knows the true cause or nature of depression, although some will assert that they do.)

So, the idea is to get the depressed person to do new things, think new things, focus on new things, and shift contexts and thus interrupt her typical depression patterns. If the depressed person is unable to put forth much effort, given the severity of her depression or her lack of motivation, you can enlist those around her to make some changes and find out whether those changes are sufficient to help the person get some traction and begin to emerge from her depression. Most of the time, however, the depressed person can make changes in one or more of these areas herself.

Remember to keep in mind the spirit of this strategy—all of these changes are experiments, little forays into the possibility of change. Not all may work, but any might.

Here is a sample dialogue with a depressed client in which contextual elements are used to undo depression:

Client:
I feel like everything has just lost its color. Food has lost flavor. Everything seems flat and lifeless.

Therapist:
Yeah, I get it. So, how do you get yourself going? For example, how did you get yourself in here today, even though everything is flat, colorless, and lifeless?

Client:
Well, I just told myself I had made a commitment and that I had to keep it no matter how I felt.

Therapist:
Some people don’t keep their commitments. Where do you think you got that value, and how have you stood by it even in the mist of your current situation?

Client:
From my family. My father always used to say that an O’Connor on his worst day was better than most people on their best day, and I always felt I had to live up to that standard. My ancestors survived the potato famine in Ireland and then the terrible boat ride over when many people died. I joke that I have Irish cockroach genes. You can’t kill us. We’re strong and we’re survivors, we O’Connors.

Therapist:
How have you used that strength and survival ability to get through your depression, and how might these be useful qualities to hasten your recovery?

Client:
Well, I haven’t given up. I’ve had thoughts about doing myself in, but I’m not going to do that to the people I love. It’s hard, but I won’t take that out. And as far as how I could use that “O’Connor” strength to get better faster? I don’t know. Maybe I could start to exercise. Even though most days I feel as if I have five-hundred-pound weights on my feet, that shouldn’t stop an O’Connor, right?

Therapist:
Right.

CASE EXAMPLE

Charles had been depressed for months when he entered therapy. He wasn’t doing well on the medications his internist had given him to treat his depression. There were troubling side effects and his depression had barely lifted, despite his having tried several different antidepressants. He had heard I had a different approach, and he was willing to give anything a try.

Together we began the investigation of how Charles “did” his depression. We discovered that he tended to stay in the basement of his parents’ home, where he had moved when he quit his job and money became tight. He ate mostly pizza and sugary soft drinks. He played a lot of video games. He had a few friends, but he wasn’t seeing them as much anymore as his depression persisted. He spent a lot of time ruminating about mistakes he’d made. He had been in college and had “blown it” by partying too much and flunking some of his first-year classes. He had concluded that he wasn’t smart or disciplined enough to make it in the university. Now, several years later, he had revised that idea—he thought he was smart enough, but had just been too immature and not ready for the hard work of college. He thought that it was too late to reenter college now, as he would be older than most of the people there.

He would argue with his parents when they tried to pressure him to do something productive, telling him that he was “sick” and couldn’t function. He would scream at them that they didn’t understand about depression. Sometimes they continued to make forays into getting him to be more active and engaged in life, but at times they just left him alone. He felt like a failure who would never get it together and make it out of his parents’ house or be independent and functional.

I asked him if there were times that his depression was a bit less severe. He said that when he could get himself to exercise and eat better, he felt better, but that it was hard to get himself to stick to any regular exercise routine.

Our first experiment was to make a game of exercise. He said he had the most energy when he first awoke, so we agreed he would do some small amount of exercise—he suggested five minutes—before he played any video games in the morning. And each time he finished a level in his video game, before he could go on to another level, he would stop and do five more minutes of exercise. He would make a scorecard and create levels of accomplishment for his exercise, much like a video game, so that he would achieve rewards, such as buying another video game with his meager savings when he had accumulated ten hours of exercise.

We made a similar game of his eating patterns. For every healthy food he ate, he got a small amount of points that would go toward earning his new video game.