There are things I need to do – so I believe – consistently, every day or every other day, if I am to keep my depression away. Running, being sociable, pursuing my interests, taking my supplements, getting enough sleep, practising mindfulness, keeping my life tidy.
Further, there are things which, according to my research, might help me actually get rid of the depression altogether.
Why then have I stopped doing them?
It’s not because I want to remain depressed – nobody would want that, surely? Or because I am too unwell to do anything, or too busy, or too forgetful, too lazy – although maybe these are part of the answer.
Whatever, I can feel I am heading for a crash, ‘cruising for a bruising’, unless I can get back on track. Just thinking about what I should be doing makes me feel tired. Time to take my own advice. I shall press the reset button, and very gently and with as much kindness as possible, start again to do the things that help.
The quest to understand why I am depressed and what to do about it – my reading and thinking and trying things out – has lead to this: cautious optimism that I can get really well. And firing on mental cylinders not yet sparked.
So that is the plan: to go for it. Sadly my other thing (rescuing bats), which usually takes all my time in the summer, has ended. Henceforth my number one priority will be the relentless pursuit of beating my depression.
Since the last post about the ‘new laws of psychology‘ and its emphasis on psychological rather than neurological/chemical underpinnings of depression, I have read more about this and tried to pin down the apparently all-important “sense I make of myself, other people, the world and the future.”
Beck’s cognitive triad
This idea comes from American psychiatrist Aaron Beck, the Daddy of cognitive behaviour therapy (CBT), who assigned a central role to what he called the ‘cognitive triad’ in depression; namely, pervasive negative attitudes that the depressed individual has towards him/herself, towards the outside world, and towards his/her future. The description of each certainly resonates with me:
1. The view of self.
The depressed patient’s cognitive schemas that relate to self-assessment consist of seeing himself as deficient, inadequate, or unworthy. He will often attribute his unpleasant feelings and experiences to some kind of physical, mental, or moral defect within himself. He will then consider himself worthless because of his presumed defects, and will “reject” himself.
2. The view of the world.
The depressed person tends to see his world as making exorbitant demands on him and as presenting, obstacles that cannot be surmounted. He interprets his interactions with his environment in terms of defeat and failure, deprivation, or disparagement.
3. The view of the future.
The depressed person’s negative cognitive patterns that relate to the future become evident in his view that his current difficulties or suffering will indefinitely continue. Thus, he anticipates unremitting hardship, continued frustration, and never ending deprivation. Such schemas essentially amount to a pervasive hopeless attitude.
Source: AN Weissman and AT Beck Development and Validation of the Dysfunctional Attitude Scale: A Preliminary Investigation. Mar 78
So if depression is not so much shonky wiring as shonky thinking, can thoughts be changed? That is the premise of cognitive behavioural therapy of course – learning how to challenge and alter our own negative thoughts, and in so doing, feel better.
I have done a course of CBT though my local NHS service, and found it helpful, but – and maybe I’ve missed the point somewhere – it seems to deal with the symptoms of depressive thinking rather than the cause. The negative thoughts I have are automatic, unconscious, constant. Challenging each one is fine, but akin to pulling drowning bodies out of the thought-flow rather than venturing upstream to stop them falling in in the first place.
Our sense of ourselves and the world and our future develops from our (mostly early) experiences and our environment. In depressed people, according Beck, that sense is negative and damaging, and it profoundly affects our thinking, which leads to us feeling bad.
I have tried to change my thinking, through CBT, but it only helps a bit. I want to change the sense I have of myself, the world and my future. To stop the bodies falling in the drowning flow of negative thought.
This cognitive triad thing gives me great hope. Potentially, all we need do is to change our deeply-held beliefs – our sense of everything. The beliefs I have (see 1, 2 and 3 above!) are irrational; surely they can be replaced with something more useful.
But how is that possible? Perhaps a psychologist would suggest therapy but I’d rather tackle it myself. From what I have researched so far, the development of self-compassion (through loving-kindness mindfulness meditation) may be the answer. More on this to follow, but the extract from Neff and Costigan gives a flavour:
Research shows that treating oneself with care and compassion is a powerful way to enhance intrapersonal and interpersonal wellbeing. When we are mindful of our suffering and respond with kindness, remembering that
suffering is part of the shared human condition, we are able to cope with life’s struggles with greater ease. We create a loving, connected, and balanced state of mind and heart that helps to reduce psychopathology while
simultaneously enhancing joy and meaning in life.
I am determined to get rid of the depression that has hobbled me for so long. Perhaps practising self-compassion will help me do that, perhaps not. In which case I’ll keep looking, keep experimenting. Let’s see what works.
In an ongoing effort to regrow my brain, a daily habit is to spend an hour or so studying via a MOOC (Massive Open Online Course). MOOCs are free courses offered by Universities and education organisations in all sorts of subjects, and the ones I have done have been excellent.
The most recent course I undertook, through the Open University’s Future Learn, was Psychology and Mental Health, run by the University of Liverpool and led by Peter Kinderman, Professor of Clinical Psychology. The course explores and critiques the biopsychosocial model of mental health problems like depression and makes a case for ditching biological (nature) and social (nurture) explanations in favour of focussing on psychological processes – or, to use Kinderman’s phrase, “the sense we make of ourselves, other people, the world and the future”.
Kinderman and co. argue that it’s all very well ascribing human behaviour and emotions to ever more specific neuronal activity in the brain, but it doesn’t explain how you got to the point of, say, not being able to get out of bed, or what you can do to feel better. (Apart from taking antidepressants).
The academic bashing of the biopsychosocial model and its various advocates would perhaps be of most interest to people who have been treated for mental health problems by psychiatrists, with drugs – but this hasn’t been my experience.
“we are shaped by thought, and our thoughts are shaped by events….these biological, social and circumstantial factors affect our mental health through their effect on psychological processes”.
So our genetic inheritance and the stuff that happens to us are important to our mental health only in so far as they inform what we believe about ourselves and the world – ie the sense we make of everything. Kinderman’s ‘new laws of psychology’ are:
Our thoughts, emotions and behaviour (and, therefore, our mental health and well-being) are largely determined by how we make sense of the world.
How we make sense of the world is largely determined by our experiences and upbringing.
These laws have profound implications for tackling depression, if Kinderman is right. We can try to change our brain chemistry with anti-depressant medication, and rationalise our thoughts with cognitive behavioural therapy (CBT) techniques, but perhaps what we need to do is change our underlying beliefs about the world. As Kinderman puts it:
Since people’s mental well-being is dependant (at least in large part) on their framework of understanding and their thoughts about themselves, other people, the world and the future, helping people think differently about these things can be helpful and should be the basis of therapy. We should not be treating illness, but helping people think effectively and appropriately about the important things in life.
This has got me thinking about my own belief system – my own ‘sense of the world’. How did I arrive at it and can it be now be changed? Fascinating. To be continued…
November: short gloomy days, no bats to worry about, and the season of Christmas bullshit approaching fast. Having returned from a lovely week in Snowdonia with Raisin – mountains and coast, fabulous – everything now feels like a struggle. The days drift by, nothing gets done, it is beginning to look serious.
So I have started running again after a long summer lay-off. It’s the quickest, most powerful fix I can find. It requires motivation, but not as much as housework Two miles first thing in the morning, and I feel good till the afternoon. It’s not perfect – my body can only stand every other day at the moment, and I still find the afternoons/evening difficult – but it’s a great help. Walking is fine, but doesn’t have the same effect, not even 5 miles in the sunshine with Raisin.
There’s lots of research on exercise and depression, some of it I have covered previously. Not all the research supports the benefits I experience, but that’s OK, it works for me.
This summer I have been too busy to write about or research depression because my other (bat rescue) thing has completely taken over. My normal keep-well routine has been completely disrupted, viz exercise, sleep, omega 3 supplements, social activities. I’ve lost a stone in weight from not having time to cook. In the middle of all this a close friend died unexpectedly, leaving me shocked and grieving.
Here’s the strange thing though: I haven’t felt depressed. It’s only now, when it’s all quietening down, that I am noticing dark thoughts clouding my mind, and energy and enthusiasm draining away.
A friend who also suffers from depression recently told me that she feels better when she is busy and doesn’t have time to think. In the past I would have associated such busy-ness with pressure and stress: both to be avoided as far as possible. It’s what precipitated my breakdown 5 years ago, and what I have tried so hard to eliminate from my life ever since. But perhaps pressure is OK – healthy even – when you are doing something you love.
Research on meaningful activity
The research literature talks about a connection between mental health and meaningful activity. What you do, and the meaning it has for you, is important for well-being.
our daily occupations are imbued with personal meanings that contribute to the perception of purpose and meaning in our lives, ultimately influencing our health and well-being (Yerxa et al., 1989)
Researchers have developed tools for measuring meaningfulness, such as the Engagement in Meaningful Activities Survey (EMAS, Goldberg et al. 2002), which reflects the extent to which people believe their activities: fit with their value system and needs; demonstrate their competence; and are valued in their social or cultural group. Studies have found, broadly, that the higher the score on the EMAS scale, the better the depression, and vice versa. EMAS talks about daily activities, and not about duration – so it’s the meaningfulness that is important here, rather than how busy you are.
Here’s the EMAS tool . Each criterion is preceded by “The activities I do…”
help me take care of myself (e.g., keep clean, budget my money)
reflect the kind of person I am
express my creativity
help me achieve something which gives me a sense of accomplishment
contribute to my feeling competent
are valued by other people
help other people
give me pleasure
give me a feeling of control
help me express my personal values
give me a sense of satisfaction
have just the right amount of challenge
Score 1-Never, 2-Rarely, 3-Sometimes, 4-Usually and 5-Always
To apply this, one could devise an activity or range of activities that would score maximum points – and then do it daily. I am going to add this to my list of experiments.
Research on being busy
So meaningful activity is helpful for depression, but that’s not the same as being busy. We looked at rumination – mulling things over and over – in a previous post. Rumination is strongly linked to depression and is best avoided if at all possible, usually by deploying positive distractions. Steve Ilardi, in his Six Step Programme to Beat Depression, has anti-ruminatory activity as one of the steps and talks about the need to find distracting things to do. He also suggests that, along with watching movies and playing video games (or whatever works as a distraction), you may as well include activities that are inherently anti-depressive such as exercise and engaging with friends. Or doing meaningful stuff.
People typically ruminate – and feel the worst – when they have nothing else to occupy their attention. Steve Ilardi
Keeping busy with positively distracting activities will stop rumination (and rumination makes us feel bad). And if those activities are also meaningful to us, we will actually feel better.
Finding the busy sweet spot
I have learnt this summer that, against all expectation, a huge amount of disruption (for me, anyway), pressure, and physical and emotional upheaval, did not make me ill. I don’t know that I could have continued much longer at the same intensity though. Feeding baby bats every 3 hours round the clock is tough; thankfully they grew out of it…
There must come a point when being busy all the time is not healthy. Mustn’t there? Perhaps it’s when the meaningfulness starts to slip – for example when the activities are such that you you don’t have time to care for yourself properly (as per criterion 1, above), or when you no longer feel in control (criterion 9). The important thing is to be aware of what is happening, and to take steps if possible to get back on the meaningful track.
Doing work you love
Since many of us have to spend a lot of our time earning money, the perfect set-up would be to do work that is distracting and meaningful. Not necessarily easy to achieve, but worth striving for.
This post is dedicated to Scott Dinsmore, a perfect-toothed, ever-smiling, overwhelmingly-enthusiastic American I’ve never met whose stuff about changing the world through ‘finding and doing work you love’ inspired me to start this website and pursue making a living from learning about depression. He died last week in a climbing accident in the middle of a once-in-a-lifetime year-long trip around the world with his wife. Living his legend.
References and further reading
Goldberg B, Brintnell ES, Goldberg J (2002) The relationship between engagement in meaningful activities and quality of life in persons disabled by mental illness Occupational Therapy in Mental Health. 18(2):17–44
One of the many fiendish ways depression perpetuates itself in the sufferer is to make it difficult to remember autobiographical events – ie things that you have done or experienced. This is important because non-depressed people, it seems, can and do call on detailed positive or self-affirming memories to cheer themselves up, using such memories to regulate their mood.
Research suggests that depressed people can benefit from purposefully thinking about happier times, if only they could remember any!
learn to recall helpful memories despite feeling depressed
Help is at hand: it has now been shown that using the “method-of-loci” technique, with a bit of initial effort recalling important memories is fairly easy – even when you are depressed.
The method of loci can be used to memorise anything, but in this context, and according to research by Dalgleish et al from Cambridge University, it goes like this:
think of 15 positive memories [this is the hard part!] – in as much vivid detail as possible, with sounds, colours, smell etc
think of a journey you know so well you can imagine it easily in your mind – could be the route to work, or the layout of your house
assign a different memory to each of 15 points along the journey by imagining an association between the memory and the point – eg picture crossing the winning line at school race day with your staircase watching in the crowd (the more incongruous or bizarre the association the better)
now you should be able to make that journey in your mind’s eye, recalling each memory point by point
If you do this mind journey often, the memories will automatically come to mind when you make the actual journey. So walking up the stairs at home will remind you of winning that race. And that will have a positive impact on your mood.
try it and see
This looks like a straightforward experiment to try. Mind you, after thinking about it all day I have only managed to come up with one powerfully positive memory. Maybe we need a technique for that part too!
I’ve talked before about my drinking, and how and why I stopped. My alcohol use was wound up tightly with my depression, one feeding the other, and this went on for years. Today marks 500 days since my last drink and it seems like a good time to reflect on that.
Going without alcohol has not been as difficult as I expected (and my expectations were built on many and various experiences of failed attempts in the past). I don’t have much willpower or self-discipline; they wouldn’t have been any help when things got tough. So instead of relying on those, I made big changes to my life and my behaviour that made not drinking the easy choice, in contrast to the old days when it was the other way round.
The important changes were probably these:
attitude to drinking. I accepted, with as much self-compassion as I could muster, that my alcohol use was essentially a coping mechanism for depression that was no longer doing its job. This done, I realised the wistful stories I told myself about the fun and enjoyment I got from drinking were just that: stories. None of them were true.
absolute commitment to tackling my depression.Before I stopped drinking, I worked hard to develop habits that would help my depression (exercise, diet, sleep etc). Drinking was the last seriously unhelpful behaviour I changed. I doubt I could have done it otherwise.
Coming out as a teetotaller. Very helpful at social functions where drinking is normal or expected. Outside my immediate social circle, people in my world don’t care if I am not drinking, and I have found that I couldn’t care less what they think anyway! But it hasn’t been a problem.
Planning ahead. Taking my own drinks to parties/functions where appropriate or sorting out a strategy in advance.
Maintaining stocks of alcohol-free drinks at home – whenever I fancy a beer (most days), or a glass of wine – I have one. Simple. This may not suit everyone, but it has worked really well for me.
Impact on my depression
The benefits of going alcohol-free are strong, and include:
improved physical health (fewer headaches and ailments generally; weight loss)
improved appearance (face less saggy, skin clearer, eyes brighter)
financial (my household spending has decreased dramatically)
more sociable (and more likely to invite friends into my house, which I hated doing before)
available for productive activities in the evening (including those which involve driving)
Has it improved my mental health? Yes definitely, albeit in tandem with the other things I now do (exercise, sleep etc). My mornings used to start with imagining shooting myself in the face, then the blood, bone fragments and brain tissue dripping down the wall behind my bed. That very rarely happens now, thank goodness.
Sorry to mention such a gross image, but that was how it was when I was drinking, and that is what I think of if ever I feel tempted to drink again. I am so much better off alcohol-free.
Lack of confidence is something I experience on a daily basis. Perhaps it is related to my depression, perhaps not. However, I can feel my comfort zone gradually shrinking so that I am reluctant to try news things and risk fresh failure and pain; sticking instead to what I know will not hurt me. This is not going to help me stay well.
Time, then, to tackle the confidence problem, with the help of The Confidence Gap by Dr Russ Harris.
The approach in this book is ACT – acceptance and commitment therapy.
ACT, originally called comprehensive distancing (great name!), was developed in the late 1980s. The objective is not happiness; rather, it is to be present with what life brings us and to “move toward valued behaviour”. It has been described as getting to know unpleasant feelings, then learning not to act upon them, and not to avoid situations where they are invoked. Its therapeutic effect is said to be a positive spiral where feeling better leads to a better understanding of the truth. [source: wikipedia]
Dealing with negative thoughts and feelings
The Confidence Gap starts from the assumption that negative thoughts are not inherently problematic. It doesn’t matter whether thoughts are true are not; what matters is whether they are helpful. The thing with negative thoughts, and ‘unhooking’ from them is to diffuse their power by noticing the thought, naming it and neutralising it. How do you do this? With mindfulness. Mindfulness develops our ability to notice thoughts in a detached way; to unhook them from snagging the mind.
Unpleasant feelings and sensations in the body can feed negative thoughts and lead to a depressive spiral. ACT uses ‘expansion’ to deal with feelings and sensations: again the first step is to notice them. The next is to acknowledge and make space for them. In this way, Harris says, we learn to accept our fear.
Values to live by
These ACT techniques are useful adjuncts to mindfulness practice; they could be applied to many situations where negative thoughts and feelings are problematic. The Confidence Gap suggests another general principle – that of living according to your own set of values (which he defines as ‘desired qualities of ongoing action – how you want to behave as a human being’).
Values play a major role in developing confidence and enhancing performance. Not only do they provide us with the inspiration and motivation to ‘do what it takes’, they also sustain us on the journey…And even when we don’t achieve our goals..we can still find satisfaction and fulfilment from living by our values. Russ Harris, The Confidence Gap
It would not have occurred to me that confidence could be linked to values, but I have found this the most useful part of the book so far, and I will return to the issue of personal values and mental health in a future post.
The confidence gap
The ‘confidence gap’ is when you believe you can’t
achieve your goals
perform at your peak
do the things you what to do
behave like the person you want to be
– until you feel more confident. Harris argues that people may lack confidence because their expectations are too high, they judge themselves too harshly, they are preoccupied with fear, or they lack experience or skills.
To overcome these:
Unhook from excessive expectations
Practice self-acceptance and self encouragement
Make room for fear – and if possible, use it
Step out of your comfort zone and get the experience you require
Practise the skills, apply them effectively, assess the results, modify as needed
My lack of confidence comes to the fore when I am playing the trombone, which is not the ideal instrument for a timid, shy person like me, but it’s what I play nonetheless (that’s me last Saturday, second from right, photo by Tim Lawes).
I would love to have the confidence to play in public (at band practice or at a gig/concert) as I do at home – with the appropriate volume and attack. But I worry too much about making a mistake and cocking it up for everyone, or others hearing how poorly I am playing. And so every band practice or concert becomes a source of embarrassment and self-reproach. Which is ridiculous – it’s my hobby; making music with others is a wonderful thing to do.
So, I have the perfect thing to try these Confidence Gap techniques on. It’s not just about practising the skills, and getting the appropriate experience. It’s also about working with the fear and self-doubt in a smarter way.
Rules of bridging the confidence gap (Harris, The Confidence Gap)
The actions of confidence come first; the feelings of confidence come later
Genuine confidence is not the absence of fear; it is a transformed relationship with fear
Negative thoughts are normal, Don’t fight them; defuse them
Self-acceptance trumps self-esteem
Hold your values lightly but pursue them vigorously
True success is living by your values
Don’t obsess on the outcome; get passionate about the process
Don’t fight your fear; allow it, befriend it and channel it
Failure hurts – but if we are willing to learn; it’s a wonderful teacher
The key to peak performance is total engagement in the task
It looks like the warm summer weather is finally here in the UK, and certainly everything is blossoming like mad. This is a good time for sufferers of Seasonal Affective Disorder (SAD) – the hours of daylight are long, and the sun shines brightly.
But if you feel particularly low at this time, or like me experience fleeting stabs of absolute desperation even when all seems well, you are not alone. It seems counter-intuitive but spring is the peak period for suicide. The reasons are not well understood.
I will write more about suicide at a later point, but for now, if you are feeling suicidal, talk to somebody and get help. In the UK email or call the Samaritans on 0845 790 9090 (24 hours a day), or go to A&E if you need to be in a safe place.
Whatever you do, don’t listen to sad songs like this!
The Daily Mail published an article last month with the headline
Depression is NOT caused by low serotonin levels and most drugs used to treat it are based on a myth, psychiatrist claims
The story was based on an editorial in the British Medical Journal (BMJ) by psychiatrist David Healy (pictured), who argued that the popularity of SSRI antidepressants such as Prozac is based on a myth, grown from the notion that ‘SSRIs restored serotonin levels to normal, a notion that later transmuted into the idea that they remedied a chemical imbalance’.
In fact, whilst levels of serotonin may be linked to depression, it is not known exactly how, and nor is it understood how SSRI antidepressants really work.
According to Healy, the strength of the chemical imbalance myth means that SSRIs are often prescribed at the expense of more effective treatment, and with no regard to individual characteristics of a patient’s depression. But he says:
Serotonin is not irrelevant. Just as with noradrenaline, dopamine, and other neurotransmitters, we can expect it to vary among individuals and expect some correlation with temperament and personality.
Is the ‘depression is a chemical imbalance’ idea really incorrect?
The academics and medics who commented on the BMJ piece seem to be clear that the science has moved on a long way since SSRIs were introduced, and that the causation of depression is much more complicated than too much or too little of one neurotransmitter in the brain. So it is way too simplistic to say that SSRIs correct a chemical imbalance.
An article on the website io9 gives some background into how the chemical imbalance ‘myth’ took root and grew. It also summarises where the scientific thinking on depression is now:
Depression’s wide range of symptoms can be linked to myriad overlapping factors, from genetic vulnerability, to deficiency of certain neurotransmitters, to disruptions in circadian rhythms, to factors that can alter the survival and growth of neurons.
The birth of new neurons, for example, is a hallmark of a healthy brain; a prominent new theory about how SSRIs work has connected elevated serotonin levels to the elevated birth of neurons.
But the science still has a ways to go. It is also obvious that psychological stress and so-called early lifetime stress can cause depression.
Poul Videbach, professor of psychiatry at Aarhus University Hospital in Denmark (Levi Gayde, io9)
So it’s a myth, so what?
The many comments on the Daily Mail and io9 articles illustrate the two main issues arising from all this: 1. SSRIs are overprescribed because patients and doctors have bought into the myth; 2. SSRIs really do help a lot of depressed people
If Prozac, or any of the SSRIs (Cipramil, Cipralex, Faverin, Seroxat, Lustral are the others used in the UK) improve your symptoms and side effects aren’t a problem, does it matter if we don’t really know how they work? No. Keep taking the tablets.
But if sorting out serotonin levels isn’t the answer, or not the whole answer anyway, to managing depression, it makes sense to keep doing the other things that help: healthy sleep, good diet, social contact, exercise, mindfulness, anti-ruminatory activity, exposure to sunshine.