The 'sluggish wave' of depression

​​‘I don't want to see anyone. I lie in the bedroom with the curtains drawn and nothingness washing over me like a sluggish wave.’  In her novel ‘Cat’s Eye’, this is how Margaret Atwood describes depression.  As a psychotherapist, I have worked with a number of clients who have worked through their depression, and Atwood’s description is spot on.  

Someone who is depressed will often find himself caught in the following double-bind –

• He assumes that there will be a negative outcome to most situations, and
• He assumes that he is inadequate or deficient.

As a result, if something negative does happen, this simply proves his assumption that he is inadequate or deficient.  Trapped in this double-bind, he does not have the ‘escape clause’ that other conditions offer:  For example, if someone with OCD follows a routine, they will find relief from the anxiety.  With depression, it often feels like there is no end to the ‘sluggish wave’.

The World Health Organization predicts that by 2030 depression will be the ‘leading cause of disease burden’ worldwide (‘The increasing burden of depression’, Jean-Pierre Lepine and Mike Briley). In the UK it is reported that one in five people become depressed at some point in their lives (Royal College of Psychiatrists), and so it is very common.  Sadly, not enough people talk about having experienced it, and so there is often an element of shame attached to it.

If someone is experiencing depression, they may find that they are helped by –

• Talking to a trained expert , and/or
• Seeking a prescription of anti-depressants from their GP.

If a person with depression decides to talk to a trained expert, one of the approaches is Cognitive Behavioural Therapy (CBT).  This is the approach recommended by NICE, but there is some debate about whether this is the only approach that is useful.  As I am an integrative psychotherapist, I would work with the client to make choices about how to work through their depression.  These choices would be informed by the client, the presenting issue, and any current research. 

Whichever approach we choose, I always work from a person-centred core.  This means that I listen actively to the client, paraphrasing their experiences back so that they know they are understood.  I do not make assumptions and instead I work hard to understand the client’s meanings (for example, what he means by ‘depressed’ and how this impacts on his life).  Sometimes just having the magnitude of one’s feelings acknowledged can be healing in itself.  But sometimes this is not enough, and so I work with the client to see what else we can do with the client’s experiences.

There is currently research being carried out to investigate what is known as theanalytical rumination hypothesis. In brief, this hypothesis suggests that depression serves a function, just as a fever indicates that the body is fighting an infection.  Some have suggested that the ruminative thoughts involved with depression might offer opportunities for that person to improve.  What a trained expert can do is to help that person along the rumination process, finding solutions for the problems that are causing the depression. For example, someone might be depressed because of a recent relationship breakup, and the ruminative thoughts might be about the depressed person trying to work out how they will live as a single person, or how they might live in a relationship differently in the future.  

This implies that there is a resolution to the process, once the depressed person makes sense of this new information.  If this is true, trying to medicate someone who is depressed might not be useful, as it might prevent the person from working through these ruminative thoughts and finding some sort of resolution.  The research on the analytical rumination hypothesis is far from conclusive, and so professionals urge people to not stop taking prescribed medication, but it is interesting to at least consider this as a possible explanation for depression.

Some clients have found mindfulness to be a useful approach with depression.  This approach was best described by Jon Kabat Zinn in his book ‘Full Catastrophe Living’:  ‘The essence of the practice is non-doing', it is a letting go’.  The purpose is not to achieve anything but to acknowledge and be aware of what is’.  So one approach might be to stop trying to fight the depression and see how it might be to accept it, in the hope that this might give it less power, and it might eventually fade into the background.

If CBT is the chosen approach, this would involve examining a client’s thoughts and assumptions.  For example, by talking to a trained expert the following clients might start to understand that –

• Jane often labels herself a ‘failure’ simply because she has made one or two mistakes at work.
• Paul often personalises situations, assuming that when something goes wrong, it is automatically his fault.
• Bill often lives by ‘rules’ that were once useful but now trap him in a depressed state: For example, he believes in the ‘pleasure-pain principle’, assuming that if it is pleasurable to have lots of money he will be in perpetual pain if he is not rich. 

Using CBT, a trained expert would help these clients to challenge these assumptions. For example –

• With help, Jane could start to question whether one or two mistakes at work necessarily means that she will always make mistakes. Reality testing is important here, so it would be important to find examples where she has done well, or when she has not made mistakes. 
• With help, Paul might begin to realise that a situation might have gone wrong for a whole number of reasons that do not involve him (a process known as ‘decentering’).
• Finally, with help, Bill might begin to challenge these constraining ‘rules’, and he might look for evidence to the contrary (for example, he might realise that there is pleasure derived from non-monetary sources).

In addition to challenging a client’s thoughts or assumptions, behavioural techniques might also be explored.  For example –

• A depressed client could explore the possibility of participating in activities that lead to a small success. As confidence grows and apathy diminishes, these activities can increase in number and duration.  This can help counterbalance the hopelessness that is an inevitable part of depression.
• One technique might be to consider things that stimulate the client, such as pleasant smells, sensations, sights, tastes or sounds. Having a list of these can be useful when the ‘sluggish wave’ draws in.
• The client could also start to engage in more physical activities. It is well established that exercise can increase the endorphins, and so even a regular short walk every now and again might help.  

With all behavioural techniques, it is important to explore all the possible risks and benefits of these techniques, paying careful attention to any assumptions that the client might offer to avoid pursuing or sustaining these activities.  One common assumption amongst depressed clients is that the activity will inevitably fail to achieve any change, or they believe that they lack the ability to succeed in the task.  But it would be important to ask the client: 

• What would the client lose by trying?
• Has their previous approach really been helpful?
• How do they really know they will fail, if they don’t try

It might be useful to end this article with a checklist of assumptions that often trap people in depression.  How many of these ‘rules’ do you live by, and how helpful is it for you?  There is a big difference between rules to improve your life, and rules to trap you.  If you are at least aware of the rules that you live by, you can then decide which ones are useful, and which ones are destroying your life -

1. If I make a mistake, that means I am a failure
2. If I do not succeed at a task, there is no point in trying
3. I must be liked by everyone at all times
4. Because it is pleasurable to be wealthy, it is painful to have little or no wealth
5. My value depends on how other people view me
6. Disagreement means conflict, which is to be avoided
7. To be loved, I must fulfil certain conditions

 
​Chris Warren-Dickins BACP Registered Counsellor
E:  chris@exploretransform.com
T:  07816681154
W:  www.exploretransform.com