Your Depression Map


From the Introduction

"I don't know what to do. I just… I don't know what to do."

Javier stared at his hands, his eyes red, his hair askew. He sat slumped forward, elbows on his knees. His voice carried with it a tone of exhausted desperation. His depression had been spiraling slowly and seemingly endlessly downward. Nothing he'd tried had helped. And as the enormity of the task of recovery seemed only to increase, his energy sagged ever lower. Now the idea of taking action to get well seemed like a cruel mockery. He could hardly manage to brush his teeth and drag himself to my office, let alone change his life.

Years earlier, during my training, I would have felt tempted to join him in his hopelessness, his sense of futility. The idea that Javier would crawl out of the depressive abyss he was in would have seemed a remote possibility, as unlikely as a stone suddenly deciding to take flight.

But he did. Javier got well. He got well in the way that tens of thousands of people are recovering from depression right now, as you read these words: gradually, step by step, using techniques and treatments demonstrated effective in study after study.

Depression is a formidable challenge to anyone who has the misfortune to experience it. But it does get better. There are established strategies that work. The biggest roadblock is often the sense of hopelessness that is itself a symptom of depression. Even that, however, can be dealt with.

I still get asked the standard question at parties: "Isn't it depressing to work with all those depressed people?" It isn't. An image came to me on one of these occasions, and it has stuck. I feel as though my clients are powerful knights, off to confront a particularly fearsome dragon. I am the page, standing by the horse, handing them the weapons for the battle. It is an inspiring position to be in. And how much more inspiring to know that the tools are effective, that they are constantly being strengthened, and that the knights win more and more of the skirmishes. The dragon has its secrets, and they can be known.

The Kwaguilth people of coastal British Columbia have a powerful figure in their mythology: Tsonokwa, the wild woman of the woods. She is a terrifying cannibal who threatens to kill all she meets. But she too has her secrets. An encounter with Tsonokwa brings both danger and opportunity. Those who learn her secrets can deal with her, can outwit her, and can become stronger and wiser in the process.

Sometimes I think the Kwaguilth had depression in mind when they spoke of her.

The Map

This book is based on principles derived from the extensive research literature on depression, and from the experiences of the many people with depression I have seen. Here are a few of these principles:

· Depression is not a single illness. It has a variety of forms and a multitude of causes.

· Many strategies have been found to be helpful in depression's treatment.

· Effective treatment involves matching the strategies used to the causes and nature of the particular individual's depression and life situation.

Let's explore these ideas a bit further.

"Depression", as a diagnosis, is a label that we use to describe a collection of symptoms. Why do we bother diagnosing people? It's tempting to answer that we do so simply because someone is depressed. But why bother saying so? What's the point?

The diagnosis of illness has a function. It is designed to point us in the direction of a treatment. Once we know what the person has, we should know what to do about it. Do we give penicillin? Do we recommend bed rest? Do we advocate carrying on as normal? The answer to these questions may depend on the diagnosis.

Diagnosis boils down a wide variety of symptoms into a single name. Someone might complain of fever, which is common to any number of illnesses. She also has a painful sensation beneath the jaw, a loss of appetite, headache, and back pain. Each of these symptoms is characteristic of a variety of illnesses. But the combination might point in just one direction. And once one knows that direction, the treatment becomes clear. When it is established that the person has, say, mumps, we know what to do about it.

People also differ in the way they experience the same disorder. One person might have a particularly high fever, while another's is lower. One person notices swelling on one side, another on both sides. Some people also notice and report symptoms more than others do, or focus on certain symptoms and ignore others. The musician complains that her hands are shaking, while the mathematician reports on the fogginess of his mind. The underlying disorder might be the same in each case.

The diagnosis is designed to point in the direction of a treatment that will help both the musician and the mathematician. In other words:

Causes and symptoms lead to diagnosis, and diagnosis leads to treatment.

The diagnosis determines the treatment. The purpose of knowing the causes and symptoms is only to aid in the diagnosis.

But which treatment should be attempted? In the case of depression, studies have shown that multiple treatments are effective, and none is perfect. Every treatment for depression is helpful for some people and useless for others. How do we know which one to choose?

Part of the answer, as we shall see, is that there is more than one diagnosis. Depression is actually a cluster of related disorders, and some treatments work better for some of the subtypes than others. This doesn't solve the problem, however. Even those diagnosed with the same subtype differ in the treatments that will be helpful.

A different model is needed, one in which the selection of treatments is based not on the diagnosis, but on the specific cluster of symptoms and causes experienced by the person. As well, individual treatments are discarded in favor of broader treatment plans , in recognition of the fact that most depressions are best treated by using several approaches at once.

We could also rename the treatment plans strategies , since "treatment" to many people sounds like a passive process carried out by others. In truth, depression is never really treated by professionals. It takes the consent, desire, dedication, and will of the person with the depression to get well. If you have depression, the odds are overwhelming that you will get well. And when you do, it will be your efforts that brought you back to health.

In this book, you will be asked to consider your symptoms and the causes that seem to have contributed to the depression. You will then select strategies, or treatments, based in large part on these specifics.


Organization of the book

This book is designed to guide you through a lot of information on depression in search of the best strategies for your situation. Some chapters will relate more closely to you and your experience than others. As you complete the exercises, you will be directed toward certain chapters that are likely to be particularly helpful for you. That said, it will likely be valuable for you to read the entire book.

The book is divided into two main sections. Part One, &Finding the Path," covers a broad range of material on depression and some of the roadblocks to effective change. It also lays the groundwork for everything that is to come. Part Two, "The Journey" provides chapters on each of the main approaches for overcoming depression. By the end of Part One you should have a reasonably clear idea which of these approaches are likely to be the best for you.

Chapter 1, "Journeys: The experience of depression," opens with descriptions of various people's experiences with depression. It then describes the major diagnoses associated with depression. The prevalence and course of depression are discussed.

Chapter 2 argues that our culture promotes some unhelpful ideas about depression and its cure - ideas that can stand in the way of getting well. This chapter discusses some of the myths about depression and invites you to consider which of them might be holding you back.

Chapter 3 presents several ways to understand the experience of depression, beginning with a basic model and building toward a comprehensive view: the Depression Map. This understanding incorporates a much broader perspective of depression than people typically see, and is supported by the research. The ways in which symptoms cascade and build on one another are discussed, and resulting strategies for promoting change are highlighted.

Chapter 4 discusses the symptoms of depression, including some that have found their way into the diagnostic definitions of depression and others that have often been ignored. As you read, you will be asked to identify the symptoms of your own mood difficulties using the Depression Map. This is the first step in arriving at a treatment plan for yourself.

Chapters 5 to 7 address the causes of depression. We look beyond the "chemical imbalance" and "environmental stress" points of view to provide a comprehensive examination of how individuals become and stay depressed. An exercise that covers all three chapters enables you to relate these causes to your own experience, and to select promising intervention strategies accordingly.

In Chapter 8, "Charting Your Course," you are asked to complete a questionnaire on your experience of depression. Your replies will point the way toward promising coping strategies.

Part Two, "The Journey," consists of chapters and exercises on the various treatment strategies that have been found to be effective. You will probably find that some of the ideas are particularly helpful, while others do not apply to your situation. The exercises in Chapters 4 to 8 will help guide you toward the best.

Regardless of which strategies you eventually use, goal-setting will be essential. Chapter 9, "Getting ahead by giving up," discusses effective goal-setting strategies that can be used regardless of how else you decide to manage your depression. You will be asked to identify your own goals, and you will be provided with a set of techniques for working toward them.

Chapters 10 and 11 consider some sources of outside help. Chapter 10 reviews the different professionals who treat depression, and provides specific recommendations for dealing with each. Chapter 11 discusses the different types of psychotherapy available and how to choose between them.

Chapter 12 emphasizes the role of your own behavior, and discusses some of the most important lifestyle-based approaches, including exercise, diet, and sleep.

Chapter 13 examines physical approaches to depression. It opens with a discussion of pharmacological strategies for altering depressed mood. This section presents the most widely-used medications, how they work, and how to avoid some of their pitfalls. Other physiological treatments are then discussed, including information on nutrition, electroconvulsive therapy (ECT), and newer approaches.

Chapter 14 emphasizes the role of thoughts in depression. All of us see reality imperfectly. During depression these imperfections in our ideas about the world become magnified and can serve to lock the depression in place. The first half of the chapter aims at increasing your awareness of the changes that your own thinking goes through. The second half provides strategies to unravel and "reprogram" negative, unrealistic, or unhelpful thinking.

In Chapter 15 the place we give emotion in our lives is considered. Emotion is a central part of being human, but all too often we regard it as an impediment to be overcome rather than a powerful personal resource. The metaphor of a river is introduced to point toward recommendations and practices for changing the way that we relate to our emotional lives. This chapter also examines the role of stress in depression, and provides strategies for managing stress effectively.

Chapter 16 examines strategies for coping with some of the situational factors that contribute to depression. This chapter considers overwork, financial management, time management, and coping with the inevitable challenges that life throws our way.

Chapter 17 stresses the point that we are social beings. Isolation and difficult social relationships are powerful factors in promoting depression, and working on these areas of your life can have large payoffs. A series of strategies are provided for working with relationships and building a sustaining social life.

Chapter 18 examines the role of meaning in your life, and encourages you to ask what you find meaningful in life and what holds you back from giving these activities a central role.

Finally, Chapter 19, "The Road Ahead," considers the idea of coping after a depressive episode has passed. It provides strategies designed to reduce the likelihood of becoming seriously depressed in future.