Depression Two (Feb 2001)Saturday, 02 April 2011 01:48
February 13, 2001
Alice wrote to me to tell me how much she had been helped by counselling and by my books, but she added, ‘I understand now why I get depressed, and I’ve really tried to change, but I can’t make myself feel good about myself. I tell myself I’m valuable and all that, but deep down I know I’m not. What can I do?’
Believing that you are, in essence, bad and unacceptable is absolutely central to depression. If this is how you feel about yourself then, when you suffer a disaster, you blame yourself and think that you are even more wicked and unacceptable than you had realised. Doing this you cut yourself off from other people, from society and nature, from your past and your future, and thus, inadvertently, create the prison of depression. The key to this prison is to come to see yourself as valuable and acceptable, but many people have great difficulty is finding this key. No matter how much they suffer, they cannot bring themselves to believe that they are, in essence, valuable and acceptable.
So, to find the key to the prison of depression you might need some help.
The help most often offered to someone who is depressed is antidepressant drugs. When in the 1960s antidepressant drugs were first used many people believed that depression would disappear, just as many infectious diseases had disappeared with the discovery of antibiotics, but instead the incidence of depression continued to rise. Different kinds of antidepressants were created, first the tricyclics, then the monoamine oxidase inhibitors (MAOIs), and more recently the Selective Serotonin Reuptake Inhibitors (SSRIs), of which Prozac is one, but none of these has the magic ingredient to change how a person feels about himself. Antidepressant drugs, like alcohol, nicotine and the illegal drugs, can lift our mood and make us feel happy with ourselves for a little while, but none of these drugs can change the ideas and beliefs which are integral to how we see ourselves as a person. No drug will change you from hating yourself to loving yourself.
The public is given a great deal of misinformation about antidepressant drugs. While Prozac has been greatly hyped, research shows that no single antidepressant has any greater effect on depression than any other antidepressant. The talk about depression being a chemical imbalance in the brain and about the SSRIs working on the serotonin in the synapses of the brain is quite misleading. All antidepressants work unspecifically on the whole brain, and just what they do is not understood. Doctors often insist that there are no withdrawal reactions when a patient stops taking an antidepressant, yet the evidence is that coming off any of these drugs at all abruptly can leave the person feeling ill, shaky, unable to sleep and anxious. This reaction is often interpreted by the doctor, and sometimes by the patient, as evidence that the patient is still depressed, and so the antidepressant is again prescribed.
In the report on the 1994 International Conference on Moods Disorders Joseph Mendels MD wrote, ‘There is now clear evidence that, for a substantial proportion of the millions who suffer from major depressive disorder, the condition is often chronic or recurrent. Many of our patients require long-term maintenance treatment.’ By 1999 David Nutt, the Professor of Pharmacology at Bristol University, was writing, ‘Of those who have suffered one episode of depression 50-85% will have a subsequent episode, while of those who have had two episodes 80-90% will develop a third. With each recurrence a further recurrence becomes more likely and the period in remission tends to become shorter.’ Many psychiatrists now prescribe a maintenance dose of an antidepressant which the patient is required to take for the rest of his life, but research shows that between 20 and 70 percent of patients on maintenance doses relapse.
All these research results concern depressed people who were treated only with medication. Research studies where the treatment combined medication and some form of therapy produce much more encouraging results. When medication and therapy are combined the medication can lift the person’s mood, and then the person can feel that he has enough energy and enthusiasm to do something for himself. He might join a yoga class, or start exercising regularly, or, if he feels particularly low in winter (Seasonal Affective Disorder as it is now called), he gets a bright light and thus has a pleasant break each day sitting in front of it. Or he might find a therapist.
The effectiveness of therapy depends on the quality of the relationship between therapist and patient. You might have to try two or three therapists before you find someone who you feel is right for you. However, before you start looking for a therapist, you need to know a little about what different kinds of therapy are on offer.
If you are an NHS patient the kind of therapist you are most likely to encounter is a cognitive therapist. Many clinical psychologists work in this way and there are also a number of nurses in psychiatric units and in the community who have trained as cognitive therapists. A great deal of research has been carried out on the effectiveness of cognitive therapy, and all this shows that it is much more effective than medication and that its effects are long-lasting. People don’t relapse, or, if they start to feel themselves going down the slippery slope into depression, they use the techniques they have learned to stop this happening. Cognitive therapists begin by getting you to listen to the way you talk to yourself. If you don’t value and accept yourself then all the time you’re putting yourself down. You tell yourself you’re unattractive, you’re sure to fail, no one likes you, you deserve to be punished, and so on day after day. The cognitive therapist shows you how to monitor your self-talk and how to develop ways of talking to yourself in encouraging, supportive ways. If you talk to yourself as your best friend rather than as your worst enemy you’ll soon discover that you’re valuable and acceptable.
Researchers in the effectiveness of therapy divide all the therapies into two groups, prescriptive and exploratory. Cognitive therapy is a prescriptive therapy. The therapist will begin by finding out about your background, but this exploration soon gets turned into the prescribing of exercises for you to practise. Some cognitive therapists find that this way of working can be too limiting and not totally appropriate for different clients, and so they combine prescriptive therapy with exploratory therapy.
There are many different kinds of exploratory therapy – Freudian and Jungian psychoanalysis, humanistic therapy, existential therapy, cognitive analytic therapy, psychodynamic therapy, and so on – but all are concerned with exploring, not simply the person’s past experience, but how the person interpreted those experiences. If you hate yourself then there have certainly been events in your childhood which you interpreted at the time as evidence that you were bad and unacceptable. Perhaps your father deserted your family, or perhaps your mother died, or perhaps someone sexually assaulted you, and you said to yourself, ‘If I’d been really good this wouldn’t have happened.’ Exploratory therapy lets you look at these events and see them again with an adult eye, and thus realise that, though that was how you saw these matters when you were a child, now you’re an adult you can see these matters differently and realise that you weren’t to blame for what happened to you.
It’s hard to draw a clear line between therapists and counsellors, and indeed the British Association of Counselling has now changed its name to the British Association of Counselling and Psychotherapy (BACP). Some 50% of GP practices now have access to a counsellor. Professor Michael King led a large study comparing the effectiveness of counselling with that of GP care and with cognitive therapy and found that patients found counselling much more helpful than medication or cognitive therapy. Having someone who is on your side and who sees you as valuable and acceptable can be of immense help in changing your view of yourself.
Many depressed people endure not just the isolation of the prison of depression but the loneliness of knowing few people or living in a family where people hurt them, or ignore them, or treat them as doormats. Joining a self-help group for depression can make a great deal of difference. Two organisations, Depression Alliance and The Fellowship of Depressives Anonymous, have groups across the UK. Andrea, a member of Depression Alliance, wrote in their journal A Single Step, ‘A self-help group can be the first step to integrate oneself back into society. It gives you some confidence to see that you can cope with this group of unknown people and enjoy their company.’
In a self-help group you’ll meet people who know what it is to be depressed. They’ll understand what you’re going through and not despise you. The only drawback of self-help groups, in my experience, is that you’re likely to encounter people who have made being depressed their whole identity. They speak of being ‘a depressive’ and they have no intention of changing.
However, a self-help group can be extremely helpful in learning to value and accept yourself. Andrea wrote, ‘Listening to other members of the group I always think that all these people are really nice; none of them is ugly and horrible. How can they possibly have a low opinion of themselves? Then I think that maybe the others feel the same about me; perhaps I am not this horrible and worthless person I am convinced I am.’
Whatever kind of therapy you choose, if you go into therapy expecting that the therapist will take your pain away but you won’t have to do anything or change in any way, then the therapy will certainly fail. You need to go into therapy being prepared to change even though neither you nor your therapist can predict what will be the outcome of these changes. How you feel about yourself is central to your identity. If you change from hating yourself to valuing and accepting yourself then everything about you and your life will change. I have seen many people make this change and all of them went on to lead lives – happy lives – very different from the life they led when they were depressed.
How you feel about yourself is central to every decision you make. If you value yourself and you’re buying something for your dinner you’ll choose something simply because you fancy it, but, if you believe you’re worthless, you’ll think, ‘I don’t deserve something nice,’ and you’ll buy something dreary and perhaps not very good for you. Seeing yourself as wicked and every disaster a punishment you deserve, you’ll be too terrified to take a holiday anywhere interesting, but, valuing yourself, you’ll choose to jet off all around the world. Most importantly, when you don’t value yourself you’ll let people hurt you and use you, but when you value yourself you’ll defend yourself against those who would bring you down.
Moreover, as you come to value yourself, you find yourself in situations where you have to learn new skills. Hating yourself, you kept people at arms’ length, but, now that you like yourself and so expect other people to like you, you have to learn how to really get to know people and let them get close to you. Feeling inadequate, you never put yourself in any competitive situation, but now, sure of your worth, you have to learn how to compete and how to risk losing.
Indeed, to value and accept yourself you have to accept that life is full of risk and chance. The great advantage of being depressed is the security of the prison of depression where you can make sure that every day is the same and that you’ll be correct in expecting that everything will turn out badly. It is the fear of change that keeps a person locked in the prison of depression. To get out of that prison you have to ask yourself, ‘Am I prepared to change?’ The best answer to this question is ‘Yes.’
Dorothy Rowe Breaking the Bonds: Understanding Depression and Finding Freedom HarperCollins £8.99
Dorothy Rowe Depression: the Way Out of Your Prison Routledge, £10.99
UK Council of Psychotherapists and the British Confederation of Psychotherapists each publish a register of psychotherapists accredited to each organisation. These registers are available in public libraries.
The British Association of Counselling and Psychotherapy’s new phone number is 0870 443 5252
Depression Alliance can be contacted on - London 020 7633 9929, Scotland 0131 467 3050, Wales 01222 521774
Fellowship of Depressives Anonymous 01702 43 38 38