Depression Leapfrog

What's the REAL destination?

One of the great problems with clinical depression is that it attracts almost all of a person’s attention and energy. The temptation is to focus exclusively on the ailment and its resolution.

As a consequence, many people find that most of their time gets taken up with depression management strategies. Their days involve appointments with physicians and therapists, consulting with other healthcare professionals, taking naps, planning graduated exercises to get out of the house, figuring out what to eat, trying to detect negative thoughts, and so on.

It’s exhausting.

Many of these activities are quite helpful. But they run the risk of making the person’s life all about depression and not at all about recovery or “normality.” All thoughts about “what will I do when I’m better” are put aside until that day dawns.

But the handing of control over one’s daily life to the illness sometimes serves to make it more powerful. And the relinquishment of all one’s regular routines, pleasurable events, and goals for the future may feed the very dragon we are trying to tame.

Consequently, I often invite depressed clients to imagine that we had an instant and utterly effective cure for the depression – a magic pill, or the waving of a wand. “So imagine for a moment that it’s gone. This whole thing is over. If that happened, what would you do? What would you want in your life?”

In other words, if your energy was back to normal and you didn’t have to spend every ounce of it fighting the depression, where would you like to allocate it?

I try to get as long a list as I can from the person. Some of the items may not be practical right away, such as “I’d return to work full-time.”

We can, however, usually identify a few activities the person could start doing without waiting for the wand to have its effect. “I’d see more movies” can become part of the therapy, as can “Take up my hobby/sport/avocation again” or “See friends more often.”

The intent is to jump past the depression to the desired outcome, and then spend at least part of our efforts aiming straight at the destination rather than focusing exclusively on the barrier that seems to sit in the way.

I like to do this kind of work at least twice in the course of therapy for depression. 

The first time is when we first embark on the journey. “What if, a few weeks or months down the road, the depression is completely gone? We follow you around with a video camera for a week. We can’t see what you are feeling or thinking, but we can see what you are doing. What would we see?” This enables us to make the reclaiming of at least part of this “well life” an early task of therapy.

I like to revisit the question once the person has made some real progress. Their energy is better, and their ability to envision a fulfilling life is likely to be greatly enhanced. “So you’re doing pretty well. Imagine you take this pill (jelly bean) and it’s completely over. You don’t have to focus on the near horizon of depression recovery any more. What do you want to include in your life?”

Most people imagine that they will recover in sequence: They will begin feeling a bit better. Then their motivation will begin to return. Then they can begin to take on the elements of a better life.

The sequence is perfect, but backward. “First you will begin living at least a bit of the life you would like to have if you were not depressed. Then your motivation will return. Then the mood will lift.”

We need to leapfrog past the depression to the real destination. Then we need to make that destination at least a part of the therapy - in addition to the symptomatic and stabilization work we may be doing.

What if you wanted to be UNhappy? The $10Million Question

What if you could earn money by feeling worse?

Sometimes when you are trying to find your way, it’s useful to look at where you DON’T want to go and use that as your guide.

Throughout our lives, much of our behaviour is designed with the ultimate goal of creating a positive emotional state. In effect, I want the better job, the cream cheese bagel, the Hawaiian holiday, and even a sense of meaning and purpose BECAUSE I believe that if I get those things I will be happy. Or content. Or joyful. Or at least not depressed.

We spend our lives oriented in this one direction, and often seem to miss the target: we don't feel all that happy. Daniel Gilbert has written an excellent book, Stumbling on Happiness, showing that human beings are fairly poor at guessing what will make them happy in the future. As a result, a good part of our lives is spent pursuing goals that will not give us what we imagine.

In our depression groups, people would often try to figure out what might help them feel better, and they felt blocked or stumped in this quest. So we turned the question around and asked what they might do if they wanted to feel worse instead. Suddenly the barriers evaporated and people came up with all kinds of ideas. Listen to country music, call up a critical relative, sit naked in front of a mirror – the main challenge was stopping the exercise once it got rolling.

The secret, of course, is that most roads downward run both ways. Behind each technique for producing misery lies an alternative that may lead to an alleviation of misery, or even to a positive emotional state. As well, once we come up with a list of strategies to make ourselves unhappy we can sometimes realize with a shock that we are already doing many of these things – as though we really did want to feel worse, not better.

I find that this is almost always a helpful exercise for people’s personal growth or therapy. What would you do if your agenda was to feel unhappy, stuck, bored, depressed, burned out, or otherwise dissatisfied with your life? What has led you in that direction in the past? What strategies, yet untried, do you think would lead you there if you put them into practice?

The exercise looks like it’s headed the wrong way. But I believe we have greater clarity when we look for things that make us feel worse than when we try to imagine what will make us feel better. In effect, by generating the list and using it as guidance to find the opposite, we may produce greater improvement than by chasing unsatisfying rainbows. 

For the purpose of this posting, let’s try a challenge.

Imagine that 10 days from now you could win a large sum of money (in my groups, we make it $10 million - what the heck, it's imaginary) if you could make yourself more unhappy on that day than you are now. I’m giving you 10 days because maybe some of your strategies won’t work right away and require some time to have their undesired effect. 

The fine print: You can only do or change THREE things (maximum) in your mind or life. And you can't list anything that's not in your own power to do (no alien invasions, no global economic meltdowns).

So: I dare you. If you wanted to feel worse, you would …

1. ___________________________________

2. ___________________________________

3. ___________________________________

Reply and suggest your three options. Let’s see what you come up with. If I get enough replies I'll tabulate them and comment in a future post.

The Most Useful Mnemonic Ever

Three is a ... ?

When I attended first year psychology (a course so general in scope that it invariably turns into a kind of academic variety show), the instructor amused us for an hour by discussing mnemonic devices and the theory behind them.

Some mnemonics work by ordering concepts into letter sequences:

• SMART goals are small steps characterized by being Specific, My own, Action-oriented, Realistic, and Time-defined. 
• The cranial nerves are supposedly remembered by “On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops.” (In other words, Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Auditory, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal.) With its letter repetitions this is perhaps the least helpful mnemonic in history (or at least that’s how I considered it while writing a neuropsychology exam).

Other mnemonics rely on the memorability of imagery. Greek orators allegedly remembered their speeches by placing their ideas in sequence in different rooms of an imaginary house. During the talk they would walk through the house and be reminded of what to say next.

But way back there in that first psychology course I learned one of the most basic and widely-known mnemonics – and it has proven itself to be invaluable to me ever since. It’s a visual mnemonic used for remembering lists of unrelated ideas or items. To begin, you have to memorize a rhyming sequence:

• One is a bun
• Two is a shoe
• Three is a tree
• Four is a door
• Five is a hive
• Six is a bundle of sticks
• Seven is heaven
• Eight is a gate
• Nine is a mine
• Ten is a hen

You can add more numbers, but I find that 10 usually suffices. If I have more items to recall it’s generally time to start a paper list.

To remember your list of items, you create an image that combines the item with the visual element associated with each number. If you need to buy eggs at the store, you might imagine a bun with egg in the middle.

When it's time to remember your list, call up the numbers one at a time, recall the element associated with that number (eg, a hive), and retrieve the item from the image you created. The last image you created for that element will usually be quite accessible to memory. "A bun - ahh, an egg muffin. I need eggs."

I use this mnemonic whenever:

• I catch myself thinking of things I should remember at a later time, 
• and I do not have immediate access to pen and paper or don’t want to bother with the list making tool on my phone.

A Sample List

I was using it this morning on my way to work. So here’s my To Do list:

1. Ask the clinic receptionist to mail out a new clinic announcement with brochures. A bun sandwich in which the filling is a stack of brochures.
2. Write a blog post. A computer on my desk, the browser showing a person’s blog about shoes.
3. Take the box with my tax information to the accountant. My accountant’s office, with a Christmas tree in the middle of the reception area.
4. Check the payments from my online diaphragmatic breathing course (https://www.udemy.com/breathing-made-easy/) to ensure none came in during 2012. A door opening to reveal a person breathing diaphragmatically, money in hand.
5. Send slide handout pdfs to the workshop coordinator in New Brunswick. A handout package under a beehive with honey leaking all over it.
6. Edit the next lecture for my online course on group therapy (see last week’s post). A circle of chairs in a group room, each with a large stick on it.
7. Pay payroll taxes at the bank. My bank as the unlikely entrance to heaven, a bearded god-figure as the teller.
8. Book flights for a workshop in Kingston. Me at the airport waiting room, with a literal farmyard-style gate leading to the plane.
9. Go online and renew my Canada-USA Nexus card. A sign pointing to the United States which leads into a dark mine.
10. Sort through the papers which seem to have built up in my computer bag. A hen sitting on a stack of paper.

Quiz Time

Try something. This isn’t your To Do list, so it doesn’t mean much to you. But you can easily remember it anyway. Read the above ten items one more time, forming each image in your mind. Then let the images go. Don’t try to retain them.

Then scroll up to the “One is a bun” list, hiding my To Do list. Feel free to use the rhyming list as a reminder, given that you probably haven’t memorized it yet.

Write the numbers from 1 to 10 on a piece of paper. Beside each number write down the things I have to do today. You’ll probably get most of them without much difficulty.

Now: Imagine not using the mnemonic. If I told you 10 things I had to do today, how many of them do you think you would remember? In this particular instance the order of the items is random. But what if I asked you to remember the 10 items and the number assigned to each one – how well do you think you would do?

If this worked for you with someone else’s To Do list, imagine how well it might work for a list of items that have personal meaning for you.

When could you use this strategy? 

I use it whenever I have a few things I want to recall later. So ...

• Anytime you have a list of items to recall and don’t have paper or electronic device handy (in the shower, driving to work, eating dinner in a restaurant).
• When you have a short list of things to remember and don’t want to keep checking your paper or phone – like when you are doing a quick shopping trip.
• When you have to remember the order of a list (first Home Depot, then Acupuncturist, then Flower Shop, then Postal Outlet, then London Drugs).
• When you have five things to say to someone (like symptoms you want to report to your physician) and you don’t want to be looking at a script (this is a substitute for the Greek orator’s imaginary house).

You’d think that given the usefulness of this strategy I would have taken the time to learn a huge set of mnemonic devices to assist me. But I haven’t. This one is good enough for most purposes.  Try it yourself.

The Project Resistance Curve

Lately I’ve been working on a major project for the clinic, and I’ve reached a very familiar point. I don’t want to do it.

I’m bored. My mind is coming up with every possible excuse to avoid working on it.

Fortunately, I’ve been through this enough times that I recognize it. I know most of the tricks my mind will play on me to try to get me distracted.

• “Hey, remember that other project you thought of last year? That would be more fun, wouldn’t it?”
• “This thing isn’t going to work out anyway. No one will want it, so all this effort will be wasted.”
• “There are more important things for you to do. Like wash the car. Or clean out your desk drawers. Or rearrange your filing system.”

Anything to get me away from the task.

It has occurred to me that I can’t be the only one this happens to. In fact, I know it isn’t: clients report a similar phenomenon all the time. And in graduate school whenever you went to someone’s home and noticed it was clean, they would nod self-consciously. “I know. Thesis avoidance.”

But by this point in my life it has happened so many times that the rises and falls in enthusiasm have begun to show a pattern. Maybe other people experience the same pattern. Or maybe different people experience different patterns, each as individual as a fingerprint. Probably not: the pattern isn’t complex enough to be so unique.

Attraction (+) or Repulsion (-) to a Project by %age Completion

So here’s mine. I’ve graphed the subjective experience over the percentage of the project that’s been completed. Points above the centre line indicate attraction to the project – wanting to work on it, and feeling tempted to put everything else aside to devote attention to it. Points below the line indicate repulsion, and the further below the line the greater the aversion.

Initially when the project occurs to me it seems extremely interesting – possibly because it holds the promise of distracting me from some other project I’m already stuck doing. If I manage to hold off until I complete whatever I was supposed to do before it, the enthusiasm can be quite high. “This is great! I’ve discovered my true calling.”

Often there is a feeling of inspiration – a sense that I can see the entire completed project, in detail; all I have to do is follow the instructions, or write it all down. Others report this feeling for their own projects as well, it’s not just me. (And no, you closet diagnosticians, this does not describe a hypomanic episode.)

As the project progresses, the illusion of inspiration (and it is always an illusion) fades.  Unexpected complications appear. The beautiful structure that seemed so flawless is, it turns out, flawed. Things need to be reworked. Details need to be filled in. And the sheer quantity of drudge work the project will entail becomes obvious.

The initial burst of interest fades, and the project becomes a vaguely interesting sideline. There’s still an attraction to it, but it is gently subsiding, and the hope is that I can complete the project before it vanishes altogether.

This invariably turns out to be impossible. The level of interest crosses the neutral line and becomes an aversion. This is where the brain begins to come up with roadblocks, excuses, and diversionary tactics.  The feeling of aversion intensifies, in part because the end is so far off that it might as well not exist. The project begins to seem like Sisyphus’ job of rolling the rock endlessly and pointlessly to the top of a hill for eternity.

Eventually the end of the project begins to inch closer. Suspense develops. Is it possible to get to the end before the aversion becomes irresistible and the project is put away unfinished?

If I keep slogging, there is a quite sharp shift in motivation as the end comes into clear view. This usually happens when the project is about 90% complete. Suddenly it seems easier to get to work. Things begin flowing again. The aversion disappears and interest rises, often matching or exceeding the initial enthusiasm. There is a flurry of work.

Unfortunately, this doesn’t quite last until the last “t” is crossed. At this point there is a sense that “I’m basically done; I can relax and celebrate a bit.” Giving in to this thought can prolong the project in a way that seems silly to anyone who has been following the progress. “What are you doing? Go to the damned mailbox and send it to the publisher (or whatever)!”

Why bother posting such a narcissistic bit of navel-gazing? In part, because clients often describe a very similar pattern. Creative types notice the evaporation of interest, and they despair that they will never finish anything. Students put their theses on hold and wait for interest to return. It has been helpful to discuss my pattern with them and see if they notice their own characteristic project resistance curve over time.

As well, different points on the curve sometimes seem to get mistaken for mood disorders.  More than one young adult that I’ve seen has been precipitously diagnosed with bipolar II disorder on the basis of their initial enthusiasm for a project. Others have had depressive episodes queried during their lulls.

So what are people’s experiences? When you have a big project, what’s your curve like?

Metaphors: Six Guys Walk Into a ...

How do we learn new ideas?

One of the most powerful methods is to relate the new concept to an existing idea that we already understand.

Imagine living in pioneer times and wanting to connect Vancouver and Edmonton, after a road has been built to Calgary.

One option would be to strike out further north and build a completely new road directly to Edmonton. But this would be hugely expensive – so expensive that it might never get done. The alternative would be to use the existing road to Calgary, and then build a spur highway from Calgary to Edmonton. Most of the road already exists already, so this option would be vastly easier.

The brain is essentially a road map of connections from one node to another. If we want to learn an entirely new concept – let’s say “the face of Sarah Palin” – we could try to create an all-new series of connections to build the ideas of “Sarah Palin’s nose,” “Sarah Palin’s glasses,” “Sarah Palin’s eyes” and so on. Or we could use information we already have – perhaps “Tina Fey’s face” – and then build little spurs away from that concept to fit Palin “except different glasses,” “except bigger hair,” “except less sense of irony” and so on.

By doing this we treat Tina Fey as a metaphor for Sarah Palin. At a neural level, this is probably exactly what is happening. We will use many of the same connections for both faces, for the sake of efficiency. So metaphors may be more than just a literary trick you learned in English class: they are an external manifestation of the structure of the brain.

Or not. Regardless, metaphor is a great way to get an idea across quickly.

In a recent discussion on an online forum in which I participate, someone suggested that we all share the metaphors we often use in therapy. Good idea. And it may become a recurrent “bit” I use in this blog. We’ll see.

Here’s one of mine. It's a two-parter and comes across like a joke, and leaves it up to the listener to contemplate how to connect the dots, but it often sparks useful discussion in therapy. It can be translated for “Three Women …” but in practice I’ve mostly found it useful with men.

Three Guys Walk into a Gym

Three guys walk into a gym and decide to use the chin-up machine. This is a device with elevated handles so you can practice chin-ups, but with a platform to stand on that can give a variable boost.

The first guy doesn’t turn the machine on. He just reaches up, grips the handles, and does 20 chin-ups, his feet leaving the platform.

The second guy tries the same thing, but doesn’t get off the ground. He turns the machine on, sets it to give him 50 pounds of lift, then reaches up and does 20 chin-ups.

The third guy takes over, leaves the machine on 50 pounds, and doesn’t get to the bar. So he turns the machine up to a 100 pound boost and does 20 chin-ups.

So: Which guy is the strongest?

Three Guys Walk into an Interview

Three guys walk into an interview, and are asked what it would take to make them happy with their lives.

The first guy says that before he could feel contented he would need to succeed in business, become the president of his company, live in a mansion, earn a seven-figure salary, have a loving and supportive family, and be admired by thousands. Then he could be happy.

The second guy says that before he could feel contented he would need to have a good job, earn a six-figure income, live in his own house in a nice area, and have a few good friends. Then he could be happy.

The third guy looks a bit confused. He says, “I’m not sure I understand the question. I don’t have any of those things yet, and I guess it’s possible I never will. I’m happy now.”

So: Which guy is the strongest?

PsychologySalon Talks: Out of the Blue, Tuesday March 26

On Tuesday March 26 at 7 pm we kick off our four-talk 2013 series of Psychology Salon presentations for the public.

Our series is at the Vancouver Public Library, Central Branch. It's held in the Alice MacKay Room beneath the concourse.

The first talk in the series is Out of the Blue:  The Nature and Treatment of Major Depression.

Here's the blurb:

Think you don’t know anyone with depression?  You are almost certainly wrong.

Forget bird flu. Clinical depression is the real epidemic in Canadian society. Within 5 years it will be the leading cause of long-term disability claims (several indications suggest that it already is). A recent study indicates that 20% of BC women have been prescribed antidepressants.

But what is depression, exactly?  Is it overdiagnosed?  How is it treated, and are these treatments effective?

At this talk you’ll learn about:

• The signs and symptoms of depression.
• How clinicians distinguish true depression from the everyday blues.
• Overdiagnosis and overtreatment.
• Risk factors for depression.
• The controversy about “biochemical imbalances.”
• Problems with a medication-only approach.
• Evidence-based nonpharmacological strategies.
• Self-directed coping strategies, including free resources available from the web.

We’ll try to cut through the myths about depression and see the reality.

Like all PsychologySalon talks, this presentation is for everyone: those with depression, those treating it, policy makers, business leaders, and the general public. Whether you have clinical depression or not, depression touches your life.

Many thanks to the Vancouver Public Library for cosponsoring the Psychology Salon series in 2013!

Upcoming Talks

All talks start at 7 pm and are held in the Alice MacKay Room of the Main Downtown Branch of the Library (below concourse level).

Tuesday May 28 - Superhero Psychology 101: Understanding the Appeal.  With Dr Lindsey Thomas. Our culture seems obsessed with superheroes - certainly in the movies and popular culture.  What needs are served by these characters in fiction? Is it a longing for lost gods, an externalization of our narcissistic desire for power, a reaction against the drabness of modern life, or just a desire to see special effects on screen?

Tuesday September 24 - The Vision Project: Setting - and Reaching - Your Life Goals.  With Dr Randy Paterson. What do you want, really? What would you be doing if you took your life seriously?
Life is like a sailing trip.  You want to enjoy the ride, but every now and then you have to look at the map and put your hand on the tiller.  This PsychologySalon evening covers the strategy, the concepts, and the traps along the way.

Tuesday November 26 - How to be Miserable: 12 Brilliantly Effective Strategies.  With Dr Randy Paterson. What if we stopped trying to feel happier, and instead tried to feel WORSE? We might discover that we are already experts at this dubious skill. This presentation uncovers widely-held cultural beliefs, values, and habits that promote misery. With tongue only partly in cheek, we'll point out the signposts to despair (which, if disobeyed, might lead to a sunnier destination).

Mark your calendar!  Hope you can make it.

Workshop for Therapists: Facing Fear, Friday March 22

A quick reminder about my upcoming workshop "Facing Fear: Using Exposure and Related Therapies for Anxiety Disorders."

This program is taking place next Friday, March 22 at the Holiday Inn Vancouver Centre. The program runs from 8:30-4:30.

Registration is limited to 40 people, and we have a few slots left.

The program is intended for professional therapists who have an interest in the treatment of anxiety.

For further details, to get the flyer, and to register, visit the Changeways Clinic website presentation calendar here.