Six Key Approaches to Treating Depression Including The Brain Simplified

Depression: helplessness, hopelessness, sadness, feeling overwhelmed, trouble concentrating, sleeping all of the time or not being able to sleep, overeating or complete loss of appetite, significant weight gain or weight loss, irritability and easy to anger, isolating and lack of interest in usual activities. It may include suicidal thinking and/or attempts, but not always.

How the depressed brain functions:

Brain cells (neurons) communicate by sending electrical signals down long extensions (axons). Brain cells are not connected to each other. When the electrical signal reaches the end of the axon, it releases chemicals into the space between that axon and the next brain cell. These chemicals, called neurotransmitters, cross the space and attach to specific sites on the next cell’s receptors. In this manner, messages are passed on between brain cells. Once the message has been sent, the chemical neurotransmitters are sucked back up by the sending brain cell, a process called re-uptake. In depression, the amount of available chemical neurotransmitters is very low. Brain cells do not communicate effectively and the person’s overall functioning is compromised.

How do you treat depression?

First, get a physical including lab work to rule out any underlying health issues such as deficient vitamin D levels or thyroid dysfunction.

Anti-Depressant Medications: Most of the anti-depressant medications used today function by slowing down the re-uptake process and help to keep neurotransmitters present in the space between cells longer so that signals are sent more effectively between brain cells. The neurotransmitters targeted by medication tend to be serotonin, dopamine, and norepinephrine. 

Selective serotonin reuptake inhibitors (SSRIs) include Celexa, Lexapro, Prozac, Zoloft, amongst others.
Serotonin and norepinephrine reuptake inhibitors (SNRIs) include Cymbalta and Effexor, for example.
Norepinephrine and dopamine reuptake inhibitors (NDRIs) are represented by only one medication, Wellbutrin.

By the way, many recreational drugs attach to the receptor sites in the brain which are meant for the neurotransmitters. Cocaine, for example, attaches to dopamine receptor sites. If the brain thinks there is more neurotransmitter available than needed, which would be the case if another chemical is filling the receptor sites, then the brain stops producing that neurotransmitter – hence withdrawal and depression when a person stops using drugs.

Counseling: People suffering from depression benefit greatly from counseling. The type of counseling most effective for depression as demonstrated by research is Cognitive Behavioral Therapy (CBT). A more modern version being used now is called Dialectical Behavioral Therapy (DBT). Both of these therapies have a person look at their patterns of thinking and work to change negative and extreme patterns to more constructive thinking which helps to improve mood and outlook. A focusing technique called Mindfulness is currently incorporated into these approaches. Mindfulness helps a person to not be influenced so much by past experiences or worries about future outcomes and helps a person to more fully experience the present moment. A key component of mindfulness is the elimination of negative self-assessment and judgment.
Issues of anxiety are also effectively treated by these therapeutic methods. Depression and anxiety frequently co-exist.
(Finding a counselor that you like and feel comfortable talking with can be just as effective no matter what therapeutic approach they employ.)

Multiple research studies over many years have shown that therapy plus medication results in more improvement than either therapy or medication alone.

Sleep: In depression, sleep is generally disrupted. The person may have trouble falling asleep, may awaken in the night and not be able to go back to sleep, or wakes early in the morning and can’t get any more sleep. Ongoing sleep disruption takes a toll on a person’s mood, functioning, and health. A person should not remain in bed trying to go back to sleep if it has not come in about half-an-hour. Our brains are creatures of association. If you lie in bed thinking and ruminating for hours, your brain comes to associate bed with thinking. It determines that lying in bed is your time and place for thinking. Get up out of bed and leave the bedroom if possible. Keep the lights low and activities quiet and mellow, even boring, and follow these guidelines:

Keep a schedule. Go to bed at the same time each night and get up at the same time every day.

Have a bedtime routine such as: dress for bed, brush teeth, organize items for the next day, read for a little while.

Turn off all electronics an hour before bed. Lights from electronics disrupt sleep cycles. Cover any lights that must stay on, such as clock lights. Have a dark room. Keep things a little cooler as well at nighttime. Do not sleep to the TV. Again, the brain makes associations, you might not be able to sleep without a TV, or you might wake up at certain times because the brain thinks it is TV watching time. You do not get the benefits of all of the brain’s sleep cycles with a TV on.

Do not get hooked on sleeping aid medications. These also disrupt the natural sleep cycles and you do not get truly deep, restorative sleep. Melatonin is produced naturally by the brain just before nightfall and signals the brain and body to relax for sleep. You can get melatonin over the counter and take it an hour or two before your regular bedtime. Talk with your physician about the effects of long-term use.

Learn and practice relaxation techniques such as progressive muscle relaxation, deep breathing, or meditation as part of your bedtime routine.

Exercise: Exercise earlier in the day and not close to bed time. Aerobic exercise, which gets your heart pumping, has been shown to increase levels of serotonin and dopamine in the brain. Find an activity you like to do. Walking gets you out into the fresh air and sunshine. A recent study has found that being out in the morning sunlight improves mood.

Socialize: Human beings are meant to affiliate with other human beings. Positive interactions with others can lift a depressed mood. It can be as simple as a pleasant ‘hello’ in passing or witnessing joking or teasing which happens naturally in many interactions. If a person is inclined, volunteer work can help improve one’s own outlook. Loving a pet fits under this category, as well.

Work to solve problems: High stress situations and ongoing life problems contribute to depression. Treating the symptoms of depression can help put one in a better state to approach and solve life problems. Seek out information and educate yourself on the issue, explore options, seek assistance, start taking steps to solve, improve, or change the situation.

Many of these approaches you can do on your own or with others and you can seek assistance from professionals for an objective view of your situation. 

Camping Demonstrates Personal Growth

I went camping last weekend. I am not the same person I used to be. Several aspects of this camping trip make that very clear to me.

Organizing and packing: I do it all and I am very good at it. Several times this weekend as an item was needed I said, “I have that!” This is in contrast to my ex-husband giving up on me by our second camping trip partly because I did not contribute to organizing, packing or meal planning due to not knowing how to do it. I have the ability now because after the divorce, I wanted to take my two sons camping and I studied up on products and read books in my own manner of learning and careful preparation. Do not ask me to wing it.

Hiking: This trip, I hiked up a snow covered trail and over streams by traversing rocks and wet logs until I came to a back-country high mountain lake. Years ago, I was non-athletic and needed to be guided through walking along a slanted trail and downhill. This weekend’s hike was not without consternation, but I dealt with it with the confidence I have developed. My feet slipped over the snow. I jolted and caught my balance and repeatedly felt I might fall. I anticipated getting hurt. As I stepped on a log to cross a stream, it moved and I did slip down into the water. My shoes and socks were now soaked for the rest of the hike. I acquired a large bruise on my inner calf. These risky situations would have paralyzed me in the past.

I still don’t like those thoughts and fears. I wished I had brought my sturdy hiking boots rather than running shoes and I am considering purchasing a walking stick for hiking situations. (I had been told it was a groomed, moderate path. I didn’t think of snow.) Rather than catastrophizing, now I tell myself such things as “So what if my feet are wet. I am wearing my wicking socks. I shouldn’t get a blister and they will dry quickly.” I also had confidence in my conditioning. I am a runner. I earned the right to proclaim that about myself. “I am a runner!” Years ago, with trepidation, I took up fitness walking. Now, I am on ten years of running. I have overcome plantar fasciitis, bunions, and am managing asthma. On this hike, my muscles and lungs were strong and I knew I had endurance. I noticed my own preference: I will stick with running for regular exercise. I prefer solid more predictable paths. (I relish forming my own opinions on what is best for me.)

Camp Cooking: This trip, I tried Dutch-Oven cooking for the first time. Chocolate cake was my debut! My brother-in-law who has known me since I was a pre-teen exclaimed, “I can’t believe you went out and bought a Dutch-Oven! I can’t believe you are even trying this!” There you have it. Being willing to try something new, to take a risk, to go out of my way to pursue something out of my regular experience is far from how I used to be. I prepared the charcoal briquettes which used to be the man’s job. I forgot the cooking oil. I decided I could substitute melted butter. It wasn’t finished cooking at the time the recipe had indicated. I had to make decisions about additional cooking time and on-or-off the coals. “Maybe the oil cooks hotter than butter and that changed the cooking time,” I wondered. My camp-mates were impressed with the resulting Chocolate Delight Cake. In my own mind I downplayed it as I tend to do, “What is the big deal?” I realize the big deal is they know how far I have come!

Reasonable and Mindful Rather than Positive

I run a group for adolescents in which I teach about distorted thinking. The first thing I tell them is that we all do it. Our brains take in thousands of pieces of information per second and the brain must identify, sort, classify, and decide what to do with this information. The brain takes short-cuts to do this efficiently. Most of the time, this works very well, and we are able to function. Sometimes, however, these short cuts, or ways of classifying, lead to mistakes in thinking. I let them know that I have been a therapist for over twenty years, teaching about distorted thinking, and I still do it myself. I tell the adolescents that you are not going to get rid of it. The goal is to learn about the different types and recognize when you are thinking in distorted ways and to change it so that your thinking is at least not making a situation worse than it needs to be. I educate that whatever mood you are feeling, distorted thinking increases it. Distorted thinking increases anger, depression or sadness, anxiety and worry. By catching one’s distorted thoughts and changing them, strong emotions can be managed. Then I ask the adolescents, “So what do you do with distorted thoughts, how do you change them?” And somebody always says, “Think positive thoughts!”

I tell them that if they are able to do so, finding something positive about a situation is helpful and switching to positive thinking can improve your mood. But then I say, “But this world isn’t all rainbows and butterflies. Horrible, awful things do happen and no matter how you look at some things, you can’t change it to a positive.” This gets their attention. In an instant, skeptical, bored, disdainful teens show a little respect and interest. Keep in mind, some of the teens in my groups have experienced terrible abuse that the average person doesn’t want to believe takes place. All of the teens in my groups are there because they have lost control of their emotional reactions and have landed in my treatment center. I tell them that the goal is to notice distorted thinking as it happens and to change it to more reasonable thinking, to put it into better perspective. Then I begin to teach them about cognitive distortions. See my blog post:
http://www.psychsage.com/2014/02/halt-calamity.html

I was very pleased as I attended a PESI workshop this month, “Cognitive Behavioral Therapy and Mindfulness: An Integrative Evidence-Based Approach,” presented by Daniel J. Moran, Ph.D. He echoed almost exactly what I have been saying in my adolescent group about adjusting thinking to be more reasonable. He of course taught some basic concepts of CBT such that there is an activating event followed by a person’s beliefs about that event followed by the consequent emotions which results in actions or behaviors. He then explained Rational Emotive Behavioral Therapy in which irrational beliefs are disputed or challenged. Extreme emotions are then transformed into more adaptive emotions even though they could still be negative emotions. He then moved into discussing how the technique of mindfulness can be incorporated with cognitive behavioral therapies and he specifically discussed Acceptance and Commitment Therapy.

I had been aware of the usefulness of mindfulness as being focused on the present moment experiencing it without the distraction of or distortion by thoughts of the past or the future. Moran pointed out that one does not have to have the emotional reaction which follows a thought and one can choose whether or not to react. Based on this, he recommended using mindfulness to notice one’s internal thoughts without the emotional reaction. He presented that simply being mindful of one’s cognitive distortions can reduce their ability to bring about an automatic powerful emotional response. It is important to notice the thoughts without judgment. “There is one of those thoughts.” Getting some distance from it reduces its emotional power. The person can then decide whether to act on the thought or not. Just because you think it does not mean you have to do it.

Gaining some control over emotional reactions requires being mindful of one’s thoughts, noticing them without judgment and even with some detachment. Practicing mindfulness during daily activities can develop the ability to use mindfulness to manage distorted thinking and to manage emotional reactions.

Boundaries Protect: Five Tactics for Setting Boundaries

“I can’t say, ‘No.’ I don’t want to make them mad at me!” This person is struggling with setting a boundary. The person doesn’t want to go along with someone’s request, but is more concerned with the other’s feelings than how agreeing to the request makes the person themselves feel. Now, it is good to be thoughtful and helpful and to care about others’ needs. The problem comes when an individual always compromises and ignores or subverts one’s own needs and feelings. The problem is being out of balance and skewed in favor of the other too much. People do have the right to care about themselves, to protect themselves.

Boundaries are the limits we put into place to protect ourselves from being harmed by others. They are rules which guide people such that they don’t harm each other. People with healthy boundaries respect the boundaries of other people, even if the other people do not know to enforce those boundaries themselves. Harm comes about in situations where people with poor boundaries interact. A common scenario is the combination of a person who doesn’t respect others’ boundaries taking advantage of someone who isn’t good at recognizing and enforcing their own boundaries. Some people care so little of others’ boundaries that they cross them even when they are clearly expressed, for example, a thief steals even with signs saying ‘Shoplifters will be prosecuted.’ The crossing of boundaries can happen on a continuum from simply, without malice, not recognizing that a boundary exists to quite knowingly pressing through boundaries.

Pia Mellody, in her book, “Facing Codependence,” gives an excellent explanation of the various combinations of intact and non-intact boundaries. She also explains how boundaries are learned. In general, we learn boundaries as children from our parents who both teach us and demonstrate by their own behavior, how we should be in this world. A child who grows up with parents with poor boundaries, for example, a child who is being sexually molested, is not taught appropriate boundaries, has its own inherent boundaries crossed by a more powerful adult, and doesn’t learn what appropriate boundaries are or even that they can have their own boundaries. This child grows up having difficulty even knowing how to gauge appropriate boundaries. People generally do grow up having learned boundaries, and vary in their abilities to enforce boundaries in different situations with different people. For example, a person may be very good at holding boundaries with acquaintances but doesn’t maintain boundaries and gives in easily to Mother’s demands.

Most of us struggle to sort out boundaries in complex situations. It is overly simplistic to think we can simply say, “No,” in any situation which makes us uncomfortable. For example, at work, people cannot simply refuse to do aspects of a job they don’t like doing. However, when job duties are compounded so much that they practically cannot be completed in the allotted time and this continues indefinitely such that it is causing burnout in the employee, this would be the time for the employee to recognize limits and boundaries and speak to the employer about making changes. (Labor laws exist to protect employees from abuse.) In personal relationships, people must compromise and take into account each other’s feelings and needs, but when does one person’s compromising become unhealthy self-deprivation or another’s lack of compromise become selfishness rather than healthy self-care.

There are five tactics which help in setting boundaries:

Recognize your own feelings. The first step in setting appropriate boundaries is honoring your own feelings. Do not deny or ignore any feelings. Some feelings have gained a bad reputation as being “bad” feelings or “weak” feelings. In fact, all feelings are guides and should be noticed. Feeling nervous or uncomfortable may be an instinct telling you something isn’t right. Anger and frustration can be signals that you need to enforce a boundary or ask for changes to be made. Sadness could mean you are not taking care of your own needs.

Know your preferences. Sometimes people do not enforce boundaries because they do not know their own opinion! When a person doesn’t know what they like or what they want, they open the door for others to do the choosing for them. If you can’t make a decision, someone else will make it for you. When you leave all of the choices and decisions up to someone else, over time, you lose yourself. Some find they “don’t even know who I am.” Notice your own likes and dislikes, have a favorite color, know what vegetables you like and don’t like, have an opinion on what movie to see.

Be reasonable, give yourself guidelines. Decide what you are willing to live with and when it is time to speak up. For example, you might choose to speak up when something has annoyed you at least three times. If it only happens once, you don’t say anything, you just tolerate it. If it happens repeatedly, three times in our example, you determine this is worth speaking up about and asking for change. Practice assertive communication. Or you might have values be your guidelines. You might decide that you will not live with someone who breaks your trust or who isn’t loyal. Know your own values.

Practice honesty. Be honest with yourself. Be honest with others. Many of us have been taught to lie in the practice of being polite. We have been taught it is polite to always appear happy. It is polite to not be a bother to others. When someone asks you how your day was, it is ok to reply, “Some good, some bad,” rather than the standard, non-informative, “It was fine.” Or we have learned to lie by omission. We do not want to burden others with our own experiences, so we don’t tell. But the reality is we are not having true, real relationships with others, if we do not share our own experience. We lose ourselves and our ability to have boundaries when we don’t express our honest experience.

Learn to say, “No.” Many people shudder in fear and trepidation at the thought of actually saying “No” to any request. But we become over-committed and then over-stressed when we are not able to set limits on our time and energy we have available to give to others. We harm ourselves, and others take advantage when we are not able to set a firm limit. Abusers are attracted to those who don’t recognize their own right to hold a limit. The December 2013 issue of Psychology Today magazine has an article by Judith Sills, PhD titled, “The Power of No.” She provides guidelines on how to begin the practice of effectively, kindly, assertively saying “No.”

http://www.psychologytoday.com/articles/201310/the-power-no

Maintaining boundaries is a way to protect ourselves from interpersonal harm. It is also how we stay connected to our own identity. Boundaries help us to maintain the “self.” To be human is to be in relationship with other humans. Learning to have boundaries in relationships with other people contributes to healthier, more equal relationships for all involved.

Speak Up Without Causing Destruction: Communication Styles and Assertiveness

Hello Friends and Colleagues. I have not posted for several weeks because I came down very sick with a fever and other changing symptoms. My energy is back and I have just a lingering cough. I am ready to provide you with the post I had promised you on communication styles.

There are three main communication styles and one sub-style:

First is the Non-Assertive or Passive Style of communication. A person who expresses themselves with this style tends to ignore and to not express their own rights, needs, and desires. They are indirect, inhibited, and self-denying. This person tends to feel hurt and to be anxious and can build up resentments. The behaviors they display include: permitting others to infringe on their own rights, avoiding unpleasant, risky situations and conflict, and not speaking up or stating their own opinions. They allow others to choose for them. A person with the passive communication style tends to not achieve their own desired goals. A stereotype associated with this style is the “Doormat” or the “Pushover.”

Next is the Aggressive Style. A person who expresses themselves aggressively tends to express their own rights, needs and desires but, unfortunately, they do this at the expense of others. They are emotionally honest, direct, and expressive, but in a hurtful manner. They are self-enhancing. They tend to anger and resentment. The behaviors they display include: having inappropriate outbursts or overreactions, putting others down, getting even or getting revenge. They tend to justify their blow-ups. They choose for others and they achieve their desired goals with indifference for others and even by hurting others. The stereotype associated with this style is that of people “walking on eggshells” around the aggressive person.

A sub-style is the Passive-Aggressive Style. A person with this style is predominantly passive most of the time. This person feels anger and resentment due to their passivity. Some express this anger in a sneaky manner by being outwardly passive but behind the scenes getting revenge. The person may spread rumors, undermine another’s efforts, cause property damage, or even manipulate relationships. Others will be generally passive and build up such anger and resentment over time until they have an aggressive outburst or angry explosion. Usually, they dislike this angry outburst, feel guilty and ashamed, and return to being generally passive. The stereotype could be “Backstabber” or “Ticking Time Bomb.”

Finally, there is the Assertive Style. This is the ideal to which we strive. The definition provided by Alberti and Emmons in their book, “Your Perfect Right,” is:

Assertive behavior promotes equality in human relationships, enabling us to act in our own best interests, to stand up for ourselves without undue anxiety, to express honest feelings comfortably, to exercise personal rights without denying the rights of others.

A person with an Assertive Style expresses their own rights, needs, and desires while respecting others. They are emotionally honest, direct, and expressive in a respectful manner. They are self-enhancing and they work through their emotions in a constructive manner. They feel good about themselves. The behaviors they display include: valuing self and others, being self-confident, communicating effectively, choosing for themselves, and being more equal and honest in relationships. This person achieves their desired goals without harming others.

Some key aspects to improved assertiveness include: developing self-knowledge or self-awareness, improving effective communication skills, developing strong boundaries, and managing emotions. These will all be topics of future posts.

Do you have any experiences with these communication styles you would like to share and any knowledge you have gained related to this topic? 

Knowing, Protecting, and Expressing Identity

I think therefore I am - Descartes. But who am I? How do we know who we really are (identity) and how do we honor that unique person?

Without a sense of identity, people flounder. They can have difficulty in relationships with others and trouble maintaining stability in life. Poor sense of identity is an underlying cause of many maladaptive behaviors and much mental anguish.

Identity is a sense of one’s unique self which is separate from others and is in relation to others. It includes what we believe, our preferences, values, passions, unique talents and attributes, and the groups with which we associate.

Closely connected with identity is self-esteem which is an evaluation of one’s own worth.  It includes the amount of confidence in self based on experience and on successful achievement.

Our identity develops from our genetic composition and from the beliefs and values taught to us by caregivers. Then it is honed by our own experiences and assessments, is influenced by society and culture, and is adjusted in response to feedback from others and to our experience of outcomes.

We honor our unique identity by developing healthy boundaries (the limits we set) and by having an assertive approach to interpersonal interactions.

A couple of useful books on boundaries are: 

1. Boundaries, Where You End and I Begin by Anne Katherine, and
2. Facing Codependence by Pia Mellody.

An assertive approach to interacting with others serves to: express our true selves honestly, protects the self, gets one’s needs met, and allows one to have safety in relationship with others.

In my next post, I will discuss several styles of interpersonal interaction, including the assertive style.

Readers, do you have anything you would add, especially any references to good books on these topics?

Feel the Fear and Do It Anyway

I first read, “Feel the Fear and Do It Anyway” (1987) by Susan Jeffers, as a college student. A few key points have remained with me throughout life, even without specifically going back to the text for a reference.

The title itself has often been a mantra in the back of my mind. In situations where I want to take a beneficial course of action, but I am nervous about my ability or the actual outcome, I tell myself, “Feel the fear and do it anyway.” It helps me to have the energy and confidence to take action.

In explaining how to get past fear to make a decision, Jeffers points out that at each step, we make a choice. Then, we find out how that turns out. If we do not like how it turns out, we make another choice. There is always another choice to be made. This seems obvious when stated, but we can tend to operate as if a particular decision is all there is. We tell ourselves we have to get it right. In actuality, we cannot know all aspects or know for certain the outcome of our choices. It is more important to know we can make further choices and that we are capable of managing what comes of our choices. I believe my grandmother used to say, “What come, what may.” Jeffers states, “Every time you encounter something that forces you to ‘handle it,’ your self-esteem is raised considerably. You learn to trust that you will survive, no matter what happens. And in this way, your fears are diminished immeasurably.” (Chapter 7, p. 117.)

In chapter eight, a life grid is presented which shows the importance of diversifying the number and type of people or activities which we value. I have used this grid to help get this concept across to my clients. For example, some people put all of their focus and energy into a relationship with another person. Nothing else in life is of much significance. In this instance, the grid is a single large box filled completely with RELATIONSHIP. If that relationship ends, the box goes blank, demonstrating what the person has of importance in their life – nothing. This puts the person into crisis. Instead, if a person develops several areas of value, several areas in which they invest their energy and focus, then they have an actual grid of several squares, each representing a different area of importance in their life: school, work, friends, relationship, hobby, spirituality, health. In this situation, if one area of importance slips or struggles, there are still several other areas which remain important and bring value into the person’s life. The multiple areas of value buffer and support the person while struggling in the one area. Their entire life does not go into crisis.

In an article related to this topic, “How to Make Yourself Do It When You Just Don’t Want To,” Halvorson lists as reason number one for procrastinating “being afraid you will screw it up.” While Jeffers emphasizes developing confidence in one’s ability to handle any outcome, Halvorson encourages thinking of the possible negative outcomes of non-action as a motivator to go ahead and do the thing you are nervous about doing. She also discusses a couple of other reasons for procrastination and specific ways to address them. http://www.psychologytoday.com/blog/the-science-success/201402/how-make-yourself-do-it-when-you-just-dont-want

Jeffers’ book is helpful to people who know they could make changes and improve their experience of life, but who stay frozen by their own fears.