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Tuesday 29 January 2013

Managing Depression: The 24 Hour Rule

Just get out the door.

Behavioural activation is difficult.

Depression, like all emotional states, brings with it a set of behavioural impulses to do things that will usually intensify, rather than alleviate, the depression:  Stay home, eat little (or binge on sweet or fatty foods), isolate, be inactive, and so on.

Family members (and some clinicians) often look on in frustration. “You’re doing exactly what I would do if I wanted to feel worse!” It can look like the person deliberately wants to maintain the depression. But they don’t.

If we look deeper it’s easy to see the rationale behind all of these behaviours. I didn’t sleep well, so I wouldn’t be able to concentrate if I went in to work anyway. I have no energy, so exercise seems ridiculous. I can’t string a sentence together, so going out with friends would only be embarrassing.

Plus, I’m used to doing what my instincts tell me, and they tell me to do exactly what I’m doing.
When we first give the rationale for behavioural activation (the more friendly name for which is goal setting), the whole idea can seem overwhelming. “So even though I have no energy, no motivation, and apparently no ability to think straight, I’m supposed to live a busy life. Yeah, I'll get right on that.”

The plan is to start small, of course. And it helps to have a few simple guidelines.

One of these is the 24 Hour Rule.

The idea is simple: At least once in every 24 hour period, you have to get out of your home.

We can’t impose this on people, we can only suggest it. But it’s a good general rule for people with mood difficulties. Staying at home can feel a bit cozy and warm, but eventually it leaves people feeling like invalids. Lying in bed is the way to recover from the flu, but it generally makes depression worse, no matter how attractive it feels.

Getting out will usually feel aversive, uncomfortable, and futile, especially at first. But ultimately it gets easier and it helps us reconnect with life.

Fine, but what should you do?

A dietician once told me that when a depressed client hasn’t been eating, her first agenda is “Eat something!” It doesn’t matter what it is. Later on, you can start working on a healthy diet.

Similarly, at first it doesn’t much matter why a person leaves home. Maybe it’s to sit and drink coffee on the front step. Maybe it’s to go to the convenience store to buy the chips they’ve been told they shouldn’t eat. Maybe it’s to attend a doctor’s appointment. Fine. Once getting out has become a habit, we can start to work on enjoyable and healthful activities.

The 24 Hour Rule makes the point that we are not asking for the world. People with depression don’t suddenly have to find the resources to adopt an exhaustingly full life. At first, it’s just to get out the door.

Online Course

Want more behavioral strategies for working with depressed mood? PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.

Tuesday 22 January 2013

Blue Monday: A Tuesday Post



January in Vancouver. Not all that bad, really.
Apparently I have been living under a rock. Yesterday a reporter called wanting to film an interview about “Blue Monday.” I had to look it up. Those who pay more attention to the news are treated to this idea annually.

Blue Monday is allegedly the most depressing day of the year. It has an interesting history as a kind of cultural meme: something that has entered the public consciousness despite being based on nothing at all.  Something like the idea that we only use 10% of the brain, an utterly groundless but widely-believed notion that no one seems able to source.

The idea of Blue Monday originated with a tutor for an offshoot of Cardiff University in Wales (a connection the university seems to have been attempting to play down). It was, according to sources on the internet (yes, I am embarrassed by some of my research efforts, in case you are wondering), part of a public relations campaign for a UK travel agency hoping to sell more vacation packages.

The scientific basis for the notion that any particular Monday is the worst of the year is, needless to say, absent. Though often dismissed as pseudoscience, the Blue Monday idea doesn’t even aspire to those modest heights. It comes complete with an utterly meaningless equation that seems to have been constructed just to look complicated.

The campaign appears to have been stitched together from a brainstorming session about what might be depressing about early January. The elements are:

  • Weather (lousy in many northern countries this time of year).
  • Time since Christmas (allegedly traumatic, though many people seem to find it a bit of a relief).
  • Debt (see Christmas, above).
  • Time elapsed since failing to abide by New Years resolutions (which seems counterintuitive, because by the 21st of January, this year’s Blue Monday, most such resolutions are only a hazy memory).
  • Low motivation levels (the link between these and January seems unclear; perhaps it has something to do with biorhythms).
  • A feeling of needing to take action (as opposed to blissful apathy).

Are any of these valid? To a greater or lesser extent, probably all of them, though summing it up as an authoritative statement about any particular day is nonsense.

During my interview I was waiting for the question of whether many people do indeed find this date the worst. I was all set with my answer: “I’m sure of it. I’d be willing to bet that about 1 in every 365 viewers will find this the worst day of 2013.” No such opportunity arose, unfortunately.

To the reporter’s credit, he was actually looking for someone to snort derisively at the idea and he found one in me. Most of the snorting wound up on the cutting room floor though, as apparently it wasn’t telegenic.

Is January difficult? It doesn’t seem to produce notably more cases of clinical depression than other months. But yes, many people feel the January blahs. The social whirl of the holidays is over, the climate doesn’t encourage many of the activities that normally give us joy, and the gloss is off the pristine new year. We have already determined that no, this is not the year when we will live flawlessly or revolutionize ourselves.

What to do about it? Here’s a plan.
  1. Welcome the blahs. They may sound inarticulate, but actually they are telling you that something is amiss. And you’ve felt them before and lived, so you know they aren’t lethal. 
  2. Brainstorm. What are you blah about? Only do this with pen and paper, or it counts as rumination. Then act.
  3. Exercise. The catch-all recommendation for almost any type of distress. It’s probably more powerful than seeing a therapist.
  4. Socialize. You may have overdosed on people in December, but that’s no reason to become a hermit in January.
  5. Plan. You were looking forward either to the holidays or to their end. Now both are behind you and it’s a long while til summer. Find something to look forward to in February.
  6. Kill the revolution. If you haven’t violated your New Years resolutions yet, do so now. Revolutionary change seldom works. Identify small changes instead. And like Obama said yesterday, count on every positive step you take being imperfect. It’s still worth taking.
  7. Watch or read the news in smaller doses than usual. And look at the “Reader’s Feedback” sections NEVER. Nothing will kill your faith in the human race faster.
  8. Get off the computer, stop reading blogs, and go live your life.
Online Course

Want to learn about behavioral self-care for the blues? PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.

Tuesday 15 January 2013

Learning to Distrust Instinct: An Essential Aspect of Depression Recovery


There are hundreds of different ideas about how to overcome depression. Get regular exercise. Watch your diet. Examine core beliefs. Enhance social contact. Conduct behavioural activation. Schedule rewarding activities. Buy crystal amulets. Whatever.

When I talk about depression I’m always afraid that I’ll completely bore the audience, because most people could easily recite the same list I do (which doesn’t include the crystals, BTW). Much of depression treatment is tediously common knowledge.

There are some bits of obscure or counterintuitive thinking, however, and they can often be key to the process. One of these is the importance of learning to distrust one’s instincts.

I live on the West Coast of Canada, and not unlike the West Coast of the United States we are supposed to believe in all kinds of things: astrology, past life regression, quantum healing, you name it.

One idea that’s imbedded itself deeply in the psyche of many is that our instincts are always infallible, and that the key to recovery from almost any ailment is to learn to let our instincts guide us.

It’s a lovely idea, but the specifics are often lacking. Like: What IS an instinct? How does it differ from a notion or an assumption? How did instincts get to be so wise? Do they ALWAYS point in the right direction, or only sometimes?

If you dig around in people’s ideas about instinct, a picture usually emerges. An instinct is a behavioural impulse developed not through conscious reasoning or education. It emerges into consciousness with a powerful emotional sense of rightness or conviction (a “feeling in one’s bones”). And, sure enough, it often seems to have access to information that we might not ordinarily use in constructing our plans. It seems mysterious, as though it comes either from a deeper, more knowing part of the self, or from outside. It can even be interpreted as a form of spiritual guidance from unseen deities.

And, importantly, it is always right.

But it isn’t.

Depression is commonly classified as a mood disorder, but really it is a disorder of everything: thought, behaviour, physical functioning, emotion – and instinct. During depression people can exhibit all kinds of deep convictions:

  • I am the most worthless (stupidest, least lovable, most offensive) person on earth.
  • The things that I once hoped for will not and cannot ever work out.
  • This feeling will never pass; I will be depressed like this forever.
  • I know with certainty what others think of me, and it’s not anything good.
  • Working against this state is futile.

If you ask about these types of ideas, it quickly becomes apparent that these are not (or not entirely) the product of conscious reasoning. They are not viewed as hypotheses, which might be confirmed or disconfirmed. They are certainties. They are as substantial and undeniable as gravity. They are felt in the bones. They have weight.

Try to distinguish these deeply-held beliefs from what people normally think of as instinct, and you quickly descend into hair-splitting.

It’s tempting for believers in the infallibility of instinct to try to fence off depressive (or anxious, or paranoid, or angry) thinking and distinguish it from “true” instinct. But the starting point for this effort is usually a presumption of the positivity or truthfulness of instinct, and so the argument quickly becomes circular.  “Instincts are right, and some of the convictions that clients have during depression are wrong, and so even though they feel as solid and indisputable as instincts they can’t really be instinct.

Rather than trying to make a distinction that the thinker cannot discern (and that I don’t believe really exists), it seems a better option to encourage a buffer of distrust in instinct-like beliefs – particularly ones that align with a form of distress or disorder the person already has.

So a dog phobic should treat their instinctive certainty that the neighbour dog is vicious with suspicion. A manic person needs to cultivate distrust in grandiosity (a difficult task, that one). And a depressed individual needs to view particularly bleak convictions as possibilities rather than certainties.

We don’t need to convince our clients that any particular idea is wrong. They believe one thing, we believe the opposite: Why should they trust our own beliefs over theirs?

But perhaps we do need to point out that depression affects not only our notions, or transitory ideas, but also our deeper instinctive feelings. I like to have clients identify depression-like thoughts that feel particularly instinctive, or solid, to them. We can experience wonder at their solidity, and at the fact that seemingly incontrovertible knowledge can shift, change, or fade.

“Was there ever a person you felt in your gut, in your bones, the sense that we will be friends, or lovers, for as long as we live – and it turned out otherwise?” “Did you ever have a sense of certain knowledge that you were doomed to fail an exam that you subsequently passed?” “Have you ever believed instinctively that someone hates the sight of you, and later found out they quite liked you?”

We don’t have to reform our instincts during depression. We don’t have to turn them into unconditional positivity. We don’t have to stamp out our negative ideas.

But we do have to recognize that the sense of instinctive solidity that comes with them is an illusion. We need to demote them from the realm of knowledge to the less satisfying territory of hypothesis.

And then test them.

Online Course

Want more behavioral strategies for working with depression? PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.

Friday 4 January 2013

New Year's Resolution: Manage Stress Better!


Is this one of your pledges this year?

One of the best strategies is to learn diaphragmatic breathing, and then learn how to apply it in the situations that normally stress you out.

To this end I've created an online video course called "Breathing Made Easy" on udemy.com.

Want to take it?  Use a coupon code to get a 47% discount for the next 2 months - from $15 to just $8.  The code is "psychsalon".  All small letters, all one word.

Can you pass along that code to others or repost this offer? Yes.

Udemy is a site offering courses in all kinds of things, and it started with computer courses. Nobody cares if someone sees they are taking a computer course, so when you sign up they ask for your full name.  Feel free to enter a pseudonym instead - something like "stomachbreather." Or whatever.

Here's where to find the course, including a promo video that tells you more:

http://www.udemy.com/breathing-made-easy/

Have fun. And best wishes for 2013, no matter what your resolutions are.