I recently emerged from a very long depression. While I am quite enjoying this rare life interlude of an existence not characterized by overwhelming apathy and despair, and am wanting to just savor the radical sense of being remarkably and unexpectedly enthusiastic about this whole being alive thing, my therapist keeps pushing me to think about how I can cope better when the depression returns. This isn’t a fun question to tackle, of course, because in my current state I’d prefer to believe that the depression won’t ever return. I do realize that this is completely wrongheaded. My particular manifestation of bipolar disorder is constituted by something like eighty percent down, fifteen percent in between, and a mere five percent up. (To really look at that, which I don’t often do, makes me feel both profound grief about how much of my life I’ve lost to depression, and intense rage about the unfairness of it all. Which is probably why I don’t like to think about it too hard.) But I do know in my head, at least, that the chances of the depression being permanently gone are close to zero, and I’ve thus been reluctantly willing to do the kind of strategic thinking that my therapist is asking me to do.
Part of this ongoing discussion has involved looking closely at what helped, and what made things worse, during my last rather lengthy period of depression. In considering where I was last year, a year in which almost every single day I woke up and thought about how much I wanted to die, I’m struck by a number of things. One is that I did not believe, I just did not believe, that I was actually suffering from depression. As is usually the case for me when I’m down, I was convinced that the two basic problems were that 1) life was genuinely, inevitably, and unalterably hopeless, meaningless, and horrible; and 2) this was because I was morally failing, too lazy to get my act together, and prone to making awful decisions. I’m honestly not sure what it would take to convince the depressed version of me that she is in fact depressed; I never really quite believe it until after I’m beginning to come out of it again, and the clouds of gloom have dissipated a bit. Even when I got hospitalized for a week or so last March, I was thinking in the back of my mind, “It’s not actually that bad. Most people have suicide plans; that’s just life, not anything requiring particular care or help. I’m probably exaggerating all of this, anyway.” And it’s tricky, you know, because mental health assessments are largely based on the self-reports of the people being assessed, rather than on more objective measures like blood tests (which alas do not exist for depression), and it doesn’t seem too hard to game the system. I’ve been hospitalized nine times; believe me, I know how to answer their questions in a way that gets you sent home versus gets you admitted. So how I can trust the system, especially when I struggle to even trust my own accounts of what’s going on?
Put another way, a very basic problem for me is that I experience depression not as something that’s happening to me, but as something I’m doing to myself. Thus I don’t think I need or deserve help or care, or even compassion. And in looking back, I’m realizing that a lot of the things that people say that are intended to be helpful actually exacerbate the situation by reinforcing this premise. When I’m down, I find that both mental health professionals and well-meaning friends are prone to making suggestions about things I could do to improve the situation, such as exercise, eating nutritious food, making sure I’m regularly getting out of the house, adding structure to my life, staying socially connected, practicing mindfulness, or listening to uplifting music. Don’t get me wrong: these are all good and useful things, and there is in fact a decent chance that a depressed person would benefit from doing them. But for me, hearing all of this again and again when I’m depressed reinforces my already stubborn belief that it’s all my fault. I could choose differently, I think to myself. I could exercise more, and do more to serve others (a favorite prescription, I’ve found, from all too many LDS bishops, who like to cheerily remind you that you just need to stop being so darn self-centered and focusing on your own misery). I’ve been in so much therapy and learned so many wonderful skills, I’ll remind myself. Why am I not using them? And then I’ll spiral further into the darkness that I fully believe is of my own making.
This brings me to Cognitive Behavioral Therapy, or CBT. Considered the gold standard in the treatment of depression and anxiety by many mental health practitioners, the practice of CBT involves learning to identify and challenge negative patterns of thinking. Thus you are given lists of “cognitive distortions” like overgeneralization, in which you generalize from one unfortunate instance to thinking that everything is terrible; catastrophizing, in which you assume that the very worst of all possible worlds will come crashing down on you in any given circumstance; or mind-reading, in which you jump to conclusions about what other people are thinking. It’s all quite logical. And for me, it’s all quite useless. Though let me qualify that a little. I do think that noticing this sort of thing can in fact be helpful in some situations. (I’m also aware that some people do find the skills of CBT to be both empowering and curative, and I want to acknowledge and validate their experience.) But it doesn’t resonate with me very well, and I think there are a number of reasons for this. One is that the entire thing is built on the essentially philosophical premise that thoughts cause emotions. And for me, that’s simply quite frequently not the case. Very often, the causal arrow runs the other direction: I’m hit with an emotion, and it leads to some kind of congruent thought. When this is happening, intervening at the level of thought accomplishes basically nothing. Another way to conceptualize the problem is to use the framework of “emotional mind” and “rational mind.” CBT targets the rational mind. But for me, that’s pretty much all it does; I can use my rational brain and do all the logical exercises, thoroughly fill out the thought record journals they ask you to keep, and correctly identify the distortions at work. Meanwhile, my emotional mind goes merrily on its way, churning up anxiety and terror and despair, untouched by all the logic in the world.
But on an even deeper level, I find CBT problematic because of its implicit assumption that you can exercise willpower in a way that will control your experience. It’s oversimplistic and probably unfair to reduce it to the idea that you can think your way out of depression, but on some level, that’s what it’s saying. Though I would give it credit for being much more thought-out and substantive than say, The Secret (the bestseller which promulgates the patently absurd notion that through the “law of attraction” you can lure good things into your life through sending out positive energy), I think CBT and The Secret ultimately exist in the same sort of universe, one grounded in the idea so entrenched in American culture that what happens to you is ultimately on you, because of your decisions (good or bad), and that you can escape negativity through an exercise of will, drawing on the power of thought and/or energy.
This paradigm has the obvious appeal of telling you that if you just do the right things, think the right ways, and send out the right vibes, you can opt out of life’s suffering (and as an added bonus, you can casually dismiss the suffering of others, because clearly it’s their fault that bad things have happened to them, and they just need to follow your example and submit themselves to the god of Personal Responsibility). The thing is — at least in my experience — this is complete and total hogwash. Life just isn’t that smooth or neat or fair, and you can do all the right things and still crash and burn and lose everything, or do all the wrong things and run into good fortune anyway. I’m not trying to say that the decisions we make and the actions we perform don’t matter, because obviously they do. But I think it’s very, very easy, and in fact quite seductive, to wildly overstate the control we have over what happens to us in our lives. Perhaps it’s just too terrifying to really confront our own helplessness in the face of the vagaries of the universe.
Ahh, you may be now saying, well of course you can’t ultimately control what happens to you. But what you can control is your response to it. I’ve heard that all my life, and for many years accepted it without much question. (And then used it as one more club with which to attack and blame myself for being depressed, because sure life was hard and challenging, but what was wrong with me that I wasn’t choosing to respond to the challenges with a positive outlook?) But there are things that have made me wonder whether even this common idea fails to acknowledge some of the harder realities of existence. I do still think it expresses an important truth, that we have some real choices even in the face of catastrophe. I’m not arguing that we are passive puppets entirely in thrall to the whims of the divine or to fate. I’m not by any means a radical determinist; I have a genuine belief in human free will. And yet. The experience of being bipolar has raised some very difficult questions for me, as it has illuminated some of the limitations of much of the conventional wisdom that I hear. Consider this. In February of this year, over the course of a couple of weeks and for reasons still not entirely clear to me, my mood reversed itself for the first time in a very long time. I started the month as I’d started every month for the previous year: feeling utterly wretched, and thinking I simply couldn’t survive the sheer awfulness of my life for much longer — and yet also feeling the despair of knowing that I’d repeatedly told myself in the past that I couldn’t go on, and then every month I had, and rather than that being comforting it left me with the horrifying prospect that I would continue to survive and the misery would never end. But I ended the month with — for the first time in ages — no suicide plans, and feeling excited and hopeful about where I was going next. Night and day.
And the thing that strikes me about this shift, something that has also struck me in the past when one of these rare reversals has taken place, is that while I probably did make some decisions that ended up playing some sort of catalyst role in things getting better, on a moral level I was pretty much exactly the same person at the end of the month that I was at the beginning of it. I wasn’t serving other people more, reading my scriptures more diligently, or even carefully doing thought-records and questioning my negative thinking patterns. But my life got easier, startlingly so. I didn’t have to grit my teeth and try to will myself into thinking positively when I woke up in the morning (which of course I never did; I just felt guilty for not even trying). Instead, I found myself waking up already excited for the day and all the things I wanted to do. In this state, it is something like a thousand percent easier to respond to hard things in healthy ways. So when I think about this idea that you can at least choose your responses to things, if not the things themselves, I feel wary. I want to be careful. I suspect that we all experience limitations around this, many of which we may not even be fully aware.
And now I’m going to finally get to Augustine (because what’s an analysis of psychological questions without stirring some theology into the mix?) I hear a lot of flak for my love of Augustine, and I get it; I really do. Yes, he was a serious misogynist, and yes, he damned the unbaptized babies to hell, and yes, you can bring up all kinds of problems with his ideas. But for all of that, I think he had some profound insight into the limitations of the human will, and our radical dependence on God’s grace. Many centuries before Freud posited the unconscious as an explanation for why we act in such apparently irrational ways, Augustine described the human situation as one in which we are deluded if we think we can just exert our willpower and do the right thing (to put it in the lingo of the 21st century). Like the apostle Paul, he grappled with the problem of being deeply divided against yourself. “Lord, make me chaste,” he famously prayed — “but not yet.” He argued that while we may be “free” in the sense that we have the ability to make choices and do what we desire, we are nonetheless in bondage to that desire, entangled and ensnared by the forces of temptation and sin. Augustine most decidedly did not argue for any notion that we can choose our response to whatever situation is put before us. Rather, he said that without the transformative power of grace, we would never be able to even desire the good in the first place. (For what it’s worth, I think this is not dissimilar to the dynamic described in the story of King Benjamin’s people, who experience a “mighty change” as result of the work of the Spirit, a change which causes them to “have no more disposition to do evil, but to do good continually.” (Mosiah 5:2)) To be wildly anachronistic, I think Augustine would have found CBT completely nonsensical. And I think that giving at least a small dose of an Augustinian worldview to cultures like ours, which heavily emphasize the virtue of positivity and the power of human effort, would not be a bad thing.
These days I’m pretending to be an Episcopalian (see my most recent post). I should note, by the way, that my recent church attendance, like my recent adoption of various other healthy habits, began only after the depression started to lift, so I’m not doing the thing where you explain how escape from the oppressiveness of Mormonism magically fixed everything for you. I’m not spinning a narrative in which any particular religious tradition pulled me out of my personal hell. But that said, I really am loving Episcopal worship services; they’re doing something good for me. And I’ve noticed something about the way I’m currently approaching church, something that’s actually very different from the past. For most of my life I heard (and at least sort of believed) that you go to church to have a spiritual experience of some kind — and I got the very strong impression that if that doesn’t happen, if you don’t feel the Spirit at church, it’s basically your fault. Maybe you weren’t worthy. Maybe your heart was in the wrong place. Maybe you had a frazzled morning, and the wrong attitude. (I mean, think about the conventional wisdom about sacrament meeting talks: if you don’t find them meaningful, whose fault is that? Why yours, of course, because a truly virtuous Latter-day Saint would manage to find the good in even the most random or platitude-filled talk, and have an edifying spiritual experience under the most challenging of church circumstances.) And so I found church terribly stressful on a level that I didn’t even consciously realize, because I felt like I wasn’t going to connect with God there if I didn’t put forth a solid effort. This wasn’t even limited to LDS services; when I visited other churches, even if I liked what they were doing, part of me was always like, “okay now, I’d better experience something meaningful here, or why did I even come?” Needless to say, given the intense pressure I was putting on myself to feel something, spiritual experiences of any sort in a church setting were few and far between (though once in a while, something somehow got through to me despite all the madness).
I have no idea how or why this changed, but it did. I don’t even necessarily think it’s because I’m doing the Episcopalian thing now instead of the Mormon one, though starting fresh may have helped. But I no longer go to church with those kinds of expectations. In the church where I’m currently attending, I love the liturgy, and participating in it feels good to me on a deep level. And that’s enough. Some weeks it goes beyond that, and I might briefly get a glimpse of something transcendent. But not every week. Sometimes the words are just words, and I’m just there listening to them and saying them without anything really happening as a result. Quite often my mind wanders and I start planning the rest of my day, or wondering what’s going to happen next on whatever show I’m currently binge-watching on Netflix, and then have to bring my attention back to the present moment. But all of that’s okay. I can’t even explain why this is, but I always leave church services feeling glad that I went. (In fact, I like them so well that in recent weeks I’ve been going to Wednesday services as well as Sunday ones.) And yes, there are real reasons why the Episcopal tradition in particular is meeting my spiritual needs right now, and I don’t want to downplay that. But honestly, the shift in my own approach to worship has also made a significant difference.
Bringing this back full circle to the problem with which I began this post, what am I going to do about this thorny issue of how to better manage my depression in the future, based on things that I can see more clearly now, but which will more than likely fade from view when hopelessness again takes root? My therapist has been encouraging me to actually write out a dialogue between the depressed me and this rarer, more cheerful me; he thinks working toward greater integration of the two will yield something helpful. And so I’ve been thinking a lot about what I might tell myself to do differently in the future.
The biggest thing I’ve come up with is that acceptance is key. In addition to CBT, I’ve also had a lot of experience with what’s called Dialectical Behavioral Therapy, or DBT. Though it’s not without flaws of its own, I’ve found DBT to be a major improvement over CBT. Particularly helpful, I think, are the Buddhist ideas about mindfulness that DBT has incorporated. In the practice of mindfulness, you just notice and observe your thoughts, rather than trying to out-logic them. I’ve found that to be much more effective than doing elaborate thought records and then challenging everything irrational when things in my head get a little crazy. Instead of engaging the craziness, you just take note of it, and the very act of taking that observational stance gives you some distance from and perspective on the turmoil. Another basic building block of DBT is the notion of “radical acceptance,” which involves simply accepting things as they are. It doesn’t mean you have to approve of them — you can hate what’s going on all you want — but you nonetheless accept it as the reality of your current situation. In doing so, I’ve found that you have to drop a belief that I find ridiculously seductive despite the fact that it makes absolutely no sense: the notion that you can change the past. (I’m thinking, for example, of engaging in the always enticing “if only” line of thought, in which you spend a ton of time and energy imagining how your life would be different now if only you’d opted for A instead of B at some crucial point, as if the process of going over that again and again and again will eventually exert some kind of magical force that will rewrite the present.)
And as part of that acceptance, I think I desperately need to let go of the burden of believing that I can fix the depression, whether through thoughts or behavior. It would help a lot, I suspect, to drop the toxic narrative in which I’m only depressed because I’m doing the wrong things, and failing to do the right ones. It’s a delicate balance in some ways, because I’m not advocating for an approach which encourages passivity or further fuels the sense of helplessness that is usually closely intertwined with the hopelessness I experience — but as I said, reminders that I should be treating my depression with x, y, and z, tend to be counterproductive. Is there a way out of this dilemma? Perhaps — and here I’m going back to the different way in which I’m currently approaching religious worship — I need to disentangle the behaviors that are probably worth doing from any expectation that engaging in those behaviors will alter my experience. Many years ago, when I was in one of the worst depressions of my life, my therapist at the time suggested that I watch the sunset every night, even though it would probably bring me no pleasure to do so. At the time I blew off the idea as nonsensical — why do something that wasn’t going to make any difference? But I think I have a better sense now of why he suggested it. On an intuitive level, I sense that there is something valuable and important about doing that kind of thing, even if you can’t see that it affects you in any way. I’m wondering if it might make a difference to encourage myself to do the good things mentioned earlier, like exercise and continuing to attend church services (I’m fully aware that the real test of my newfound love for all things Episcopalian is going to arise when my mood tumbles again!) and adding as much structure as possible to my life, but dropping the accompanying pressure to get myself out of the depression through such activities, seeing them instead as simply things to help me survive it.
(Also: these things are hard, they’re incredibly freaking hard, when you’re depressed. In my current “up” state, adding something like exercise to my life doesn’t require all that much effort. But even knowing that exercise is super good for you and especially good for depression, even being well acquainted with all the research that shows it may be as helpful as antidepressants, I just couldn’t do it while I was down. It felt utterly impossible. So I’m just brainstorming here, but I’m thinking maybe I need to have very, very small goals, like crazily small, with accompanying bribes. Like: do five minutes of something that’s good for you — though it probably won’t feel good at all or make much difference, so don’t even worry about that — and then you can do whatever you want for a long time, even if that means lying in bed and staring at the ceiling.)
I don’t know. On the one hand, I am intimately acquainted with the depressed version of myself and the way she thinks, even when I’m not currently experiencing that state. On the other hand, when I’m not in the despair, my emotional reality is so different that it’s hard to really know what will help. It’s good to think about, though. And I think it would be amazingly wonderful if I could chip away at the notion that when I’m down, I have some kind of moral obligation to “fight back” and “get better” (as is expected of people in America who experience illness of any kind — you’re supposed to be a warrior and exhibit bravery and all of that). I think I need to work on ways to live with the reality of my condition, instead of thinking that a truly virtuous person would find a way to overcome it. And I think I need to remember, as my therapist has been emphasizing lately, that my status as a beloved child of God who is worthy of blessing and care is exactly the same — exactly — regardless of where I currently am in my emotional cycle, regardless of whether I am accomplishing a ton and am happy and positive to boot, or whether I haven’t left my bed in three days. Theologically speaking, in other words, it would be tremendously helpful if I could ease up even a little bit on the sort of works-based salvation mentality that I may vigorously refute intellectually but seem to have deeply internalized nonetheless, and make more room for grace.