Our adult son is getting more and more disabled with his depression. Whether he has bipolar, schizophrenia or something else, we’re not sure, but he is so isolated he’ll hardly talk to anyone. His basement room is in shambles and he smells bad. He used to talk about killing himself but now he doesn’t even talk enough to let us know if he’s suicidal. We worry too about our granddaughter who is brave, but should be a little frightened to visit him on weekends. How can we help when he is so withdrawn? This has been a recurrent or cyclic problem by the way, but more intense each time.

Answer:

Your situation sounds excruciating. At the bottom line, while not ‘hovering’, it’s good that you can remain watchful, given that he’s been on such a downward slide. In some ways, he could be safer while he’s nearly debilitated. I would suggest that you remain vigilant when he begins to get activated again, even if he appears cheerful at first, as this is statistically a risky time.

Apart from his essential safety needs, the question is how to get him in for mental health treatment. If it comes to it, you can call the County Designated Mental Health Professionals in Seattle. These are the people who come to make an outreach visit and, if necessary, have the authority to impose a 72-hour mandatory commitment for safety, evaluation and treatment. In King County they are accessed by calling the Crisis Clinic at 206-451-322.

Your son would have to meet stringent criteria before he is forced into inpatient treatment – in his case, being either a danger to himself or what they call gravely disabled. The latter category is more likely to be met if you tell them that on your part you are not able to adequately tend to his essential daily needs. This might be the stance to take depending on how you would want to influence their decision. The CDMHP’s can at least make an on-site assessment and give some key recommendations apart from anything being involuntary, so don’t hesitate to call them if you feel you should.

I wonder if you could marshal as many others in your community and his as possible. Consider asking neighbors, his doctor (via phone), past friends of his, co-workers, his boss or former boss – anyone and everyone, to periodically make a brief visit, express their concern and reinforce your message that he needs to accept help. The idea would be not only that you get help in your role but that he gets the sturdy demonstration of support. I wouldn’t think that his daughter could be enlisted without it being a little too frightening and heavy a burden for a 15 year-old. I can only offer this as a tentative suggestion that needs to be heavily tempered with your own judgment. A key factor though would be that all those in the network come across as loving and supportive, not confrontational.

Finally, recall the speech given by flight attendants before takeoff. If the cabin loses pressure and the oxygen masks come down, you must put your own on first, your child’s next. In other words please take care to conserve your own energy and to get what you need to keep going for the long haul. You want to mean it when you tell your son you’re strong for him and are never giving up.

How can I decide whether to take an antidepressant medication?

Answer:

It’s good to be ambivalent. Careful thought is better than little thought. Usually, I will support the decision a patient makes. Occasionally, I’ll lean on someone to take something or to delay taking it. Here are guidelines I’ll often bring up in a discussion about the decision:

You may want to gather information, but you may also want to limit your research. The more you cruise the information sources, the more you may find that there are few established facts that aren’t contradicted by someone. I myself hold with the dominant view that most people who take an antidepressant are helped, and that the benefit outweighs the consequences. As with all health information, consider the source. Treat carefully any testimonials, no matter how impassioned or who they are from. Take the same care with information that comes from the pharmaceutical companies as well as that which comes from the rabid zealots in any camp.

If you are inclined against taking medication, you should ask yourself how much energy you are prepared to put into the alternatives. A passive sit-and-wait strategy may or may not be a good one, whereas a reasonable plan of action should give you more confidence. You should also ask, if I’m not doing badly enough to take a medication now, how much worse would it have to get to change my mind? How will I know when I’m there, and can get past my hesitation if I get there?

If you are inclined to take it, can you make a good commitment to doing it right? This means taking it daily as prescribed, keeping in touch with the one who prescribes it, tolerating the manageable side effects, and staying on it for a long-enough period of time. As a general rule, eight months is the shortest period of time anyone should be on the medication, and longer is often better, depending on your specifics. While on it, would you enjoy the benefit with complacency, or could you use the opportunity to learn what got you down and what can keep you up, so that you’ll be equipped to stay off it once finished?

I moved to Seattle to renew my life, yet I’ve been as depressed as ever. Shouldn’t I be less vulnerable in a beautiful place like this?

Answer:

I encounter people in this situation regularly. Seattle is a city of transplants, and the adjustment is not always quick or easy. Here are several reasons we could designate a special “Seattle depression” for newcomers in the the Emerald City.

First of all, moving sucks. You may have escaped a messy family situation and a doomed marriage, a rotten job and hell-hole physical setting, but you’ve come to a place where you don’t know many people. Isolation correlates with depression. Often, being with irritating people who you know may still better for your mood than being alone. Seattle has a reputation as a place where people are generally insular and hard to get to know. Whether or not the reputation is deserved your feeling blue and insecure will not help your efforts to integrate.

But I’m an introvert, you may say. People are a pain, and I like to be alone! Just the same, being human, you have tribalism in your genes. You don’t have to change you personal nature, but you might benefit by adjusting your patterns of affilliation.

Besides the isolation that comes with moving, you have disrupted your usual routines. Routine is good for your mood, plain and simple. Humdrum activity is still activity. It gives a sense of purpose it keeps you in motion and it lends structure to your day, whereas now that structure may be hard to come by.

The reduced light that comes with our long winters is undeniably a factor in depression, but an overblown one in my opinion. The problem with winter is not just the reduced sunlight but the fact that we don’t move around as much. Physical activity is good medicine for depression and it just doesn’t come as easily in the Seattle winter.  If you get a boost from taking walks in the summer, get a good parka and don’t let the went winter stop you.

All the disruption, lack of routine, reduced activity, seperation and isolation contributes to a sense of anomie – a breakdown in the usual social norms and standards that give us a sense of regulation, stability and belonging. Even a slight sense of dysregulation and weakened structure adds to anxiety.

As I have mentioned several times before, depressed people ruminate to try to find answers. Ruminating is a vortex. It gives the allusion that we are seeking answers when in fact we’re moving farther from solutions.

You can place all blame the nature of the city if you wish.  But if depression is the fault of this locale, we would have a measurably higher rate of depression.  We don’t.  Incidentally, the only city with a measurably higher rate of suicide is Los Vegas.

So what is to be done? As Mark Twain stated, “It takes a heap of livin’ to make a house a home”. You may need a plan to direct your activity more productively, to find more connection, gratification and pleasure, and tune your thinking to be less depressive. Then, you can begin feeling like you belong, perhaps even like it would be depressing to leave. CBT or cognitive-behavioral therapy is a practical way to do this.

My husband is never satisfied. He complains about his work, our house and our kids, even though he’ll occasionally admit it’s all fundamentally OK.
I keep trying to tell him he’s depressed and occasionally he’ll kind of acknowledge it, but real soon he’ll go right back to blaming everyone and everything else for his woes.
I’m blue in the face from telling him he’s stuck in a bad pattern. How can I get him to address this?

Answer:

A man named Salvador Minuchin tells this story: A farmer had a donkey that would do anything he was asked. When told to stop, the donkey would stop. When told to eat, he would eat. One day the farmer sold the donkey. That same day, the new owner complained to the farmer. “donkey won’t obey me. When you ask, he will sit, stop, eat – anything. When I ask, he does nothing.” The farmer picked up a two-by-four and walloped the donkey. “He obeys,” the farmer explained. “But first you have to get his attention” *
The parable is a little crude and of course it’s not to be taken too seriously. But the point is that no communication is effective unless the receptivity is there. My guess is your husband is not in a receptive state when you talk with him, and maybe this can be addressed first.
The “two by four” can be as direct as actually saying something along the line, “I want to talk about something critically important to me. Could you promise to hear me out?” This is followed up later with something like, “It’s so important to me that I get this message across in the right way. Would you indulge me please by summing up what you heard me to say, so that I can check out your understanding?”
Another way to increase his receptivity would be to recruit others in this man’s life who have the clearest channel. Does he tend to listen to a favorite uncle, or a minister? You can also recruit the whole “village”, including his M.D., his barber, neighbors, people at work, his religious community, great aunt Gertrude and so on.
There are many other ways improve the receptivity of the listener. But you might also check to make sure you’re not inadvertently using something which is backfiring. We all fall into this – repetitious nagging, shouting, sarcasm or shutting down in the hopes that he’ll pry in just the right place…these are 2×4′s which will not budge anyone’s ass.

*Families and Family Therapy, 1974

I take care of my ailing mother, and I’m very willing to do it. One problem though, is that she expects more than I can provide. I know that if I give her all the time she wants from me, her life would be better. On the other hand, mine would be worse, and by a larger proportion -a net loss between the two of us. She cannot recognize this, and her expressions of sadness at the neglect she experiences makes my want to cry. I am plagued by guilt. What can I do?

Answer:

Guilt is an interesting word. It’s a feeling, and it’s also a status based on fact. A feeling is never right or wrong. We cannot “correct” an emotion. But a fact is either true on untrue. We are either guilty of doing something wrong, or we are not guilty. If we do something wrong, then we should feel guilty. It’s an important emotion, a signal that you are not aligned with your values and your community. To feel better, we have to make things right, and stop the improper behavior. If you have earned guilt and don’t feel guilty, it could be a problem.

On the other hand, it’s easy to feel guilty when we aren’t actually guilty of anything. If you take some time to attend to other matters and to rejuvenate yourself, and your dependent mother complains, you are getting a signal from her that you’ve done something wrong, that you’re unfairly causing her pain. You could assume guilt, and of course you’ll feel guilty. But then you could ask:

• Is this signal from my mother an accurate one?

• If she say’s I am unfair could she be wrong?

• If she does not take responsibility for her own contentment, then must I assume the duty?

• Are there other signals telling me I am not unfair? There is my doctor’s advice, my friends, my wife, an article, etc..

• Is it not possible to be compassionate and “selfish” at the same time?

There is another aspect to this. Without guilt, you would probably still feel badly. It is hard, and sad, to see your mother suffer. And it is harder to experience a degree of helplessness in the face of this. It is difficult to accept this limitation in the ability to help someone you love. But there is an escape. If you assume guilt, the implication is that you are making a choice. Even the implication that you are making a bad choice still implies that you have some control. Oddly, this sense of having power is easier to fathom than to fully acknowledge the lack of power. So, you could make the harder – but perhaps more wholesome and congruent – stark sadness about your mother’s suffering. Or there is the possibly easier – but less authentic – sense of guilt. I’m not which is more appealing.

I get no kick out of anything. Is this part of my depression? I know it’s a drag on my family, but how can I be expected to do things if there’s no satisfaction in it?

Answer:

The inability to enjoy things normally enjoyed is such a tough aspect of depression. The catch-22 is that doing enjoyable things is an important aspect of getting better. Some might be interested to know the jargon name for the symptom, anhedonia (an, meaning of course “without” and hedone is Greek for pleasure, as in hedonism). The general advice is to treat it like physical conditioning or any skill – practice. Do more fun things, and try to find the fun in it.
Let’s say you push yourself to take a walk. Without meaning to, you might go into it with hands clenched, head down, cursing under your breath and treating it like a forced march. You’ve done your walk, and gotten little pleasure. Or, you can keep your eyes up, look at interesting things, feel the air, hear the sounds, appreciate the rhythm in your stride and taking care not to use the time to stew about something you cannot control. Then, you’ve had your walk made a diminished your anhedonia at the same time. The way in which you participate makes a difference.

Another key in reducing anhedonia is taking care to make the right mental connections. When depressed, we automatically assume getting out (or getting up, or talking to a friend or whatever form the pleasant activation takes) equals discomfort. It may in fact cause some discomfort in the short term which is what makes us feel so certain it’s not worth it. But you have to connect with the longer term result: after completing the walk there is more comfort, not less.

During and after the activity, remember that depression dampens your perception of the experience. This means that you do not want to take your initial assessment of the experience at face value. Look hard for everything positive you can get from it. An initial thought, “that movie was awfully flat, and getting there was exhausting” might translate to “I see I haven’t lost my knack for panning a bad movie, not that was 100% percent bad, and getting there was an achievement.”

Finally, keep in mind that it takes practice. Visiting friends, volunteering or getting to the gym will be hardest in the beginning (maybe after the initial surge of initiative has worn off). With repetition, you’ll make a better connection with the payoffs, and it will become easier.

Several years ago I survived a devastating divorce. With the help of therapy and a support group I came through some pretty heavy depression. Now, I’m happy to have a new mate in my life and we’re talking about getting married. Here’s what’s weird: suddenly I find myself crying about my old divorce again from time to time. Is this normal?

Answer:

Some might remember Elizabeth Kubler-Ross, who wrote On Death and Dying. The work was good in that it helped to break our taboo about talking about death, and it also helped to normalize and explain grief. She was the first to talk about grief coming in stages: denial, anger, bargaining, depression, and acceptance. Some talked about additional stages such as shock and testing, but the common belief back then was that we were supposed to go through each stage in turn. You finish up one, then move to the next.

It was a lie. The fact of the matter is, everyone grieves differently. The idea of stages is a nice one in general, but we don’t all have to hit all stages, and we certainly don’t hit one at a time, nor fully complete each one, never to look back. It’s much messier. No one has to take my word on this. Just look to your own experience or ask someone who has had a catastrophic loss. Many years afterwards, when you think the bereavement is settled, you can be startled by a new wave of depression, anger or whatnot. The best way to make it all worse might be to assume what’s happening is abnormal, since you aren’t following the “rules”. It would be pretty reasonable to assume these aftershocks are likely to come at a time of transition when our new handholds on normalcy get rattled.

I’m married and we have two year-old. My day starts at 5:00 when I get up, make my lunch and go to work. I pick up our son on the way home. Then I clean up breakfast, run the laundry, make supper, wash dishes. All at the same time I’m keeping our son entertained and getting him ready for bed. My husband comes home from work and watches TV. He says his job is so hard; he’s too tired to do anything else. The weekends aren’t a lot different. By the end of the day I’m so depressed. I wonder if I should ask my doctor to change my medication. And this is not what I thought my life should be like. I’m so confused!

Answer:

You don’t come across to me as confused. You come across to me as exhausted, and aware of a major contributor. Your husband may be confused. He may need some help and support. Of course, he must have his own version of things. But since he’s not here…

I believe that for many married woman there comes a time to fulfill the wifely duty. The duty is this: to take your husband firmly by the collar, make sure you have every bit of his attention, and state something along this line:

Husband of mine, I love you dearly. I adore you. Because of that, I’m not going to allow you to erode this precious marriage.

What you are doing has to change. When you created this child of ours with me, you signed on to major shift in our lifestyle, mine AND yours. As a part of this change, it means that when you get home from work, you must remain “on”. It’s just the way it is.

When you flop by the TV extensively, it is not the image of a husband and father I want. Furthermore, there is a pile of duties, which you are leaving to me. The result is that I’m drained. And I’m furious. I know you’re exhausted too, so take a breather when you need. But don’t flop, and don’t stick me with your share of our daily chores.

Now, you might think I’m complaining because I’m depressed. In fact, I’m depressed because I keep having to repeat this complaint. I will get better, but be warned – this will not mean you can go back to planting your butt on the couch. I want you right here. With me, sleeves rolled up. And I’ll be with you.

Am I clear? Now what are you going to do beginning today?

This abbreviated sample statement might be stronger than anyone would really want, but the idea is to be intense, forthright and resolute, as part of the package in loving. Thoughts?

My relationship has needed a lot of help for a long time, and I’m tired. If I had the energy to do just one thing with my partner to pull us out of our nosedive, what should I do?

Answer:

First, you have more energy than you think, and all you have to do is use it. Believe me, it’s there. You will find this out if you go through all the painful work of splitting up and reestablishing yourself.

But we’ll go with the idea that you can do just one thing. Now, different professionals will give you different recommendations. Some would say to increase the number of positive interactions with your mate, or to practice new communication methods. Others would advise you to show more warmth and regard, increase your attentive listening, or when you want to talk or complain, to make approaches that are gentle. All these ideas are worthy enough that I had to find a way to sneak them in here.

My own single recommendation would be this: choose the one most negative thing you can recognize that you are doing – something that is eroding the relationship, or that your mate would dearly love for you to stop. Then, stop doing it. If you are complaining at length, back off. If you are shutting off the complaints, then open up and make an accommodating response. It won’t kill you. If you are clutching, give some space and if you are generally backing away, come towards. If you have no interest in sex, first get a medical checkup and then do some reading or talking about how to stir your own libido. If you think you are starved for more sexuality, calm down and settle for the talk, the touch and the romance for a while, without sex on the agenda. If you are the one who is loose and permissive with the kids, show more backbone. If you are the one who is strict and firm, try easing up.

There are more examples but my point is this: it is likely that you are responding to the stress in your relationship by doing something that is making that stress worse. Of all the cruel ironies, the solution you are using is part of the problem. There may be many reasons for this. One of the reasons may be that your partner is doing the very same thing as you, but in the opposite direction. You may feel you have to go further in your own direction to provide a counterbalance, so to speak. This is because your partner is so darn stubborn and predictable, you say? Well, neither of us can change what your partner is doing. In fact, you see, your efforts to change him or her may only be increasing the polarization.

So grit your teeth if you must. Better yet, breathe easy. Stop what you are doing with your partner, and try moving in the opposite direction. Then, watch what happens.

Let me repeat my caveat that all rules have exceptions. The suggestions here are general in the extreme and are not meant to apply to everyone.

I’m feeling so crummy these days. When I’m at my lowest, the negative thoughts start to take over and I feel like a goner. Any suggestions? I’m stuck at home with a disabled spouse.

Answer:

I’ll suggest it’s more useful to see how the negative thoughts trigger the emotions. While we can’t directly or easily control our emotions, we can get a better handle on our thoughts. Also, while emotions by their definition can never be wrong, thoughts generally either true or false. They can be put to the test.

What you can do is start to look for your own most depressing thoughts (maybe something like, “this life stinks”), and try to see how it is distorted (see below). Then you can practice taking a more rational assessment (perhaps, “this life is hard, not stinky, and it is meaningful and principled, and furthermore, I still have a good measure of control over the quality of my days”), which will begin to improve your mood. It takes some concerted practice.

You can try reading Feeling Good and The Feeling Good Workbook by David Burns for more on all this. As a preview, here are what he might consider the “Top Ten” cognitive distortions. It would be a strange individual who never engaged in a few of these:

1. All or Nothing Thinking
This refers to the tendency to evaluate personal qualities or situations in extreme, black or white categories. For example, before you developed chronic pain, you used to play baseball on the weekends. Now you find yourself thinking, “If I can’t play baseball, I can’t enjoy the sport anymore.” There is an apparent advantage to thinking in black-and-white, all-or-nothing terms. It is more predictable and creates the feeling that there is order in the world around you. This, in turn, should give you an edge to controlling your world. Unfortunately, it doesn’t work that way. Uncertainty is all that we have. Living comfortably with uncertainty is possible, but it takes time to master.

2. Overgeneralization
This refers to the tendency to see a single negative event as a never-ending pattern of defeat. Given the preceding example, you might respond, I’ll never be able to enjoy anything anymore. Misery does love company, but globalizing misfortune in this way creates an exaggerated sense of rejection and loneliness.

3. Mental Filtering
This refers to the tendency to dwell exclusively on a single negative event, and thus to perceive the whole situation as negative. For example, you are preparing brunch for some friends and discover that you do not have an essential ingredient to make a dish you were planning to include. All you can think about is how the whole brunch will be ruined. It gives you indigestion.

4. Discounting the Positive
This refers to the tendency to take neutral or even positive experiences and turn them into negative ones. For example, a friend comes over to visit and tells you that you look great. Your immediate though is this: I don’t feel great. She doesn’t understand. Maybe not, but try a simple thank you first before you check it out. Maybe you don’t look as bad as you feel!

5. Jumping to Conclusions
This refers specifically to jumping to a negative conclusion that is not justified by the facts of the situation. Two types of jumping to conclusions are mind reading and fortune telling.

5-A. Mind Reading
You assume you know why someone else does what he or she does, and you don’t bother to check it out. For example, you pass a coworker in the hallway and say Hi! He doesn’t respond. You think He must be upset with me. What did I do wrong? When you check it out, you find that the coworker was preoccupied about a sick child he had just left at home.

5-B. Fortune Telling
You know that things will turn out badly. Given your bad luck, you predict it as an already established fact. For example, you wake up with a headache. You say, Now my whole day is ruined. I had so much to do and I’ll never get it all done.

6. Magnification and Minimization
In magnification, you exaggerate the importance of a negative event or mistake. If, for example, you experience a flare-up in your pain, you find yourself saying, I can’t stand this! I can’t take this anymore. As a matter of fact, however, you can. You may not want to, and that’s okay, but you can take it. In minimization, conversely, you take positive personal qualities or events and deny them their importance. For example, a family member comments on how nice it is to see you at a family outing, and you reply, A lot of good it does if I can’t participate in the activities.

7. Emotional Reasoning
This refers to taking your emotions as evidence for the truth. If you feel that something is right, then it must be true. For example, you find yourself thinking, I feel useless. [Therefore] I am useless.

8. Labeling
This refers specifically to identifying a mistake or negative quality and then describing an entire situation or individual in terms of that quality. For example, instead of seeing yourself as an individual who has a pain problem, you find yourself saying, I’m defective, imperfect, and good for nothing.

9. Personalization
This refers to taking responsibility for a negative event even when the circumstances are beyond your control. For example, you and your spouse go out to eat at a fancy restaurant, but the service and food are poor. You find yourself feeling responsible for making a bad choice and ruining your evening together.

10. Shoulds
These are attempts to motivate (or browbeat) yourself by saying things like, I should know better, I should go there, or I must do that. Such statements set you up for feeling resentful and pressured. They also imply that you are complying with an external authority.