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Undoing Depression
Richard O'Connor, Ph.D.

Introduction

The essential question that patients and therapists ask themselves over and over is: why is it so hard to get better? Once we understand the hidden meanings and motives behind our behavior, once we understand that what we're doing is essentially self-destructive, that these repetitive patterns prevent us from feeling good about ourselves and getting to where we want in life, why don't we just stop? Once we have the right medication to prevent us from sinking back into the blackest depths, once we can start feeling a little more optimistic about the future and ourselves, why do we remain shy, passive, and withdrawn? Why do people persist in self-destructive behavior when they can see that it does them no good? Freud had to invent theories as elaborate and arcane as the death instinct to answer this question--the idea that, as a counterpart to a desire to create, enjoy, and live we have an equally strong desire to destroy, suffer, and die. All my experience tells me that there is a much simpler answer: People persist in self-destructive behavior because they don't know how to do anything else.

I'm convinced that the major reason why people with depression stay depressed despite therapy, medication, and support from loved ones is that we are simply unable to imagine an alternative. We know how to do depression. We are experts at it. Our feelings about ourselves and the way we see the world have forced us over the years to develop a very special set of skills. We become like those who are blind from birth. They become very attuned to sounds, smells and other senses that sighted persons take for granted. They can read Braille as well as anyone else can read printed matter. They get very good at memorization. But asking them to imagine a sunset, or a flower, or a Van Gogh is pointless--they have no reference, it's beyond their experience. Expecting us to stop being depressed is like expecting a blind person to suddenly see the light of day--with one important difference: eventually, we can do it. Depression becomes for us a set of habits, behaviors, thought processes, assumptions, and feelings which seems very much like our core self; you can't give those up without something to replace them, and without expecting some anxiety along the way. Recovery from depression is like recovery from heart disease or alcoholism. The good heart patient knows that medication isn't enough; lifelong habits of diet and exercise, how one deals with stress, must change. The recovering alcoholic knows that not drinking is not enough; ways of thinking, relating to others, dealing with emotions have to change. We depressives become shaped by our disease as well; the skills that we develop with depression in a vain effort to save ourselves pain--skills like emotional control, isolation, putting others first, being overresponsible--prevent our recovery. We have to give up the depressed habits that keep us down and make us vulnerable to relapse.

This book presents a "program" for depression. AA people know that not drinking is not enough; they have to "live the program." Like alcoholism, depression is a lifelong condition that can only be cured by a deliberate effort to change our selves. Later chapters explain how in five key elements of our personality--feelings, thoughts, behavior, relationships, and the self--depression has taught us certain skills which have come to feel natural, a part of who we are. But in fact we have to unlearn those skills and replace them with new habits--which are explained in detail--for real recovery to take place. Practicing the exercises described later can be a way for people with depression to "live the program"--and live a vital, rich existence again.

I believe very strongly that people can recover from depression but that medication and/or conventional psychotherapy don't go far enough. People need new tools, and practice in using them, in order to make a full recovery. In putting these techniques together I've had the benefit of being able to draw on a great deal of research and clinical experience developed over the last twenty years, which has suggested new ways of thinking, acting, relating, and feeling to replace the old ways of being that have never worked and often made things worse. I've also had the benefit of working in clinics in the real world to help me understand how these methods can be applied in everyday life. Further, my own experience with depression and recovery has helped me learn first hand what's helpful and what's not.

This is an unorthodox theory of change and recovery. I remember how for decades the analytic community debated whether true "structural change," as opposed to mere "symptom relief," could ever come from anything other than full-blown psychoanalysis. Now prominent scientists argue that recovery can only come from medication. These dogmatic positions are appeals to magic, not reason. I believe that people can make substantial changes in how they live their emotional lives, in their personalities, even in their brain chemistry, by making changes in their behavior. This is despite the fact that there certainly are unconscious forces at work that oppose change. But rather than postulate that these unconscious forces can be overcome only through the psychoanalytic method or by use of medication, it seems to make perfect sense to suppose that the need for these defenses and resistances can be removed. People learn and grow through experience, but the depressed person, out of fear, avoids the curative experience. I think that by practicing, by taking big challenges in small steps, by learning gradually that fears can't kill you and impulses don't overwhelm you, the depressed person learns alternatives to depressed behavior; and enough non-depressed behavior means you're not depressed anymore.

This book is meant both for the interested professional and for the lay reader, especially those who suffer from depression. Because it's meant for both audiences, I'm asking both to read things they aren't ordinarily asked to read. There is a lot more "how-to-do-it," more self-help, than mental health professionals are ordinarily exposed to. But I urge the professional to read these sections carefully, and to ask yourself what effect would it have on your patients--whatever theoretical frame of reference you operate from--if they actually practiced these skills. I think you might find they would be helped, perhaps substantially changed. And the lay person is being asked to read much more theory than most self-help books require. This is partly because I feel the theory helps organize a way of thinking, gives you something intuitive to hold on to, rather than just learning a list of behavioral techniques. But it is here more because I find the theory comforting and ultimately hopeful. The basic assumption is that we need to find ways to express ourselves and to connect with others as we go through life. Despite what depression tells us, no one is inherently bad, no one is worth more than anyone else, each of us can help each other, everyone can achieve this goal, to express the self and to make connections with other people.

When I was 15 I came home from school one day to find that my mother had committed suicide in the basement. She had bolted the doors and taped a note to the window saying she was out shopping and I should wait at a neighbor’s. I knew something was wrong and was climbing in a window when my father came driving in after work. We discovered her body together.

She had put a plastic bag over her head and sat down at the table where I played with my chemistry set. She ran the gas line from my Bunsen burner into the plastic bag, and turned on the gas. Later we learned that she had also taken a lethal dose of a sleeping pill that my father sold in his job as a pharmaceutical representative. Her body was cold, so she must have started to set things up soon after we had left the house in the morning. This was not any cry for help; she went to a great deal of trouble to make sure she would end her life.

Until two years before, my mother had seemed happy, confident, and outgoing. I remember her joy getting ready to go out to a party, or singing 40's songs with my father on evening car rides. When I look back at the course of my life, I realize now how much it has been shaped by my need to understand what happened to her.

To understand also what was happening to me, because I’ve had my own depression to contend with. I didn’t recognize it for a long time, though I’m a reasonably well-trained and experienced psychotherapist. I've been a patient myself several times, but I never put a label on my problems; I always told myself I sought help for personal growth. This is despite the fact that there were long periods in my life when I drank too much, when I alienated everyone close to me, when I could just barely get to work, when I would wake up each morning hating the thought of facing the day and my life. There were many times I thought of suicide, but if I couldn’t forgive my mother, I couldn’t forgive myself either. And I have children and family, patients, and colleagues I couldn’t bear to do that to. But for many long periods life seemed so miserable, hopeless, and joyless that I wished for a way out. Everyone who has ever been depressed knows it's impossible to be sure, but I think those days are finally behind me now. I don't hit the deepest depths, but I live with the after-effects. I still struggle with the emotional habits of depression. But accepting the fact that it's going to be a long struggle has made me more able to deal with the short-term ups and downs.

I’ve worked in mental health for twenty years, as a therapist, supervisor, and agency director. I’ve studied psychoanalytic, family systems, biochemical, cognitive, you name it, ways of understanding people. I’ve worked with some wonderful teachers, and had some wonderful patients. I won’t pretend to have all the answers on depression but you won’t find many people with more experience, both personal and professional.

I believe now that depression can never be fully grasped by mental health professionals who have not experienced it. I've repeatedly seen "comprehensive" theories of depression develop, flourish and dominate the field for a time, then be rejected because new, contradictory evidence is found. These are all theories that try to explain depression from a single point of reference--the unconscious, the brain and its chemistry, cognitive processes, family interaction. Many psychologists and psychiatrists seem to have a fatal predilection for theory-building--for making their experiences fit with some pre-existing theory, or for destroying someone else's theory, or for developing a new theory that will explain it all--rather than trying to figure out practical ways to help their patients. They get too far away from experience. I realize now that no simple, single-factor theory of depression will ever work. Depression is partly in our genes, partly in our childhood experience, partly in our way of thinking, partly in our brains, partly in our ways of handling emotions. It affects our whole being.

Imagine if we were in the state of science where we could reliably diagnose heart disease but knew nothing about the effects of exercise, cholesterol, salt and fat, stress and fatigue. Patients who were diagnosed would be grasping at all kinds of straws that might help them recover. Some would stop all exercise, some would exercise furiously. Some would withdraw from stressful situations. Some would take medication to reduce blood pressure without knowing that their unhealthy diet undoes any beneficial effect of medication. Many would die prematurely; some would get better accidentally; without good controlled scientific studies, medicine would not learn what was causing some to die, some to recover.

This is where we are with depression. We get all kinds of advice, some of it helpful, some of it not, most of it unproven. The depressed patient is in the dark about what exactly he or she needs to do to help recovery. But in fact a great deal is known about how people recover from depression. It doesn't all fit into a neat theoretical package, so it's hard to pull together; but the knowledge is there to be used.

Depression is a complex condition that blurs our Western boundaries between mind and body, nature and nurture, self and others. Many people with depression seem to have been primed for it by loss of loved ones in childhood. Most people with depression describe difficulties in their childhood or later in life that have contributed to low self-esteem and a sensitivity to rejection, an uncertainty about the self and an inability to enjoy life. But these observations are not true for everyone with depression: some people who have no history of stress, who appear very stable and well integrated, develop it suddenly, unexpectedly, in response to a life change. There is clearly a biochemical component to depression, and medication can be very helpful for most people, but it is not sufficient treatment for very many. The truth is that whether the roots of depression are in the past in childhood, or in the present in the brain, recovery can only come about through a continuous act of will, a self-discipline applied to emotions, behavior, and relationships in the here and now. This is a hard truth, because no one deserves to feel this way, and it doesn’t seem fair that the blameless have to help themselves. Besides, the depressed are always being told to snap out of it, pull themselves together, don’t give in to weakness, and it’s the cruelest, most unfeeling, advice they can be given. What I want to do here is to give guidance and support along with advice, to help the depressive find the resources he or she needs for recovery.

People who are depressed are in over their heads and don't know how to swim. They work very hard at living, at trying to solve their problems, but their efforts are unproductive because they lack the skills necessary to support themselves in deep water. The real battle of depression is between parts of the self. Depressed people are pulled under by shadows, ghosts, pieces of themselves that they can’t integrate and can’t let go. The harder they work, the more they do what they know how to do, the worse things get. When their loved ones try to help in the usual ways, the common-sense ways that only seem natural expressions of caring and concern, they get rejected. The depressed person then feels more guilty and out of control.

People with depression have to learn new ways of living with themselves and others—new emotional skills. These skills take practice, coordination, and flexibility. Instead of flailing at the water in panic, they have to learn emotional habits that are much more like swimming—smooth, rhythmic, learning to float, learning to be comfortable in the water. Depressed people are great strugglers, but to struggle is to drown. Better to learn how to let the water hold you up.

The families of people with depression also have to learn new skills. Many of their usual patterns of family interaction are related to the depression, rewarding it or blaming the victim. With the best intentions, family members sometimes make things worse for the depressive. They have to learn how to mix confrontation and support, caring and limits. In the process of changing, some family members will come to grips with distressing truths about themselves—but the truth is nothing to be afraid of.

The next chapter describes the nature, impact, and pervasiveness of depression. Chapter 2 reviews the different kinds of depression that current science delineates, and describes briefly some of the controversy involved in diagnosis. Chapter 3--"Why Don't We Have a Theory?"--reviews some of the reasons why mental health professionals have difficulty agreeing on what depression is, and then presents a way of understanding it--as a response to pain or loss that unfortunately has taken some unnecessary twists because of the way the individual experiences the world. The concepts of self psychology and of defense mechanisms are introduced, two points of view which greatly help us understand how depression works. Chapter 4 elaborates on the "skills of depression"--how we become very good at doing certain things that, tragically, only perpetuate our depression. Two cases are discussed in detail which illustrate how these depressed skills are used, and how they backfire on the user.

Part II reviews the major functional areas where depression affects us--feelings, behavior, thought processes, relationships, and the self. Habits that we take for granted, assumptions that we unconsciously make about people, ways of working and communicating that seem to make perfect sense to us--these all must be questioned and examined for real recovery to take place. Not that everything we do is wrong; but too much of it only perpetuates a depressive cycle that goes on continuously, outside our awareness. The first chapter in this section focuses on changing emotional habits because those changes must come first. Once we begin to change how we experience and express our feelings, our emotional life becomes a more reliable guide to differentiate between healthy and unhealthy behavior. There are some very specific exercises in these sections, which I urge the reader to practice--just reading about them doesn't help. A last chapter in this section reviews how psychotherapy and medication can help, and how a better understanding of their effects contributes to a complete understanding of what depression is.

Part III takes this new knowledge and extends it further, into the world of work, marriage, divorce, and the family, and the community. In an age when depression is epidemic, we have to use our knowledge out in the real world to help keep ourselves, our children, and our communities healthy. In the last section, some specific principles for maintainijng recovery are described. Then, twin themes--of the development of the self, and of the self's interaction with the world as understood by the theory of psychological defenses--are brought together in a discussion of creativity.

Obviously this is an intensely personal book for me. I want to keep would-be suicides alive, I want to spare people the useless pain of depression. There is a great deal more that can be done now than was available for my mother or for myself when I was younger. Medication and psychotherapy offer hope to everyone. Learning techniques of self-control, skills of communication and self-expression, challenging one’s assumptions about the self and the world, can give people who literally don’t know anything other than depression the chance for a rewarding life.

Something that touches me deeply at our clinic is the large number of people who don’t know they are depressed. People are usually prompted to call for help not because of subjective feelings of depression, but because something is going wrong in their lives; their children won’t listen, there is a marital problem, they are having trouble at work. But it often doesn't take much digging to find that the caller has been depressed for some time; the family problem, the job problem, is a manifestation, not a cause, of the depression. This is a person who feels almost no joy in life, who has no hope, no ambition who feels stuck, powerless, and perennially sad—and who thinks this is the normal way to feel. It’s not.

 

Special Note: If you believe that reading Undoing Depression would be helpful to you, and you cannot find it in your library, please e-mail us and we will see what we can do to help.