Out of the Blue: Six Non-Medication Ways to Relieve Depression (Norton Professional Books) (9 page)

A group of people diagnosed with major depression were guided to learn and use MBCT and then compared to a similar group getting the standard treatment of psychotherapy with antidepressants. Over the fifteen months after the study, only 47 percent of the group following the MBCT course experienced a recurrence of their depression compared with 60 percent of those continuing their normal treatment, including antidepressant drugs. In addition, the group using MBCT said they had a higher quality of life in terms of their overall enjoyment of daily living and physical well-being (Kuyken et al., 2008).

The results of this study are in line with the many other MBCT studies that have been done with depressed people. If you would like to know more about this approach, one good book is
The Mindful Way Through Depression: Freeing Yourself From Chronic Unhappiness
(Williams, Teasdale, Segal, & Kabat-Zinn, 2007). I have also included a number of other research studies using MBCT in the references section at the back of the book.

Obviously, there are fewer side effects with MBCT than with medications, and it is less costly for those who have to pay for their medications. And, once learned, mindfulness can be used to stave off or reduce the severity of future recurrences of depression.

It may be hard to imagine if you have never practiced mindfulness, but there can be quite a dramatic and positive effect from getting people to just sit with and notice—but not get caught up in doing anything about—their depression. As I mentioned before, much of the suffering comes from the struggle not to feel as one feels or from judging oneself as bad or weak. Dropping this overlay can provide significant relief.

Here is a sample of guided mindfulness work during a session with a depressed client:

Therapist:
There is some thinking and some evidence that shifting your relationship to your depressive experiences can be helpful in relieving them. Would you like to give it a try to find out whether it might be helpful to you?

Client:
I’ll try anything.

Therapist:
One of the ways to make this shift is to learn to just observe your thoughts and sensations without trying to change them or get swept away by them. You may have heard of this; it’s called mindfulness.

Client:
Yeah, I’ve heard of it, but I’m not really good at meditation. I’m too antsy.

Therapist:
This merely involves observing, rather than formal meditation. Let’s try a little bit right now to show you how it works. Just notice what thoughts are occurring to you right now . . .

Client:
I’m thinking, “I hope this works.”

Therapist:
Perfect. Now, the key is to watch or observe or notice the thoughts without giving them any weight or getting caught in them. Just observe them like someone walking by the window outside. You would just notice them and not run after them or think they had anything to do with you. One way to create this distance is to notice them as “thoughts” rather than “my thoughts” or “what I’m thinking.” There is kind of a disidentification that can happen. You can do the same thing with feelings, sensations, and perceptions. So, just try it again with any part of your experience, whatever catches your attention.

Client:
Okay [settles back in chair]. I’m noticing a tension in my right shoulder. Or tension in the shoulder, to say it in a distant sort of way.

Therapist:
Good. You’re getting it.

Client:
I’m now noticing that there’s this voice saying, “This will never work.” The tension in the right shoulder gets worse as the voice says that. Now I notice that as I said this, the tension released a little. I notice that there is some gurgling in my stomach. And a slight tingling sensation in my head, just above my right eyebrow.

Therapist:
Good. Now just take a couple of minutes in silence and just observe without speaking . . .

Client:
That’s interesting. I feel a little better. More in control in some way. And calmer.

Therapist:
All right. People who use this method find that it helps, and there is some research that says that regular practice of this mindfulness can help both lift depression and prevent recurrence. And that practicing mindful observing is, like other things, a learnable skill that you can get better at and that gets easier the more you use it. So, you might start with just a minute or two as we just did, and when that’s feeling pretty easy, start to extend the time as you can.

Client:
Good. This will give me something to do with my mind instead of obsessing.

Mindfulness can be used to notice slight or dramatic variations in one’s experiences, sensations, and thoughts during depression. The depressed person may be surprised to notice that what she thought was one unitary, consistent experience of depression is actually different from moment to moment, even containing some moments of non-depression or better feelings or hope. Having these observations of variations in the depressive experience can be helpful in doing the marbling we discussed in Chapter 2 or the pattern changes we discussed in Chapter 3.

And speaking of patterns, when the client has gotten good at being mindful in the midst of depression, she might begin to notice patterns—patterns of thoughts that accompany or worsen the depressed feelings, patterns of impending worsening or relapse, patterns of the lifting or imminent lifting of depression. Again, all these observations and insights may be helpful in changing the pattern or staving off deep or serious depression.

EXTERNALIZING

Because people who are depressed tend to blame themselves or feel that depression has completely obliterated their personalities, another way to shift their relationship to their depression is to use a method called “externalizing.” In this method, the depression is never spoken of as being within the person or part of the person, but instead as an external influence or entity.

For instance, we wouldn’t say “your depression,” but instead “when depression comes” or “when depression tells you that you will never get better” or “How does depression keep you in bed?” Or you might start with a little distancing language, such as “the depression” or “the blues.” Just take care not to attribute depression to the client or think of it as part of his being or personality. Anything that implies that the depressive experience originates in or is part of the client’s identity is off limits when using this approach in therapy. Thus, no notions of the client having a “depressive personality” or “depressive tendencies” or “depression genes” or “broken brains” should come from the therapist.

Persistent use of this new externalizing language can shift the client away from self-blame and from having depression become his whole identity. After I used this method for a time with a client of mine, she suddenly brightened for a moment and said, “I know what you’re doing. You’re trying to find the jewel under the garbage.” Indeed I was, since this approach is a bit like searching the ruins of a person’s life for the self he used to be, the self he can be, the self he is, beyond the reach of depression. One practitioner called the process of externalization “the archeology of hope,” and I think that poetic description fits well.

This can be challenging for us therapists to do, since we have been inculcated in the culture of internalization with our training in diagnosis and exposure to stories about the biochemical or psychological origins of depression. Some of us veteran therapists learned in ancient days that depression was anger turned in. Or that some people have “depressive personalities.” So perhaps this method will not only help our clients shift their relationship to depression, but help us shift our own rigid views of it as well. Giving up our preferred and precious theories about depression may be challenging, but certainly not more challenging than what our depressed clients are doing in struggling to come out of such an overwhelming experience of depression.

There are several steps to helping people make this shift:

1. Discover, create, or co-create a name for the depression. It might be a clinical name, such as “depression.” Or it could be an idiomatic phrase, like “the black dog,” or “the fog,” or “The Big Dread,” or “the blues.” Or the person might come up with his own idiosyncratic name for the experience, such as “Fred,” as one of my clients with a wry sense of humor did.

2. Begin to systematically banish all internalized words, phrases, and descriptions of depression. This is done by gently shifting the kinds of words and phrases used previously to words and phrases that indicate that the depressive experience is not part of the client’s identity or core self.

3. Ask about all the ways that the depression has undermined and negatively influenced the person and his life. Talk about it and refer to it as an unwanted, undermining, external influence, almost like a bully or a verbally abusive partner. Identify any other unhelpful thoughts, feelings, perceptions, and actions that ally with the main sense of depression to make things worse.

4. Find any evidence of times when the person has defied that negative influence or shown up as his better or previous self despite the depression. If necessary and possible, enlist his loved ones and supporters for this evidence. The question here is when and how the person has pushed back against the takeover of his life by the depression or held on to his strengths and abilities.

5. Consolidate the person’s independence and defiance of the takeover of his whole life by depression by excavating evidence of his resilience and strength from the past.

6. Further consolidate the person’s recovery of his best self by projecting those resiliences and strengths into the future.

Here’s an example of such a dialogue:

Therapist:
You keep referring to being in a fog when you get depressed. How does The Fog start to roll in usually?

Client:
I begin to get confused, making word mistakes or forgetting things, like that I started boiling some water or was supposed to call a friend back.

Therapist:
Okay, so The Fog creeps in on you first in your memory. What kinds of strategies have you developed to push back against The Fog messing with your memory?

Client:
I set alarms on my iPhone and put little Post-it notes around.

Therapist:
Great. Good thinking. And can you remember a time when you caught a glimpse of yourself, your non-depressed self, beyond The Fog since it rolled into your life this last time?

Client:
Well, I had a good day a few days ago. I even laughed at a joke my friend made.

Therapist:
What do you think helped that day be a better day, to help you escape The Fog?

Client:
Well, for one thing, I was with my friend. She really understands me and accepts me so I don’t have to fake it with her.

Therapist:
So being in the presence of that friendship and support helps you find your way out of The Fog sometimes?

Client:
Yeah, I guess so. The Fog was distant that day.

Therapist:
And what did you connect with in yourself when The Fog was more distant?

Client:
I remember thinking that maybe someday I wouldn’t be depressed anymore. That I would come out of this. I haven’t had that kind of hope for a long time.

Therapist:
And if you could stay connected to that sense of hope, would that help you keep The Fog at bay a bit more?

Client:
Yeah, I think so. I think it would.

Here is another sample dialogue:

Therapist:
How do you think of depression?

Client:
I call it The Soul Sucker. It sucks all the juice from my soul and all the light from my heart.

Therapist:
What mechanisms do you think The Soul Sucker uses to bring you down?

Client:
Chemicals in my brain.

Therapist:
And when those chemicals in your brain change, what is The Soul Sucker able to convince you of about yourself and your life?

Client:
That life isn’t worth living and that I am nothing; less than nothing.

Therapist:
So Hopelessness joins with The Soul Sucker to try to rob you of your will to go on. Do you ever challenge those notions, despite the altered brain chemistry?

Client:
Most days not, but on occasion, I have fought back. When I remember that my wife and kids love me, sometimes I feel better about myself. I have pretty good kids and my wife seems to still love me, even though I’ve been a shit while I’ve been so depressed and I can’t imagine why she sticks around.

Therapist:
And, in your best moments, why do you think she sticks around?

Client:
She tells me that she still remembers the “real me,” and she knows I’m a good person underneath it all.

Therapist:
What do you think?

Client:
I waver. Maybe I am and maybe I’m not. Most of the time I think I’m a loser.

Therapist:
Are those your thoughts or ones that The Soul Sucker would prefer you accept and take on board?

Client:
I think they are depression thoughts.

Therapist:
So, The Soul Sucker, Hopelessness, and Depression Thoughts are allies that conspire to lay you low?

Client:
Right.

Therapist:
And what are your internal allies and who are your external allies in standing up to these suckers?

Client:
Well, my kids and my wife are my external allies. And you, I suppose. Internally, I was always a stubborn bastard, so maybe that stubbornness will do me some good. I could have given in to this, but I came to therapy and I took medications, which I never thought I would. I thought they were for weaklings.

Therapist:
And how might you make even more headway and stave off The Soul Sucker, Hopelessness, and Depression Thoughts if you can stay connected to your inner and outer allies?