To repeat: the sadness in depression is caused by (a) making negative comparisons between (i) your perceived actual circumstances, and (ii) some hypothetical circumstances--for example, what you would like to be, or what you think you ought to be, or what you are accustomed to -- in combination with (b) a sense that you must do better and are helpless to change the actual or hypothetical circumstances. There is a variety of possible reasons for making such negative comparisons persistently.
This chapter outlines a step-by-step strategy for fighting depression. The first two steps inquire into the unfavorable self-comparisons, asking: Which particular negative self- comparisons are most frequently in your mind when you are depressed? and Why do you persistently make these negative comparisons between your actual state and your benchmark state? The third step examines whether there are side-benefits of depression you must deal with. Step four inquires into the sense of helplessness that converts your negative self-comparisons into sadness. Step five is the preparation of a plan of intervention into your thinking process. And step 6 swings you into action, both in dealing actively with your thinking processes and also in getting you off your depressed duff into a more active and pleasurable mode of life which helps counteract depression.
Step 1): Find out which negative self-comparisons you are making, and in which ways you feel helpless to achieve what you think you must achieve.
As described in Chapter 10, you do this by writing them down as in Table 10-1. A therapist can help by urging or encouraging. If you have trouble stating the neg-comps, a therapist can use the tools of the clinical art to learn the content of the your consciousness--that is, what you think about while feeling sad.
Of course, this may require some probing. For example, you may immediately say that you are suffering because a beloved spouse has died. But instead, you may say (as many do) that you think poorly of yourself because you are depressed, in which case further inquiry is needed. This may lead to such negative self-comparisons as that you feel like a failure in your work, or you feel that your life has no meaning, or that you are guilty of dishonest conduct.
The particular negative self-comparisons you are making may not be of importance in themselves, and they may change over time. But inquiry into these self-comparisons can help you, or your counselor, trace the causes of your depression.
Notice how this first step requires observing yourself, and noting the thoughts that lie in your mind.
Concerning the sense of helplessness, notice your reactions when you contemplate your negative self-comparisons and ask yourself why you do not change your actual or hypothetical circumstances. Observe yourself saying that you cannot, must not, are unable to, are not allowed to, and so on -- all manifestations of feeling helpless to do anything about your condition, and therefore hopeless about improving your life and mood.
Step 2): Try to learn the causes of the negative self- comparisons, and of the helpless attitude.
By self-inquiry, or in discussion with a counselor, try to trace the causes of your making the negative self-comparisons. Perhaps you (and your counselor, if you have one) can figure out, for example, whether as a child you were frequently rebuked by your parents, whether you have work goals which seem very difficult for you to attain, whether you interpret your everyday experiences in a reasonably objective fashion, whether it is reasonable for you to feel unable to improve your circumstances, and so on. In this diagnostic state, the categories discussed in earlier chapters (and portrayed in the various boxes in Appendix A) may serve as guides to the inquiry.
A systematic attempt to diagnose the causes of the depression using these categories--or any categories---was not part of traditional psychoanalysis. Freudians have assumed that the therapist knows in advance what the cause is--childhood loss of a parent or of parental love. But I hope that by now you are persuaded that there are many, rather than just one, possible causal elements involved in depression.
Cognitive-behavioral therapists tend not to seek the original causes of a person's depression. And I agree that depression can often be cured without knowing the original causes, by focusing only on the present thought patterns. But sometimes learning the original cause illuminates the present situation. For example, when I realized that my over-demanding work goals stemmed from the ought's my mother urged on me, I immediately saw that I should not continue to enslave myself to them, and in that moment I gained a great sense of freedom which sent me on my way out of depression.
In this diagnostic stage you must use your entire store of wisdom, insight, and experience. Counselors have a store of experience that non-psychologists lack, and that is one way they can be helpful. Another way they can be helpful is to offer a less biased interpretation of events in the past and present than a person has himself.
Step 3): Check whether there are any "beneficial" aspects of depression which act as obstacles to letting go of your depression (see Chapter 9).
If there are--for example, the desire for the fruit of depression-causing overwork, or the pleasantness of self-pity-- then you must choose between staying depressed and giving up the benefits of depression.
If you discover such a benefit which presents an obstacle to the cure of your depression, you must be honest enough to acknowledge that you can't have it both ways; you can't have both the cure and the fruits of depression. With this acknowledgment may come some sensible compromises. In the case of the depressed adult who fears punishment for some actual deed, it may be possible to tackle the possibility of legal or moral punishment head-on to ascertain what (if any) punishment may really be warranted, and to get it over with if possible. In the case of overwork, understanding the obstacle to a cure may lead to a choice of work level that will be an optimal combination of work output and depression.
Giving up the state of depression, and fighting it off when it threatens to come back, has costs. I repeat this because it is important to understand that it is so. An important cost is the energy required to grapple with the depression, just as it takes work and energy to staunch the bleeding from a wound. It is often easier to let the blood flow, than to repair the wound-- that is, easier to let the negative self-comparisons course through one's mind than to examine them and either rebut or repress them.
Depressives are not skilled at staunching their mental bleeding--their negative self-comparisons. Everyone gets battered and cut in the world of people and work, but the depressive tends to let the bleeding go on and on. And it takes much work to change one's habits in this respect. But it must be done; it is the price that must be paid if you are to escape from depression. More about this in the next section.
Step 4): Address your sense of helplessness and hopelessness.
It is an accompanying sense of helplessness that converts negative self-comparisons into sadness and eventually depression. Therefore, if you can acquire the attitude that you are capable of altering your life situation, rather than simply accepting it, you can reduce sadness. Tactics for dealting with helplessness are discussed in Chapter 17.
Step 5): Intervene in the depressed person's thinking with the aim of reducing negative self-comparisons and the sense of helplessness.
Let us assume that drug therapy will not be used for now. Yet something stronger than rest and distraction is necessary. The type of intervention must then be determined by the causes of the depression diagnosed in the previous steps. The chapters to come discuss specific ways of intervening for specific sorts of problems.
As a review and preview, here are the various ways of battling your depression: (a) Improve the numerator in your happiness ratio by altering your perception of the facts of your life. (b) Sweeten your ratio by changing the benchmarks you use for self-comparisons. (c) Change the dimensions on which you evaluate yourself. (d) Reduce the number of self-comparisons you make. (e) Diminish the sense of helplessness and increase your sense of competence to change your actual circumstances and hypothetical benchmark states. (f) Change aspects of your life that lead to negative outcomes. (g) Use Values Treatment.
Several sorts of interventions may be useful for any particular sort of cause. For example, one might intervene entirely in the present by creating habits to shut off the past, or one could also delve into the past to help relieve the problem. But one mode of intervention may be more efficient and successful than others.
Your past history, and especially your childhood, is almost inevitably involved in your depression. But the influence of the past can be relatively great or relatively little, and it may be relatively difficult or relatively easy to pry you loose from the relevant aspects of the past. The other side of this coin is that changing your present conditions may have greater or less influence, depending on the strength of the influence of the past on your mood.
An analogy may help. Consider a building's plumbing. A faucet that was installed some years ago is leaking badly. If the faucet was weak at the time of installation, then past events influence the present leak. If one can replace the faucet and thereby resolve the problem, the present situation can be effectively separated from its past, just as some habits people have can be changed in the present without further influence by the past that created the habit. But it may be that a new faucet will also go bad quickly because the rest of the plumbing that was installed years ago is defective and will ruin the new faucet. If so, the present leaky faucet problem cannot be separated from the past in a simple way, but rather the entire system created in the past requires inspection and repair. Just so with some kinds of contemporary behavior: a person may take herself out of one depressing situation and invariably find her way into another depressing situation because of some general tendencies created in the past.
This suggests that therapeutic strategy depends upon the continuing role of the person's past. That is why it is often (though not always) useful for you to know the cause of the present negative self-comparisons before deciding whether to concentrate on your present or your past. To paraphrase Robert Frost, "Find out why a fence was put up before you tear it down."
Step 6: Get into Action.
Two kinds of action are important: carrying out our self- curative plan, and participating in the worlds of work and of pleasurable life activiity. Let's talk about them in that order.
Excellent self-knowledge and terrific plans by themselves will do you no good. Your plan of action will help you only if you carry it out. More specifically, this means that you must WRITE DOWN your thoughts and the analysis of them, as in Table 10=1. In many cases, it also means carrying out actions that will liberate you from hang-ups with respect to other people or with respect to phobias such as fear of elevators.
Yes, writing your thoughts requires effort. But this one thing only can I guarantee you: If you don't make at least some effort, you will either remain mired in your depression for a long time, or at the least you will remain in it for longer than you need to.
Two wise therapists put it this way:
We can't say this often enough: the major function of therapy is educational. To have therapy sessions or to read self-help books without practicing and without doing homework assignments is like attending lectures at school without reading or studying. It is like taking piano lessons without practicing. You may get something out of it but only a fraction of what you might otherwise have derived. Keeping a notebook, recording observations about your own thinking and behavior, and practicing new thinking and behavior are the best ways of changing.1
Again, writing your thoughts, and carrying out other curative actions, requires effort. This means laboriously hauling yourself uphill rather than sliding effortlessly downhill. Exerting effort requires expenditure of energy and will. It is a drag, a cost.
Now let's talk about the second type of action you must crank up, participating in the worlds of work and of pleasurable life activity. Even normal people do not readily expend the energy and will that they believe would be sensible for them in the long run--in exercising for fitness, for example. And depressives typically have an even greater propensity than do normal people for not swinging into action and doing the things that they believe they ought to do for their own well-being.
A few depressives, like me, are lucky enough to go in the opposite direction of working too much rather than too little. This has the benefit that when they finally come out of their depression, their lives are not blighted by the accumulation of problems caused by lack of work while they were depressed. I was lucky enough to enjoy my main work, writing and research, and to find it easy to do, and therefore it required little energy to stay at it. Indeed, the hours while I was writing were the only oasis in my life when I could concentrate on what I was doing and not be obsessed by my depressed thoughts. My too-strict work discipline, which is a problem for me in other ways, was also a benefit at this time.
Some people have said to me that my working meant that I was not "really" depressed, because not working is a standard symptom of depression. All this proves is that not all depressives have the same auxiliary symptoms. Whether a person should be called "depressed" properly depends only upon that person's thoughts and feelings, and°on how long the sadness persists.
Why don't non-depressives people get right at the tasks that they know they "should" undertake for their own good? You know the answers: (a) They prefer leisure to exertion. (We are talking here, of course, of work which is not so enjoyable that people have no difficulty getting themselves going.) (b) They convince themselves that not doing the task really won't be very harmful, and doing it will not be very beneficial. (c) They fool themselves that they are just postponing the task for a short time, and keep repeating the procrastination. (d) They start the task and then give up because they lose patience.
Depressives share all these patterns of inactivity with non-depressives, but more so. They give themselves more excuses for not acting, they have less patience with which to continue a frustrating task, and so on. So whereas normal people often are too slow starting but eventually do start, and are too quick to quit but at least get most or the task done, depressives may never get started, or else stop when they have barely begun.
Depressives also have some special twists of their own. Among these specialties of depressives are: (a) They often are afraid to get going because then they must give up the benefits of being depressed (see Chapter 8). (b) They lack hope that the task will result in success, and therefore have a special excuse not to start. (c) They often have ridiculously high standards for successful accomplishment of the task, and therefore have "rational" grounds for believing that they will fail. (d) They are experts at manufacturing logical reasons why it is not worthwhile getting into action.
The worst part of the depressive's inactivity hang-up is that inactivity breeds a greater propensity to remain inactive. The depressive first fails to act, then berates himself for being a worthless person because he fails to act, then fails to act because he knows he is so worthless that attempting action is useless and a waste of effort, and on and on and on. If ever there is a vicious circle, full of negative feedback, this is it. The circle becomes tighter and tighter until, like the famed boudini bird which flies in ever-narrowing arcs, it disappears into its own anus.
How to get out of the vicious circle? The theory is as simple as the execution is difficult: Get started in even the smallest way, enjoy some satisfaction and pleasure from successfully carrying out even a tiny task, and then use that experience as the basis to do something just a little bit bigger. Just DO SOMETHING.
It is here that the theory and skills of behavioral therapy are at their most effective. The idea is to get a benign circle going, with positive feedback. In that way the arcs gradually become greater and greater with self-reinforcing vigor, until -- reversing the natural history of the boudini bird--you are in self-sustained flight and zoom out of your depressed inert state.
There are lots of practical tricks that can help you. The chapter on "Do-Nothingism: How to Beat It" in David Burns's book Feeling Good contains a host of useful suggestions. Or, a counselor may be particularly useful in this role, especially if you and the therapist have a clear understanding that you want very specific help on the very specific problem of getting doing, doing something, and eventually carrying out your plan of action.
Judaism differs from Christianity in its belief that actions are more important than beliefs. If an orthodox Jew consults a rabbi about a crisis of belief, the usual advice is to carry out the daily routine of being a Jew, and not worry about the beliefs. Experience has shown that belief often follows after the actions. And even if the belief does not follow, the sense of crisis usually seems to disappear.
In the same way for a depressive, actions lead thoughts. If you start doing things, even the littlest things, and feel satisfaction about them, you will feel more capable of doing more, and you will think you are less worthless, and then you will do more.
Not only the world of work but the world of pleasure is also important. Here I'll merely repeat the important advice given earlier, advice which every competent therapist agrees with: Do some things which you enjoy. If you enjoy dancing, go out and dance tonight. If you like to read the funny papers before you start work for the day, read them. If you delight in a bubble bath, take one this evening. Let the very first move in your anti-depression program be some activities that will brighten your days with some of these innocent pleasures.
***[OUT?] How can you be sure that what I tell you here is true? You can't know for sure, without thorough study of the large scientific literature, and even then you could hardly be sure. But I make these two suggestions: (1) Have a little faith in me and other writers on this subject, and do what we suggest. (2) If you cannot muster a bit of faith in us, at least have faith in the scientific method. That is, try this plan out. If the process works, you will gain. If the process fails, you can Right?
This chapter describes the strategy for fighting depression. Steps one and two examine the unfavorable self-comparisons you are making. You ask: Which particular negative self-comparisons are most frequently in your mind when you are depressed? and, Why do you persistently make these negative comparisons between your actual state and your benchmark state? The third step examines whether there are side-benefits of depression you must deal with. Step four inquires into the sense of helplessness that converts your negative self-comparisons into sadness. Step five is the preparation of a plan of intervention into your thinking process. And step 6 moves to action, both in dealing actively with your thinking processes and also in getting you into a more active and pleasurable mode of life which helps counteract depression.