Dr. B's Blog

Churchill and the Stigma of Depression

This article is an interesting follow-up to the previous entry I made. I think that the author does an effective job teasing apart what works and for whom:​

In the case of depression, the core stigma is that depression is a weakness, a moral failing. That depressed people are soft, weak, pitiable. This attitude is specific to depression – not even bipolar disorder is seen in the same way, let alone the other diagnoses. They have their own stigmas. Depression’s is weakness.

Now this is why Churchill is a good counterexample. Not just because he’s famous or ‘great’, but because he was famously tough. He faced down Hitler. He was blood, sweat and tears. In the most famous photos of him (and they are famous, out of all his photos, because they correspond to the mental image) he is almost unsmiling – but never despairing. Just resolute.

I think the key here is the notion of Churchill being a counterexample ​and not just an example of someone with mental health difficulties being successful. It's the notion of opposite action in, ahem, action. By that, I mean that we have someone dealing with the syndrome of depression. Withdrawal, isolation, self-doubt are all part of this syndrome. What we see in someone like Churchill is that he's working to act opposite to those action urges. 

Perhaps what makes a good role model is to highlight someone doing behaviors that are specifically opposite to the action urges we're trying to deal with. Again, some research is needed here, but two articles to start the conversation.​

If it's raining outside.

If it’s raining outside, and you happen to be out there, you’re probably going to get wet. That is, unless you’ve prepared by bringing a raincoat, umbrella, poncho or trash bag. This truism is often the way I frame my discussion of emotion. It’s generally accepted by most people that when it’s raining outside, you’ve got a couple options to avoid getting wet - prepare by bringing the aforementioned gear or don’t go outside. To expect not to get wet without doing either of those things is kind of absurd1. Natural reactions - getting wet - to everyday occurrences - rain - are, umm, natural, and, double ummm, normal.

We don’t expect people not to get wet just by willing themselves to be dry or by believing that if they only thought about things differently, they’d stay dry.

Or that if “normal” people were in the same situation, they’d be dry.

It’s. Just. Not. True.

If someone is able to stay dry in a rain storm, chances are they’ve got a nice big golf umbrella, a good pair of hiking boots and a fancy Gore-tex jacket. You may not have any of those things right now, but you can learn to get them. And, in the meantime, you can work on using what you’ve got, maybe a trash bag or an old newspaper, to keep yourself as dry as possible.

With that tidy metaphor out of the way, let’s get down to the business of learning about emotion. Understanding it so that we know what we’re dealing with. Emotion comes from prompting events. These events can be internal (e.g., thoughts) or external (e.g., a car accident). They can be actual or they can be just perceived. It doesn’t really matter because in dealing with emotions, perception is reality.

A prompting event can lead to an interpretation of that event. These interpretations are deeply personal and are often what people think of when they try to deal with emotions. I don’t know how many times I’ve heard, “If I could just think differently, I wouldn’t feel so bad.” That’s sort of true. And sort of not true at the same time. In other words, just thinking about things differently (or changing your interpretations), is not always going to work to change how you feel2. If it always were so easy, self-help books would be all anyone ever needed for therapy and I’d be out of a job!

A prompting event can also lead to any number of physiological reactions. When you get frightened and get goosebumps? That’s the sort of thing I’m referring to. Flushing face, tension in your shoulders. Additionally, interpretations can also lead to physiological reactions. “Someone’s broken into my house and my life’s in danger” will lead to a racing heart and quickened breathing, for example. These physiological reactions are hard-wired and not something that we can just stop doing3 right away.

We then have what are called, in DBT parlance, “action urges.” These are the things that you are driven to do as a result of the situation/interpretation/physiological reaction. When you’re scared, you run. When you’re angry, you lash out. When you’re ashamed, you hide. Again, these are all considered hard-wired reactions. Think of it from an evolutionary perspective. Back in the day, things that caused fear were often life threatening. It made sense to run when your life was threatened. Right?

So, we have at least 3 sources for the formation of an emotion. There are other potential sources, such as history and vulnerability factors, and we’ll get to those in another post. But, to get back to our metaphor, there are 3 storm fronts that are moving your way and there’s not much you can do to keep them from getting to you. At least right now, all you can do is cope with them4.

Footnotes:

Not absurd in the “crazy” way, but just absurd in the strict definitional sense.↩

Read about behaviorism and learning theory to understand why.↩

We can do things like progressive muscle relaxation to deal with these reactions.↩

As we progress through these skills, you’ll be able to control the weather. How cool will that be?↩

Group 06/24/2011

Today we continued our discussion of distress tolerance skills. We reviewed the importance of practice even when not distressed to be ready for the times that we are. We also talked about the ways in which we might not even realize that we are going through a crisis. One of my colleagues, Dr. Martha Golden, likes to start this module with a definition of "crisis" and I think that may be appropriate here as well.

A crisis is defined as:

specific, unexpected, and non-routine events or series of events that [create] high levels of uncertainty and threat or perceived threat

This does not mean that there will be a catastrophe as a result of the event; just that there is a perception that it might. We then moved into discussion of the new skill: accepting reality. We practiced several exercises from Distress Tolerance Handout 2 and each picked an activity to do for homework.

We then discussed the concept of "Half-Smiling" as a way to respond to emotional experiences on a physiological level allowing us to work on counteracting that strong, and often unaddressed, aspect of emotion. As before, we practiced half-smiling.

Both of these activities - observing your breath and half-smiling - are experiential interventions, meaning practicing them and tweaking your practice is essential to making them work. Next week, we'll be discussing more reality acceptance exercises and the concept of radical acceptance.

Dr. Linehan talks about her own struggles.

Dr. Linehan has been an inspiration to many, including me, in trying to figure out how to deal with borderline personality disorder. I count myself among the fortunate few who have had an opportunity to be trained by Dr. Linehan and her "children" during my own training to be a DBT therapist. Does this revelation that she, herself, has struggled with borderline personality disorder change the way I think of her? Yes, but only in the most positive ways: I knew that she talked the talk, but now I know that she walks the walk. When I teach skills to my clients, I often use personal examples as illustrative. I don't have any illusions that my own personal struggles match in intensity their own, but I do think it's helpful to share how the skills I'm teaching have helped me. The stigma associated with chronic mental illness is real and difficult to deal with. Even more for those who already struggle with emotion regulation.

The NYT reports:

“That did it,” said Dr. Linehan, 68, who told her story in public for the first time last week before an audience of friends, family and doctors at the Institute of Living, the Hartford clinic where she was first treated for extreme social withdrawal at age 17. “So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward.”

You are no coward, Marsha. Thank you for your courage and your story.

Group 05/27/2011

After going over the homework, we spent time discussing the importance of judgement in our lives. In light of the work we'll be doing on reducing judgement, it seemed important to make sure that we understood exactly what judgement does for us. Some of the relevant points that people made were:

  • Judgement helps keep us safe
  • Being judgmental allows us to make decisions more quickly
  • Judgement can help us correct our behavior

We, of course, also discussed ways that being judgmental makes being mindful hard.

  • Being judgmental makes us compare our current experience to past and/or imagined situations, moving us from being present in the moment to being elsewhere
  • Being judgmental generates extra emotion; emotion that we probably don't need help creating
  • Being judgmental also makes us focus on details to the exclusion of the bigger picture, again making it hard to see the whole situation as it is

Tying the non-judgmental stance work we're doing to the next module to be covered in group, Distress Tolerance, homework was to answer two questions:

  1. How does being judgmental create distress?
  2. How does being unmindful create distress?

Next week: beginning Distress Tolerance module.

Group 05/20/2011

In today's group, we reviewed making wise mind choices and discussed all the factors involved in making a wise mind choice. As we discussed last week, it's important to consider all the facts of a situation, how you feel about it and what your body tells you about it. There were a couple other key points addressed in the homework review: make sure you address both sides of the question and a wise mind choice does not need to be permanent. That is, you can decide to decide later.

The new material consisted of an overview of the Mindfulness "What" skills:

  • Observe: Just notice using your senses, without words
  • Describe: Just the facts. Only observable information should be described. No interpretations, assumptions or judgements.
  • Participate: Just do it. Within the Participate skills, we broke it down to 6 levels of participation:

    1. Wake up
    2. Get up
    3. Show up
    4. Act as if you care
    5. Wholeheartedly
    6. Flow

Homework: choose one of the "what" skills and practice it.

Group 05/13/2011

Today in group we discussed the core mindfulness skills. We went over the pros and cons of each state of mind - Reason mind, Emotion mind, Body mind - and how they can be used to help make Wise Mind choices. The premise is simple: make sure you're attending to each of these states of mind, stop, synthesize and make a choice that balances each of these factors as appropriate to the situation. During the discussion of Wise Mind, we reviewed times each of us has been in a wise mind place and how it physically feels to be make a wise mind decision. For many people, wise mind lives in your diaphragm. It "feels right" in your body, particularly settled, in that place.

Homework: Making a wise mind choice. (Homework handouts)

More on rain

  • How do you predict the rain?
  • How do you predict emotion?
  • Why do we still get caught in the rain?

Answer these questions and I think you’ll have a nice understanding of how one might look at emotions in a different light.

We know how to predict when it’ll rain. We understand the science behind it, but we can’t make it rain or make it stop once it’s started. Sometimes all we can do is prepare ourselves.

Similarly, we understand what creates an emotion. We can pretty well predict what might make someone emotional but we have little control over emotions.

We do have control over how we respond to them.

Progressive Muscle Relaxation

The topic of PMR came up today in one of my groups and I encouraged them to do a google search on progressive muscle relaxation. I figured I’d do the same and post my results here.

I found a site at Arizona State University that has audio of someone reading a PMR script. I haven't heard the audio but the transcript looks good. Have a listen.

Mindfulness and affective experience

A recent study (.pdf link) published by researchers at the University of Pennsylvania points to the benefit of mindfulness practice on working memory and emotion.

In the MT [mindfulness training] group, WMC [working memory capacity] decreased over time in those with low MT practice time, but increased in those with high practice time. Higher MT practice time also corresponded to lower levels of negative affect and higher levels of positive affect (indexed by the Positive and Negative Affect Schedule). The relationship between practice time and negative, but not positive, affect was mediated by WMC, indicating that MT-related improvements in WMC may support some but not all of MT’s salutary effects.

It seems like this blog is turning into one about mindfulness. This is really an unintentional side-effect of the fact that I have found mindfulness practice can be an integral part of many empirically supported psychological treatments.

Take for example CBT for panic disorder. Some core components are:

  • Identifying automatic thoughts
  • Challenging negative automatic thoughts
  • Identifying emotion associated with those thoughts
  • Interoceptive awareness and interoceptive exposure
  • Relaxation techniques

All of these key techniques are enhanced when one is practiced at being mindful. The same can be said for the treatment of depression and other types of anxiety. Further, I believe that the affective “stability” (for lack of a better word) afforded one practiced in mindfulness, can enhance life in a number of ways.

Does that mean that people who are “good” at being mindful don’t get depressed? No, but I believe that they don’t suffer nearly as much. And reducing suffering is what I try to do.