Recurrent depression
I recently found something I wrote a couple of years ago, while trying to make sense of a particularly difficult period of depression;
“Recurrent depression is cyclical. It comes and goes in longer periods than just days or weeks. Each low episode can last months, and within that time it can make everything much harder, with deep lows and any better times feeling fleeting and insecure. The hardest part of the fact it is recurrent is in the way that when you’re low you forget the good months and better years and just remember the times in the cycle where you were fighting it, and it feels like you’ve spent your whole life feeling low, that every time you thought you’d beaten it, it comes back and that there’s nothing to look forward to but more of the same. I can understand why depression is a killer. The only way to give each apparently endless low a meaning is to try so hard not to see it as a setback or as a return to the hardest darkness but to try and learn from each one, to gain as much practice in management and insight from each time to help the next time become easier. And maybe each time it comes around, each low period, be it weeks, months or longer, will get easier to manage and survive through as a result. And perhaps the low times will come less often.”
It’s been the recurrent nature of my depression that has kept me on varying doses of 
Citalopram for almost 11 years. It is the recurrent nature of depression in general that seems to present such a challenge to both sufferers and those providing treatment. I’ve often wondered if one can ‘recover’ from something that has been part of one’s life for so long? Or does one just end up learning to manage it more effectively, becoming ever more aware of those tiny changes to the delicate balance of your mind that could, without proper attention, tip you downhill again? Can ‘recovery’ be more than just a lasting period of absence of symptoms if at any moment the black swan of relapse could ‘disprove’ it ever was.
Preventing relapse
For me, on a day to day basis, it’s about finding and using the tools that I know keep my mind healthy. That’s not to say I don’t have bad times, but I’m becoming increasingly better at stopping those times spiral down into longer darker times and, in general, I can function ‘normally’. These tools have become even more important recently as I start the long (and never previously successful) process of trying to cut down my dose of Citalopram.
MBCT – ‘the integration of core cognitive therapy principles with sustained mindfulness practice’
Among the more common tools of diet, a lot of running and swimming (I can’t overemphasise the importance and impact of exercise on my mood), writing, militant amounts of sleep and my SAD light, I attended an eight week course at Breathing Space. This is a course designed by Segal, Williams & Teasdale in their book Mindfulness Based Cognitive Therapy for Depression – a New Approach to Preventing Relapse and taught by trained members of the Buddhist community, supervised by a consultant psychiatrist.
MBCT has been clinically proven to help recovery and prevent relapse. It is based on the idea that moods influence thoughts – everyday sad moods can reawaken and trigger negative thoughts if people have experienced them before. People who have been depressed in the past have learned associations between low mood and negative and depressed thoughts. Whereas most people might be able to ignore the occasional sad mood, in people who have been depressed in the past, a slightly low mood risks bringing about much larger changes in thought patterns.
This idea immediately rang true with me – in the past I have identified that difficult or sad times and events in my life can, if I’m not careful, ‘re-awake the sleeping beast’ of depression (I talk about my depression in a range of metaphorical terms and you can read my exploration of the use of metaphor in mental health here).
ABC
The course was divided into three parts that mirrored the ABC (activating event, belief and consequence) model of CBT. These were [A] developing awareness, [B] being with our experience and [C] choosing how best to respond.
Developing awareness
We spent the first weeks cultivating awareness, using mindful meditation to focus on each part of the body in turn, and the immediate feelings associated with them. When trying to stay aware of how your foot feels, and then your leg and so on for half an hour, the mind wanders. It’s natural. But part of the point of the exercise was recognising when our mind was wandering, noting where it went, and pulling it back to simple awareness of sensation. This in itself helped me start tracing my train of thoughts, identifying how I ended up in a default muddle of negative thoughts and what triggered them.
We then moved on to trying to become more aware of the spectrum of pleasant, neutral and unpleasant events occurring in our lives and try to record how they made our bodies feel as well as the emotions and thoughts they triggered. There was a real emphasis on pulling apart the thoughts, the bodily feelings and the emotions – these can get very closely linked in those with a tendency for depression. It’s not just moods that influence thoughts.
For example when someone who hasn’t suffered from depression in the past wakes up feeling tired and achy after a bad night sleep, they are likely to be able to identify it for what it is, have a coffee, a nap, or a day feeling tired and get on with their lives. Someone who has previously linked these feelings to those thought patterns of depression is more likely to enter a vicious cycle; bodily sensations (tired and achy) -> thoughts and ruminations (‘I don’t think I’ll get much done today’ -> ‘i’m useless, I always get like this’ ->’another wasted day’) -> emotions (frustrated, sad, disappointed, depressed, irritable) -> behaviour (cancel everything that day -> ongoing rumination and changes in sleep patterns) -> feeling tired the next morning. By using meditation to increase our awareness, we were learning to identify thoughts, bodily sensations and moods for what they are and no more.
Being with our experience
The next stage of the course was one of the most interesting. MBCT teaches that pushing away unwanted thoughts, feelings and emotions can make them worse. Instead, you should cultivate an attitude of acceptance, using the increased awareness mindfulness gives us to identify what is really going on at that point and help us choose what the best way to respond is.
Our teacher told us about an interesting experiment, the mouse in the maze (described in a different context here) which showed that when your brain is in ‘avoidance’ mode you are cautious and vigilant for things going wrong and show less creativity and flexibility in response to new tasks than those whose brains are in ‘approach’ mode.
Normally when there’s a ‘rustle’ in the undergrowth of our minds (a sad feeling, an unwanted thought), this puts us in avoidance mode. Fight or flight kicks in, switching on the part of the brain that says you are under threat (of course, the brain can’t distinguish between threats in the world that lead to negative thoughts and threats from negative thoughts alone). We are compelled to try and solve the problem leading to endless rumination without creativity or flexible thinking, no ‘solution’ to the problem and an escalation of negative thought patterns. Instead, MBCT suggests we turn towards those initial feelings or thoughts, trying not to see them as a threat but approaching them, using our increased awareness to become more familiar with how they actually feel and no more, almost welcoming them. This way, we are in a much better position to see them for what they are, and to deal with them effectively.
What is really going on then?
One of the things we looked at in more detail was the negative thought patterns that our moods can easily trigger. We often treat thoughts as facts – very seriously. The more damaging ones tend to take place just below the surface of our awareness and often masquerade as questions that could have answers (What’s wrong with me? Why am I bothering? I wish I was a better person, I’m stupid to think like this, something has to change). We take these thoughts to be an accurate reflection of reality and get sucked into believing them. So how do we ‘turn towards’ and accept these thoughts. Firstly, see them as thoughts not facts and treat those damaging and negative ones as symptoms of a pattern of depression rather than anything true in the world. Increasing our awareness of our mind through meditation enables us to take a step back from them – hearing them more like a radio in our head rather than a description of reality and, once we know they have arisen, deciding not to follow them along the destructive routes that they can take us. Jon Kabat-Zinn describes the effects of this in his book ‘Full Catastrophe Living’;
“It is remarkable how liberating it feels to be able to see that your thoughts are just thoughts and that they are not ‘you’ or ‘reality’…the simple act of recognising your thoughts as thoughts can free you from the distorted reality they often create and allow for more clear-sightedness and a greater sense of manageability in your life’
Choosing how best to respond
The final part of the course was exploring this sense of manageability. When we can see our thoughts and moods more clearly, we can choose which ones to act on and which ones to simply leave alone and let pass.
In general, ‘acting on them’ doesn’t mean thinking more about them, believing them, ruminating and trying to solve them. Instead ‘acting on them’ might mean identifying “I’m feeling a bit sad at the moment and it’s led to me getting more and more of these unhelpful negative thoughts which are lowering my mood and making me feel tense. I should think about what I can do to take best care of myself right now”.
This might be doing something pleasurable that you know boosts your mood, or it might be doing something, however simple that gives you a sense of satisfaction. It might just be turning towards those negative thoughts, not trying to intellectualise and ‘solve’ them, but calmy gaining an awareness of what they actually are and how they are trying to influence you. It might just be focussing your attention entirely on what you are doing right now and how it feels. All of these things can help you to step off the train of destructive thoughts that can take you deeper into a depressive state without you even noticing.
Practicing a skill
This is just a basic overview of how I experienced and understood MBCT in practice – with an emphasis on the parts that made the most sense to me. There’s a lot more to be said, and if you are interested, I really recommend the Segal/Williams/Teasdale book. Having said that, while the theory is interesting, reading the book alone won’t be enough. Much of it is learning a skill and it involves regular practice and meditation to build and maintain that mindful awareness. Luckily, even if you can’t go on a course, there are more and more audio resources available to help you learn to meditate. One I enjoy is the Headspace app which guides you through meditations and can also be set to send you reminders to do mini mindful ‘checks’ on yourself throughout the day.
For me, it makes a lot of sense. The beast is still lurking in the depths of my mind, but he’s fast asleep and now I’m in a much better position to be aware of the moods and thoughts that can stir him, and how best to manage them to knock him back out.