V. Sierpina
The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness by Mark Williams, John Teasdale, Zindel Segal, and Jon Kabat-Zinn. New York: NY: The Guilford Press, 2007, ISBN-13:978-1-59385-449-2
Unstuck: Your Guide to the Seven-Stage Journey Out of Depression, by James S. Gordon. New York, NY: Penguin Press, 2008, ISBN 978-1-59420-166-0
One of the pressing major problems in contemporary health care is the treatment of depression. Despite a plethora of pharmaceutical remedies acting at multiple points in the neurotransmitter pathways in the central nervous system, some patients remain treatment resistant. This poses a vexing puzzle for clinicians, for the patients and their families, and for society. The toll of human suffering, lost productivity, and darkened, narrowed lives is enormous.
Into this breach, some light has come as two books by noted authors, scientists, and clinicians to offer evidence-based self-care strategies for those “stuck” in chronic depression.
The Mindful Way Through Depression is a practical sequel to an earlier academically-oriented book on cognitive-behavioral therapy (CBT)approaches to resistant depression using mindfulness based stress reduction methods. This book adds as an author the renowned architect of that well-researched method of mindfulness, Dr. Jon Kabat-Zinn under whose tutelage, I was privileged to learn MBSR.
In its most succinct definition, CBT essentially offers therapy by helping people change their inner automatic thoughts, often negative and habitual, to more positive, creative, and therapeutic ones. The inner tapes are in a sense “reprogrammed” by offering alternative scripts, vantage points, and interpretations of life events. MBSR is a practice of meditation that promotes moment-to-moment non-judgmental awareness. This is a discipline fostered by regular sitting and walking meditation, movement meditation with yoga, and self-awareness through a reflective body scan.
The marriage of these two methods was well researched and demonstrated to be highly effective in patients with recurrent, treatment resistant depression in a series of elegant studies reported in the first book. This version offers a self-directed way to engage in the 8 week mindfulness training using the book, an accompanying CD, patient stories, and reframing exercises. The authors caution not to utilize this program when immersed in a major depressive episode, wisely counseling the person to seek services of a trusted counselor, therapist, or physician. They also instruct the reader that the mindfulness-CBT approach is not a one-time treatment but rather a practice, a discipline, and a way of life that reveals its fruits gradually over time. Continued practice is essential to lasting freedom from chronic unhappiness.
Part 1, “Mind, Body, Emotion,” describes the brain science and psychology behind depression, forming a solid scientific foundation for the following activities. It is illustrated with case histories, statistics, and interesting studies explaining why people get stuck in depressive moods and lifestyle patterns. Part 2, “Moment by Moment,” introduces the methods of mindfulness and encourages the reader to practice them. Practical approaches to mindful eating, walking, breathing, awareness of our thoughts and feelings, daily chores are all introduced in a lightly handed but useful way helping the reader shift from usual daily awareness and habit to a more conscious moment to moment state. This perhaps is the critical aspect of this approach, knowing that change is possible, that in the present moment, things can be alright, despite a background and history of negative affect and experiences.
Part 3,” Transforming Unhappiness,” is the nexus of mindfulness and cognitive behavioral therapy. The operative element in this section is that we are not our thoughts or our feelings. Through mindfulness, we create a space into which we can look, as observers, onto our inner thoughts and feelings and create a cognitive and emotional detachment from them. While accepting and befriending our thoughts and feelings, we paradoxically loosen their grip over our inner lives and our habitual depressive tendency. Additional techniques of mindfulness such as yoga and meditation are presented in this section as the reader becomes more skillful in creating that edge, that opening through which change can happen. Yet change or “fixing” is not the direct goal here, rather it is on refining our awareness of life, awakening to the full spectrum of our feelings, behaviors, and bodily sensations. This then creates that new vision which is developed in Part 4, “Reclaiming Your Life.”
This final section presents, “a unified strategy for living more fully in the face of all of life’s challenges and…the specter of recurrent depression.” Clinical examples illustrate narratively that the way out of depression is real and possible. An easy-to-implement 8 week program is introduced to foster everyday mindfulness practices that can be adopted for the reclaimed life. Resources, readings, and a list of retreat centers are provided in the final section.
As a primary care physician, I am often troubled that patients whose life circumstances are chaotic, their family and social backgrounds filled with abuse, trauma, and impoverishment of spirit somehow believe that their remedy for unhappiness is possible through a pill. Though contemporary psychopharmacology offers many benefits, personal transformation and change is ultimately rooted in one’s willingness to reframe and reform dysfunctional thoughts, feelings, and actions. Both of these books offer such a path, if only the patient will take the time and effort to embark on it.
James Gordon is a well known, well respected psychiatrist,and healer who trains professionals in mind-body techniques and brings those to populations stressed by war and other traumas. I have been fortunate to study and work with him. Unstuck: Your Guide to the Seven-Stage Journey Out of Depression, his latest book is a creative and useful guide that can help professionals and patients reframe the narrative of depression. I presented this book as part of a recent psychiatry grand rounds discussing integrative methods for depression. Though many attendees expected me to focus on herbal and nutritional supplements such as St. John’s wort, SAMe, and fish oil that he covers in this work, I mainly took another approach that more closely mirrored Dr. Gordon’s intent. This involved using art and story to describe the 7-stage “hero’s journey” as described by historian and mythologist Joseph Campbell. Among the many positive comments I received from attendees, a former psychiatry department chair extolled my presenting this hero’s journey approach as a way of reframing the narrative and the social construct of the experience of depression. This is just the point of this excellent book.
Too often, those stuck in chronic depression, see themselves as victims. This view is often reinforced by friends, families, and healthcare professionals caring for them. We all see the enormous suffering engendered by the depression and wish it were not so. We offer medicine, counseling, shock treatments, and even surgery to alter this downward spiral.
What Gordon presents instead is the possibility that depression is not a state of chronic victimhood but rather a true opportunity and call to grow, to evolve, to change. Rather than being stuck in an insurmountable chasm, it is rather, like Bunyan’s Pilgrim’s Progress or Dante’s Inferno a life process. In this process occur learning thorough new experiences and gaining higher level skills, developing more operative emotional and spiritual awareness, and ultimately moving from the abyss to the mountaintop.
As a skilled, experienced clinician and gifted writer, the Dr. Gordon introduces the topic of depression with facts and patient stories, scientific studies, statistics, and perspectives on the role of drugs and other conventional therapies for this condition. He presents alternatives such as nutrition, exercise, meditation, guided imagery, art and movement therapy, yoga, acupuncture and herbal therapies, spiritual practices. He illustrates several mind-body techniques, breathing exercises, and self-care strategies, including cognitive-behavioral techniques in the Introduction section. These are revisited and further developed in the 7 journey chapters.
The seven stages are laid out in chapter format following Campbell’s classical schema : Chapter 1, “The Call: Finding the Right Way,” develops the premise that the awareness we are depressed and that some of kind of change is necessary is the first and necessary step on this journey. Chapter 2, “Guides on the Journey,” promotes finding and meeting others who can help us and well as fostering our own inner guidance and wisdom. Chapter 3, “Surrender to Change,” addresses allowing and encouraging ourselves to let go of what constrains and freezes us, and to move into the current of life. Chapter 4, “Dealing with Demons,” deals with meeting the challenges, self-doubt, loneliness, procrastination, pride, resentment, perfectionism, fear and finding in them the source of our own meaning, purpose, and direction. Chapter 5, “The Dark Night of the Soul,” allows and invites the deepest life-giving freedom to emerge as we move through the despair that may come to any of us. Chapter 6, Spirituality: The Blessing,” is about experiencing the unity and peace, the love and generosity, the connection something or someone greater than ourselves that can transform our lives. Chapter 7, “The Return” is learning to live every day joyously, deeply, consciously, with ourselves and others, in the light of what we have experiences and are always learning(pp41-42).
Each chapter is abundantly populated with cases, practical advice, transformative exercises, metaphorical perspectives that heal, and a concluding self-care section. These are summarized in “The Return” chapter with ten guiding lessons or suggestions: relax, move, be aware, acceptance, have patience, time out, fear not, ask for help, trust your inner guide, celebrate everything. Simple, direct, but eminently wise and Zen-like practicality are imbedded in these 10 suggestions. A detailed resource section provides further tools for healing.
What Unstuck and The Mindful Way Through Depression both offer are ways of radically reframing perspectives on the troubling issue of chronic depression. By changing the narrative of our struggle with depression as a “hero’s journey” we move from victim to agent. By being more mindful of our thoughts, sensations, and feelings, we move from marionette or automaton to becoming detached yet involved observers of those inner processes. Both approaches offer freedom and hope.
I strongly recommend reading these books, practicing the techniques and methods personally, and then offering them as resources to our patients, clients, and colleagues whose lives are chronically unhappy or stuck in depression. While neither book claims to be a substitute for professional care, both can serve as enormously useful complements to the integrative care of depression.
Victor S. Sierpina, MD
Associate Editor, Explore, Professor, University of Texas Medical Branch