Undoing Depression

This is an article that was featured in the magazine "Going Bonkers"

What You Need to Know

By Dr. John R. Rifkin

Life is intrinsically hard, which means we all get injured during the process, in one way or another. “Life” injuries often cause anger, and anger turned inward, leads to depression.

Depression, known by therapists as major depressive disorder, is a problem for many people. Statistically, about one in six people will experience a major depression over the course of their lives, though many people believe that the incidence is much higher. The first step in undoing depression is to understand what it is, how it can affect you, and what causes it.

Depression has no single cause, and often results from a combination of things. You may have no idea why you or your family member are experiencing depression.

Whatever its cause, depression is not just a state of mind. Depression is related to physical changes in the brain, and connected to an imbalance of a type of chemical that carries signals in your brain and nerves.

Your brain is a giant messaging system that controls everything from your heartbeat, to walking, to your emotions. It's made up of billions of nerve cells called neurons. These neurons send and receive messages from the rest of your body, using brain chemicals called neurotransmitters. These brain chemicals, in varying amounts, are responsible for our emotional state. Depression happens when these chemical messages are not delivered correctly between brain
cells, disrupting communication.

So why isn't your brain delivering your chemical message correctly?
Some of the more common factors involved in depression are:

Trauma and stress. We all know the effects that chronic stress and trauma can have on your physical health. Stress can cause physical changes in your body, including your brain, causing depression. Issues like financial problems, the breakup of a relationship, or the death of a loved one can bring on depression. You can become depressed after changes in your life, like starting a new job, graduating from school, or getting married.

Family history. Genetics play an important part in depression. It can run in families for generations.

Pessimistic personality. People who have low self-esteem and a negative outlook are at higher risk of becoming depressed. These traits may actually be caused by low-level depression (called dysthymia).

Physical conditions. Serious medical conditions like heart disease, cancer, and HIV can contribute to depression, partly because of the physical weakness and stress they bring on. Depression can make medical conditions worse, since it weakens the immune system and can make pain harder to bear. In some cases, depression can be caused by medications used to treat medical conditions.

Other psychological disorders.

Anxiety disorders, eating disorders, schizophrenia, and (especially) substance abuse often appear along with depression.

Depression can severely disrupt your life, affecting your appetite, sleep, work, and relationships. Some people say that depression feels like a black curtain of despair coming down over their lives. Many people feel like they have no energy and can't concentrate. Others feel irritable all the time for no apparent reason. The symptoms vary from person to person, but if you feel “down” for more than two weeks, and
these feelings are interfering with your daily life, you may be clinically

The symptoms that identify depression may include:

Constant feelings of sadness, irritability, or tension

Decreased interest or pleasure in usual activities or hobbies

Loss of energy, feeling tired despite lack of activity

A change in appetite, with significant weight loss or weight gain

Achange in sleeping patterns, such as difficulty sleeping, early morning
awakening, or sleeping too much

Restlessness or feeling slowed down Decreased ability to make decisions
or concentrate

Feelings of worthlessness, hopelessness, or guilt

Thoughts of suicide or death

The good news is that depression is very treatable. Most patients, even those with severe depression, show improvement after they seek treatment. Your doctor will prescribe treatment based on the pattern of your depression, its severity, persistence of symptoms, and your history. While it is true that some instances of major depression may go away without any treatment, the risks of not treating outweigh the risks of treatment. Treatments may include psychotherapy, medication or both.

Understanding Anger
Some therapists define depression as anger that gets turned inward, against your self, combined with a feeling of hopelessness and/or helplessness. Most psychotherapy, therefore, is focused on helping people reconnect with their anger and turn it out of depression and into the two healthy uses of anger: self-nurturance or empowerment. This is what I call “unbending anger.” In order to “unbend” your anger, you must first be able to realize when you are angry. Part of what makes this difficult is that most of us think of anger as simply yelling and screaming, throwing things or breaking things. This is aggressive behavior, not anger. Anger is actually a secondary emotion, one of three secondary emotions, that follow a pain or injury. The other two secondary emotions are sadness and fear.

The other reality about anger is that it is energy -- energy that is actually
meant to fix what is hurting us. Learning to turn your anger outward, into healthy energy, is an important step in undoing depression. A therapist can help you learn how to do this.

Stop, Drop and Roll

No, this isn't a fire drill. In addition to the ongoing support that a client receives from their therapist, the therapist also supplies tools, or methods the client can use to help them combat their feelings of helplessness. The tool that I like to use for helping the client “unbend" their anger is what I call “Stop, Drop and Roll.”

“Stop, Drop and Roll” is a form of a cognitive behavioral therapy that is focused on helping the client to identify their dysfunctional use of their angry feelings and begin to utilize that energy for self-nurturing and empowerment. Before you can remember to "Stop, Drop and Roll", you must notice you are on fire. Negative thoughts create an internal fire, so notice when you have them.

Stop. Stop the thoughts as soon as you notice them.

Drop. Get grounded and figure out what the anger is all about, really. Roll. Roll forward and make a plan about how and where you can put the energy of the anger you are feeling.

Let's look at the example of Dora to help clarify how to work out of depressive thoughts and behaviors. Dora came to me as a 27 year old single woman who was suffering from a moderate level of Major Depression. She was the youngest of five daughters, and grew up in a family that was not very warm or emotionally expressive. Her belief was that her father, who was distant and involved in his work to the exclusion of his family, really wanted a son, and was disappointed with her being a female after so many failed attempts. That was her belief about herself: she was simply another failed attempt.

Dora had recently experienced the breakup and rejection of a relationship she'd had for three months with a boyfriend and, in spite of being very bright and having graduated from college, she was working at a job she didn't enjoy. What precipitated her coming in for therapy was that her supervisor had found her crying at work and sent her to the company's employee assistance program. They had discovered that she had been having suicidal thoughts and had referred her for psychotherapy. After clarifying her diagnosis and referring her to a psychiatrist for anti-depressant medication, we began to focus on trying to discover what Dora's depression, and her underlying anger and injury, was all about. We began to investigate how she was abusing herself in her own thoughts.

Dora was caught in the web of low self-esteem, constantly telling herself that she was unattractive, unintelligent and generally worthless. She believed that nothing would ever work out for her, and that she was doomed to an unfulfilling life. Once we identified these negative and self-destructive thoughts as problematic, we began to use "Stop, Drop and Roll" to intervene.These negative thoughts were examples of how she was catching on fire, and we agreed that she would begin to notice these thoughts.

Once she was able to notice these self-abusive thoughts, we worked to help her begin to intervene by stopping the thoughts when she noticed them. This was the "Stop" step. At the same time, we worked to help her begin to use the “Drop” step, to get grounded and begin to understand where the anger that she was turning inward, was coming from. She discovered that some of her anger was related to the real, here and now injuries of being rejected by her boyfriend. Some of her anger related to feeling stuck in the unfulfilling clerical job she had to go to day after day. As we explored her family of origin, she began to realize that she never felt that she had received the attention and appreciation from her father that she needed. She never felt valuable or appreciated. Old injuries had produced anger in her that she was
unaware of, and that she had been directing against herself.

It helped Dora to understand her depression. She also was helped by the impact of her anti-depressant medication, which continued to help improve her mood and functioning over the course of the first two months of treatment. She began to understand the emotional dynamics that had contributed to her mood sinking so low.

Once she understood the dynamics of her depression, she was more ready to begin the "Roll," or action step in completing the "unbending" of her anger. She began to have plans about how and where to put the energy of anger that had been previously fueling
her depression.

In terms of diverting that energy into self-nurturing, she began an exercise program that included running in the evenings. She felt that she didn't have the money to afford an exercise club, but she was able to begin to gradually work herself into running and getting into better physical shape. An added bonus from this process was that the exercise produced endorphins in her brain, which also have a natural antidepressant impact. She also began to treat herself to luxurious baths after her
runs. These self-nurturing activities were used to intervene in her previous
behaviors of ruminating about all the bad things that had occurred in her life.
Dora also began to work into more empowerment, or acting on the world so that the world would nurture her more effectively. One of the goal activities was to become more social, and eventually she decided to join both a running club and a hiking club.

Through these behaviors, she began to make more friends and to have a greater social support. She also decided that she wanted to have a better job, and began to look for
alternatives in the newspaper and within the company for which she worked. When nothing materialized right away, she decided to look into going back to school and getting a Masters degree.

At the end of treatment, which took most of a year, Dora was not depressed. She continued on her antidepressant medication for another year, which is the usual course of treatment, to insure that her depression did not return. She also continued occasional psychotherapy meetings during that year. Eventually she felt ready and was able to successfully withdraw from her medication without any relapse into depression.

Dora's successful case is a good example of how most cases of major depression respond to appropriate treatment. The tragedies that you read about are usually because the person did not find help or did not find it soon enough. Almost all kinds of depression are treatable with medication and/or psychotherapy. Even after you've learned that you have depression and sought treatment for it, you may not feel better immediately. Depression can be frustrating, because recovering from it takes time. While you do have to be patient, there are still some steps you can take now to help yourself feel better.

Every day can feel like a struggle when you're depressed. Medical care and therapy are the most important steps to recovery. But there are other things you can do to help yourself undo depression:
Realize that nothing comes out of the blue. Your depressed state has a root cause. Examine past troubling events or situations in your life, and talk to a therapist about them.

Feel Your Feelings. Depression is the suppression of feelings. Acknowledging those feelings often causes depression to improve. Recognize early signs. It's important to recognize and treat depression as early as possible, which decreases your risk of becoming depressed again. If you pretend the problem isn't there, it's probably going to get worse. Watch for the types of events that contributed to depression in the past, and be alert for early symptoms.

Set realistic goals. You may feel overwhelmed by everything you "should" be doing at home or at work. Try not to be hard on yourself. Remember that depression is an illness and that you can't force yourself out of it. Focus on small, realistic goals to ease yourself back into your work and family routine.

Do what you enjoy. Even if you don't really feel like it, set aside time to do things that you like. Get together with friends. Take a walk. Go to the movies. Take up a hobby that you set aside years ago.

Hold off on big decisions.
Since depression can color your outlook on everything, it's best to avoid making
any big decisions; quitting a job or moving, for instance, until you feel better.
Establish priorities. Direct your energies into what's most important to you.

Take responsibility ONLY for your actions. Depressed people often
feel guilty about things that they have no responsibility for (like the death of a
parent or the divorce of their parents).

Be generous. Helping others puts your own situation into perspective. Cultivate intimacy. Let down your defenses so people can see and accept you as you are. During depression, people often feel disgusted with
their true selves, and hide that self from everyone. Stop hiding and be happy
with who you are.

Gain Perspective. During this time, you may be overly critical and pessimistic. Seeing things in the proper perspective can heal a lot of inappropriate pain.

Getting Support. Even though millions of people are coping with depression right now, it's a medical condition that can make you feel completely alone. One way that some have found helpful to work through this feeling is to join a support group. Whether they meet in person or online, support groups offer a place to talk about depression where people can help each other. Keep in mind that support groups are not a substitute for therapy or medical care. They are also different from group therapy, since they aren't led by a professional.

Avoid alcohol. Although you might think it will help you feel better, alcohol can make your depression worse. Depressed people are at special risk of developing substance abuse problems, and alcohol interacts with many antidepressants.

Exercise. There's more and more evidence that exercise helps with mild to moderate depression. When you're considering an exercise plan, don't be too ambitious. Find an activity that you like, start slowly, and work up to exercising three times a week or more for 20 to 30 minutes.

When your loved ones are depressed, they're not the only ones who suffer. Typically, many of those around a depressed person; friends, family, and loved ones, also struggle with the effects of his or her condition.

Watching someone you love
fight depression can be frustrating and frightening. Remember, you can't take responsibility for someone else, and the decision to get help is up to the person
with depression. But, there are things you can do. For many people with depression, a friend or loved one who cares can be their most important resource.

What can you do? Learn about depression. Educate yourself on the causes, symptoms and
treatments. Knowing about the condition will help you better understand what a depressed person is going through.

Do what you can to make sure that a person with depression gets medical care. Encourage your friend or loved one to stick with his or her therapy or medication. Offer to go with him or her to appointments as support. Be supportive and patient. Listen to what the depressed person has to say. Without being pushy, encourage your friend or loved one to do the things that he or she used to enjoy. See friends. Go to the movies. Take a walk.

If someone you know is thinking about suicide, don't ignore it. Do whatever you can to get help for that person. Get in touch with his or her doctor or therapist.

Helping a person with depression can be exhausting and overwhelming. Here are some things to keep in mind that can help both of you: Try to get other people involved in helping a person who's depressed, since doing it on your own can be difficult.

People with depression often resist attempts to be helped. It's okay to feel angry and frustrated, but don't confuse the person you love with the illness. Depression isn't anyone's fault. It is not possible to “snap out” of depression. No matter how overwhelmed you feel, take time for yourself.

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