Tuesday, June 21, 2016

Feeling Trapped in a Life You Don't Want: Hopelessness & Chronic Depression

I originally published this post in March, 2009.  I was just looking at it again today, while browsing through my blog...I thought I would re-publish this, and maybe work on adding to it.   I have been reviewing treatment guidelines for mental illness, and have been asked to help prepare some official guidelines for my workplace...while I find this task, of preparing "guidelines,"  meaningful or useful in some ways, with some worthwhile observations and tips to be discovered in the existing research, I finally find the task a great source of weariness and frustration.  This particular post really represents something that is much, much closer to the "core" of who I am, or who I want to be, as a psychiatrist.  And it reflects more deeply--than any "guideline" could-- my beliefs about caring for people who are suffering.   

This post is in response to a comment on my previous post "What to expect from an antidepressant".

What is the purpose of a life?

What needs to be present in a life to make it worthwhile?

If a life is like a work of art, a giant canvas that you have been working on for decades--what if you feel that the canvas has already been wrecked? The damage may have been caused by "bad genes" (e.g. an inherited tendency to be depressed, etc.), which in the canvas metaphor might mean the canvas itself is fragile, thin, easily damaged, doesn't hold pigment very well, etc.

Or the damage may have been caused by "bad environment" (e.g. a traumatic childhood, lack of support, lack of opportunity, natural disasters, war, poverty, etc.), which in the canvas metaphor might mean the canvas itself has been damaged by others, or by environmental adversity, causing it to be very difficult or painful to work with in the present.

Or the damage may have been caused by your own past efforts (e.g. a history of spending years trying to develop oneself-- in school, in relationships, in work, etc.--but where these efforts have ended in failure, pain, breakups, sorrow, regret, guilt, or a sense of having burned your bridges--and where the past failures obstruct future opportunities, e.g. via a poor academic transcript, work record, etc.). In the canvas metaphor this might mean there is a lot of paint on the canvas, but none of it is what you want, none of it is where you wanted it to be, none of it you actually like, it all looks like a collection of mistakes. If it was a literal canvas, you might feel like the best action would be to just throw the painting away, and either start fresh, or give up painting altogether. You might feel like you never wanted to paint in the first place, that the task was forced upon you by the fact of your birth, and by the social expectation that you are supposed to live out your life.

For many people who struggle with chronic depression, I think there is some combination of all these three possibilities: genes, external environment, and personal efforts which haven't worked out, all contributing to a state of hopelessness, tiredness, exhaustion. It can feel like a daily struggle just to make it through the day, a yearning for time to pass just for things to be over. Life can feel like a trap, a life sentence to a prison term, a forced existence that you never really wanted, or have long since stopped wanting.

The idea of a medication somehow "treating" this problem can seem absurd. Or the idea of so-called "cognitive therapy" changing this problem can seem insulting. It is like observing a painting you don't like in an art gallery, and then being told that you have to do some exercises to change your thinking, so that you will start to like it, then have it up on your living room wall for the next 60 years. In some ways this dynamic reminds me of salesmanship, in which case it can feel like the therapist, or even the whole external world, is trying to "sell you" the idea that your life is supposed to be worthwhile, when all you see is something you hate and want to get rid of.

I don't have easy answers to this problem.

But here are some of my beliefs about approaching it:

There are people who will care about you, and who will sit with you through your suffering. A role of a therapist in this type of situation, I think, is to sit quietly, to be gently and consistently present.

The world is full of possibility. No matter how bad conditions have been--internally or externally, past or present--growth and change are possible. The brain is a dynamic structure. It is as powerful and consistently active when alive as is the heart. But the brain reinforces its own pathways. If these pathways give rise to feelings of despair, hopelessness, and futility, then every moment of life can become experiences of despair, hopelessness, and futility. If these pathways of thought, emotion, and felt experience, have been trodden for decades, it can be hard to forge new pathways within the mind.

Immense, profound life change is possible, regardless of how severe problems have been, how long they have been present, or how much damage the problems have caused.

Such changes may require an enormous amount of energy and time, and may require a lot of external support.

There are many individual life stories of profound life change, stories of journeys through chronic hopelessness towards meaning, energy, and joy. Historically, some of these stories are of mythical proportion, and are present in literature and the other creative arts. Many religious stories contain themes of this sort.

Contemporary examples include stories of individuals overcoming lifelong addictions which had devastated their previous life histories (here I am not saying chronic depression is an addiction, but that addictions and depression can both be characterized by feeling very stuck in something bleak and hopeless). The lore in addiction treatment has wisdom to share about making radical life change--in "12 step" models, for example, individuals are called upon to admit "powerlessness" over their problem, and to make a set of statements of faith about a "Power greater than ourselves", etc. While I am wary of the potential for dogmatic religiosity in such statements, I also see that if dogma can be set aside, the "12 steps" can be seen as a sort of "leap of faith", a new contract with life, to live--and work-- with the help of a supportive community. It admits, powerfully, that one must reach out to connect with the possibility of change, it is almost impossible to do alone (the "higher power" idea can simply be an admission that one needs external help).

Psychiatric medications in chronic depression usually do not lead to "profound life change" (sometimes they do, but really this is in a small minority of cases). However, often they help a small to moderate amount. Either to relieve some suffering or pain, or to potentiate energy that might then help to effect a new course in living. I do not feel that any effective treatment leads a person to become resigned to an unpleasant status quo, and then to learn how to "accept a bad life". I feel that effective treatments allow unpleasant circumstances to feel more bearable, then to facilitate the hope and actions that are necessary to improve the unpleasant circumstances.

Cognitive therapy can help. The goal, however, in cognitive therapy, cannot be simple "salesmanship". I think the goal has to be building a satisfying life, where there are healthy, stable relationships: meaningful work, meaningful love relationships, and meaningful activities that bring joy or happiness.

With any type of process that causes deep changes in the brain, the pathway may require you to go right back to the simplest foundations.

I'm reading Norman Doidge's book about "neuroplasticity" right now (The Brain that Changes Itself), which incidentally I recommend highly. The evidence he presents is quite convincing, to some degree surprising, but on another level intuitively very obvious--the brain can change itself, sometimes very radically.

But if new paths are to be formed in one's "mental forest" one may need to start with tasks that seem extremely simple, even infantile, perhaps even "insulting" in their simplicity. Cognitive therapy can seem extremely trite, or even a ridiculous exercise in mental manipulation--an exercise to comform oneself to how society as a whole expects you to think or feel, trying to convince you to think good thoughts about a bad situation.

The thing is, though, these seemingly ridiculous tasks (such as cognitive therapy, etc.) can start new paths forming. In conjunction with this, new connections can begin with the external world, in the form of new friendships, new involvements in creative work, new involvements in education, etc.

There may well be burned bridges, but there is a vast energy available to build new bridges, if you so wish. And your past experiences may eventually become more useful to you than they are right now.

Depression can be extremely tenacious. It is so extremely tenacious that in some cases it is almost like a character that wants to perpetuate itself. The depression itself, so to speak, sets up arguments in one's mind about why this or that action (e.g. medication, therapy, life change of other sorts) cannot or should not happen. In the forest path metaphor, it is like the depression not only has become an extremely well-trodden pathway in a dense forest, but it has also put high fences around the pathway, and a deep moat full of crocodiles on the other side of the fence too.

Once again, I emphasize that I have no easy answers. As I look at the above post, I see that it is rambling. Parts of it probably sound preachy or trite. Probably annoying to look at if you are feeling trapped in a depressive state. I think I come off sounding like a salesman myself, trying to convince you to buy that painting you don't really like.

My intention, though, is to convey my belief that change is possible. There is proof that change is possible. I see this proof in my own clinical experience, as well as in the stories of others. Deep change in a chronically unhappy life is possible, but may require a great deal of external help, and may require a type of commitment to change that is extremely difficult or exhausting to initiate. And your depression won't want you to make any such commitment.


Anonymous said...

Thank you very much for this post-- many of your comments here completely parallel my own experience. It is reassuring sometimes to have someone recognize that there are no easy answers to this, because sometimes it seems that there is a kind of reflexive tendency towards optimism/ hope/ etc. And most of the time it seems to me that this just makes things seem MORE hopeless. (Maybe it's counterintuitive, but sometimes-- to me-- recognition that there are no easy answers, no sure things, etc. makes things seem LESS hopeless.)

I don't want to make sweeping generalizations about therapeutic techniques/ the therapeutic community, etc. But one thing that has interested me is this idea of "stigma"-- and the idea that more severe mental illnesses, such as bipolar disorder, schizophrenia, etc are associated with greater stigma compared to unipolar depression or anxiety, etc. among the public-- and maybe among the "therapeutic community" in general. It seems to me that the opposite is the case, because it does seem to me sometimes that "chronic depression" is viewed with considerable frustration by many therapists-- not necessarily because it's difficult to treat, but also because there sometimes seems to be a belief that it is a kind of malingering...or evidence of some unwillingness to change, etc. I do feel sometimes that some therapists feel that "therapeutic change" is basically achieved once a patient smartens up and stops complaining...or, in any case, stops demanding care. (I am reminded here of David Dawson's comments about patients with borderline personality disorder who abruptly leave consultations...and his belief that somehow this refusal of care constitutes some kind of improvement!).

And I guess the part about cognitive therapy that frequently bothers me-- aside from the "salesmanship" that you discuss in your post, and that seems to me to be a perfect summation of this therapy-- is the idea that somehow patients with depression are somehow incapable of judging things. I am probably not expressing this very well, but there IS a kind of infantilization common in much CBT thought, e.g. this idea that somehow the therapist is in a much better position to judge a situation than is a patient who has inhabited this particular situation for many months or years, etc. The idea behind some of this seems to me-- and maybe I've just been exposed to bad CBT writings/ discussions/ therapeutic approaches, etc-- is that the reason the therapist is NOT in this particular situation is simply because he/she has the benefit of a more rational mind. The assumption seems to be that people who are depressed are incapable of appropriately judging situations/ people/ etc-- they're lacking in basic reason, they seem incapable of calmly evaluating situations, etc etc. Whereas the therapist (of course!) possesses complete and perfect reason. There does not seem to be much acknowledgement that perhaps the patient IS seeing thigns correctly-- that perhaps they have a very good understanding of their situation, their interactions with other people-- etc-- and that perhaps they are coping very well with their situation, all things considered. The attitude (and maybe I'm just overly sensitive to this) seems to be that there is something lacking in the "depressed" patient, and he/she just needs to buck up and learn more appropriate ways of coping. It is as though the only thing separating the therapist from the patient is the therapist's own superior reasoning abilities or superior defenses (e.g., THEY don't engage in "all-or-nothing" thinking, etc).

I guess I wonder sometimes about this idea of "depressive realism" and CBT...I wonder how these ideas can be reconciled. So much CBt thought seems predicated on this idea of distorted thoughts, etc...but it doesn't seem to me that the evidence always supports this. Or maybe I'm just misreading the evidence. In any case, thank you again for this post. I don't think that you have engaged in any kind of "salesmanship", and I think that your comments are very helpful.

L said...

Thank you. I really, really needed to read this today. You do not come across as trite, rather you come across as someone who understands and is compassionate about how difficult it is to both survive and live a life worth living struggling with chronic depression.

Anonymous said...

I have been rereading some of your older posts. I had forgotten about this post. I'm glad that I found it again, it really captures this experience/ feeling for me, and sometimes it feels that not many things do.

I remember years ago reading an article by Roy Baumeister (Suicide as an Escape from the Self-- I just googled it to remind myself), and I remember that at the time that article really resonated with me also-- though I can't actually remember the particulars of the article. I will have to find a copy and reread it.

I am really grateful for your blog. Your posts sound like you, and it is good/comforting to hear your voice.

Anonymous said...

Thank you for this post. I read it the first time in 2009 and didn't hear it, but I hear it now. This is what has started to help me see that big change is possible: If you do not like who you are it is possible to start from scratch and rebuild something. It's possible to think about character outside of an Axis II diagnosis (which for me makes me feel more stuck and angry). It is possible to think about/ develop/ cultivate character traits that better reflect who you want to be. I realized that most people work hard on their character development, and that character is not just something innate that is revealed (and to feel hopeless about if something good is not miraculously emerging, with no effort!). I started to think: If I was raising a child, what kind of person would I want that child to be/ what kind of values would I want to instill in that child? (I read some parenting books that helped). Also: That self-compassion does not mean excusing personal bad behaviour. It is possible (and OK) to feel extremely disappointed in yourself and in your past behaviour but to still be able to talk kindly to yourself.