When I reflect on my last bout of depression, which seized me by the teeth and chewed up nearly two years of my life, I can still feel its ferocity. I’m better now, and have been for some time. But back then, the darkness gripped me so hard that I began to speak only when necessary. Thoughts would wander into my head, but I couldn’t summon the motivation to say them out loud. My hopelessness was impervious to internal efforts to correct my distorted thinking, the company of caring friends and family members, or a succession of meds.
For a while, therapy could do no more than help me stay on the planet—a profound contribution, but one I could barely appreciate at the time. It made no difference that my actual life was bountiful, that I had rewarding, creative work and many people who loved me. It only made me feel more desperate. I had everything, and yet here was my life, so much dust.
Somehow, I held on. I saw two therapists concurrently, both skilled and enormously caring. Ever so slowly, the blackness began to lift. The road back was long, but now I was able to recognize it as a road. Gradually, I began to breathe a little better. One morning, I startled myself by feeling thankful to be alive. Even now as I think of this, tears come to my eyes. Because, even now, it feels like a miracle.
After Therapy, What Then?
But it’s a miracle with a catch. Treatment had worked, and I’m grateful beyond words, but it hadn’t addressed an urgent question, one that seems fundamental for both clients and therapists: how can people stay well once they’ve emerged from their most recent bout of misery? Most clinicians know that if a person has suffered one episode of depression, he or she is much more vulnerable to another. In my own life, I’d already slogged through several.
Yet my therapists and I didn’t talk much about this—how to stay healthy after we parted ways. I didn’t bring it up, and I don’t remember any of them doing so, either. We didn’t talk about how healing is only partly about gaining new skills and self-compassion. It’s also wrapped up with the client’s experience of the therapist’s presence—the almost overpowering sense of relief you feel as you’re greeted by a person who’s a thousand percent in your corner, whose face lights up at the sight of you, even though you feel profoundly unlovable. Slowly, under the dependably warm gaze of your therapist, your wretchedness starts to melt.
Clinicians and clients alike experience the magic of this phenomenon. But what’s left largely unspoken is what happens for a client once therapy ends. Even though you’re feeling better, and maybe even excited by the prospect of trying out your wings, you also confront the flip side of therapeutic constancy—the persistent and utter absence of your healer. You no longer have that guardian angel watching over you. You’re now your own angel. Good luck with that.
For the last few years, I’ve been practicing my own, jerry-built plan for keeping myself on an emotional even keel. It’s loosely based on the research on modifiable risk factors for recurrent depression. My thinking is that if there’s a personal risk I can significantly ratchet down, I’ll be less vulnerable to a next bout of misery.
Yet the makeshift, hope-for-the-best nature of my project makes me wonder why more clinicians don’t take a far more active role in helping clients put together programs for staying well. Of course, some clinicians do this. But many do not, perhaps because at the time of parting, the client seems so genuinely and markedly better. Regardless, I wish my own therapists had talked with me directly about how to stay healthy over the long haul.
Having “The Talk”
Virtually all clinicians make clear to departing clients that they’re welcome to return to therapy at any point. But for clients with recurrent depression, that may not be enough. I propose that before termination, therapists talk with clients candidly about the possibility of another episode of suffering down the line.
This is a complex and delicate proposition. No therapist wants to present a perspective that might become a self-fulfilling prophecy for a departing client. But while this conversation may be harrowing, I believe it’s vital. Without it, a person may wait too long before returning to therapy, wrongly hoping she can cope with her latest depression on her own. I’ve certainly been there. Another person might avoid returning to therapy because he imagines his therapist will be disappointed or judgmental about his latest collapse. Still another individual may decide that therapy is useless because here she is again, drowning in misery when she was supposed to have been cured.
Any of these conclusions is potentially dangerous. Working with clients to process their long-term vulnerability—along with their ultimate resilience—may be lifesaving. As part of this learning experience, clients also need to know that while depression may return, there are specific ways to increase their odds of staying well. Before leaving, the client and therapist can co-create a concrete plan. For me, numerous times over the last three years, a few simple, tailored practices have brought me back from the cliff. To say I rely on them is an understatement.
But here’s the thing: I know I’m far from home free. No amount of steady practice and self-knowledge assures that I’ll never slide again. I’ve been a mostly happy person for quite a while now, but I can’t predict my state of mind two months from now, or two years, or at any point in the future. I know only that right now, at this very moment, I’m glad and grateful to be here.
This blog is excerpted from the article, "In the Shadow of Depression," by Marian Sandmaier. The full version is available in the July/August 2018 issue, "When Depression Comes Back: Going Beyond the Limits of Therapy."
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