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Case Studies - Page 3

I do soft belly along with Theresa and with all my patients. It's of course helpful for me to be as relaxed and open as possible in my sessions. It conveys an important message to my patients: "We're on this journey together. I'm not an observer. I'm here with you, learning as well as teaching, experiencing life, and dealing with my own stress along with you." Dealing with depression and its challenges, and with stress, generally, is, I'm recognizing and admitting, not separate from our lives, an extraordinary response to a pathological situation, but an ordinary and ongoing part of them.

We speak in the weeks ahead about the historical context of Theresa's depression: her mother's coldness; her isolation as a young black girl in a still-segregated, white southern community; her tendency to take responsibility for the emotional lives of others—her parents first, and then her employees and lovers. Still, I'm continually bringing our focus back to what's happening right now—how present feelings reflect past disappointments, and how she can relax with, learn from, and move through them. If she were to ask, I'd explain that this is a meditative, present-oriented approach to psychotherapy.

Theresa, significantly more relaxed as well as reassured after our first session, felt encouraged and supported by the Prescription for Self-Care. Each week, I ask her about her progress, and I express appreciation for what she's doing well, while not being dismayed by what has been too difficult, or what she's ignored or neglected. Our work isn't about her "good" or "poor" compliance (what an ugly, condescending word!), but about what she can learn from difficulties, avoidance, and defeats, as well as from "success."

Sometimes, patients who seem originally committed to this Unstuck approach grow discouraged and are reluctant to pursue it. Nagging doubts remain about whether antidepressants might be the best and easiest answer, after all, or at least a necessary precondition for improvement and therapy. I respond with information on the most recent metanalyses of drug research, which show that when unpublished negative studies are included along with positive, published ones, drugs are little better, if any, than placebos. I tell patients that I'm not "against" the drugs: I just see them, with their uncertain benefits, significant side effects, and potential for habituation, as a last resort, not a first choice.

Like many depressed people, expecting to get a prescription but not much more in the way of attention, Theresa is afraid of being "left alone" with her depression. I assure her that I myself have been on the journey through and beyond depression, and that I'll be there with her at every step of her journey. I make sure she understands we'll have regular appointments—a usual feature of psychotherapy, but a major departure for people who are used to seldom seen, drug-prescribing physicians. I tell my patients they can call me anytime, and find that this reassurance is itself powerful medicine: even though patients know they can call me, that I'm always there, almost no one does.

In our first or second session, I directly address the comprehensive biological dimensions of depression. "Depression isn't a disease," I say, "but diseases of various kinds, and imbalances in biochemistry and nutrition, can cause or contribute to it." I make sure my patients see a competent primary care physician who can rule out the obvious physical causes of depression: reactions to medication, and conditions like cancer, diabetes, heart disease, multiple sclerosis, and so on.

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