Out of the Blue: Six Non-Medication Ways to Relieve Depression (Norton Professional Books) (4 page)

Depressed person:
I’m afraid I’ll never come out of this darkness.

Your response:

[Possible responses: “You’ve been really afraid.” “You’ve been feeling pretty discouraged.” “You’ve been worried you’ll never feel better.”]

Depressed person:
Nothing will help.

Your response:

[Possible responses: “Nothing has helped.” “You’ve tried a lot of things and haven’t felt better.” “You’ve been thinking that nothing will help.”]

2. From Global to Partial Reflections

The next technique for acknowledging and inviting at the same time is to reflect the depressed person’s generalized statements as more partial. When the person says something like “always,” “never,” “nobody,” “nothing,” “everybody,” or another global term, you can reflect her statement or the feeling she is conveying but use more limited words such as
usually
,
typically
,
rarely
,
almost nobody
,
very few people
,
little
,
most everyone
, and so on. Your task here is to help her feel understood, but at the same time to introduce a little space into the stuck place she feels herself to be in.

Your reflections can be less global than the person’s original statement in both time (
lately
,
recently
,
these days
) and quantity (
most
,
very few
,
almost everyone
,
little
,
rarely
). For example, if the depressed person says, “Nothing is helping,” you might respond with, “You’ve tried most everything and it hasn’t worked much.”

Try your hand at this technique by covering up my suggested responses and writing or saying what you would say in response to this statement:

Depressed person:
It’s all meaningless.

Your response:

[Possible responses: “Not much makes sense these days.” “You can’t find much meaning.” “You can barely find any reason for doing anything.”]

3. Validating Perceptions but Not Unchanging Truth or Reality

To use this technique, acknowledge and validate the depressed person’s perceptions without accepting the fixed, objective truth or unchanging reality of those perceptions.

When people are depressed, they often have an unrealistically pessimistic view of life, so agreeing with that pessimistic perspective may further discourage them. But we can’t just dismiss the person’s felt experience and tell her that her point of view is wrong. This technique involves finding a crucial balance by joining with and validating the person’s felt sense of the way things are while at the same time separating those views from accepted reality.

To do this, use phrases such as
your sense
;
as far as you can see
;
as far as you remember
;
the only way to handle this, in your view, was
; and so on. The goal is to help the person feel heard and understood without joining in her distorted or discouraged conclusions.

Try this technique by covering up my suggested responses and writing or saying how you would answer the client’s statement:

Depressed person:
I’ll never get better.

Your response:

[Possible responses: “You think you won’t get better.” “Your sense is that there’s not much hope.” “As far as you can tell, nothing’s been working and you’re afraid nothing will.”]

Combining All Three Techniques

Of course, as you get more practiced at these techniques, you can combine two or three of them in the same reflection. For example, if the person says, “I’ve just got to kill myself. I can’t take this anymore,” you could use all three techniques in your response by saying, “So, you’ve really been so discouraged lately and suffering so much that killing yourself seems the best possibility for relief right now.”

However, if the person gives you the sense that she feels invalidated or that your response minimizes her experience or suffering, you can switch to another of the techniques or return to pure acknowledgment for a time, leaving out any of the possibility elements.

For instance, suppose the person says, “I can’t get up and going,” and you use the partial reflections technique and respond with, “Sometimes getting going is really hard for you.” What do you do if the person comes back with, “Not sometimes. Every damn day! You just don’t get it, do you?”

You could respond with, “Sorry, I didn’t mean to minimize what’s it like for you to struggle with this. And you’re right, I probably don’t fully get how things are for you. So, your sense is that you can’t get going pretty much every day.”

The person will often respond with something like, “Well, on the days I see you, I manage to get up, but the other days it just feels too hard.” And that is the beginning of possibility.

Your task in using these techniques is to stay very close to the person’s experience while introducing small openings into her discouragement and sense of hopelessness. She will let you know when those possibilities start to become viable and real for her when she begins talking about possibilities and change herself.

Inclusion

Another method of marbling is what I call “inclusion.”

Have you ever had a client come to your office and say something like, “I can’t go on. I have to kill myself”? In the back of my mind, I’m usually thinking, “Wait a minute, why did this person bother to get up, get dressed, and put on makeup [or comb his hair], just to tell me they’re going to die?” The people who are truly committed to dying would probably stay home and kill themselves. They wouldn’t give us the chance to intervene.

So, my sense is that even if the person has decided to kill himself, there is another aspect of him that hopes that coming to see me will change his mind—that I’ll be able to say something that will give him hope or relieve his desperation.

A while ago, I heard a story about a study of people who had jumped off the Golden Gate Bridge, intending suicide, but had been rescued or survived the attempt. The researchers were searching for something that might help them identify people at risk and prevent future suicides. They found one commonality among the survivors: On the way down from the bridge to the frigid waters below, almost all of them had some variation on the thought
Maybe this wasn’t such a good idea.
That indicates to me that very few people are 100 percent hopeless, even in the moments before their imminent death (or perhaps they are even more ambivalent when things have gone so far).

The inclusion method tries to acknowledge and capture this complex experience using three techniques, which I will describe below.

Permission

In addition to feeling depressed, many people who experience depression feel that they have done something wrong, or are feeling the wrong feelings, or are thinking the wrong thoughts, or are just basically “wrong” in some fundamental way. One way to help them with this sense of wrongness is to give them permission to feel, be, or think the way they do—and not to feel, be, or think the way they don’t.

This means that there are two kinds of permission that can be helpful with people who are depressed: “Permission To” and “Permission Not To.” These two types of permission are reflected in the following statements:

“It’s okay to feel depressed.”

“You don’t have to have hope right now.”

This permission-giving takes the person off the hook for being wrong or not feeling or being or thinking something he doesn’t feel or isn’t being or isn’t thinking. It also allows him to stop trying to keep himself from feeling, being, or thinking something he finds he can’t readily stop.

Now I want to be clear here that the permissions I suggest are for the most part all about
experience
, not actions. For example, I wouldn’t say to someone, “It’s okay to kill yourself,” but instead, “It’s not unusual for people feeling as bad as you do to think about killing themselves. It’s okay to think that. It doesn’t mean you’ll act on it.”

So, no permissions for self-harming actions or actions that might hurt someone else.

In this vein, I once had a client come to me after a referral to another therapist had proven disastrous. Her old therapist had retired from practice and sent her to a colleague whom he thought was very skilled. But on the first visit to this new therapist, the client, Mary, admitted to the therapist that she was in such misery that she considered suicide every day. Her previous therapist had known this about her, and given the fact that she had thought about suicide for the whole ten years and never acted on it, hadn’t really considered it an issue. But the new therapist, trained in the latest standards and concerned about liability, told Mary that if she wanted to continue in therapy with him, she would have to sign a “suicide contract,” agreeing that she would not kill herself, or if she felt she couldn’t keep the contract, that she would inform him immediately so she could be committed to a psychiatric hospital.

It’s a pretty standard and reasonable idea, this suicide contract, but for Mary, the effect was instant and bad. After she reluctantly signed the agreement, her suicidal impulse, always present, became a compulsion. She now felt compelled to kill herself right away. She called the old therapist to tell him she had signed the contract under duress and that she would like to renege on it. The new therapist refused to allow this, and when she told him she couldn’t continue in treatment with him under those conditions, he sent her a certified letter telling her he recommended that she check herself into the hospital immediately.

This letter further alienated her from him, since she saw it as a “cover your ass” kind of letter. It was all about him, and he didn’t get how this policy of his was harmful to her and had put her life in danger. She called her previous therapist, asked for a new referral, and was given my name.

When she explained to me the effect of the contract, I asked her what about signing the contract had made suicide so compelling. She told me that she had always had that as her escape hatch if things got too bad, and signing the contract had closed that escape hatch and made her desperate.

I told her that since she had been suicidal for all of ten years and hadn’t acted on it, I wouldn’t be needing such a contract, and treatment continued on without that becoming an issue ever again. She had permission to have suicide as an option. Notice I didn’t give her permission to kill herself, just to have that escape clause available in her mind.

Okay, have you got the permission technique? Let’s have you try it to find out. Again, cover up my suggested permissive responses below and come up with your own way of responding with permission to this depressed person’s statements.

Depressed person:
It’s all meaningless.

Your response:

[Possible responses: “It’s okay not to have meaning right now.” “You don’t have to know what it all means right now. We’re just working on how to get you feeling better today and tomorrow.”]

Depressed person:
I feel hollow.

Your response:

[Possible responses: “It’s okay to feel hollow.” “Feeling hollow is pretty common for someone who’s depressed. You don’t have to feel any other way right now.”]

Inclusion of Opposites

The next way to give permission is more complex and nuanced and may be especially helpful for people who are depressed. It involves giving permission to have two opposite feelings or to be two ways at once.

For example, someone may feel like dying and also want to live. Or he may feel like killing himself but not want to hurt his family and friends by killing yourself. A person may consider himself optimistic but also pessimistic. Or generous and selfish. Or sane and crazy.

This technique, then, involves giving the depressed person permission to include, feel, or be those contradictory things simultaneously. You might say, “You can be hopeless and have hope at the same time.” Or, “You’re all messed up and you’re okay.”

It’s as if the person is trying to fit two feelings or two aspects of himself through a door and has gotten stuck. This inclusion technique makes a double-sized door to allow both aspects or feelings to coexist without conflict or choosing which one is right. One major way to communicate this is to connect the two contradictory aspects with the conjunction
and
. The word
and
signifies inclusion of both, whereas the conjunctions
but
and
or
imply one or the other.

“You can feel as if you can’t get out of bed and you can get up.”

“You felt as if you couldn’t get out of bed today, and you got up and came to see me.”

“You wanted to give up, and you wanted to keep going.”

“You feel as if there is no end to this, and you think you will come out of it.”

“You are down on yourself, and you have compassion for yourself.”

“You can’t find your sense of meaning, and you think you are going through this depression for a reason.”

“You don’t want her to leave you alone, and you don’t want her with you because you feel so ashamed and nonresponsive.”

“You can’t sleep, and you’re exhausted.”

“You don’t want to die, and you don’t want to live like this.”

“You don’t want to actively kill yourself, and you find fantasizing about dying comforting.”

You might have to stumble around with this before you hit on the inclusive reflection that really moves the person, helps him feel both understood and validated at a deep level, and perhaps helps him shift in some way. This technique can be challenging because this is not a logical way to speak or think, at least for most Westerners (non-Westerners may have an easier time with this way of thinking).

Oxymorons

In the English language, we have a natural way to use inclusion called the oxymoron. This is when two opposite concepts are put together in a two-word phrase, such as
sweet sorrow
or
exquisite suffering
.