O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Depressed, anxious, or both? Part Two

Depression is a Treatable Illness

According to the National Institute of Mental Health, an estimated 17 million adult Americans suffer from depression during any 1-year period. Depression is an illness that carries with it a high cost in terms of relationship problems, family suffering and lost work productivity. Yet, depression is treatable.

Everyone feels down from time to time, and often these feelings can be attributed to a situational or environmental cause. A rift with a friend, or the loss of a job, can cause feelings of self-doubt that will leave one feeling sad for a time. But when feelings such as helplessness, sadness, or hopelessness last longer than a month, there may be more going on.

In the case of job loss, it is normal to feel depressed and worried about the prospect of finding new work and to ponder what led to being let go, or fired. But if the thoughts turn to rumination about failure, and hopelessness about finding another job, then it may be time to seek treatment.
Depression wrecks motivation through its characteristic anhedonia—Latin for inability to feel pleasure. Often this is a gradual process, creeping up over time in such a way that even the depressed person doesn’t see it coming. One day, it is there. Unshakable, unspeakable. Shame and self-doubt take hold as feelings of worthlessness erode a once-affable person. Family and friends try to help, but often give up after their attempts are met with an attitude of hopelessness.

How Psychotherapy Can Help

In my work with clients who come in for psychotherapy because of depression or anxiety, I take a careful history to see if medical problems may be causing any or all of the symptoms. Biological factors can interact with mood, increasing the severity of depression. Medical disorders such as low thyroid can mimic depression and cause some of the same symptoms such as low energy, sleep disturbance, and difficulty with focus and concentration. Once medical causes are ruled out, we reconstruct the timeline of when they starting feeling depressed or anxious. Sometimes these feelings are rooted in childhood experiences and memories, but not always. We start where the clients are, giving them a wee bit of mastery so they can feel hopeful.
Recapturing a sense of mastery is vitally important in recovery from depression. In psychotherapy, we identify what negative or distorted thinking may be contributing to feelings of helplessness. Research has shown that when someone feels helpless and out of control, they tend to avoid those situations where they are likely to feel overwhelmed. Yet, like the phobic avoidance described in the previous post, the more you avoid life, the more depressed you will become. Psychotherapy helps people to see the choices they make and to slowly incorporate fulfilling activities back into their lives. Unlike a family member making the suggestions that can easily feel like a demand or criticism-the collaborative relationship developed in counseling, allows the depressed person to take ownership for their healing. This in itself gives back a sense of control. Gradually, people can identify options and set realistic goals that enhance their sense of well-being. Whatever triggered the depressed feelings is seen from a different vantage, and automatic negative thinking begins to diminish. Going back to bed becomes less appealing as life feels more enticing.

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Anxious, depressed, or both?

Anxious people fret. Depressed people brood.

Anxious people worry about what may happen, while depressed people ruminate about what has already happened. In each case, life becomes more and more constricted.

Sometimes the two conditions may look similar because both use avoidance as a coping strategy. Think of avoidance as going back to bed and pulling the covers over your head: back to the womb. Safe and secure. Everyone has the urge to go back to bed to avoid facing some task or situation at one time or another, but depressed or anxious people turn to avoidance habitually.

In both cases, the anxious or depressed person may even end up avoiding people, places, and things they used to love. The difference is that the anxious person is avoiding occasions that trigger overwhelming, out-of-control feelings of panic, while the depressed person has lost the ability to feel pleasure in once-loved activities.

Anxiety that Causes Phobias

For instance, Julie was missing out on occasions like social and family gatherings, going to a favorite antique store, or seeing shows she used to enjoy—all because she was afraid to drive on freeways. She would go far out of her way to avoid them. Google Maps allowed her to program her navigation system to skip all freeways and bridges. But just getting from point A to point B on surface streets was too time consuming and life restricting. She didn’t apply for jobs that required driving across a bridge. She stayed home more and more. Eventually, even driving across town was daunting. She was miserable.

When a phobia such as Julie’s is pervasive, it prevents experiencing the fullness of life. Because her anxiety was interfering with her happiness, Julie was motivated to tackle her fear of driving. She came to therapy with a willingness to stick with it, even though she knew her anxiety would increase (at least temporarily). We outlined a plan that would allow her to gradually try driving on the freeway—getting on an easy entrance close to her home, and then taking the very next exit. We worked on relaxation and self-soothing so that she would be able to calm herself when she noticed the beginnings of panic. We discussed ways she could cope when she felt anxious.

Exposure Therapy Helps Master Fears

We also explored how she was holding herself back from pleasurable activities. She listed the things she would like to do if able to drive further from home, such as visiting a certain antique shop and crossing the Bay Bridge to see a show in San Francisco. Making this list helped her stay motivated when she wanted to give up.

Psychologists call what we did exposure therapy. We slowly introduce the feared situation in a way that is tolerable. This allows for mastery and gradually increases confidence. Avoidance is the opposite of mastery. It is not easy to face fears. It takes persistence and sustained motivation.

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Finding Happiness: You Can’t Always Get What You Want

 Those only are happy who have their minds fixed on some object other than their own happiness. – Mill

Grasping for Happiness may Lead to Depression

Judging by the huge number of psychological and self-help books claiming to know the secret to happiness and how people can increase it, we have become a nation obsessed with happiness. Happiness is important to well-being and for physical and emotional health, but research has shown that the more we value happiness, the more likely we will feel disappointed. These studies suggest that encouraging a goal of maximizing happiness (as many “self-help” books do) may be counterproductive.

Happiness is not an achievable goal in the same way academic success is, through working hard and studying. Happiness is more slippery than that. By making happiness a goal to be achieved, we set difficult-to-obtain standards that can be easily frustrated. Frustration leads to disappointment and discontent and, paradoxically, decreasing happiness.

When we expect to feel happy and instead end up feeling blah, bored, or bothered, our experience is incompatible with our goal of happiness. When people put too much emphasis and value on seeking happiness, they become vulnerable to paradoxical effects.

Unhappiness (though not depression) is often attributable to a particular circumstance, such as hearing that a close friend had an accident. So in positive circumstances, people have every reason to feel happy. You might, for instance, plan a special occasion like a party or a night out, fully expecting happiness as a result. Yet you might feel let down instead if the occasion couldn’t live up to your expectations for it. So the more you desire happiness, the less likely you may be to obtain it, especially when happiness appears within reach.

Accepting the Good, and the Difficult Emotions

It makes sense to follow John Stuart Mill’s suggestion not to have your mind fixed on personal happiness. Eliminating happiness as a goal to be achieved helps people better accept negative emotional experiences, improving overall emotional health.

In psychotherapy, we work on accepting that not all experience will be positive or happy. It is by accepting both our difficult experiences along with the more favorable ones that we begin to live life more fully. And in living fully, with ups, downs, and the in-between experience, we may be surprised to find happiness is often just around the corner—obtainable—if we’re not grasping for it.

In mindfulness-based cognitive therapy and stress reduction, we teach non-judgmental acceptance of all of our thoughts, feelings, and physical sensations. And, paradoxically by practicing this acceptance, those moments of happiness sneak up on us, and we can be surprised to find ourselves feeling happy for no apparent reason.

Iris B. Mauss, Maya Tamir, Craig L. Anderson, and Nicole S. Savino. (2011). Can Seeking Happiness Make People Happy? Paradoxical Effects of Valuing Happiness. Emotion.

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How Lifestyle Changes Can Be Therapeutic—And What To Do When They’re Just Too Hard

The October 2011 issue of American Psychologist featured an article on how mental health professionals significantly underestimate how unhealthy or missing lifestyle factors—for instance, nutrition and diet, or service to others— contribute to many emotional health problems. It also discussed how immensely helpful improving these factors was in treating many mental and physical health problems. Researchers have termed these improvements TLCs, or therapeutic lifestyle changes.

The eight lifestyle factors include exercise, nutrition and diet, time in nature, relationships, recreation, relaxation and stress management, religious or spiritual involvement, and service to others. Plentiful research supports the importance of these eight TLCs—as does plain common sense. And each lifestyle factor contributes to the others. Exercise and diet affect mood, and recreation (inscribed in the word itself: re-creation) will help instill a sense of well-being. In a virtuous cycle, when people feel physically comfortable with their bodies, when they feel vital and energetic, they will have the energy to engage in activities such as service to others and feel inspired to spend time in nature and contribute by giving to others.

Many folks today are facing challenges in obtaining the most basic and fundamental needs, such as food and shelter and financial and physical safety. These must be met before additional needs can be addressed. Yet by addressing lifestyle factors with the means at your disposal, it may be possible to shore up your resilience, your ability to withstand hard times. Certainly, it is difficult to think about exercise in times of financial stress, but it could be possible to carve out time to participate in a softball league or to make time to walk in nature, or the public park. Cutting out the cable channels can make for creative ways to spend that time. Some of the poorest people are the most active in service to others, because of what giving gives back to them.

It seems obvious that TLCs have to potential to help people lead better lives. When we’re healthy and we know something is good for us, we usually do it. But how do we implement these when depression or anxiety are present? In that case, those TLCs begin to feel like burdensome “shoulds”—and most everyone has resisted doing something just because we should, even if not depressed.

Depression & Anxiety Make Implementing Healthy Behavior Difficult

Depression and anxiety make change feel impossible to achieve. A well-meaning partner will say, “Just get up an hour earlier and go for a walk.” But to a depressed person, that’s a monumental effort. Getting up and exercising when you are feeling fatigued and lethargic is no simple thing. Sleep, as well as energy, is affected by depression; bouts of insomnia, for example, can lead to too much daytime sleeping, making sufferers look lazy to their families. ”Just get up and go,” the non-depressed person might say; “don’t lie around all day.” And while this may be absolutely the right thing to do, the depressed person has no “get up and go.”

Likewise, someone with social anxiety has trouble engaging in activities that will bring social connection. Avoiding people becomes the norm, thereby limiting potential rewards that come with socializing. For the depressed or anxious, not doing what they know they should be doing leads to self-incrimination and shame, worsening both conditions.

How Psychotherapy Can Help

Psychotherapy can help. During the first appointment, psychologists take a history that includes past and current relationships, educational and employment history, and family background. We also ask about current and past medical problems, medications, and use of substances. It is imperative to take this history to understand how the various life factors are impacting the current or “presenting” problem, as we call it.

Of course, while psychotherapy can begin the dialogue, the difficult part for many is implementing TLCs. What gets in the way of exercise, eating well, and taking time for you? If relationships are difficult, how are you contributing to that? Are you engaging in retail therapy or overindulging in drugs, alcohol, or other substances? An important component to any therapy is to look at what is working and what is not—and then taking responsibility for making changes in your life. Good therapy is not just about saying “Uh huh, you poor thing.”

Including the eight lifestyle behaviors in your life will undoubtedly help you feel better, use fewer psychiatric medications, and live life more fully, but if getting there from where you now feel like climbing Mt. Everest, then consider finding a good psychologist to help you.

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The Benefits of Practicing Mindfulness in Nature

The Benefits of Practicing Mindfulness in Nature

Research has consistently shown that time spent in nature helps people cope with depression and anxiety. Combined with other self-care activities, it can be as effective in treating psychological problems as anti-depressants.

But too often we run from activity to another and then finally, plop down on the worn sofa—unaware that these moments in nature are always available to us. In the park by the office, or in our own backyard, we can rest, listening to the buzz of sound all around. When we slow down enough to see the canvas of nature, we can experience contentment akin to one-ness with the natural world.

In mindfulness-based cognitive therapy and stress reduction, we ask participants to practice meditation daily, both formally and informally. Formal practice includes sitting or laying down and focusing on the breath, or on sounds– the intent is to be still and focused. Informal practice can be doing any routine activity mindfully. As the old saying has it, “Chop wood, carry water.” Some days we can eat a meal mindfully, without watching TV or reading the paper, just chewing and noticing the senses of smell, color, taste, and texture. Mindfulness can mean sitting in the garden and being attentive to the sounds of insects and the rustle of the breeze and doing nothing but sitting. (The Japanese Buddhist word for mindfulness practice, “zazen,” simply means “seated meditation.”)
Beginning a formal meditation practice can be daunting because of our innate resistance to sitting still with no distraction but paying attention to your breathing. In some meditation practices, the instruction will be to focus attention on a word, or to count to ten and start over. There are many ways to be still and it is important to try different kinds of meditation to find a practice that best suits you. When I teach Mindfulness-based stress reduction groups, participants will gravitate to one form of meditation over another. Each person is different. Some find mindfulness of sights and sound to be more effective, while others will focus on their breathing. In these classes, we practice many different ways to meditate and each participant is encouraged to find one they think they can continue to work with after the group ends.

Mindfulness Meditation: Informal Practice in Nature

But informal practice is always available and readily accessible to most of us: no special cushions, meditation rooms, or fancy teacher required. In fact, giving yourself permission to just do one thing, with presence, is a great way to slow down. If you can find some time each day to be mindful, especially in the natural world, that will go a long way in helping ease the symptoms of depression. Go outside and sit in your garden or the local park and be with nature. Even just a few minutes of watching the birds, weeding or pruning the roses will help boost your mood.

Berman, M. G., Jonides, J., & Kaplan, S. (2008). The cognitive benefits of interacting with nature. Psychological Science, 19, 1207–1212.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta- analytic review. Journal of Consulting and Clinical Psychology, 78
Maller, C., Townsend, M., Pryor, A., Brown, P., & St Leger, L. (2006). Healthy nature, healthy people: ‘Contact with nature’ as an upstream health promotion intervention for populations. Health Promotion Inter- national, 21, 45–54.