According to a report by the Royal Society for Public Health, social media app Instagram is more harmful to young people’s mental health than other social media platforms. The report, which stems from a survey of nearly 1,500 teens and young adults, linked Instagram to bullying, anxiety, depression, and fear of missing out.

The report did not, however, find that social media use is universally bad for mental health. Social media sites were linked to self-expression, a sense of community, a sense of identity, and greater social support. Some sites offered other benefits. YouTube, for example, promoted awareness of others’ experiences, decreased depression and loneliness, and offered access to reliable health information.

The report suggests social media platforms can protect users’ mental health by:

• Adding pop-up warnings pointing to the risks of heavy use.
• Providing methods to identify and support users who experience mental health issues.
• Offering notifications to alert when a photo has been digitally altered.

We Need More Studies on Kids’ Mental Health

[fat_widget_right]Opinion pieces that raise alarm bells about psychological screening in schools often neglect a vital piece of the puzzle: we know little about children’s mental health, and many childhood mental health issues go undetected. Routine mental health screenings could change this, offering better services to children with mental health concerns.

Number of University Dropouts Due to Mental Health Problems Trebles

The number of students leaving universities in the United Kingdom due to mental health issues has increased threefold in recent years. More students are requesting counseling, as schools struggle to keep up with their mental health needs.

Walgreen’s Mental Health Initiative Expands Reach

With about 1 in 5 Americans experiencing a mental health condition, mental health concerns are more prevalent than physical health issues. The Walgreens Boots Alliance, now in its second year, expanded mental health access and screenings in an attempt to provide more treatment and more resources. The retailer, which partnered with Mental Health America for the service, says 75% of people who completed mental health screenings are taking steps toward follow-up care.

How Does My Social Circle Affect My Depression Risk?

Loved ones can be both a cause of depression and a support system for fighting depression. Some relationships provide relief and social support. Others are a source of depression-triggering stress. Some are both. Experts say the key is to recognize and cultivate healthy relationships with others.

The Climate Crisis May Be Taking a Toll On Your Mental Health

Ecoanxiety, the fear of an impending environmental crisis, is increasingly common. A new report from the American Psychological Association (APA) suggests this anxiety may directly affect relationships and functioning. For instance, every standard deviation of rainfall and temperature increase is expected to produce a 4% increase in interpersonal conflict.

A recent randomized controlled study of therapy for treatment-resistant depression produced evidence that a brief trial of intensive short-term dynamic psychotherapy (ISTDP) may have large advantages in outcome over a “treatment-as-usual” approach, including counseling, cognitive behavorial therapy (CBT), CBT group therapy, and increased medication (Town, et al., 2017). This study expands upon previous studies that support ISTDP as an effective first-line treatment for depression (Driessen, et al., 2015), treatment-resistant depression (Abbass, 2006; Solbakken and Abbass, 2015), other treatment-resistant conditions (Solbakken and Abbass, 2014), and for depression complicated by co-occuring personality issues (Abbass, Town, and Driessen, 2011).

This new study supports what I and other clinicians practicing ISTDP have long observed in our practices, and may signal hope for the 20%-50% of people with depression who do not derive satisfactory benefits from treatment (e.g., Lambert, 2013). In this article, I will contextualize these results by discussing the psychological factors that can make a depression “treatment resistant” and highlight the features of ISTDP that may make it uniquely effective in addressing these factors. I will also reflect upon and review in detail the results of the study.

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What Factors Can Make a Depression “Treatment Resistant”?

To understand what makes ISTDP useful for treatment-resistant depression, it is important to understand factors that can make a depression treatment resistant (Abbass, 2015). Here are a few:

Relationship Difficulties with the Therapist

Even if your therapist uses a structured or systematized approach to therapy for depression, the therapy is always more than just a technique—it is a relationship. Many of us have difficulties in approaching relationships of all kinds, and the therapeutic relationship is rarely an exception. Some of us withdraw and detach from the opportunity for closeness. Some of us become fearful and hide or attack. Some of us take a passive role, a controlling role, a codependent role, etc., and we often have a variety of roles we switch between at different times.

These roles or interpersonal stances are often learned in our developmental history. They usually occur automatically and habitually, and they can have real advantages in certain situations—it’s not always smart to be honest and close with everybody in our lives. However, when we take on certain automatic interpersonal roles with our therapist, these can become barriers to engagement in therapy and can render the treatment less helpful.

For instance, if I am passive with my therapist, I may shirk the aspects of therapy only I can do for myself. If I am scared of my therapist, I may spend sessions shaking or attacking rather than feeling safe to communicate my needs. If I withdraw and detach from my therapist, I won’t be able to form the secure attachment that can help me explore my inner world and learn from my experiences. Needless to say, when we take on roles in therapy that form barriers to optimal engagement with our therapist, treatment efforts can fail and our depression may be labeled “treatment resistant.”

Self-Worth Difficulties

People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?

Absolutely. Many kinds of self-hatred arise in and can be addressed in therapy. A sense of worthlessness or unworthiness, hopelessness, self-doubt, withholding from oneself, wanting to hurt oneself—all of us are capable of feeling this way, and usually these feelings and attitudes contribute significantly to depression. These ways of relating to ourselves can come up in therapy, and if they are not addressed adequately they can interfere with the progress of therapy, rendering depression “treatment resistant.”

People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?

Repression

Repression is an unconscious (read: automatic, unintentional) psychological mechanism that can contribute to worsening depression. In repression—used differently here than in Freudian psychoanalysis—when anger is stirred up toward people we love, the anger unconsciously reflects back against ourselves. This symbolically “protects” the loved person from our anger. Because of our guilt about our anger, it is channeled into punishing us. In an unconscious effort to protect our beloved from our anger, our unconscious mind can shut down our body to prevent the anger from being felt or thought about. This can be an emotional root of the “vegetative” symptoms of depression, such as feeling heavy, weak, and tired, and can contribute to the physical pain that can come with depression—in repression, the body can become the target of our angry feelings.

Many therapy models attempt to address unconscious repression processes with conscious techniques, such as behavioral activation, education, or medications, which can all help. However, behavioral changes, education, and medications alone cannot help people overcome the unconscious repression process. When repression is contributing to the depression and not being addressed adequately, behavioral activation techniques or medications may fail and the depression may be deemed “treatment resistant.”

Why Choose ISTDP?

Intensive short-term dynamic psychotherapy (ISTDP) has distinctive features that target specific factors that can make a depression harder to overcome in therapy:

Addressing the Therapeutic Alliance

As described above, interpersonal barriers, such as passivity, dependency, opposition, or detachment, can hamper the therapeutic alliance, limiting the effectiveness of any therapist and any therapy approach. For that reason, ISTDP therapists are trained in specific techniques for assessing the intensity of people’s interpersonal barriers and then helping people with them. A good ISTDP therapist will notice and then help you see the ways you wall off from interpersonal contact, and can help you see the damage this is doing in your therapy, your relationships, and your depression. With this new information, you may become more motivated to overcome the barriers you put up, and a good ISTDP therapist will have a variety of ways to support you in that process. Once these interpersonal barriers begin to come down, which can only occur when you are ready to bring them down, it can become possible to get to the root of your depression and resolve it together.

Addressing Self-Defeating Tendencies

In the same way certain interpersonal tendencies can become a barrier between you and the therapist, your tendencies toward self-defeat, self-neglect, and self-attack become a barrier between you and self-compassion. This can severely hinder your ability to let yourself engage in and benefit from therapy. A good ISTDP therapist will make efforts to help you see the ways you treat yourself, notice how they impact your ability to use the therapy, and see how entrenched these patterns have become. Sometimes this process can reignite the self-compassion that is necessary to get a good therapy result. Once you can begin to see yourself with more positive regard, the therapist can support you in getting to the roots of why you had to turn against yourself and become depressed in the first place.

Overcoming Repression

An unconscious and thus out-of-awareness emotional process like repression cannot be overcome unless your therapist can help you see it, which will make it conscious and help you gain some control over it. In ISTDP training, we learn about the verbal and nonverbal cues that let us know repression is occurring, and we learn skills for helping people begin to become consciously aware of their unconscious emotional processes so that they can begin to think about how they feel rather than automatically and unconsciously have those emotions convert into physical symptoms and depression. When people can consciously recognize, reflect upon, and feel the feelings that get buried by repression, this is the antidote to the unconscious repression process, which can help relieve a major contributor to treatment resistance in depression (Abbass, 2015).

Anxiety and Treatment-Resistant Depression

One final dimension of ISTDP that may make it uniquely effective for treatment-resistant depression is the therapist’s ability to optimize the intensity of the work by paying careful attention to the level of anxiety you are experiencing, and tailoring the therapy to your unique anxiety tolerance. ISTDP therapists are trained to observe bodily patterns of anxiety. Some bodily anxiety signals (such as muscle tension) tell us, “We are on the right track, and this is a level of anxiety I can cope with,” while other signals, like stomachaches or dizziness, say, “We are over my threshold of anxiety tolerance. Time to slow down, regulate anxiety, and understand what’s happening.”

This ability to carefully track and work with anxiety signals from the body can help therapists optimize your therapy experience, and can help prevent a situation in which either too-low anxiety (such as boredom) or too-high anxiety (flooding, dissociation) becomes a barrier to treatment. This systematic attention to bodily anxiety signaling does not exist in any other therapy model, and can help ISTDP therapists to optimize your therapy in a unique way, reducing the likelihood your depression will not respond to treatment (Abbass, 2015).

Results of the Study

The study lasted six months and included 60 participants who were randomly assigned to two groups: ISTDP and “treatment-as-usual,” which included counseling, CBT, CBT group therapy, and increased medication. Self-report measures and observer ratings were used to assess outcomes, and were taken at baseline, three months, and six months from the start of therapy. Here are some of the results found at the six-month mark:

• Symptom remission: Thirty-six percent of treatment-resistant depression participants who received ISTDP had total symptom remission, compared to only 3.7% of the “treatment-as-usual” group.
• Partial symptom remission: Forty-eight percent of participants who received ISTDP had a partial remission, compared to 8.7% in the “treatment-as-usual” group.
• Medication changes: In the “treatment-as-usual” group, 53% of participants required increases in their psychiatric medication doses; only 10% required this in the ISTDP group.
• ISTDP treatment length: The average number of sessions of ISTDP in the study was 16 (Town, et al., 2017).

Reflections on the Results and Limitations

The study is limited by its duration, sample size, and the fact it took place in a clinic that has highly focused ISTDP training for its clinicians. Further studies are needed before we can assess the strength and duration of outcomes and the applicability of these findings to people in other settings.

However, the study provides evidence of large, significant effects—including full remission in some cases—of a brief trial of ISTDP for treatment-resistant depression. It also shows ISTDP had a significant advantage over the counseling, CBT, CBT group therapy, and increased medication approaches that were included in the “treatment-as-usual” group. This may be useful information for those experiencing treatment-resistant depression and finding unsatisfying results with treatment-as-usual, secondary care approaches.

While there is much research to be done to learn more about therapies for treatment-resistant depression, the Town, et al. (2017) study is a promising contribution that may pique the interest of clinicians, researchers, and people in therapy interested in a cutting-edge, efficacious approach for treatment-resistant depression.

References:

1. Abbass, A. (2006). Intensive short-term dynamic psychotherapy of treatment-resistant depression: A pilot study. Depression and Anxiety, 23, 449-452.
2. Abbass, A. (2015). Reaching through resistance. Kansas City, MO: Seven Leaves Press.
3. Abbass, A., Town, J., & Driessen, E. (2011). The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Psychiatry, 74, 58–71.
4. Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (169-208). Hoboken, NJ: Wiley.
5. Solbakken, O.A., & Abbass, A. (2014). Implementation of an intensive short-term dynamic treatment program for patients with treatment-resistant disorders in residential care. BMC Psychiatry, 14, 516-522.
6. Solbakken, O.A., & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant depression. Journal of Affective Disorders, p://dx.doi.org/10.1016/j.jad.2015.04.00
7. Town, J.M., Abbass, A., Stride, C., & Bernier, D. (2017). A randomized controlled trial of intensive short-term dynamic psychotherapy for treatment-resistant depression: The Halifax depression study. Journal of Affective Disorders, 214, 15-25.

Self-guided positive visualization techniques can combat negative thoughts, potentially changing the way the brain functions, according to a study published in the journal Frontiers in Human Neuroscience. Sensory memories, including images, of negative events figure prominently in conditions such as posttraumatic stress. Negative emotions accompanied by images may also feel more troubling than those not accompanied by such images, pointing to a role for imagery in mood.

Previous research has shown guided imagery can improve mental health, but little research has been done on the effects of self-guided imagery techniques.

Effects of Self-Guided Visualization on Mental Health

The study included 24 female and six male volunteers ages 20-55 years old, with an average age of 35. Each underwent a psychological assessment at the beginning of the study. Participants did not take any medications and had no formal mental health diagnoses, though some had subclinical depression symptoms. None of the participants had any experience in meditation or mindfulness techniques.

[fat_widget_right]The study began with a two-day seminar that included group training and at-home practice in guided imagery techniques. The techniques were designed to help participants manage previous trauma, achieve goals, improve social interactions, and support daily mental health. For example, to aid with goal achievement, a participant might visualize the detailed steps of the goal, followed by imagery of achieving the goal.

Participants continued home training in the techniques for 12 weeks and then participated in another two-day seminar. Researchers performed psychological assessments and electroencephalogram (EEG) brain scans at the end of the study.

Results of Self-Guided Positive Imagery

After mastering the visualization techniques, participants had fewer depression symptoms and better overall mental health. EEG data showed significant changes in the brain’s right medial prefrontal cortex. This brain region is linked to life satisfaction and visualizing positive emotions. Participants’ brains also showed increased connectivity in the temporal lobe of both brain hemispheres. This suggests the neurotransmitter gamma-aminobutyric acid (GABA) might have increased. GABA is linked to reductions in anxiety and depression.

The study’s authors say further research is likely to focus on how self-guided positive imagery affects cognitive function in healthy people. For those with mild depression symptoms, this approach could be beneficial.

References:

1. Teach yourself everyday happiness with imagery training. (2017, February 24). Retrieved from https://www.sciencedaily.com/releases/2017/02/170224111813.htm
2. Velikova, S., Sjaaheim, H., & Nordtug, B. (2017). Can the psycho-emotional state be optimized by regular use of positive imagery?, Psychological and electroencephalographic study of self-guided training. Frontiers in Human Neuroscience, 10. doi:10.3389/fnhum.2016.00664

When you are the spouse or partner of a person experiencing depression, you may feel stuck between wanting to help and realizing depression is a force larger than your love at times. You may be on edge, hypervigilant, worried, and feel hopeless when you cannot fix it for them.

First things first. If your loved one is in a depressive state lasting longer than two weeks characterized by sleep disturbances, lack of interest in once-enjoyed activities, weight gain or loss, sad feelings, fatigue, irritability, suicidal thoughts, and/or social isolation, you should get professional help immediately. You can start with your family doctor, who may refer you to a mental health professional. Depression is not something to “wait and see” on, and it’s not something just anyone can identify or diagnose. Keep in mind, also, it is common for a depressed person to not want anyone (especially a loved one) to worry, so they will often put on a good front and minimize their true feelings.

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When your spouse or partner is hurting, it is natural to want to solve it for them—to search for actions you can do to remove depression and replace it with happiness. While this is a valiant and tender-hearted gesture, it is also ill-fated. Depression doesn’t simply go away because you’ve loved more. Clinical depression can be a chemical imbalance, a residual effect of past trauma, a situational outcome, or a genetic predisposition, making treatment difficult in the best of circumstances.

So what does it feel like to watch your spouse or partner go through depression? Well, it’s depressing. It creates a situation that may feel out of control, hopeless, and heavy. You may become a watcher—watching what the depressed person says, what they look like, how they acted, and what didn’t happen. You may become a detective trying to identify something that will create change and bring lightness. “If only …” may become your new motto, “Why don’t you try …” your new daily suggestion.

As a partner and (at least to some extent) caretaker, you will need to keep yourself healthy. That may mean seeking your own individual therapy, seeing friends, doing activities you enjoy, exercising, eating healthy, and setting clear emotional boundaries about what you can change and what you must accept.

You may become consumed with fighting this depression and then, without realizing it and without meaning to, you may get angry—angry your loved one isn’t getting better, angry your life stinks, angry you can’t change this. You know it isn’t your loved one’s fault and they didn’t ask for depression, but you may get impatient anyway, wanting change to happen more quickly than they may be able to move. You may experience a grieving of sorts—for the loss of the life with your loved one that you once knew.

As a partner and (at least to some extent) caretaker, you will need to keep yourself healthy. That may mean seeking your own individual therapy, seeing friends, doing activities you enjoy, exercising, eating healthy, and setting clear emotional boundaries about what you can change and what you must accept.

It is not unloving to learn to maintain a distance from the depression; it may, in fact, be the only thing that keeps you healthy and available. Observing your loved one suffering while you live fully can be difficult to comprehend. You will no doubt ask yourself if you should be laughing, eating out, or seeing a movie. However, who will take care of you if you don’t? Finding lighter, more upbeat activities can create space that allows for some happy times for you. This space can fuel you when times are heavy and tough. As with all things, “this too shall pass” can be a mantra to absorb and hold true.

In time and with treatment, your spouse or partner can be happy again, and you can feel less worried and vigilant.

You may know how common depression is—6.7% of all Americans age 18 or older experience at least one major depressive episode each year, according to statistics compiled by the National Institute of Mental Health. It might even be expected in certain contexts, such as the loss of a job or a loved one. Other times, it creeps in mysteriously. As a therapist, I see many people who struggled for a long time before they finally sought help.

One of the first things I do when meeting for the first time with a person experiencing depression is try to figure out if their blues are an internal or external job. This can take a little time to unravel, as there are many layers that can lead to someone feeling depressed. It’s important when treating depression to try to change what we can control and learn coping skills that can help us with the rest.

So how do you know if your depression is a product of your environment—family, friends, job, housing or financial situation—or if it instead stems from unproductive or self-defeating thoughts, self-esteem or self-control issues, or possible biological reasons that may warrant a medical assessment?

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When It’s an External Job

Perhaps this winter has been a difficult time in your life. The holidays are past, the weather is cold, and the days are short. The nation is apprehensive and divided about a new presidential term. Maybe you are worried about tax season, waiting anxiously on news from college applications, or feeling bad after excess food or drink at the end of the year.

Many people seek therapy after enduring a difficult situation. They have been caring for a sick family member, are going through a breakup, or have failed a class for the second time in a row. They need help for a depression which is mostly a result of a life situation that has happened to them. They feel like a weight has been put on them and can identify what it is.

Right now, many people are feeling the weight of conflict on a global scale. Some are worried about climate change, health care, humanitarian crises, or unemployment. “State of the world” depression, as I call it, is a common woe in 2017.

These cases call for action:

• Tools (to date again, for example, or to reconcile with a partner or roommate)
• Skills (to interview for a different job or take better care of themselves)
• Ideas (for how to ease overwhelm around finals at the end of a semester)
• Information (how to sleep better, study better, or manage time more efficiently)

Taking action on external depression is an important step toward feeling better and more empowered. Fortunately, therapy can help—especially solution-focused therapy, which is practical and tool-oriented.

When It’s an Internal Job

Have you had a time in your life when you just couldn’t seem to get enough sleep? When the things you always looked forward to didn’t interest you or when you had trouble feeling much of anything at all? People with these depression symptoms might say their lives are “better than most” and may feel guilty for feeling down. They may struggle with feeling ungrateful because, at the same time, they feel like something is “missing.” Life may feel like an endless treadmill of nice-but-nothing-great.

The No. 1 indicator to me of an internally driven depression is when people can’t tell me anything they’re excited about in their future.

The No. 1 indicator to me of an internally driven depression is when people can’t tell me anything they’re excited about in their future. When we lose the ability to look forward to the things that historically keep us satisfied, we’re in trouble. People with internally driven depression may have grown used to being on the sidelines, watching the energy of the world bustle around them. They may find it tiring to make decisions or to engage.

These cases call for structured treatment:

• Evaluation (by a medical doctor to determine there’s no medical cause, such as anemia, thyroid problems, or other issues that may cause fatigue or apathy)
• Cognitive therapy (thought charts and other structured homework done daily to encourage the person to engage less with their “sideline”-causing thoughts)
• A “good habits” checklist (making sure they are getting enough sleep, sunshine, healthy diet, exercise, contact with others, etc.—all the recommended depression treatments to give themselves the best chance of feeling better)
• Journal therapy (structured 5-minute writing sessions that allow a solution-focused therapist to look at the person’s thoughts)

Some things are out of my scope of practice (medical evaluations, for example), but since symptoms of depression overlap with some treatable medical conditions, if there is no identifiable external cause it’s always a good idea to see a doctor, too. Recently someone I work with in therapy felt too tired to socialize or exercise, which was creating problems at work as well as causing him to spiral personally. When he learned he was anemic and started following his doctor’s medical recommendations, his fatigue went away, which started positive momentum toward participating in his usual, satisfying life.

People with internally or externally driven depression can usually expect their symptoms to improve if they use structured, research-based treatment methods such as cognitive therapy. Depression tends to call for a lifestyle tune-up—and you don’t have to go it alone.

Reference:

National Institute of Mental Health. (n.d.). Major Depression Among Adults. Retrieved from https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml

Community-based mental health services can improve outcomes in people with mental health diagnoses, several studies have found. Deinstitutionalization—the push to keep people out of long-term mental health institutions—increasingly means people with mental health conditions are living in their communities rather than treatment facilities. The Olmstead decision, a United States Supreme Court ruling on mental health treatment, enshrined the right to the least restrictive treatment available.

The number of available psychiatric beds dropped from 558,922 in 1995 to 37,679 in 2016. This is good news for those with mental health conditions, most of whom lead more fulfilling lives in their communities than in institutions. Inadequate funding for outpatient, community-based resources, however, has driven the number of homeless people with mental health diagnoses to more than 100,000.

When available and funded, court-ordered treatment programs—known as assisted outpatient treatment (AOT)—can help integrate people with mental health conditions back into their communities. The 21^st Century Cures Act, which former President Barack Obama signed into law in December 2016, includes additional funding for AOT. Research in several states points to the efficacy of these programs. In New York, for example, researchers looked at more than 3,000 people with access to AOT. AOT reduced mental health hospitalizations by 77% and homelessness by 74%.

Stop Smoking Services May Boost Mental Health of People With Depression

[fat_widget_right]Smoking cessation services may improve overall mental health, according to a study published in the journal Annals of Behavioural Medicine. Researchers found 66.3% of smokers who had moderate to severe depression when they used quit-smoking services experienced no symptoms a year later.

Good Outcomes With ‘Telepsychiatry’ in Medical Treatment of Opioid Use Disorder

Telepsychiatry, which offers remote therapeutic services via video conferencing, may be a good option for people with an addiction to opioids. According to a study published in the Journal of Addiction Medicine, for people using buprenorphine to treat their addiction, telepsychiatry offered similar results to in-person therapy. Participants in the telepsychiatry group were more likely to live in rural areas, making telepsychiatry a more accessible option.

Nicotine May Help Schizophrenia, Study Finds

According to a study published in Nature Medicine, nicotine may treat hypofrontality, one of the symptoms of schizophrenia. Hypofrontality denotes low activity in the prefrontal cortex during cognitive tasks. This leads to cognitive issues in people with schizophrenia. When exposed to nicotine, the prefrontal cortex of people with schizophrenia appears to work better. Smoking, which releases nicotine to the brain, is more prevalent among people with schizophrenia. One study estimated 88% of people with the diagnosis smoke.

Phyllis Harrison-Ross, Mental Health Pioneer, Dies at 80

Phyllis Harrison-Ross, who pioneered mental health treatments for children with disabilities, died of lung cancer January 16. Many public schools use Harrison-Ross’s programs, which were designed to keep children with disabilities out of institutional settings.

Trapped by the Game: Why Professional Footballers Don’t Talk About Their Mental Health

According to interviews with seven male football players, footballers do not feel safe discussing mental health issues. The interviews point to struggle as a common theme among players. They viewed the football field as a battlefield where they felt they had to struggle to “survive.” Shame and stigma often kept them from expressing any sense of vulnerability or emotional difficulties. Many also found it hard to integrate into the real world after careers in professional football.

Two new studies suggest video games could aid the treatment of depression. One study, published in the journal Depression and Anxiety, found a video game could address cognitive issues associated with depression in older adults. A second study, published in the Journal of Medical Internet Research, found video games can improve symptoms of depression, particularly among people whose depression symptoms are more serious.

Improving Cognition in Older Adults with Depression

Researchers in the first study used an app called Project: EVO with 10 adults age 60 and older who experienced depression. The app is meant to improve attention and focus. Though not specifically designed to treat depression, the researchers say improvements in attention might reduce symptoms of depression.

Even though most participants had never used an app on a tablet or played a video game before, all were compliant with the recommendation that they play the game for at least 20 minutes five times per week. Participants also had weekly meetings with a clinician.

A second group of 12 adults with depression attended weekly problem-solving therapy sessions. Compared to the control participants who attended weekly therapy, the participants who played video games experienced similar improvements in depression symptoms.[fat_widget_depression_right]

An App, a Video Game, and a Placebo for Depression

A larger trial involving more than 600 participants with mild or moderate depression assessed the value of video games in the treatment of depression. One group played Project: EVO. A second group used an app called iPST, which uses problem-solving therapy to reduce depression symptoms. A placebo control group used an app called Health Tips, which offered users healthy suggestions.

All three groups experienced similar improvements in mild depression symptoms, suggesting any purported treatment might help reduce mild depression symptoms. However, participants who were more than mildly depressed saw greater improvements with iPST and Project: EVO than with the placebo app.

The results are preliminary, and researchers do not yet know if the improvements will persist over time. They suggest the potential for an app or video game to treat depression could reduce the cost and time commitment associated with traditional depression treatment options.

References:

1. Anguera, J. A., Gunning, F. M., & Arean, P. A. (2016). Improving late life depression and cognitive control through the use of therapeutic video game technology: A proof-of-concept randomized trial. Depression and Anxiety. doi:10.1002/da.22588
2. Nodell, B. (2017, January 3). Game your brain to treat depression, studies suggest. Retrieved from http://hsnewsbeat.uw.edu/story/studies-suggest-gaming-your-brain-treat-depression

Mental health providers could improve depression treatment by helping people in therapy set attainable goals, a study published in the journal PLOS ONE reports. Although lack of motivation often appears on lists of depression symptoms, the study found people with depression were not less motivated than those without depression. Instead, people with depression had more difficulties setting goals. They were also less likely to believe they could achieve their goals.

Goal-Setting Habits and Depression

The study followed 42 people with depression recruited from two clinics in England. Researchers compared this group to 51 people without depression from the same region.

Each group made a list of goals. People with depression had as many goals as people without depression, suggesting similar levels of motivation. However, people with depression had more avoidance goals and fewer approach goals. According to the researchers’ definitions, approach goals center around positive actions, such as showing more gratitude or taking more walks. Avoidance goals aim to reduce negative outcomes, such as quitting smoking or reducing angry outbursts.

[fat_widget_depression_right]People with and without depression assigned similar levels of importance to their goals. However, people with depression were less likely to believe they could achieve their approach goals. They were also more likely to give up on their goals when encountering challenges, and they had greater difficulty setting new goals. This pessimism about goals may help explain why people with depression have trouble achieving the goals they set.

Setting Goals to Treat Depression

The study’s authors say their research provides important clues about goal setting and depression. It may be beneficial for mental health providers working with people with depression to consider helping them set realistic approach goals. By encouraging people with depression to set clear goals, to believe in their ability to achieve those goals, and to persistently pursue goals, providers can help people in therapy move toward more positive outcomes.

References:

1. Could more effective goals be the key to treating depression? (2016, December 22). Retrieved from http://medicalxpress.com/news/2016-12-effective-goals-key-depression.html
2. Dickson, J. M., Moberly, N. J., O’Dea, C., & Field, M. (2016). Goal fluency, pessimism and disengagement in depression. PLOS ONE, 11(11). doi:10.1371/journal.pone.0166259

It took a long time before I finally decided to see a psychotherapist—and for reasons that are probably very common:

• I wasn’t sure I had “issues” that warranted help. With nothing to measure against, how was I to know if my angst wasn’t exactly what everyone else felt?
• I grew up hearing family members say people should be strong enough to handle problems on their own. Seeing a therapist or asking for help was a sign of weakness.
• I had no idea what psychotherapy actually entailed. My biggest frame of reference was the film Ordinary People. I loved the therapy sessions depicted in the film, but surely the problems of the boy were far greater than my own.

It took a long time before I was able to acknowledge that my childhood had an effect upon my adult life. Again, with nothing to measure against, how was I to know? I took for granted that my self-doubt, low self-esteem, anxiety, irritability, and desire to be on my own were simply who I was. I didn’t even realize I kept people at a distance and shared nothing of myself because I had been that way all my life. It was simply my personality. I was an introvert. So what?

But thankfully, I began to piece together that negative patterns in my life were emerging and repeating. I recognized the depression I felt had begun in high school, continued and got stronger in college, and then became a recurrent theme in adulthood. After several failed relationships, the depression continued and grew intolerable. I had no idea my own self-imposed barriers against people were actually making things worse.

[fat_widget_right]At 34, I knew something was wrong because I was drinking more, not less. I could see I had always pursued relationships that were destined to fail from the outset, and if they weren’t, I would sabotage them so they did. Through either cheating or losing interest in sex, we would simply drift apart and become friends. For me, the concept of intimacy was repellent.

I give myself credit for recognizing I was stuck, unhappy, and highly unlikely to improve on my own. I was concerned about costs, so I searched and managed to find a therapy organization with a sliding scale fee. I forced myself to the initial consultation meeting, and was caught off-guard when the therapist fairly quickly asked me about my childhood. What would that have to do with anything? I managed to tell her it wasn’t happy. I had snippets of foggy, bad memories.

Over the next two months, I dared to open up to her. I told her about my mother, who had beaten me over the course of six years. It wasn’t my mother’s fault, I explained, because she’d experienced much worse: her father had committed suicide. After a particularly difficult session, I broke down for the first time. I told the therapist about a horrible beating and the announcement from my mother that she hated me.

But I was very fearful, and that would be my last session. I returned the next week and told the therapist I couldn’t afford to come anymore. My finances were too tight. She said I was always welcome to come back, and she was proud of the progress I had made.

While my first attempt at therapy ended prematurely because I was still unable to face painful, buried memories, it proved to me that something mattered about my childhood. I’d hidden it away for a reason. There was something inside me, because I’d never cried like that before.

It took about another 10 years before I dared to try therapy again. By then I’d become a poster child for dysfunction: anonymous hook-ups, juggling sex with multiple partners, heavy binge drinking on weekends, and depression. Thankfully—again—I recognized my patterns were not going to stop without outside help. I had proven myself powerless to make changes on my own.

Searching the internet, I found GoodTherapy.org. I liked I could explore psychological topics, and could find a large, supportive community.

Searching the internet, I found GoodTherapy.org. I liked I could explore psychological topics, and could find a large, supportive community. I located a doctor near my home with a specialty in childhood trauma. Though I had no idea what trauma meant, I thought back to my first experimentation with therapy, and surmised a childhood focus would probably be what I needed.

I was very nervous on the first meeting, but the therapist put me at ease. I felt an immediate rapport with him. When prompted, I told him about the “childhood” part. I showed him a scar just below my right eyebrow. My mother had thrown me and I’d caught my face on the corner of a wooden bookshelf. I wanted to be worthy of his time and was afraid he might find my case frivolous and refuse to see me. At the end of the session, I asked him if he thought we would be a good fit, and he said, “Very much so.”

About two years later I began a book, Grandson of a Ghost, as a therapeutic exercise. I still had difficulty comprehending that my childhood impacted my life, and the book helped me see—literally, in black and white—the ramifications. Here is an excerpt, taken from the moment when I was able to articulate how the abuse poisoned my sense of self:

For Scott, it was now clear that with no one to talk to, and with no frame of reference—in isolation—he grew up fearful of people and had a low self-image. The low self-esteem as a child made the world a scary place. It was terrifying before and after a beating. He was helpless and lacked any shred of control. Everything was potentially dangerous and threatening, laced with a fear of getting in trouble. Fear of making a mistake. Fear of others discovering he was actually something awful. The secret had to be hidden so that no one would find out. It would interfere with learning, because of the amount of mental energy required to keep the secret. He daydreamed constantly, lost in a fog. It made sense. He was ashamed, because he misbehaved and always made his mother cry. He didn’t deserve love, because he was the horrible dark seed somehow planted within the family and disrupting it.

Generational abuse—abuse passed down from parents to children—is a widespread problem, and it impacted my family after the suicide of my grandfather. It’s a difficult topic, and I hope my book can help people.

Three and a half years later, I am still with my therapist. My life has been transformed. The fog has lifted. I’ve learned not to overreact to threats, both real and imagined. I’ve learned to question and quickly parse an alarm. I’ve learned my abuse did have lasting repercussions. I’ve also learned that love means something. It matters. And before working with my therapist, I was closed to it. Now I see connection to others as the key that sets me free.

Scott Depalma is the author of the forthcoming book, Grandson of a Ghost. He grew up in Vermont and fled to New York City when he turned 21, unsure of anything except the need to run and disappear. Scott hopes his story helps others recognize that abuse has a lasting impact, but also that a new perspective (a rebirth) filled with joy and connection is possible at any age.

Depression can be a bear to deal with. Heaviness; bleak thoughts; and lack of energy, interest, or motivation can conspire to make you feel like you need to push a giant boulder up a hill just to find relief.

To foster self-compassion in the face of depression, education is key. Not only is it helpful to be aware of some of the possible sources of your depression, knowing how to alleviate symptoms can help you better manage it. My intention is to offer some hope by suggesting that the boulder before you might not be as heavy as you think, nor the hill quite as high.

The following list of depression sources and possible antidotes is simply a starting point. If you experience depression, may this list inspire you to think constructively and curiously about your suffering.

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Source: Disowned Anger

For some people, anger is a dangerous emotion based on unconscious beliefs or experience of harmful expressions of anger passed down in the family of origin. Anger is an important emotion, however. It often signals that someone is doing you harm. If you push down your anger, it can turn inward (the harsh inner critic) and cause a depressive response.

Antidote: If you sense a fearful or adverse relationship to anger, begin to bring more attention to it. Examine how anger was expressed in your family. How do you react to anger? Engage with it. You may notice a lessening of your symptoms with this inquiry.

Source: Being Cut Off from Emotions

If you are disconnected from your feelings for any reason, you are cut off from a major part of who you are. This is inherently deadening. Feelings make you human and alive. For people experiencing depression, feelings may feel foreign, unpredictable, scary, or pointless.

Antidote: Start a conversation about your feelings. What feelings are you in touch with? Which ones are you not? What hidden beliefs do you have about emotions? See what arises.

Source: Learned

Sometimes, depression is a learned way of being. If either of your parents experienced depression, especially major or chronic depression, you may have adopted depression as a way to feel connected with them, leading to an unconscious impression that this is how you need to be in the world.

Antidote: If either of your parents experienced depression, reflect on how that impressed on you. Do you believe depression is an essential part of being human? Are you afraid to NOT be depressed because you might feel less connected to a parent? It’s rarely that simple, of course, but there could be an element of this at play.

Source: Chemical

In some cases, depression is primarily an inexplicably chemical issue. There may be an emotional component if you traced the depression back in your family lineage, but sometimes the emotional component can change the brain chemically in ways that are then passed down between the generations, even as the emotional component or cause recedes.

Antidote: If your depression is debilitating, it is a good idea to consult with a psychiatrist. Medication, particularly when paired with psychotherapy, can sometimes lift the veil of depression enough to do the emotional work that can shift the tides.

Source: Misalignment of the Self

It can be depressing to be living a life that isn’t true to your heart and soul, especially if you don’t have a solid sense of who you are, what you need, and what brings you satisfaction and joy. If you grew up in an environment where you didn’t receive proper emotional holding and reflection, you may need help getting in touch with your true self. If you are misaligned or feel a lack of meaning in your life, it might link directly to your depression.

Antidote: Finding a good therapist who can help you explore the holes and emptiness may allow you to grieve past experiences, perhaps going back to childhood, and begin to discover who you really are. This is deep, important, and enlivening work.

Depression may be your psyche’s solution to difficulty regulating an aroused nervous system.

Source: Difficulty Self-Regulating

Depression may be your psyche’s solution to difficulty regulating an aroused nervous system. Perhaps due to trauma or an absent parent (anxious or insecure attachments), you may not have learned to regulate (calm) yourself properly.

Antidote: Do you get easily agitated or overwhelmed? Try a meditation practice and inquire about your ability to regulate. Is it hard to calm yourself? If so, working with a trained therapist can help.

Source: Existential Angst

It can be difficult being human. Having an awareness of all the suffering in the world is hard, as is the fact we all must face death. If you tend to focus on these existential issues and sobering realities, depression can result.

Antidote: Speak to a therapist about your concerns. It may be that your mind kicks up these things as a way to avoid your vulnerabilities. Explore the ways you might use existential fears unconsciously to manage other discomforts.

Source: Pervasive Anxiety

Depression can be a way for your psyche to manage deep anxieties. It may be that you are more anxious than you realize.

Antidote: Explore your thought patterns with a qualified therapist. Consider whether depression is operating as a buffer against more disturbing, anxious feelings.

Turn toward your depression. Getting to know its somatic qualities will help you unlock the doors that lead to self-compassion and healing. If you can find the resolve and commitment, you can find relief.

Recently, I’ve found myself somewhat annoyed at the Pinterest mental health community. I know some may consider it taboo to disagree with other mental health professionals or, worse, to challenge the beliefs of people who live with mental health conditions, but I feel strongly that many in my profession do a great disservice to the people we serve and our culture by perpetuating the belief mental health issues are mostly biological and always require treatment. What irks me even more is that in a well-intentioned effort to reduce stigma, we may suggest there is relatively little individual choice or personal power in creating an emotionally healthful life for oneself.

I saw a pin on Pinterest recently that read, “Depression is an Illness, not a Choice,” and it made me angry. While a temporary state of depression can sometimes be caused by biological or hormonal factors, such as in the case of premenstrual dysphoria, most forms of depression are not caused by biological factors but rather by social factors, learned thinking styles, and ineffective behavioral choices. The desire to reduce mental health stigma is well-intentioned, but our efforts can be misguided at times, and we have gone overboard.

Here’s why.

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First, feelings of depression and anxiety, among other unpleasant experiences, are a normal part of the human condition. Most of us, at one time or another, have avoided doing something because it made us nervous. Are we all disordered? Do we all need medication? By discounting the fact ups, downs, and difficult emotions can be part of normal human growth and development experiences, we fail to give people the knowledge, support, and tools they need to move past those difficult periods. We label these feelings “disorders,” which can affect how people view themselves and can become a permanent part of their identity and self-concept.

Second, the medical model of labeling feelings as “illnesses” limits recovery options. In American culture, we have been conditioned to believe illnesses require medication. So that’s how we treat them. In other cultures, even some medical illnesses do not necessarily dictate the use of medication. There is an Ayurvedic saying about illness: “When diet is wrong, medicine is of no use. When diet is right, medicine is of no need.” Although diet isn’t the only factor at play, this ancient wisdom underscores the importance of a healthy lifestyle in avoiding illness.

I believe this notion extends to mental health as well. A healthy emotional lifestyle includes learning how to communicate in relationships to increase closeness and social support; it means learning how to believe in your abilities, conquer your fears, and try new things; and it means practicing mind-calming techniques, such as meditation and yoga, and having the courage to heal old wounds while learning how to create your own happiness.

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I recently interviewed Dr. Barry Duncan, author of What’s Right With You: Debunking Dysfunction and Changing Your Life. He struck a chord with me when he said, “As crazy as it sounds, problems, like depression, also provide possibilities for living our lives differently, for reaching new conclusions. Depression is obviously painful, and it brings attention to the fact we are not happy with some aspect of our lives. The depression, therefore, can be a life-transformation vehicle.”

I agree wholeheartedly. I have experienced severe depression myself—several episodes, in fact. I have felt suicidal on occasion. Yet, those difficult times helped me. They helped me learn about myself, to seek out support and build relationships, and to have more empathy for others who go through similar challenges. Suffering can be a tool for growth, and personal growth, in turn, can lead to more happiness and inner peace.

As Dr. Duncan puts it, “Depression represents a profound crisis—it calls into question our very identity and how we are conducting our lives. It is at once a crisis point, a real danger and an opportunity for incredible change.”

By perpetuating the belief depression is an illness, we encourage people to take medication—that in many cases may not help them and can, in some cases, make them worse—without looking at the entire picture of why an individual is depressed and what is truly the best form of help for that person’s unique set of circumstances.

Third, by perpetuating the belief depression is an illness, we encourage people to take medication—that in many cases may not help them and can, in some cases, make them worse (Sparks, J., Duncan, B., Cohen, D., & Antonuccio, D., 2010; Valentstein, E., 1998)—without looking at the entire picture of why an individual is depressed and what is truly the best form of help for that person’s unique set of circumstances. My view is that in a limited number of cases, medication can be beneficial in the short term but only in combination with psychotherapy. Without therapy, the underlying cause of the depression goes unresolved and the person does not acquire the tools to prevent further episodes.

Dr. Duncan makes an excellent point when he talks about how we, in mental health professions, have contributed to perpetuating myths about a biological basis for depression and, in the process, helped pharmaceutical companies create learned helplessness in people. Many people have bought into the notions life should not include struggle and most individuals do not have the strength or creativity to navigate their challenges. We are empathic and do not enjoy seeing the people we serve suffer, so we often suggest medication. The use of antidepressants has consequently skyrocketed over the past two decades, yet two-thirds of Americans still report not being “very happy.” Something isn’t working.

Dr. Duncan surprised me with his next comment, and it gave me pause. He suggested that, perhaps unwittingly, mental health practitioners have bought into the illness model of mental health in part because it sustains our work and income. I had never thought of this before, but it’s a perspective worth examining. I don’t remember ever saying to a person after an intake session: “I think what you are going through is normal. You don’t really need therapy for this.” Hmm …

The Science of Depression

There are many theories about a possible neurological cause of depression, but very little evidence. In spite of advances in research technologies and neuroimaging studies, a biological cause or marker for depression has yet to be found (Duncan, B., 2005).

Further, meta-analytic reviews of medication treatment for depression found the difference between taking medication and a placebo was less than two points on a popular depression scale (Kirsh, I., 2014). One study found that a psychiatrist with a positive therapeutic alliance with his patients was more effective in improving depression symptoms with a placebo than was a psychiatrist with a poor therapeutic alliance administering a real antidepressant drug (Krupnick, J., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P.A., 1996). In other words, relationships may heal more effectively than medication. In its totality, the research shows that except for a small percentage of people with severe depression, medication does not work well to remit most depressions and, in many cases, has adverse effects.

How to Heal Depression

There are many options to consider in treating your depression. Here are a few:

1. Make life changes. Sometimes medication allows you to tolerate an intolerable situation. For example, if you have to take medication to cope with your stressful life, it may be time to reevaluate how you live life and perhaps make major changes. One person I work with in therapy decided she would stop being angry and verbally abusive, would learn to have healthy boundaries and say no when appropriate, and discontinue living with a husband who is addicted to alcohol and has a girlfriend on the side. Although this was a difficult time for her, she is much happier now and no longer reports depression symptoms.
2. Give it some time. Some episodes of depression spontaneously remit with time. Improvement without treatment ranges from 20% to 60% for a given episode of depression (Duncan, B. 2005).
3. Seek psychotherapy. Studies show psychotherapy is more beneficial than medication in the long run. Therapy maintains a positive effect over time, while medication does not. Psychotherapy can help you identify the causes of your depression and develop a more personalized plan for how you can get better. Therapy teaches the skills you need to manage your mood and difficult emotions. Most people report a lasting benefit when they participate in therapy for at least three to six months.

While medication may be the best option in some cases, research tells us psychotherapy is generally a more effective treatment for depression. The effects can last beyond the treatment, and there are few, if any, unwanted side effects. Therefore, in my view, it should be our first line of defense.

References:

1. Duncan, B. (2005). What’s Right With You: Debunking Dysfunction and Changing Your Life. Deerfield Beach, FL: Health Communications, Inc.
2. Kirsch, I. (2014). Antidepressants and the Placebo Effect. Zeitschrift Fur Psychologie, 222(3), 128–134. http://doi.org/10.1027/2151-2604/a000176
3. Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. A. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64(3), 532-539. doi:10.1037/0022-006x.64.3.532
4. Sparks, J., Duncan, B., Cohen, D., & Antonuccio, D. (2010). Psychiatric drugs and common factors: An evaluation of risks and benefits for clinical practice. In B. Duncan, S. Miller, B. Wampold, & M. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (199-236). Washington, DC: American Psychological Association.
5. Valenstein, E. S. Blaming the Brain: The Truth About Drugs and Mental Health. Free Press, 1998.

Depression can be difficult to tolerate. It can run the spectrum from a gnawing feeling of low and constant fatigue and worry to feeling hopeless, despairing, trapped, and desperately alone. When depression is at its worst, the prospect of suicide can feel like the only way to get beyond the pain.

If you experience any or all of this, you have a lot on your plate.

Unfortunately, many people struggling with depression complicate matters by (mostly unconsciously) employing coping mechanisms that actually work against them and compound the suffering. In the paragraphs that follow, I’ll identify some of these unhelpful coping mechanisms and explore a possible better path.

How We Cope with Emotional Pain

All human beings, to some degree or another, develop ways of dealing with pain very early on. It is an innate capacity we all have to adapt and survive, not only physically but emotionally as well.

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Just as a plant shapes itself to its environment—sometimes having to twist, torque, or reach in order to get the sunlight and nutrients it needs—people adjust their personalities in order to protect themselves and to get what they need (love, belonging, etc.).

Unfortunately, many adaptations that serve people well as children or adolescents can become burdensome as adults as the external world of the child lives within them. These mechanisms in their common forms may include withdrawal, isolation, overeating, excessive video game playing, obsessive thinking (being “in your head”), or hypersexuality, to name a few.

More uncommon or subversive are the coping mechanisms that, on the surface, appear as symptom or fixed part of the personality, but underneath serve to protect and deflect from the pain of depression.

More uncommon or subversive are the coping mechanisms that, on the surface, appear as symptom or fixed part of the personality, but underneath serve to protect and deflect from the pain of depression.

Depression can be so difficult to manage and experience that it can recruit the most potent of defenses. Especially if you grew up in an environment where depression was in the air, you may have had to protect yourself from both the aloneness and the infiltration of the depression itself.

It is possible you unconsciously had to employ more subversive defenses. The more uncommon or subversive coping mechanisms, ones that were once life-saving, now can add stress if you are experiencing depression. I am thinking specifically of low self-esteem, self-deprecation, minimizing, or doubting thoughts that may seem like symptoms of depression but rather as serve as unconscious strategies. These mechanisms, seemingly depressive thoughts that may have at one time been protective, now are self-destructive.

It might be difficult to figure out if your more negative thoughts are a symptom of your depression or a way to cope with it. And it might be a disturbing (but perhaps ultimately liberating) realization that you could be harming yourself in that way. This inquiry requires quite a bit of curiosity, compassion, and honesty.

However, if you are depressed and feel desperate, it’s a worthwhile inquiry. Are you harming yourself in an effort to protect yourself from the deeper pain and aloneness you felt as a child? You can begin this inquiry in earnest on your own, but I highly recommend you find a therapist you feel comfortable with, one who is well versed in working with depression, and one with whom you can establish a good working alliance.

Ask Yourself These Questions

The following are some questions you can ask yourself regarding your negative thoughts. Write each question at the top of a page, and respond with whatever comes to mind. Write for 10 minutes and then see what comes to you.

1. What are the negative thoughts I think most often?
2. What happens when I think these negative thoughts?
3. Are these negative thoughts a part of me?
4. What function do these negative thoughts serve?
5. Are these negative thoughts here to protect me?
6. What are some alternative ways to help me with my depression?

If the negative thoughts are indeed a coping mechanism, it is best to get help from someone who knows both the subtlety of the unconscious and the vulnerability that resides in these particular defenses. A trained and sensitive therapist can be of invaluable support because a professional can reflect back the impact of these thoughts and offer a space where you can begin to feel into the feelings behind those thoughts. This is a way to see your inner world more clearly and, ultimately, learn to work with your depression in a more dynamic way.