Escaping the Trance of Depression

When I was a psychology student, I learned about a phenomenon called “state-dependent learning,” based on the idea that our brains associate certain memories with specific environments, sensory experiences (smells, tastes, sounds, etc.), and internal experiences (emotions, thoughts, images, etc.). For example, if you study in a blue room, you’re likely to recall the studied material better if you take the test in a blue room or with something blue nearby. If music is playing when you fall in love, hearing that music again will take you back to those memories. The brain works by association, and certain associations bring up other associations.

This extends to emotions as well. If you’re happy, you’ll more easily recall happy memories. Thus it follows that if you’re depressed, it’ll probably be more difficult for you to recall happier memories. So, when you’re feeling helpless and resourceless, it’s harder to get in touch with resources.

And what happens when a depressed person seeks help from a mental health professional? Most of us therapists tend to ask our clients to talk in detail about their depression. Now, of course, that’s part of our task: to assess the level and history of depression. But an inadvertent side effect can be a deepening of the depressive experience as we bring it to the foreground. Indeed, a recent study shows that extensive discussions of problems, encouragement of ‘‘problem talk,’’ rehashing the details of problems, speculating about problems, and dwelling on negative affect lead to a significant increase in the stress hormone cortisol, which predicts increased depression and anxiety over time.

In recent years, we’ve learned that repeating patterns of experience, attention, conversation, and behavior can “groove” the brain; that is, your brain gets better and faster at doing whatever you do over and over again. This includes “doing” depression, feeling depressed feelings, talking about depression, and so forth. Thus we can unintentionally help our clients get better at doing depression by focusing exclusively on it.

To counter this effect, I like to use a method that I call “marbling.” My father owned several meat-packing plants, and early on I learned that marbling refers to the fat streaks embedded in the leaner meat in a cut of steak. It gives the steak more flavor. In a similar way, but with less cholesterol, in therapy I suggest marbling discussions and evocation of non-depressed times and experiences in with discussion of depressed times and experiences. This way, we don’t just evoke and deepen the depression, and we avoid losing contact with the depressed person by listening to her and being careful not to invalidate or minimize her suffering. By going back and forth between investigations of depressed and non-depressed experiences and times, the person who’s been depressed is reminded of resources and different experiences, and often begins to feel better during the conversation.

In his book Darkness Visible, William Styron, who almost killed himself while going through a serious depression because he’d become convinced that he’d never come out of that painful state, put it this way after he recovered: “Mysterious in its coming, mysterious in its going, the affliction runs its course, and one finds peace.” But in the middle of it, one often forgets that there’s any other place, or any experience other than unremitting bleakness and pain. It can be a lifeline to people in the midst of depression to have even a glimmer of the possibility that there will be experiences outside depression.

One of the first ways I suggest implementing marbling is to discover, with the depressed person, a map of her depressed times, thoughts, actions, and experiences, as well as a map of her non-depressed times, thoughts, actions, and experiences. This is like asking the person to join you as a co-anthropologist of her life so that she can help you not only learn about the contours and geography of her suffering, but also about her competence and better moments.

Let me give you an example. While traveling to do a workshop in another city, I was asked to do a consultation with a woman, Cindy, who was spinning her wheels in therapy. Cindy would get stuck in severe depressions regularly and would basically stop functioning, quit her job, and become dependent on her therapist, whom she’d call many nights during the week in the depths of despondency and desperate for help. This had happened with several therapists in different places in which Cindy had lived as an adult, and she was driving her current therapist to her wits’ end. The therapist told me, “I feel like Cindy is sucking the marrow out of my bones.”

I began my conversation with Cindy by asking what had brought her to therapy. She said she’d be fine, feeling confident and competent, and then she’d get depressed, losing her sense of confidence and sleeping until noon. There didn’t seem to be anything she or the therapist could do. The depressive episodes typically lasted about two months, after which the depressed feelings would begin to lift and she’d pick herself up and resume her life.

I asked Cindy to compare and contrast her more confident and competent times with her depressed times, and the following picture began to emerge.

During her depressed times, Cindy stayed in bed until noon, got up (but stayed in her night clothes), sat in her living room, ate breakfast cereals all day, did nothing, and talked only to her therapist and one male friend (who was also depressed). If working and beginning to feel depressed, she didn’t take her shower and get dressed until evening, went to lunch alone, thought about how she was getting worse and how she might have to move in with her father and stepmother if she couldn’t care for herself, or even be committed to a psychiatric institution if they couldn’t care for her or got tired of her.

During her confident and competent times, Cindy got up, showered, and dressed before 9 a.m., went to work or met a friend for breakfast, did art or played music, spent time with her girlfriends, met a girlfriend for lunch if she was still working, and gave herself credit for small or big accomplishments in the recent past (e.g., looking for a job, finishing an art project.)

As we talked about this, Cindy began smiling at times, even while discussing her depressive experience. (I told her that I wanted to learn the Cindy way of doing a good depression, and this phrase seemed to tickle her. She also got a kick out of my naming her depressive experiences “Depresso-land,” and contrasting it with “Confidence/Competent-land.”

We often talk about “depression” as if it were a uniform experience, but although many depressed experiences share common features, they always occur in specific and particular ways for the person in front of us. The non-depressed features are also very particular and specific. But we’re so often focused on the suffering of depressed clients that we neglect to investigate and discover other experiences that don’t fit with their depression. In Zen and the Art of Motorcycle Maintenance, author Robert Pirsig said that when an artist draws a tree, he doesn’t draw the branches and the leaves. Instead, as he draws the spaces between the branches and leaves, a picture of the tree emerges. This resonated with me because that’s what I do when approaching depression. I’m interested in discovering and detailing non-depressed experiences, actions, thoughts, and experiences. That way, I learn about the person’s abilities, competence, and good feelings as well as get a sense of her suffering.

Three Techniques of Acknowledgement and Possibility

Working with people who are depressed requires a delicate balance. They’re usually lost in their depressive experience and perspective, so you have to join them in that experience and let them know you have some sense of what they’re going through. At the same time, you have to be careful not to get caught up in that discouragement and hopelessness along with them.

I think of it as having one foot in their experience and one foot out. I call this Acknowledgement and Possibility. It involves acknowledging the depressed person’s suffering, validating their felt sense of things, and inviting them out of that experience.

When people don’t feel heard, understood, or validated in their experience, they often appear “resistant” and uncooperative in therapy. On the other hand, if all one offers is acceptance and validation, it’s all too easy to help the sufferer wallow and stay stuck in his depressive experience.

I remember a client I had early in my psychotherapy career who’d come in week after week soaking up my kind acceptance, unconditional positive regard, and empathy. She’d get her weekly support session and then go back to her miserable life. During one session—it was probably about our 22nd—I heard myself saying, “So, you’re depressed again this week.” And realized I wasn’t really helping her.

Around that time, I began to study with the psychiatrist Milton Erickson, who had many creative ways of challenging the most difficult patients to move on and change. I began to incorporate some of his methods into my work and noticed that my clients were changing much more quickly than they had before. But I still liked the warm, kind, active listening I’d learned in my elementary counseling training and didn’t want to lose that respectful approach. So I combined the best of both worlds and created this Acknowledgment and Possibility method. It not only respectfully acknowledges the person’s painful and discouraging experiences but also gives them a reminder that they’re not always and haven’t always been depressed. It can illuminate and prompt skills, abilities, and connections that can potentially lead the person out of depression or at least reduce their depression levels.

How do you join while simultaneously inviting? Here are three simple methods for putting one foot in and one foot out when talking with people who are depressed.

One: Reflect in the past tense. This technique may seem too simple, but it can have a subtle and helpful impact. It involves reflecting what the depressed person is telling you as if it has happened previously but is not necessarily occurring now. For example, if a person says, “I don’t want to see anyone,” you might respond, “You haven’t wanted to see anyone.” If the person says, “I’m suicidal,” you might say, “You’ve thought seriously about killing yourself.” In each of these responses, you’ll notice that the reflection is couched in the past tense.

Here are two statements that a depressed person might make, along with some sample “reflect in the past tense” responses.

Depressed person: “I’m afraid I’ll never come out of this darkness.”

Possible responses: “You’ve been really afraid.” “You’ve been feeling pretty discouraged.” “You’ve been worried you’ll never feel better.”

Depressed person: “Nothing will help.”

Possible responses: “Nothing has helped.” “You’ve tried a lot of things and haven’t felt better.” “You’ve been thinking that nothing will help.”

Two: Move from global to partial reflections. The next technique for acknowledging and inviting at the same time is to reflect the depressed person’s generalized statements as more partial. When the person says something like “always,” “never,” “nobody,” “nothing,” “everybody,” or another global term, you can reflect her statement or the feeling she’s conveying but using more limited words, such as usually, typically, rarely, almost nobody, very few people, little, most everyone, and so on. Your task here is to help her feel understood, but at the same time to introduce a little space into the stuck place she feels herself to be in.

Your reflections can be less global than the person’s original statement in both time (lately, recently, these days) and quantity (most, very few, almost everyone, little, rarely). For example, if the depressed person says, “Nothing is helping,” you might respond with, “You’ve tried most everything and it hasn’t worked much.”

Three: Validate perceptions, but not unchanging truth or reality. To use this technique, acknowledge and validate the depressed person’s perceptions without accepting the fixed, objective truth or unchanging reality of those perceptions.

When people are depressed, they often have an unrealistically pessimistic view of life, so agreeing with that pessimistic perspective may further discourage them. But we can’t just dismiss the person’s felt experience and tell her that her point of view is wrong. This technique involves finding a crucial balance by joining with and validating the person’s felt sense of the way things are while separating those views from accepted reality.

To do this, use phrases such as your sense; as far as you can see; as far as you remember; the only way to handle this, in your view, was; and so on. The goal is to help the person feel heard and understood without joining in her distorted or discouraged conclusions.

Here’s another example of a statement a depressed person might make, along with some suggested responses.

Depressed person: “I’ll never get better.”

Possible responses: “You think you won’t get better.” “Your sense is that there’s not much hope.” “As far as you can tell, nothing’s been working and you’re afraid nothing will.”

Of course, as you get more practiced at implementing these techniques, you can combine two or three of them in the same reflection.

I learned hypnosis many years ago when I began to recognize some similarities between a hypnotic trance and what I began to think of as a “symptom trance” or “problem trance.” Both types of trances often involve a narrowing of the focus of attention, and the induction of both involves rhythmic repetition. In Sense and Nonsense in Psychology, Hans Eysenck tells a story about a young English surgeon, just about through with his training, who was drafted into the army during World War I and sent to fight on the fields of France. On the battlefield, he came across a French soldier severely wounded by a mortar shell, writhing in pain and doing further damage to himself. The soldier was in imminent danger of dying unless the Englishman could get him to stay still until he could get him back to the surgical tent for treatment.

In desperation, the Englishman remembered a demonstration of hypnosis he’d seen during his medical training and decided to try what he remembered of hypnotic induction. But he didn’t know much French, so the best he could do was repeat again and again to the writhing Frenchman the only French words he could conjure up: “Your eyes are closing. Your eyes are closing.”

To his amazement, the Frenchman stopped writhing and his breathing slowed. He appeared to be in a trance that lasted long enough to get him back to the medical tent, where the British surgeons did indeed save his life. After the operation, the medical student told the British surgeons the story of his hypnosis. They all began laughing and told the baffled student that what he had really said was “Your nostrils are closing. Your nostrils are closing.”

What the story illustrates is that it was the repetition, not necessarily the correct words, that had the hypnotic effect. In a more insidious way, a similar process happens in depression. The depressed person repeats the same thoughts, activities, feelings, and experiences again and again and begins to become entranced. Only the trance is not a healing trance, a therapeutic trance, but a “depression trance,” which induces more and more depression as it’s repeated. Marbling can be an invaluable tool in breaking the depression trance.

This article is adapted from Out of the Blue: Six Non-Medication Ways to Relieve Depression by Bill O’Hanlon, copyright © 2014 by O’Hanlon and O’Hanlon, Inc., with permission of the publisher, W. W. Norton.