Thursday, July 28, 2011

Depression/ Not Depression

Depression is an illness, a series of symptoms, not your life.  The worst cases of depression I saw were people who had bi-polar disorder that was mainly expressed in depressive rather than manic states.  The few episodes of mania they experienced were rare and often brought chaos and then regret into their lives.  Mostly, they lived with depression. “Like a giant hand is holding me down,” said one client.
One of the ways to look at depression is a very simple behavioral approach I refer to as, depression/not depression.  This is a concept I got from trainings with Bill O’Hanlon (, a great speaker and trainer.  In this approach we look at the way a person spends the day as if we were observing it on a video.  We then describe the activities in terms of depression or not depression.  This is an example of a patient I saw for many years:
Depression - “I wake up and get a cup of coffee and sit on the couch.  I turn on the TV, light up a smoke and proceed to watch Today, Regis, The View and intersperse it with CNN and whatever else is on.  I’ll eat cereal or a bagel, not get dressed, not get washed and have my jammies on when the midday local news show comes on.”
Not depression - “When I wake up I get into the shower, and then brush my teeth.  If I have to have coffee, I have it while I’m getting dressed.  I leave the house.  Even if it’s for a walk around the block, I get outside.  I try to have an activity for the afternoon.  I try to plan meals and have good food in the house.  I make sure I talk to someone every single day.”
For a depressed person, not depression is difficult.  However, even those with the worst depression can do something, one thing different every day.  What I am suggesting is not meant to replace medication or other talk therapy.  It is meant to add a way to maintain success with small measurable goals.  The outcome can be significant.  Read the story.

The Story
                She set down the shoebox on the table between us and rifled through some photographs, “I don’t think you believe me, so I brought some pictures.  Here, look at this,” she said handing me a cracked color photo of a group of women with big hair wearing mid-seventies vintage clothing.  In the center of this group of five women holding their drinks up toasting the camera, I recognized a thinner, younger Hanna Berg.  “I was something, a real hell raiser, and I made good money too.”  In another image she sits on a barstool, her back to the bar, legs neatly crossed, her hands folded in her lap, the beginning a of a smile on her face.
                I’d been seeing Hanna for over five years.  Her bi-polar disorder was diagnosed shortly after these pictures were taken.  “I covered the area from Syracuse to Albany.  In the springtime I was always on the road,” she continued, describing her work taking and selling school pictures.  “We did class pictures and individual pictures and all the stuff that went in the yearbook.”  Although I’d heard this all before, Hanna felt the need to display proof of her normalcy.  The manic episodes, worsened by self-medication with alcohol and drugs, made her young life a shambles.  There were a series of episodes that saw her arrested, and then hospitalized.  After a high speed car chase and crash, she was sent to the State hospital and been one of the last long term patients before it closed.  She’d fought the mania with medication and as she got older she found that the manic episodes were few and far between.  She mourned her mania like the death of a loved one and had no choice but to accept the depression that overwhelmed her like dark grey clouds filling the sky for months or even years at a time.  Anti-depressants gave some relief, but not much. Early on she’d had electro convulsive therapy, known as ECT or shock treatment.  She said of it, “You know, it made me feel better, but my short term memory was shot.  Then I’d get anxious that I’d forgot something important and that would make me feel depressed.”  At times, she had great trouble getting out of bed, not because she was tired, but as if a giant hand were holding her down.  When I first met her she used to cry a great deal, but later she seemed to have less emotion attached to her illness.  Her diet had gotten worse and she sometimes would eat a month’s worth of groceries in a week.  She was now a pale, overweight woman in her late fifties with a halo of dyed blonde hair framing a puffy pale face.  Her occasional smile could brighten a room and I could imagine how she’d been a heartbreaker as well as a hell raiser.
                Hanna was always at a high level of lethality for suicide and we’d been through at least seven attempts in our time together.  “Look at my crappy life.  Is there really a reason to go on?” she’d said to me in the emergency room after she’d slit her wrists and been found by her boyfriend.  “Bill is a jerk.  He doesn’t love me and is only my boyfriend because it gives him a free place to stay when his mom gets sick of him.  He also knows I’ll feed him.  If I died he’d have to find a job.”
                When her elderly mother became ill, Hanna moved her into an apartment in Hanna’s building and cared for her or arranged for her care until her mother died.  Hanna also, somehow, found money to help her disabled sister who lived in a group home.  She almost always made an effort to see her sister on Sunday afternoons.  Other residents of her complex depended on her daily phone contacts even when she was in the hospital.  Few days passed when she did not have advice or a kind word for someone.
                A good friend of hers called me and asked me to go to Hanna’s apartment after not hearing from her for a few days.  She tried calling and had even knocked on her door without getting a response.  She’d tried to contact Bill, but he did not return her call.  No one came to the door for me either, so I called the landlord who came over and let me in.  Hanna was lying on the sofa, her features flat, the person gone.  Above her head was a white poster board taped to the wall.  In magic marker, it said: “Do not resuscitate.”
                Several hundred people attended her funeral service.  Many said they didn’t know what they’d do without her.

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