My Struggle With Bipolar Depression and Dream to Go to Law School

I’ve struggled to write this blog, just like I’ve struggled to do most things for what amounts to a very long time now-so long that it feels like a lifetime and what came before only fragments of a not well remembered dream.  In actual temporal time, it’s only a few years of melancholy and moderately severe major depression. But in the life of the mind, there is an unbridgeable chasm between the person I am now, who I once was, and who I want to become.  I am so lost in my isolation that my only refuge is in turning inward; a strategy which offers no solace at all-only shame and regret.

I feel so isolated. I suppose that is one of the hallmarks of mental illness – detachment – that it seems impossible to relate to anyone.  Furthermore, I’m not an attorney, just someone who has lived the hells and wonderful peaks of manic depression.  My exposure to the law is through my father, my uncles, my cousins, and Dan Lukasik.  I hope to go to law school one day, but I need to retake the LSAT first.  So why write a blog?  What good could it possibly do?  Hopefully, some of the sentiments I describe will resonate with you.  But hope is fickle; a thinly stitched veneer stretched tautly over an ever-widening mire of unfulfilled promise.  When I look back at what I hoped for, most of it has faded into the mists of time with barely even the trace of memory or, worse yet, has been completely buried beneath the scars of regret.

In the face of my futility, my stupidity, my selfishness, my demons, hope that I can one day return the love and support that has been given me has allowed me to trudge on, kept me from giving up.  Even if it flies in the face of all rational thinking, experience, and who you believe you are the sole advice I would deign to give is to no never give up hope that you can bring yourself to a better place and can make yourself into the person you wish to become.  Though there be no reason to believe, allow belief to inspire you all the same.

“I can only stand apart and sympathize/ For we are always what our situations hand us/ It’s either sadness or euphoria.”

The above is a stanza from Billy Joel’s song “Summer, Highland Falls” that has always resonated with me.  The song itself captures the sense of helplessness, at times even ironic apathy, I have felt towards a disease (or mental illness or whatever I should call it) that has allowed me to leap through the heights of “euphoria”, and to spiral down into the depths of suicidal depression, seemingly completely independent of any of the external aspects of my life.

I once told a friend that in the past three months I had had at least 45 “perfect days” (i.e., days that I could not imagine being any happier in), but that 45 was a conservative estimate and it was probably more.  I’ve also spent weeks on end consumed by vivid images of ways in which I could gruesomely kill myself.  And both of these emotions, which at the time feel so pervasive and all encompassing, occurred while living on the same college campus and surrounded by many of the same people.  So it’s hard not to “stand apart and sympathize” with the fact that regardless of daily accomplishments or minor setbacks, or even in the face of significant change, it doesn’t matter what you do.  That because of who you are, in a very intimate and fundamental sense, you are going to experience “either sadness or euphoria,” and you have little say in how intensely you are going to experience that emotion, or for how long (so let’s hope its euphoria, and it lasts forever).

This complete lack of control has always weighed on me as a moral failure because I’ve recognized what I consider the best version of myself-productive, engaged, intelligent, charming and yet, due to an inherent weakness, have been unable to maintain that persona consistently.

Instead I, and I would like to emphasize the contradiction and confusion surrounding a feeling at once of helplessness and simultaneously of complete responsibility for being who I am, have eventually always succumbed to periodic bouts of anxiety, negativity, and self-doubt.  These periods have always been characterized by an intense sense of isolation in which almost palpable barriers are restricting me from coming into touch with the people and events surrounding me while at the same time engaging/suppressing the most endearing aspects of who I would hope to be as a person.

There are two types of sadness which result from this frustration and alienation.

Painful Sadness

There is a horrible, painful sadness.  For me, this type of sadness is expressed through intense suicidal ideation-constant mental images meant to shock the senses into an acknowledgment of how base you are.  Brutal beatings, stabbings, gouging’s, hangings.  It consumes you until the idea is all there is and it takes every ounce of energy you have to beat it back.  And it breaks your heart to see someone you love not to be able to say that this is how you feel, and it’s not their fault, but you are worlds away and mired in a sadness/loathing that is impossible to understand for those who have not yet experienced it.  And they love you, so they are trying to understand, but, how could they?  And this breaks your heart even more.

Cleansing Sadness

And there is also a beautiful, cleansing sadness.  For me, this beautiful sadness feels more real than anything in the world.  When I have been at the height of mania-during the happiest times of my life, I have still felt intimately in tune with songs that deal with regret-juxtaposing the inadequacy of the self with the intrinsic sublimity of some other-which you have failed.

There is a powerlessness to this beautiful sadness, an inevitability.  It is real because it exists at the core of our most vulnerable selves, and therefore its expression comes out at a time when we are “most alive” and most in tune with our emotional intuition-when we are most ready to admit to and grasp on to that which we truly hope for and believe in.  This sadness is not manifested in horrifying suicidal ideations but rather in the awe-inspiring idea that we are not worthy of the wonderful phenomena we call life.  That we are ashamed of our ugliness amidst so much beauty and yet, in spite of our baseness, we have the opportunity to exist within as well as work towards some greater good.

Mania

In many senses, for me, the mania of bipolar has been synonymous with stripping away the debilitating fear and anxiety which were so constricting for so long, and a constant struggle has been not to glorify it.  My Mom is taking a wonderful self-help course entitled “Fearless Living” and those two words, again from my experience, imbibe what it means to be manic or hypo manic; imbued with amazing amounts of self-confidence and gratitude, it’s unbelievably easy to live a carefree, upbeat, happy-go-lucky lifestyle, all the while being extraordinarily productive.  Thus thinking in the binary can be dangerous-there is a natural tendency to see every aspect of the mania as better than every aspect of the depression.

However, beyond the fact that I have never been able to sustain mania, there is also a depth of feeling engendered by the sincere melancholy of depression that I have never encountered in the euphoric whirlwinds of mania.  And I think the small silver lining to what is a dark cloud is the depth of meaning such great sorrow can expose you to-in a way an almost redemptive suffering.  At the very least, though depression has taught me to hate myself many times over, it has also taught me to love life.  The sad beauty of such a self-effacing distinction, to hate your being while loving your existence, is something to be thankful for and, hopefully in time, something to build off of for the future.

I would like to close this blog with what have for me been some solid building blocks for sheltering myself from, coping with, and eventually recovering from depression.

Exercise

When there seems to be nowhere to turn and the prospect of getting through the day seems unbearable, working out and (especially) yoga exercises are blocks of time where you don’t have to interact with other people, can be totally in your head, and when you’re done you feel a little better physically, even if not mentally.  Really any small thing that you can do consistently and through which you can mark progress-I’m getting stronger, better endurance, or greater flexibility-is a wonderful way to establish extrinsic markers of success-I’m better at this than I was a few weeks ago, which, in turn, can catalyze good feelings about yourself as a person.

Think of something you’ve always wanted to do or be good at, and then identify manageable steps that you can take on a consistent basis that gradually takes you towards your goal.  Don’t say I need to be as good as someone else or make an arbitrary benchmark-rather say I want to get in better shape relative to how I am right now, so I’m going to run or go to yoga more often.  Or I’ve always wanted to know how to tie my flies, shuffle a deck of cards, play an instrument, or speak a foreign language, so I’m going to work on this task a few minutes each day as opposed to watching TV or surfing the web.

Taking little steps like these that are working towards longer goals, even if you are not aware of any specific professional or extrinsic benefits to achieving those goals, can be inherently rewarding in and of themselves.  If you’re better at an activity, any activity, then you were a few weeks ago, that can be one small thing that you feel good about, even as the rest of your world remains shrouded in darkness.  It can help motivate you to get through the day, can serve as a spring towards other “productive” behavior, and eventually be something you can hang your hat on.  However, it’s important not to beat yourself up after a day in which you failed to take your positive “step”-rather have a little self compassion and say tomorrow is a new day, and it’s not the end of the world, indeed its completely ok, that I wasn’t able to do anything “productive” today.

Finally, reading and writing can be extremely cathartic.  Reading great literature can give you an emotional connection to characters, ideas, and feelings during a time when you felt completely isolated and estranged from the outside world.  Fiction and non-fiction distract you from the constant stream of negative and self-critical thinking that can paralyze you.  And, in a way similar to the steps discussed above, finishing a book you’ve always wanted to read or one on a subject that you’ve wanted to know more about, can generate a (no matter how small) sense of accomplishment that, no matter how insidiously it attempts to, the depression cannot take away.

On the other hand, for me, writing is more of a risk.  I can be very critical of myself as a writer-a case in point is this blog which has been taxing at times-and sometimes end up feeling worse after sitting down to write.  At other times, writing has been akin to therapy in that it has helped me to sincerely articulate-in the best way I know how the complex matrix of emotions enmeshed within me.  Even if journaling or poetry don’t make sense to a single other person, the fact that they make sense to you can temporarily relieve part of the burden imposed by self-guilt and personal shame.  It can be an outlet for your anguish, space where you can be authentically yourself.  Sometimes, you can be so overwhelmed by your depressive thinking that you need some way to release that thinking-writing can be an effective way to do this.

In any case, don’t immediately sit down and assume that because of your depth of feeling you’re going to write the next great American novel.  Rather start with a paragraph or a poem.  It might end up being useless junk that you never look at again, and that’s ok, because part of what depression is, is a needless anguish and self-doubt that is inhibiting you in your quest to live a full life and should be discarded as soon as possible.  But amidst the uselessness you may stumble upon small snippets of truth-a rhyming couplet here, a few sentences there-that satisfactorily express for you one of the tragic and meaningful aspects of your condition (or symbolically the human condition more generally).  These small snippets are worth holding onto as they reflect the deeper truths embedded within a malaise that so often brings us to our knees and which, on sublimely rare occasions, reveals insights that one (I believe) can only obtain through suffering.

Anonymous

Further reading:

Bipolar Disorder Overview

Writing Your Way Out of Depression

The Bipolar Disorder Survival Guide: What You and Your Family Need to Know

Yoga for Depression: A Compassionate Guide to Relieve Suffering Through Yoga

The Bipolar II Disorder Workbook: Managing Recurring Depression, Hypomania, and Anxiety

Is Bipolar II Easier to Live With Than Bipolar I

 

SHUTDOWN: WHY PEOPLE WITH DEPRESSION FEEL SO NEGATIVE

Depression is a state of shutdown in which an individual’s psychological system shifts toward negative feeling states and diminishes the positive feeling states. The hallmark features of a depressive episode is a high negative mood state (characterized primarily in terms of depressed/demoralized/defeated/despairing feelings and secondarily in terms of anxiety, irritability/defensive hostility, and guilt/shame) and a diminished positive mood state (loss of interest, pleasure, energy, desire, and excitement).

Why do people get depressed? The primary reason people enter depressive shutdowns because they cannot obtain the necessary psychological nourishment needed to energize their behavioral investment system. Think of it as being akin to a state of starvation, only instead of physiological nutrition, the individual is lacking psychological nutrition. What is psychological nutrition? The fundamental principle that underlies psychological organization is that of behavioral investment. The psychological system is organized to direct mental energy and action toward investments that offer a return on those expenditures. When one is a getting a good return on one’s investments, then one feels fulfilled, energized and engaged. However, when one is not getting a good return, one begins to feel frustrated, anxious, irritable, or disappointed. If one cannot find an effective pathway for getting one’s needs met, one begins to enter into a state of psychological shutdown called depression.

So what are the core psychological needs that people have that need to be nourished? There are many different possible classification systems of needs (and motives and goals that people seek fulfillment around, see, e.g., here). I offer five categories here that overlap loosely with Maslow’s classic hierarchy of needs.

Safety and Security Needs. First and foremost, the psychological investment system is concerned with basic safety and survival. If one’s physical safety is chronically threatened, if one is in constant pain, if one is chronically hungry, and so forth, the attention of the system will largely be focused here.

The Base Pleasures. Good sex, tasty food, relaxing on a warm summer day on the beach after working hard. The “hedonic” pleasures serve as a fundamental reward and signal positive investments (at least in the short term). Good investment systems are generally characterized by meaningful effort and hard work toward a productive goal, followed by short periods of relaxing and enjoying the base pleasures.

Relational Needs. Our core psychosocial need is to be known and valued by important others. Most notably, this includes being known and valued by members of our family of origin, friends/peers, romantic partners, and community. Needs for relational value are reflective of one’s degree of social influence. And folks go about achieving social influence and relational value in different ways. For example, see here for power and achievement needs relative to belonging and intimacy needs.

Developmental Growth Needs. We can think about an individual’s psychological system as being akin to an investor’s portfolio. An investor has resources that have the potential for growth and loss. An investor with a diverse portfolio whose investments are growing in a way that is exceeding expectation is flourishing. The same is true for an individual. Each individual will have “personal projects” that are engagements they are involved in that afford opportunities for growth (hobbies, interests, creative and playful endeavors, meaningful work projects, etc.). If an individual is chronically stuck and not growing or is largely cutoff from their growth pathways, or is frequently failing to meet expectations, or is deeply investing in pathways based on extrinsic reasons that are not consistent with their underlying emotional/motivational needs (or intuitive sense of potential), then the investment system is vulnerable.

Existential/Transcendental/Virtuous Needs. Adult humans are meaning-making creatures that need to have a narrative for how their lives and personal projects make sense. As Victor Frankl notes in his timeless classic Man’s Search for Meaning, if they cannot place their suffering, personal projects, virtues and relationships in the context of a larger narrative that provides meaning, then they will be vulnerable to developing a nihilistic attitude, which is the belief that their lives or actions really don’t matter, because really nothing matters. A nihilistic narrative can undercut the emotional value that folks get from engaging in such projects, leading to existential crises or depressions.

Why do people have trouble getting their psychological needs met? Sometimes the answer is obvious. For example, consider the city of Aleppo in Syria. The people of that city have been completely brutalized and many folks there undoubtedly feel depressed. (As an interesting aside, it is worth noting that the field of psychiatry/clinical psychology is divided as to whether such individuals should be considered “clinically depressed”). In other obvious cases, folks get depressed because of chronic pain or illness, or death of a loved one or because they get addicted so substances that ruin their lives or because they are abused or isolated.

Other times the issue is much more complicated. Consider that there are many people that live in nice houses and seem to be surrounded by caring people and are achieving in their lives, yet they also get depressed. Indeed, despite the fact that we have more and more technology and more and more resources and control over our environment, we seem to be struggling more than ever with feelings of depression and anxiety. What is going on in these cases?

The short answer is that I think the modern, fast-paced society is placing many new, unusual stressors on our emotional system. And I don’t think people have been well-educated about how to appropriately process negative feelings. People have been given much more freedom to acknowledge negative feelings than in past generations (read this story to see what I mean), but there has not been good education on how to learn and grow from such feelings (see here or here). What I see in my clinic is that individuals try to avoid negative feelings, and wish everything would just be fine. They often try to act publicly like everything is fine, but they have no idea how to maturely process and learn from their negative feelings. Instead, they enter into an intra-psychic battle with their negative feelings, often working to banish them, or criticize themselves out of their feelings or try to “stay positive”. This creates a powerful “split” in their psychological systems. Namely, their feeling system is sending one signal, their internal narrator is in conflict with that signal, and they are trying to publicly present a totally different image than their inner conflict. All of this sets the stage for a “neurotic breakdown”.

In addition, I see many parents who value their kids, but who do not know how to guide their children in processing negative feelings. Instead, too many have been caught up in “self-esteem nation” and act in an overprotective way, essentially communicating both that their kids are fragile and that others are responsible for keeping you happy. Another group teaches their kids to repress and minimize their feelings. I am not blaming parents here. The modern world is complicated and psychologists and psychiatrists have generally not done a great job being clear about the nature of emotions and relational needs.

At the societal level, we need to recognize both the dramatic changes the information technological revolution has brought to our world and how many of the institutions that provided guidance for the good life are breaking down. Religious systems have lost much of their authority. The political system has broken down into a polarized way. I think our educational system is broken in the way it assesses performance and fails to teach character values. Science often seems to characterize the world as an amoral, meaningless physical system. In other words, in terms of our existential/transcendental understanding, there seems little that supports the deep-seated need that many people have for true meaning making. So, we live in a fast-paced, high-stress world in which we are overloaded with choice, we regularly observe massive amounts of inequity in power and resources, we give lip service to negative feelings but often characterize them as disease states and provide very little real education about human emotions and needs, and institutions that provided deep meaning making systems have lost their authority.

The bottom line is that depression arises, in most cases, when people do not receive the necessary psychological nourishment from their investments. This arises because of brutal environments and injury from traumas, diminished capacities to meet growth expectations, intrapsychic and interpersonal conflict with important others. Unable to find a path forward folks shutdown and, unfortunately, getting depressed in modern society likely creates more problems than it solves. So folks get trapped in neurotic depressive cycles.

There is clearly no easy fix, as depression is a massive health problem. But I do believe there is much that can be done. We need (and can achieve) a much better shared understanding of human psychological needs and nourishment. We also need a clear recognition from institutions like the World Health Organization that depression emerges as a function of psychological malnourishment, rather than being brain disease stemming from neurological malfunctions.

My ultimate vision is for the development of a holistic meaning-making system that harmonizes the natural sciences, the social sciences, and the humanities in a way that affords an understanding of our human natures such that we can have a more effective guide toward fulfillment during these rapidly changing times.

Gregg Henriques, Ph.D., author of A New Unified Theory of Psychology, directs the Combined Clinical and School Psychology Doctoral Program at James Madison University. He is a licensed clinical psychologist with expertise in depressionsuicide, and the personality disorders. He has developed a new meta-theoretical system for psychology articulated in many professional journals and is now applying that system to researching well-being, personality, and social motivation, and he and his students are working on the development of a general system of psychotherapy. Henriques received his M.A. in Clinical/Community Psychology from UNC-Charlotte and his Ph.D. in clinical psychology from the University of Vermont. He also completed several years of post-doctoral training at the University of Pennsylvania under Aaron T. Beck exploring the effectiveness of various cognitive psychotherapy interventions for suicide and psychosis. Henriques teaches courses in personality theory, personality assessment, social psychology and integrative adult psychotherapy.

 

The Creativity Cure for Depression: An Interview with Dr. Carrie Barron

Today’s guest is Dr. Carrie Barron, a board-certified psychiatrist/psychoanalyst on the clinical faculty of the Columbia College of Physicians and Surgeons who also has a private practice in New York City.  She has published in peer-reviewed journals, won several academic awards, and presented original works related to creativity and self-expression at national meetings of the American Psychoanalytic Association. Along with her husband, Alton Barron, M.D., a hand and shoulder surgeon, she co-authored the book, The Creativity Cure: How to Build Happiness with Your Own Two Hands.

Dan:

Why is depression such a problem in our culture?

Carrie:

I think the level of stress has gone up enormously because we have so much to do and we’re on twenty-four hours a day. So I think because of technology, which offers us so many great things, but gives us much to do. I think that’s part of it. I also think, especially for children, we’re in a striving, ambitious, be productive all the time mentality – for children and adults. We need to play, we need to hangout, we need to have spontaneous time. I think spontaneous thought does a lot for alleviating depression and anxiety.

Dan:

We have so many different words in our culture for unpleasant experiences. We might say things like, “I’m sad,” “I’m burnt-out,” “I’m stressed-out,” or “I’m depressed.”  But what is the difference in your mind, as a clinician, between sadness, say, and depression?

depressed-83006_960_720

Carrie:

Sadness is a normal emotion. We don’t have to treat everything and be afraid of sadness. We don’t have to pathologize everything. There is a range. I mean, life can be very hard and it’s appropriate not only to have it, but let yourself have it. Sometimes it is actually moving towards the authentic feeling, rather than running away from it, that actually makes it go away. You first have to experience it, and then when you understand it, and you’re in it, it runs its course. Now, this is separate from a true major depression where you can’t get up in the morning. That’s another story. But sadness is a normal part of life.

Dan:

In your clinical practice, how often would you say depression has played a role in why people have come to see you?

Carrie:

I think it plays a role often. The categories that we have in the DSM-5, I think they’re useful so that clinicians can communicate with others. But nobody is fully described by a category or diagnosis. There’s a lot of overlap. When people are depressed, they’re also often anxious and also stressed, and sometimes it’s more one than the other. But depression does come up a lot for people and it’s very painful. I think not being able to get up in the morning, not feeling like doing anything, not being able to enjoy the sunny day or the view of the water, or whatever else people are getting into, it makes you feel very separate and alone when you are depressed and other people around you are not.  So it has, kind of, a trickle-down effect, too.

Dan:

Why did you write the book, The Creativity Cure? I found it such an interesting book, a fascinating read. You wrote it with your husband who is a surgeon. Can you tell our audience why you wrote it?

creativity cure book

Carrie:

There are two things.  I talk about this now, I didn’t talk about this in the book, when I was a kid, I had some problems. I was depressed. I was anxious. We weren’t taking meds at that time. There was some chaos in my world.  I really had to find a way to survive. When I look back on it now, all those things that I recommend in my book are things I was doing, or trying to do, like using my hands. I would cook a lot. I would take long walks.  Then, later in my practice, maybe ten years ago, patients were saying, “You know, I went home and I fixed my sink and I became euphoric! I felt great!” I started to realize that meaningful hand use has a lot to do with happiness. And yet, because so much of what we do now is accomplished with a click on a device, we’re deprived of the process. And process, being deeply immersed in making, or making music, brings with it the possibility for euphoria, and satisfaction, and feeling good about living. So creativity is really about a way to have an optimal life. How you define creativity is another matter.

Dan:

What’s going on in the body, in particular, the brain when someone is struggling with depression? And how does creative action interact with that?

Carrie:

I think a lot of studies have been done, and serotonin and neurotransmitters, there’s a depleted state, and that we need to boost it up with medication or activities that do the same. Vigorous exercise can create the same biological state that antidepressants can. I want to qualify this and say that one must see their physician and make an informed decision, but certainly exercise can help a lot. Also, meaningful hand use has been shown to boost mood. Dr. Kelly Lambert wrote a book, Lifting Depression: A Neuroscientist’s Hands-On Approach to Activating Your Brain’s Healing Power, and she was the one who talked a lot about how purposeful hand use can affect brain chemistry and make people feel happier.

Dan:

What would be some examples of using your hands? When we think of creativity, many people might think of painting, for example. They might say to themselves, “Well, I’m not a good painter,” or “I don’t play an instrument.” But creativity isn’t really limited to that. Can you expand on that?

red knitting

Carrie:

Sure. I am so glad you asked that. I think this is the crucial question. And I think you hit the nail on the head. A lot of people say, “I’m not creative.” Well, first of all, I think we’re all born creative. It’s a matter of finding what you can do. It can be applied to business. You can be amazing. You could be a genius at figuring out what the team needs to be. That’s very creative. You could be an amazing cook. You could have a tremendous talent for decorating. Gardening, the design of a garden. It doesn’t have to be on a professional level. It’s really a matter of figuring out what you can get into. You may find that if you put some time into mastering a skill that you find a certain pleasure and freedom with it. That could be something like painting, but it doesn’t have to be. Knitting, crafting, it could even be fixing things. All of that involves meaningful hand use.

There are many definitions of creativity.  My definition of it is allowing most natural self to emerge to make a positive contribution. It’s allowing you a freedom, a spontaneity in the way that you live, a feeling of safety that allows you to do that so you’ll throw out an idea, you’ll say something funny in conversation, so that you are just yourself and it works. That’s really optimal living.

Dan:

You talked earlier about when you were younger and growing up having some difficult childhood experiences and learning some creative coping skills.  Myself, when I think about this, I had a very difficult childhood as well with an alcoholic, abusive father. Over time, I didn’t have what I would now think of as depression as a young adult. It developed more at midlife when I turned forty.  It seems that there’s a lot of research that suggests that when people in their childhoods have difficult experiences, either emotional abuse, or physical abuse, or deprivation, there’s some kind of linkup with adult-onset depression. Have you found you found that in your experience?

Carrie:

Yea, I think so. I think because in certain ways when you’re in your twenties and your thirties and you’re striving, and you’re distracted and you have a strong goal, that, in and of itself, that kind of commitment to a goal or emotion can stave off certain aspects of your memory or your inner life and it might get triggered in your forties.  Maybe when you have a little bit more time to contemplate or think back. I will say that there are certainly ways, I just like to not be falsely optimistic, but be really optimistic and really encourage people to understand that there are ways to look into your particular history, your particular form of depression, and work with it to get to a much better place at any age.

Dan:

In your book, you talk specifically about not only being creatively engaged, but the use of one’s hands, a physical activity, and how that somehow connects to creativity, no matter your history, or the causes of your depression. This seems to work for just about anybody with depression or unhappiness. Would you say that’s the case?

Carrie:

I do. I think it’s mild or moderate depression. I think if you have a very severe depression, you might need some medical intervention or an intense therapy. But what I like to say is that if you develop a creative habit, it’s very useful to fall back on it when you are depressed. You may not be able to master a new habit when you’re severely depressed, but if you’re mild to moderate, and you work on your knitting, or you work on your painting, or you go into the kitchen and you are inventive about your cooking, it really can shift mood, but not if you’re in a very crippled state. In a crippled state, you need to get to, sort of, a better place, and then use the creativity after that.

Dan:

You’re living in New York City, but you’re soon to be on the move. Tell us a little bit about that.

Carrie:

I’m very excited because I am going to be moving to Austin, Texas soon.  I’m going to be involved in, and working with the great people to try to develop a creativity/wellness program together. I’m not sure exactly, I haven’t submitted a proposal to them about human flourishing and aspects of human flourishing, but from my research, I outline 10 principles that are based on scientific research, but also on ancient philosophies that really help people with optimal living. Most of those are, actually, linked to creativity and linked to better health. So I’m really excited to get to work with people there.

Dan:

You actually have a website. Where can our podcast listeners and readers find you?

Carrie:

At carriebarronmd.com and we have a pretty active Facebook page has a wide following. People make lots of comments and have lots of pretty interesting things to say on that.  So that might be a place to look. And I do have an active Psychology Today blog. I try to keep it lighter for Facebook, kind of short for my website. On Psychology Today, I try to deal with deeper, more complicated issues, but try to be useful.

Dan:

Carrie, it’s been a real pleasure speaking with you today on this very important topic of depression and what we can do about it with creativity.  And we look forward to following your future work.  I hope everybody follows Carrie on her website and reads her blogs. This is Dan Lukasik from Lawyers with Depression. Join us next week for another interesting interview.

Depression Undercover: A Trial Lawyer’s Secret

Once upon a time, I was a trial attorney at a personal injury defense firm. I was good at it.  I always pushed hard; always did the best job possible.  I won a good share of cases, and, of course, lost a few as well.  I was valued highly enough to be made a partner shortly after joining the firm.

But I had a dirty little secret.  I had bipolar disorder, which was well-controlled through a close partnership with a good psychiatrist.  Still, in my mind, if word ever got out, my employers would see me as weak, a liability.  To a degree, I understood.  If the insurance companies that paid the bills learned that one of the firm’s trial attorneys had such a condition, their mandate would be clear: if you want our business, get rid of him. That is what I assumed.

Throughout my career, colleagues would make offhanded remarks about someone “not taking his medication.” I would grit my teeth and ignore it.

Instead, I was able to construct an alter-ego, the “happy warrior.”  I had a smile on my face and a sardonic remark ready on cue. But I went about my daily business feeling like a secret agent in a Cold War spy movie.  If my cover was ever blown, I was certain that my career would be at an end.

Over time, maintaining this secret identity while dealing with the usual strains of trial practice gave rise to a growing depression.  Yet I still performed at a high level and still got results.

Although I had a close friend at the firm, another partner, he would deflect when I tried to talk to him about my depression, so I stopped.  I began to worry that others at the firm might know about me.

Fear and the sense of isolation only fed upon themselves in a continuous cycle.  I finally experienced a severe episode of depression that led to a period of disability.  When I told my boss what was going on, he expressed genuine surprise that I was suffering from depression at all.

When I returned to work, I felt better, but I remained wary.  Instead of engaging in a conversation about what had happened, we all acted as though nothing had occurred.  The computer was rebooted, and business continued on as usual.  I went back undercover, and no one seemed to mind.

Simply due to scheduling conflicts and adjournments, it was some time before I tried another case.  I admit that I was a little nervous, but I was having no trouble handling my case load.  I was puzzled when my boss came into my office one afternoon as I was preparing for the trial.  He asked me if I felt good to go.  He had never done that before.  I said, “yes,” because I felt perfectly up to the task.  I never asked myself, “If he is worried about my performance, why is he even letting me try the case?”

At trial, the insurance company sent an adjuster to audit the proceedings, a routine procedure.  I knew him well, and he had an excellent grasp of the case, even though he had not been involved before trial.  We had constant discussions about what was going on, and we seemed to be in sync.  Suddenly, the insurance company pulled my old friend off the case and replaced him with a mid-level manager who consistently praised my performance.

The case went to verdict, and the jury awarded somewhat less than what the insurance company had offered settle for.  To preclude the possibility of an appeal, the insurance company threw in a few more dollars.  Case closed, on to the next one.  To me, that was a pretty good result.

Was I in for a big surprise.

Shortly after the trial, year-end reviews were scheduled.  I was getting ready for another trial, and I was very excited about it, so I wasn’t really paying attention to what was going on in the office.  Other attorneys were getting their reviews – important because raises would be discussed – but I was never called in.

Ultimately, my case settled after much hard work on all sides, and the usual time for reviews was long past.  I did start to worry then.  I even made a remark to my secretary about it.

The call finally came.  When I stepped into the conference room and saw every equity partner in the firm waiting for me, I knew.  The spy had been caught, but what would happen?

My boss said that they waited to speak with me because they did not want to put pressure on me while I was preparing for another trial.  He asked me if I felt capable of trying cases.  I paused and then broke under the years of strain.  I wept, and answered, “No.”  Whether that “No” was true then or true now or was ever true, it was the most humiliating moment of a 20-year career.

My boss started to dissect my prior trial, telling me that the insurance company’s representative was reporting that I was doing a bad job.  He even told me that the supervisor at the insurance company knew that I had depression.  After the expected awkward silence, another partner suggested that “we find a creative solution” to keep me at the firm.  I made some suggestions over the next few months.  No replies were forthcoming.  I was quietly being swept out the door.  It wasn’t hard to get the message. I found another job and moved on.

The whole experience seemed to confirm everything I feared about being a lawyer with depression.  Currently, I am not practicing, and am seeking other opportunities.

But if the story ends there, what is the point?  Can I offer my account as a teaching opportunity?  At the very heart of the tale lies the sad truth that we, as lawyers, trained to be superlative communicators, can utterly fail to make each other understood when it comes to depression.  Should I have been more candid about my condition?  My employers never told me what concerns they had or what they knew.  Could all of us have been proactive for our mutual benefit, especially after I returned to work?  I believe that there had been an opportunity to open a constructive dialogue, but my fear told me to keep my mouth shut.  I cannot speak for my former employers, although I highly doubt that they held any malice.  I doubt that they thought much about it at all until some critical pressure was brought to bear, whether from within or outside of the firm.  Unfortunately, by the time everyone was talking, my job at a firm I loved was gone.

I miss working there.  I still have close friends there.  I see them when I can, which is not often enough.  Just recently, I ran into my secretary, and we briefly chatted about my plans for the future.  And then she said something that cut me to the quick: “You were a good lawyer.”

— Anonymous guest blog

The Neuroscience of Depression: An Interview with Dr. Alex Korb

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The following is an edited transcript of the podcast recorded interview with Dr. Alex Korb.  This transcript has not been reviewed and is not a word-by-word rendering of the entire interview.

Hi, I’m Dan Lukasik from lawyerswithdepression.com. Today’s guest is Dr. Alex Korb.  Dr. Korb is a neuroscientist, writer, and coach.  He’s studied the brain for over fifteen years, attending Brown University as an undergraduate and earning his Ph.D. in neuroscience from UCLA. He has over a dozen peer-reviewed journal articles on depression and is also the author of the book, The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time. Interesting, he’s also coached the UCLA Women’s Ultimate Freesbie team for twelve seasons and is a three-time winner for Ultimate Coach of the Year.  His expertise extends into leadership and motivation, stress and anxiety, mindfulness, physical fitness, and even standup comedy. Welcome to the show.

Dr. Korb:

Thank you, great to be here.

Dan:

Let’s begin for our audience.  You’re a neuroscientist. What is neuroscience?

Dr. Korb:

Neuroscience is simply the study of the brain and nervous system. It’s a branch of biology, but it also incorporates aspects of psychology, psychiatry, and neurobiology.  It’s anything that’s going on in the brain and nervous system all under the purview of neuroscience.

Dan:

You’ve studied depression as a neuroscientist?

Dr. Korb:

Yes, that’s what I wrote my dissertation on. The aspect of neuroscience that I’m most interested in is what underlies the neural basis for our moods and emotions, behaviors, and psychiatric illnesses. Some peer-reviewed articles look at schizophrenia as well as other psychiatric disorders like depression which have a lot of basis in neuroscience and we just don’t fully understand what is happening in the brain.

Dan:

Based on your research, can you tell us what’s going on in the brain when someone is suffering from depression?

Dr. Korb:

The best way to describe it is a dysfunction in frontal-limbic communication. To simplify it, there’s a problem with the way the thinking, feeling, and action circuits in the brain are communicating with each other.  Those all have different regions of the brain that are more dedicated to each aspect of thoughts, feelings, and actions. But, normally, there’s a dynamic of how these regions are supposed to communicate with each other, and there’s something with depression that’s a little bit off.

Dan:

Can the same be said for anxiety as far as what’s going on in the brain?

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Dr. Korb:

Yes, anxiety and depression have a lot of overlap regarding the neuroscience and neurobiology behind them.  A lot of the same brain regions are involved. For example, the amygdala, which is often called the fear center of the brain, but is involved in a lot of emotional expressions, that’s one of the core emotion regions in the brain, and it plays a role in both depression and anxiety.  And there’s just a lot of overlap in brain regions, and neurochemistry that underlies these disorders and it’s one of the reasons why anxiety is one of the most common features of depression and they often co-occur together.

Dan:

When I’ve tried to explain what I was suffering from, and my symptoms and I called it “depression,” most people didn’t have any frame of reference for that. They usually thought of it as “sadness.” With respect to sadness and depression, are there different areas of the brain that pertain to sadness that are different from clinical depression?

Dr. Korb:

There’s a lot of overlap between sadness and depression, but a lot of the misunderstanding that people have is that we use the term depression and sadness, “I’m feeling depressed” or, “I’m feeling sad,” we use those colloquially, very interchangeably.

But medically, or neuroscientifically, they’re very different.

Depression and the diagnosis of depression are a lot more than simple sadness.  In fact, a lot of people who suffer from depression don’t feel sad per se. They can often feel an emptiness where emotion should be.  They have a lot of other symptoms such as hopelessness and feelings of helplessness, guilt and shame, isolation, and anxiety can be a part of it.

They can have fatigue, problems falling asleep or staying asleep or even sleeping too much and, generally, the things that they used to find enjoyable they no longer find enjoyable. Everything just feels very difficult.

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It’s hard to explain to someone why it’s difficult because it seems like it shouldn’t be. It’s a much deeper feeling of being stuck than most people experience.  I think the average person if you can think of how you felt after the week of your greatest heartbreak, that sort of touches the edge of what it means to be depressed. It’s not the depth of how badly you feel, but that you can’t escape it. For example, I like to think of depression as a traffic jam.  When you enter a traffic jam, sometimes there’s an accident. The cars are stopped, and you sit there and wait.  And you don’t know how long the traffic jam is going to be. But for most people, it was just a little stoppage on their way. But for people with depression, it’s something that their brain just can’t quite escape. They can try and try, but their brain is stuck in the pattern of activity that just drags along, and the traffic jam just continues.

Dan:

That’s a great explanation of the experience of depression. Both what’s going on in the brain and psychologically. I think people want to know what are some of the causes of depression? Many people once they’ve often been diagnosed try to figure out for themselves, and people who care about them try to figure out?

Dr. Korb:

Depression can have a huge number of different causes. This is where the traffic jam analogy does a lot to help us understand depression. If you see a traffic jam, you can say, “Oh, what caused it?” Well, a traffic jam can come from any number of causes. There’s construction on the freeway, or there was an accident, there was heavy rain or fog, or it could just be that everyone decided to leave work at the same time, and there’s no specific “cause,” it’s just that the interaction – the dynamic interaction – of all those cars just reaches a tipping point.

With depression, it’s the same way. Often, it can be precipitated by a big life event such as a divorce, or breakup, or death in the family. Or smaller life events such as a perceived emotional embarrassment or you didn’t get that promotion.  But, often it’s not “caused” by anything.  It’s just the dynamic interaction of your brain circuits with each other, combined with the sum of your current life circumstances, which causes the brain to get stuck in a certain pattern of activity and reactivity.

That’s much more likely to happen for some people than others because some people’s brains are just more at risk for falling into that pattern. This can be based on the genes you got from your parents, and your early childhood experiences and the coping patterns you’ve been doing your whole life shaped the neurocircuitry and neurochemistry of your particular brain.  So, it’s not always a specifically, identifiable cause.  I think that’s one of the reasons why people, sometimes, don’t quite believe that it’s real or don’t think they should be suffering it. But, it’s very similar to that traffic analogy where it just “sort of happened” for seemingly no reason. It’s just caused by the fact that is vague, nonlinear, dynamic system.

Dan:

Why did you write the book, The Upward Spiral? There are plenty of scientists out there who study depression, but not many of them write a book for the general public on the topic.  What is it that led you to write this kind of book?

Dr. Korb:

I just realized that there was so much useful neuroscience out there that wasn’t being effectively delivered to the people who needed it most. One of the things that made me realize that is from when I was coaching Ultimate Freesbie. After a few months, one of the girls on the team revealed to me that she had been suffering from major depression and that she’d been suffering for years, and, tragically, many months later she ended up committing suicide. It was a devastating event in my life. This was back when I was still studying neuroscience, but before I had decided to go to grad school and study depression. That event led me to want to understand exactly what was going on in her brain that could lead her to do something like that. How could the brain get stuck in a disease like this?

That lead me to going to grad school and doing my dissertation on depression to try and understand and share some of these things with other people. As I was doing my dissertation, I realized that, yes, it’s good to advance the science, but there was already so much good science out there that was so beneficial. I didn’t think that anyone was doing a good enough job communicating clearly exactly about what was happening in the brain in depression and about all the little life changes that you can make that have measurable effects on brain activity and brain chemistry.

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Dan:

The second part of your book is devoted to eight specific things you can do to alleviate depression. Quickly, they exercise your brain, set goals and make decisions, give your brain a rest, develop positive habits, biofeedback, develop the ‘gratitude circuit,’ the power of others, and your brain in therapy. We don’t have enough time to focus on all eight, so why don’t we focus in on one or two. What I thought was fascinating is that you give the backdrop for what is going on in the brain when you do these things.  A few things that popped into my mind were gratitude and your brain in therapy. What about gratitude? How can it help depression?

Dr. Korb:

Gratitude can have a lot of powerful effects on the brain. And one of the reasons going back to why I wrote this book, is that there are tons of books out there that will tell you different life changes that you can make that will help with depression, but I’ve found that a lot of them are unsatisfying because they don’t explain, why. Therefore, it’s not as convincing, and it’s very easy for people to dismiss.

So when I talk about gratitude and how practicing gratitude can be so powerful in overcoming depression, a lot of people can resist that idea because it sounds so hokey.  But if I can point to specific neuroscience studies that show that it has measurable effects in changing brain activity and brain chemistry, then you’re much more likely to do it and it gives you a much better understanding of what’s going on. Gratitude has been shown to, if people who keep a gratitude journal, improve the quality of their sleep, and sleep symptoms of depression are one of the causes of depression. The reason why I called my book, The Upward Spiral because depression can sort of be seen as a “downward spiral” where one symptom or one event can lead to seemingly to a whole cascade of events that keep you stuck. So, gratitude can help break the downward spiral that’s coming from sleep problems that are leading to difficulty in concentration, and that’s one place to break the loop.

Dan:

After reading the chapter on gratitude, I picked up a spiral notebook and started a gratitude list. It was more of a lifetime gratitude list. It’s amazing. I came up with eighty things. I was surprised. So often my experience with depression is that we ruminate about negative things. We just don’t take the time, or don’t have the skill to savor and reflect on the good things in our lives.  It seems what you’re saying is that this practice has effects in the brain.

Dr. Korb:

Yes, when you’re in a depressed state it’s much harder to see the positive aspects of your life. But that’s why it’s all the more important to build a habit of looking for those positive things because often the most important feature of gratitude is not finding something to be grateful for. It’s remembering to look in the first place because that activates the prefrontal cortex which is the more thinking part of the brain which helps it to regulate the emotional regions of the brain that are going haywire in depression.

And gratitude increases activity in the key region of the brain called the cingulate cortex that sits at the intersection between the emotional limbic system and the rational prefrontal cortex and helps modulate communication between those. Remembering things in your past that you are happy or grateful for actually increases the production of the neurotransmitter serotonin in that same brain region and serotonin is one of the most common targets for antidepressant medications.  Practicing gratitude is having effects in key brain regions that we know contribute to depression and in the neurotransmitter systems that are contributing to depression.

Dan:

I also found it interesting your chapter on our brains and therapy. What’s interesting is that many people who treat with a therapist find comfort and solace in going to therapy when they are struggling with depression. They walk out, and they often do feel better at times don’t’ always understand why they feel better.  Or, we know, there’s a recent study from National Institute of Mental Health, which concluded that as many as eighty percent of people in this country get no treatment for depression whether it be antidepressants or therapy.  So, why is it important, if at all, for people to go to therapy who struggle with depression?

Dr. Korb:

The chapter that I wrote on therapy encompasses not just psychotherapy – going to talk to someone – but it also includes medical therapy such as antidepressant medication or other forms of therapy like neuromodulation techniques. These have been demonstrated through rigorous, double-blind studies that show they have powerful effects on treating depression.  Going to see a professional if you think you are depressed is a hugely important step because they can put at your disposal all the advances of western medicine.

What’s interesting – and it’s the last chapter in the book – and it’s funny how many comments I get because they say, “You left antidepressants to the end because it’s not that important and there are other life changes people can do.” Another psychiatrist will say to me, “Why are you so dismissive of antidepressant medication? They are hugely important in the treatment of depression.”  It’s neither of those. I agree that antidepressants and psychotherapy are extremely important in the treatment of depression, and if you think you are suffering from depression, you should go to see a health professional whether it’s just your doctor or you go to see a psychotherapist.

I just don’t think antidepressants are the entire answer.

For some people, I would say about one-third of people suffering from depression; antidepressants are the answer. You can get over your depression completely simply be taking a pill. You don’t know if you might be one of those people. So, you might as well see a doctor and find out.

For the other half or two-thirds of people, antidepressant medication can still be a huge part of the answer, even if it’s not the entire answer. Taking antidepressants can also help you make these other small life changes such as increasing exercise, or changing your sleep habits, or practicing gratitude.  As you make the other small life changes, then things can start to spiral upward.

Dan:

It’s been an informative and very interesting interview with you Dr. Korb.  I want to thank you for being on the show and I highly recommend listeners to pick up and read his book, The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time.  Join us next week for another interesting interview at Lawyerswithdepression.com.

I encourage everyone to check out Dr. Korb’s website at alexkorbphd.com.

 

Depression and Suicide: A Catholic Perspective

As a psychiatrist, I had been aware, prior to his death, that Robin Williams struggled with a severe mood disorder – major depression and bipolar disorder, depending on the source of the reporting – along with related problems and drug dependence.

The vast majority of suicides are associated with some form of clinical depression, which in its more serious forms can be a sort of madness that drives people to despair – leading to a profound and painful sense of hopelessness and even delusional thinking about oneself, the world and the future.

I knew all of this, and yet this death still shocked and surprised me, as it shocked and surprised so many others. Williams seemed to be the consummate humorist, the funny man who would be just so much fun to be around. Unlike some comedians who trade only on irony and cutting humor, Williams appeared to us as a warm, big-hearted, endlessly fun, brilliantly quick, incredibly talented man. Though he was a celebrity, he was the kind of person that people felt like they knew – like the cousin, everyone just adores and hopes will show up at the family reunion.  Williams was the kind of guy that people wanted to be friends with, the kind of person that one wanted to invite to the party.

This is not the typical stereotype of mental illness, which why the typical stereotype must be relinquished: Quite simply, it is false.

Mental illness can afflict anyone, of any temperament and personality. In the wake of his death, the strange truth gradually began to sink in: In spite of outward appearances, Williams’ mind was afflicted by a devastating disorder that proved every bit as deadly as a heart attack or cancer. He suffered in ways that are difficult for most people to imagine.

Why couldn’t Williams see himself as other saw him – as a person of immense gifts and talents, a man who stood at the pinnacle of achievement in the world of comedy and entertainment?

Why couldn’t he see himself as God saw him – as a beloved child, a human soul of immense worth, a person for whom Christ died?

This is the tragedy of depression, which is so often misunderstood by those who have not suffered its effects.

Novelist William Styron – whose memoir Darkness Visible represents one of the best first-person attempts to describe the experience of depression – complains that the very word “depression” is a pale and inadequate term for such a terrible affliction.  It is a pedestrian noun that typically represents a dip in the road or an economic downtown. Styron prefers the older term “melancholia,” which conjures images of a thick, black fog that descends on the mind and saps the body of all vitality.

Indeed, the title of his book – Darkness Visible – comes from John Milton’s description of hell in Paradise Lost. We’re not talking about hitting a rough patch in life or the everyday blues that we all experience from time to time. We are talking about a serious, potentially fatal, disorder of mind and brain.

Fortunately, in most cases, depression is amenable to treatment. Because the illness is complex – involving biological, psychological, social, relational and, in some cases, behavioral and spiritual factors – the treatment likewise can be complex. Medications may have a very important role, but so do psychotherapy, behavioral approaches, social support and spiritual direction.

In some cases, hospitalization may be necessary, especially when an afflicted individual is in the throes of suicidal thinking or when one’s functioning is so impaired from the illness that he or she has difficulty getting out of bed or engaging in daily activities. For the severely depressed, even brushing one’s teeth can seem like an almost impossibly difficult chore.

This level of impairment is often puzzling to outsiders – to the spouse or parent who is trying to help the loved one. Unlike cancer or a broken bone, the illness here is hidden from sight. But the functional impairments can be every bit as severe.

I recall one patient, a married Catholic woman with several children and grandchildren, who had suffered from both life-threatening breast cancer and from severe depression. She once told me that, if given the choice, she would choose cancer over the depression, since the depression caused her far more intense suffering. Though she had been cured of cancer, she tragically died by suicide a few years after she stopped seeing me for treatment.

Depression is neither laziness nor weakness of will, nor a manifestation of a character defect. It needs to be distinguished from spiritual states, such as what St. Ignatius described as spiritual desolation and what St. John of the Cross called the dark night of the soul.

Tragically, even with good efforts aimed at treatment, some cases of depression still lead to suicide – leaving devastated family members who struggle with loss, guilt, and confusion.

The Church teaches that suicide is a sin against love of God, love of oneself and love of neighbor.  On the other hand, the Church recognizes that an individual’s moral culpability for the act of suicide can be diminished by mental illness, as described in the Catechism: “Grave psychological disturbances, anguish or grave fear of hardship, suffering or torture can diminish the responsibility of the one committing suicide.”

The Catechism goes on to say: “We should not despair of the eternal salvation of persons who have taken their lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.”

Robin Williams’ death – like the death of so many others by suicide who have suffered from severe mental illness – issued from an unsound mind afflicted by a devastating disorder. Depression affects not just a person’s moods and emotions; it also constricts a person’s thinking – often to the point where the person feels entirely trapped and cannot see any way out of his mental suffering. Depression can destroy a person’s capacity to reason clearly; it can severely impair his sound judgment, such that a person suffering in this way is liable to do things, which, when not depressed, he would never consider. Our Lord’s ministry was a ministry of healing, in imitation of Christ, we are called to be healers as well. Those who suffer from mental-health problems should not bear this cross alone. As Christians, we need to encounter them, to understand them and to bear their burdens with them.

We should begin with the premise that science and religion, reason and faith are in harmony. Our task is to integrate insights from all these sources – medicine, psychology, the Bible, and theology – in order to understand mental illness and to help others to recover from it. In cases where recovery proves difficult or impossible, we pray for the departed and never abandon those who still struggle.

Aaron Kheriaty, M.D., is associate professor of psychiatry and human behavior at the University of California-Irvine School of Medicine. He is the co-author with Msgr. John Cihak of The Catholic Guide to Depression.

Interview with Dr. John Greden, Director of the U. of Michigan Depression Center

Today’s podcast interview is with Dr. John Greden, Professor of Psychiatry and Clinical Neurosciences in the Department of Psychiatry, Founder and Executive Director of the University of Michigan Depression Center, Founding Chair, National Network of Depression Centers. His research over the past 30 years has focused on studying biomarkers and developing treatment strategies to prevent recurrences of depression and bipolar disorders.

Listen to my interview with him on Itunes or Google Play.

Please note that it takes Apple and Google Play time to upload podcasts interviews. If this interview is not available, check back a little bit later.

How to Prevent Stress From Shrinking Your Brain

 

Have you ever felt so stressed out and overwhelmed that you can’t think straight? We now know that prolonged stress or trauma is associated with decreased volume in areas of the human brain responsible for regulating thoughts and feelings, enhancing self-control, and creating new memories. A new research study, published in today’s issue of Nature Medicine, is a first step in uncovering the genetic mechanism underlying these brain changes.

Depressed People’s Brains are More FragmentedIn this study, conducted by Professor Richard Dumin and colleagues from Yale University, scientists compared the genetic makeup of donated brain tissue from deceased humans with and without major depression. Only the depressed patients’ brain tissues showed activation of a particular genetic transcription factor, or “switch.” While each human cell contains more than 20,000 genes, only a tiny fraction of them are expressed at a given time. Transcription factors, when activated, act like light switches, causing genes to be turned on or off. This transcription factor, known as GATA1, switches off the activity of five genes necessary for forming synaptic connections between brain neurons. Brain neurons or nerve cells contain branches or dendrites that send and receive signals from other cells, leading to interconnected networks of emotion and cognition. The scientists hypothesized that in the depressed patients’ brains, prolonged stress exposure led to a disruption of brain systems involved in thinking and feeling. Depressed brains appeared to have more limited and fragmented information processing abilities. This finding may explain the pattern of repetitive negative thinking that depressed people exhibit. It is as if their brains get stuck in a negative groove of self-criticism and pessimism. They are unable to envision more positive outcomes or more compassionate interpretations of their actions.

Glucocorticoids Damage Brain Neurons 

The stress response involves activation of a brain region known as the amygdala, which sends a signal alerting the organism to the threat. This results in activation of the HPA (hypothalamic-pituitary-adrenal) axis and release of a cascade of hormones, including cortisol, widely regarded as the quintessential “stress hormone.” While short-term cortisol release prepares the organism to sustain “fight or flight” and fend off an attacker, long-term exposure appears to cause brain neurons to shrink and interferes with their ability to send and receive information via branches called dendrites. In animal studies, under chronically stressful conditions, glucocorticoids such as cortisol can remain elevated for long periods.

Traumatic Experiences Can Shrink the Hippocampus in Those Who Don’t Recover

This finding is another piece of the puzzle regarding how stress and prolonged distress may impair our ability to think in creative and flexible ways. Research in both mice and humans has demonstrated an association between stress exposure (foot shock in mice, life events in humans) and shrinking of the hippocampus – the brain center responsible for forming new, time-sequenced memories. Studies in women with PTSD resulting from childhood sexual abuse and Vietnam veterans with PTSD have shown 12-26 percent decreases in hippocampal volume, relative to those without PTSD. In another study, patients recovered from long-term major depression showed a 15 percent decrease in volume of the hippocampus, compared to non-depressed patients.

Major Life Stress Damages the Prefrontal Cortex

In addition to hippocampal shrinkage, major life stress may shrink brain neurons in the Prefrontal Cortex (PFC), the brain area responsible for problem-solving, adaptation to challenge, emotional processing and regulation, impulse control, and regulation of glucose and insulin metabolism. In a study of 100 healthy participants conducted by Dr. Rajita Sinha and colleagues at Yale University, and published in the journal Biological Psychiatry, those with more adverse life events had greater shrinkage of gray matter in the PFC, compared to their less-stressed peers. Recent major life events, such as a job loss, make people less emotionally aware while life traumas, such as sexual abuse, seem to go further, in damaging mood centers that regulate pleasure and reward, increasing vulnerability to addiction and decreasing the brain’s ability to bounce back.

Summary 

While the evidence is not yet conclusive, these studies suggest that prolonged exposure to stress can shrink the brain, both via the damaging effects of cortisol on brain neurons and by disrupting expression of genes that facilitate neuronal connections. This raises the question of whether there is anything we can do to prevent such damage. Since we can’t always control how much we are exposed to financial, relationship, or illness stress, are there preventive activities we can do to maintain cognitive resilience so we can continue to deal effectively with the stressors? It is not known if we can reverse the damage by these methods, but we may lessen it and make our brains more resilient to stress.

Brain-Enhancing Activities to Combat Stress

While the below list is not exhaustive, the three activities below have enhanced brain functioning in controlled studies.

Take a Daily DHA Supplement – DHA or Docosahexaenoic acid is an Omega-3 fatty acid that is a central building block of brain tissue. DHA is thought to combat the inflammatory effects of cortisol and the plaque buildup associated with vulnerability to Alzheimer’s disease. According to Dr. Mehmet Oz, in one study, a dose of 600mg of DHA taken daily for 6 months led the brain to perform as if it were three years younger.

Exercise Most Days – In studies with mice exercise led to a more improved performance on cognitive tasks than exposure to enriched environments with lots of activities and stimulation. Exercise leads to increases in BDNF or brain-derived neurotropic factor, a substance that strengthens brain cells and neuronal connections. BDNF is also thought to promote neurogenesis or the creation of new brain cells from existing stem cells in the hippocampus. Although these effects can’t be studied in living human brains, researchers have found increases in BDNF in the bloodstream of humans following workouts.

Do Yoga, Meditate, or Pray – These activities can activate what scientist Herb Benson at Massachusetts General Hospital calls “the relaxation response,” which lowers blood pressure and heart rate and lowers subjective anxiety. Benson and scientists from a genetics institute showed, in a recent study, that inducing the relaxation response can beneficially alter the expression of genes involved in inflammation, programmed cell death and how the body handles free radicals. The effects shown were in the same genes implicated in PTSD and depression. According to Jeffery Dusek, Ph.D., co-lead author of the study, “Changes in the activation of these same genes have previously been seen in conditions such as post-traumatic stress disorder; but the relaxation-response-associated changes were the opposite of stress-associated changes and were much more pronounced in the long-term practitioners.”

About the Author

Melanie Greenberg, Ph.D. is a licensed Clinical Psychologist and expert on Mindfulness and Positive Psychology.  Dr. Greenberg provides workshops and speaking engagements for organizations,  life, weight loss, or career coaching, and psychotherapy for individuals and couples. Visit her website: http://www.drmelaniegreenberg.biz

This article originally appeared in Psychology Today.

 

Why So Many Lawyers Suffer From So Much Depression

As to being happy, I fear that happiness isn’t in my line. Perhaps the happy days that Roosevelt promises will come to me along with others, but I fear that all trouble is in the disposition that was given to me at birth, and so far as I know, there is no necromancy in an act of Congress that can work a resolution there.” – Benjamin N. Cardozo, February 15, 1933

Law is a prestigious and remunerative profession, and law school classrooms are full of fresh candidates. In a recent poll, however, 52% of practicing lawyers describe themselves as dissatisfied. Certainly, the problem is not financial. Associates at top firms could earn up to $200,000 per year just starting out, and lawyers long ago surpassed doctors as the highest-paid professionals. In addition to being disenchanted, lawyers are in remarkably poor mental health. They are at much greater risk than the general population for depression. Researchers at John Hopkins University found statistically significant elevations of major depressive disorder in only 3 of 104 occupations surveyed. When adjusted for sociodemographics, lawyers topped the list, suffering from depression at a rate of 3.6 times higher than employed persons generally. ( A more recent study from 2016 found that lawyer suffered from depression at a rate nearly three times that of the general public). Lawyers also suffer from alcoholism and illegal drug use at rates far higher than nonlawyers. The divorce rate among lawyers, especially women, also appears to be higher than the divorce rate among other professionals. Thus, by any measure, lawyers embody the paradox of money losing its hold. They are the best-paid professionals, and yet they are disproportionately unhappy and unhealthy. And lawyers know it; many are retiring early or leaving the profession altogether.

Positive Psychology sees three principal causes of the demoralization among lawyers.

Pessimism

pessimism

First is pessimism, defined not in the colloquial sense (seeing the glass as half empty) but rather as the pessimistic explanatory style. These pessimists tend to attribute the causes of negative events as stable and global factors (“It’s going to last forever, and it’s going to undermine everything.”). The pessimist views bad events as pervasive, permanent, and uncontrollable, while the optimist sees them as local, temporary and changeable. Pessimism is maladaptive in most endeavors: Pessimistic life insurance agents sell less and drop out sooner than optimistic agents. Pessimistic undergraduates get lower grades, relative to their SAT scores and past academic record, than optimistic students. Pessimistic swimmers have more substandard times and bounce back from poor efforts worse than do optimistic swimmers. Pessimistic pitchers and hitters do worse in close games than optimistic pitchers and hitters. Pessimistic NBA teams lose to the point spread more often than optimistic teams.

Thus, pessimists are losers on many fronts. But there is one glaring exception: Pessimists do better at law. We tested the entire entering class of the Virginia Law School in 1990 with a variant of the optimism-pessimism test. These students were then followed throughout the three years of law school. In sharp contrast with the results of prior studies in other realms of life, the pessimistic law students on average fared better than their optimistic peers. Specifically, the pessimist outperformed more optimistic students on the traditional measures of achievement, such as grade point averages and law journal success.

Pessimism is seen as a plus among lawyers because seeing troubles as pervasive and permanent is a component of what the law profession deems prudence. A prudent perspective enables a good lawyer to see every conceivable snare and catastrophe that might occur in any transaction. The ability to anticipate the whole range of problems and betrayals that non-lawyers are blind to is highly adaptive for the practicing lawyer who can, by so doing, help his clients defend against these far-fetched eventualities. If you don’t have this prudence to begin with, law school will seek to teach it to you. Unfortunately, though, a trait that makes you good at your profession does not always make you a happy human being.

Sandra is a well-known East Coast psychotherapist who is, I think, a white witch. She has one skill that I have never seen in any other diagnostician: She can predict schizophrenia in preschoolers. Schizophrenia is a disorder that does not become manifest until after puberty, but since it is partly genetic, families who have experienced schizophrenia are very concerned about which of their children will come down with it. It would be enormously useful to know which children are particularly vulnerable because all manner of protective, social and cognitive skills might be tried to immunize the vulnerable child. Families from all over the eastern United States send Sandra their 4-year-olds; she spends an hour with each of them and makes an assessment of the child’s future likelihood of schizophrenia, an assessment that is widely thought of as uncannily accurate.

This skill of seeing the underside of innocent behavior is super for Sandra’s work, but not for the rest of her life. Going out to dinner with her is an ordeal. The only thing she can usually see is the underside of the meal – people chewing. Whatever witchy skill enables Sandra to see so acutely the underside of the innocent-looking behavior of a 4-year-old does not get turned off during dinner, and it prevents her from thoroughly enjoying normal adults in normal society. Lawyers, likewise, can not easily turn off their character trait of prudence (or pessimism) when they leave the office. Lawyers who can see clearly how badly things might turn out for their clients can also see clearly how badly things might turn out for themselves. Pessimistic lawyers are more likely to believe they will not make partner, that their profession is a racket, that their spouse is unfaithful, or that the economy is headed for disaster much more readily than will optimistic persons. In this manner, pessimism that is adaptive in the profession brings in its wake a very high risk of depression in personal life. The challenge, often unmet, is to remain prudent and yet contain this tendency outside the practice of law.

Low Decision Latitude

stressed

A second psychological factor that demoralizes lawyers, particularly junior ones, is low decision latitude in high-stress situations. Decision latitude refers to the number of choices one has – or, as it turns out, the choices one believes one has – on the job. An important study of the relationship of job conditions with depression and coronary disease measures both job demands and decision latitude. There is one combination particularly inimical to health and moral: high job demands coupled with low decision latitude. Individuals with these jobs have much more coronary disease and depression than individuals in other three quadrants.

Nurses and secretaries are the usual occupations consigned to that unhealthy category, but in recent years, junior associates in major firms can be added to the list. These young lawyers often fall into this cusp of high pressure accompanied by low choice. Along with the shared load of law practice (“this firm is founded on broken marriages”), associates often have little voice about their work, only limited contact with their superiors, and virtually no client contact. Instead, for at least their first few years of practice, many remain isolated in a library, researching and drafting memos on topics of the partners’ choosing.

A Win-loss Game

winloss

The deepest of all the psychological factors making lawyers unhappy is that American law is becoming increasingly a win-loss game. Barry Schwartz distinguishes practices that have their own internal “goods” as a goal from free-market enterprises focused on profits. Amateur athletics, for instance, is a practice that has virtuosity as its good. Teaching is a practice that has learning as its good. Medicine is a practice that has healing as its good. Friendship is a practice that has intimacy as its good. When these practices brush up against the free market, their internal goods become subordinated to the bottom line. Night baseball sells more tickets, even though you cannot really see the ball at night. Teaching gives way to the academic star system, medicine to managed care, and friendship to what-have-you-done-for-me-lately. American law has similarly migrated from being a practice in which good counsel about justice and fairness was the primary good to being a big business in which billable hours, take-no-prisoners victories, and the bottom line are now the principle ends.

Practices and their internal goods are almost always win-win-games: both teacher and student grow together, and successful healing benefits everyone. Bottom-line businesses are often, but not always, closer to win-loss games: managed care cuts mental health benefits to save dollars; star academics get giant raises from a fixed pool, keeping junior teachers at below-cost-of-living raises; and multi-billion dollar lawsuits for silicon implants put Dow-Corning out of business. There is an emotional cost to being part of a win-loss endeavor. In Chapter 3 of my book, I argue that positive emotions are the fuel of win-win (positive-sum) games, while negative emotions like anger, anxiety, and sadness have evolved to switch in during win-loss games. To the extent that the job of lawyering now consists of more win-loss games, there is more negative emotion in the daily life of lawyers.

Win-loss games cannot simply be wished away in the legal profession, however, for the sake of more pleasant emotional life among its practitioners. The adversarial process lies at the heart of the American system of law because it is thought to be the royal road to truth, but it does embody a classic win-loss game: one side’s win equals exactly the other side’s loss. Competition is at its zenith. Lawyers are trained to be aggressive, judgmental, intellectual, analytical and emotionally detached. This produces predictable emotional consequences for the legal practitioner: he or she will be depressed, anxious and angry a lot of the time.

Countering Lawyer and Unhappiness

new-lawyers

As Positive Psychology diagnoses the problem of demoralization among lawyers, three factors emerge.Pessimism, low decision latitude, and being part of a giant win-loss enterprise. The first two each have an antidote. I discussed part of the antidote for depression in Chapter 6, in my book

Pessimism, low decision latitude, and being part of a giant win-loss enterprise. The first two each have an antidote. Chapter 6 of my book details a program for lastingly and effectively countering catastrophic thoughts. More important for lawyers is the pervasive dimension-generalizing pessimism beyond the law – and there are exercises in Chapter 12 of my book, Learned Optimism that can help lawyers who see the worst in every setting to be more discriminating in the other corners of their lives. The key move is credible disputation: treating the catastrophic thoughts (“I’ll never make partner,” “My husband is probably unfaithful”) as if they were uttered by an external person whose mission is to make your life miserable, and then marshaling evidence against the thoughts. These techniques can teach lawyers to use optimism in their personal lives, yet maintain the adaptable pessimism in their professional lives. It is well documented that flexible optimism can be taught in a group setting, such as a law firm or class. If firms and schools are willing to experiment, I believe the positive effects on the performance and moral of the young lawyers will be significant.

As to the high pressure-low decision latitude problem, there is a remedy as well. I recognize that grueling pressure is an inescapable aspect of law practice. Working under expanded decision latitude, however, will make young lawyers both more satisfied and more productive. One way to do this is to tailor the lawyer’s day so there is considerably more personal control over work. Volvo solved a similar problem on the assembly lines in the 1960’s by giving its workers the choice of building a whole car in a group, rather than repeatedly building the same part. Similarly, a junior associate can be given a better sense of the whole picture, introduced to clients, mentored by partners, and involved in transactional discussions. Many law firms have begun this process as they confront the unprecedented resignations of young associates.

The zero-sum nature of law has no easy antidote. For better or for worse, the adversarial process, confrontation, maximizing billable hours, and the “ethic” of getting as much as you possibly can for your clients are much too deeply entrenched. More pro bono activity, more mediation, more out-of-court settlements, and “therapeutic jurisprudence” are all in the spirit of countering the zero-sum mentality, but I expect these recommendations are not cures, but Band-Aids. I believe the idea of signature strengths, however, may allow law to have its cake and eat it too – both to retain the virtues of the adversarial system and to create happier lawyers.

When a young lawyer enters a firm, he or she comes equipped not only with the trait of prudence in lawyerly talents like high verbal intelligence, but with an additional set of unused signature strengths (for example, leadership, originality, fairness, enthusiasm, perseverance, or social intelligence). As lawyers’ jobs are crafted now, these strengths do not get much play. Even when situations do call for them, since the strengths are unmeasured, handling these situations does not necessarily fall to those who have the applicable strengths.

Every law firm should discover what the particular signature strengths of their associates are. Exploiting these strengths will make the difference between a demoralized colleague and an energized, productive one. Reserve five hours of the work week for “signature strength time,” a non-routine assignment that uses individual strengths in the service of the firm’s goals.

There is nothing particular to the field of law in the re-crafting of jobs. Rather, there are two basic points to keep in mind as you think about these examples and try to apply them to your work setting. The first is that the exercise of signature strengths is almost always a win-win game. When Stacy gathers the complaints and feelings of her peers, they feel increased respect for her. When she presents them to the partners, even if they don’t act, the partners learn more about the morale of their employees – and of course, Stacy herself derives authentic positive emotion from the exercise of her strengths. This leads to the second basic point: There is a clear relation between positive emotion at work, high productivity, low turnover and high loyalty. The exercise of a strength releases positive emotion. Most importantly, Stacy and her colleagues will likely stay longer with the firm if their strengths are recognized and used. Even though they spend five hours each week on non-billable activity, they will, in the long run, generate more billable hours.

Law is intended as but one rich illustration of how an institution (such as a law firm) can encourage its employees to re-craft the work they do, and how individuals within any setting can reshape their jobs to make them more gratifying. To know that a job is a win-loss in its ultimate goal – the bottom line of a quarterly report, or a favorable jury verdict – does not mean the job cannot be win-win in its means to obtaining that goal. Competitive sports and war are both eminently win-loss games, but both sides have many win-win options. Business and athletic competitions, or even war itself, can be won by individual heroics or by team building. There are clear benefits of choosing the win-win option by using signature strengths to better advantage. This approach makes work more fun, transforms the job or the career into a calling, increases flow, builds loyalty, and it its decidedly more profitable. Moreover, by filling work with gratification, it is a long stride on the road to the good life.

Martin E. P. Seligman, Ph.D., is the Fox Leadership Professor of Psychology at the University of Pennsylvania, the Director of the Positive Psychology Network, and former President of the American Psychological Association. Among his 20 books are Learned Optimism and The Optimistic Child. Here, from his book Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment, is his chapter entitled “Why Are Lawyers So Unhappy?”

© by Martin Seligman. Reprinted with permission from the author.

Are you a law student or lawyer struggling with depression? Do you need help developing a practical, constructive game plan to help you cope and recover from depression?  If so, I can help.  I created my life coaching practice specifically devoted to helping law students and lawyers who struggle with this condition. Visit my website at www.yourdepression.com to learn more.Share this:

The Blues Is Depression. Should You Treat It With Pills?

What people refer to as the blues is usually depression.  Depression, or the blues, is an unpleasant emotional state characterized by what therapists refer to as “the negative cognitive triad.”  That’s 1) negative thoughts about oneself, which are the voices of your inner critic harping on you for what you supposedly have done wrong, should have done differently, and on and on 2) negative thoughts about others that lead you to see what you don’t like in them instead of heeding their virtues and enjoying them, creating relationship problems and 3) negative thoughts about the future.

Some people describe the blues, and also depression, as feeling like there’s a dark cloud over you.  Others refer to depression as seeing the world through dark glasses.  Feelings of hopelessness and helplessness are another indicator.

How can you get rid of your blues and your inner critic by treating the underlying depression?

There are four main strategies:

  1. Change your feelings.Take pills or use one of the newer treatment methods that change your bluesy mood by changing your inner body chemistry and brain functioning.
  2. Change your thoughts.  Eliminating the inner critic may get rid of the depressed, bluesy feelings.
  3. Change your actions. Get exercise.  Go out and be with people.  Express more gratitude.  Do acts of kindness.
  4. Identify and address the problem that initially triggered your depressed feelings and thoughts.  Find a new solution and both the negative feelings and the negative thoughts will evaporate.

Why do people take antidepressant medications?

There are four main reasons why people who may be distressed by something in their lives end up defining their depression as an illness and taking medication.

First and foremost, depression is a terrible feeling that sufferers sorely want to get rid of.

Second, most folks have not been fully informed of the medications’ downsides. I’ll elaborate on drug dependency below.  In addition, these medications can cause serious weight gain, a significant drop in libido (ability to enjoy sex), hazy thinking, and a general emotional numbness that blocks feelings of joy in addition to feelings of depression.

Third, people who take the medications may not have been informed of their relatively low rate of effectiveness.  They can be effective if they work, but they only work for something like about 60% of people who use them.

Fourth, most people who take anti-depressant medications have not been informed by their doctor about alternative treatment options.  To a man with a hammer, the world is a nail.  Physicians know about illness and prescribe medications.  As psychologist Martin Seligman has explained, depression is a relatively normal, if quite unpleasant and often self-defeating, response of giving up in response to a challenging life circumstance.

What are the downsides of assuming that depression is an illness and therefore needs pills? 

As mentioned above, two particularly negative side effects of medication that doctors do not sufficiently explain include potential weight gain and decreases inability to experience sexual arousal. Doctors may mention them but often do not clarify that both extra pounds and decreased interest in sex can have strongly negative impacts on personal self-esteem, on attracting a mate and on sustaining a marriage.

The other significant risk that doctors may or not fully explain is that users may have a hard time getting off these medications.  When a drug company says that their anti-depressant medication is not addictive, strictly speaking, they are telling the truth.  A strict clinical definition of an addictive substance or activity is one that induces both dependency and craving.  Antidepressants do not induce craving.  Over time they do, however, make users drug dependent.

Craving is a familiar feeling to anyone who has fallen in love.  The intense sexual desire that drives someone in love to find every way possible to be near the object of their desire is a craving.  Someone who craves alcohol similarly may wake up in the morning already urgently wanting a drink.

What does “drug dependent” mean?   Drug dependency is the state a body goes into when it has adapted to the presence of a chemical to the point that the body requires steady doses of the substance to maintain normal functioning. We are all, for instance, chemically dependent on water.

Our society is highway-dependent.  Many of us have become accustomed to having highways that enable us to drive to work from the suburbs.  Having bought a house in the suburbs on the assumption that we can take the highway to work, we have become highway dependent.  It’s unlikely that anyone has a craving for highways.  Many of us though have become highway dependent.

If you for some time have been taking an antidepressant medication, the odds are that your body has become drug dependent.  That means that if you should decide today that as of tomorrow you will no longer take the medication, starting tomorrow, you are likely to discover that without the pills that you normally take your body will plunge into a serious depressive state.

Does this depression mean that you need after all to stay on your meds because the pills are all that have stood between you and the depths of despair?   Not at all.  To the contrary, this depression means that your body has become dependent on the antidepressant pills.  Is this addiction?  No, but it is drug dependency.

I am not saying that no one should ever take antidepressant medication.  They do help some people.  Some people experience relatively few to zero negative side effects.  My point is just that if you are considering taking these medications, or have for some time been using them, you deserve accurate information about the factors to take into account in your decision, including information about other treatment options.

Here are six vital points to consider.

1) There now are multiple excellent alternatives to medication for working your way out of depression, including various kinds of talk therapies such as CBT, energy therapies such as Bradley Nelson’s Emotion Code and Body Code, acupuncture, exercise, electrical stimulation of the brain, the visualization you can download for free from my website, or read about how to do on one of my other blogposts, couples therapy, and more.

2) Depression is induced by a situation in which you have experienced insufficient power. If you close your eyes and picture whom or what you may feel angry at, you will see an image of the trigger person or situation. Fix that situation, and your depression will be likely to go away.

3) If your doctor is recommending medication as a short-term fix, use the pills until you feel better. Use your renewed energy to address the power-loss situation. Then begin the medication-weaning process asap.

4) Wean slowly. Consult your prescribing doctor for an appropriate weaning schedule for the particular medication that you are taking.

5) Be aware that research has shown that the most powerful way to overcome depression and keep it far from you, in the long run, is the combination of therapy and medication. Medication alone and psychotherapy alone have very similar effectiveness rates, but medication has an impact more quickly, and psychotherapy tends to have more longer-lasting impacts.

6) There is a visualization exercise that you can do with a therapist, a friend, or on your own that may help you conquer the depression in just a few minutes.  See my posting on A New Treatment for Depression.

6) In my clinical experience, I find that most depression is a response to relationship problems. Look into marriage educationcouples counseling, or a combination of both to upgrade your relationship. These treatment routes can make you a double winner.  You can both end the depression and simultaneously gain a vastly more gratifying marriage or romantic partnership.

Susan Heitler, Ph.D., a Denver Clinical psychologist, is an author of multiple publications including From Conflict to Resolution for therapists, The Power of Two and poweroftwomarriage.com for couples who want to strengthen their relationship. Dr. Heitler’s most recent book is Prescriptions Without Pills, with a free companion website at prescriptionswithoutpills.com.

 

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