Theresa, a 37-year-old African-American civil-rights lawyer, tells me in our first session together that she's been miserable for a month. During that time, she's lost weight she can ill afford to lose, and has been sleeping only four to five hours a night. Alternately listless and agitated, she's been unable to concentrate at work. She leaves her office late, feeling guilty for what she hasn't done, anxious that she'll have to make up for it the next day. She used to go dancing with friends in the evenings, but now she tells them she's tired. At home, she watches TV and eats frozen dinners. Sometimes, she measures her wine in bottles, not glasses. She's feeling increasingly hopeless. She's clearly clinically depressed, and her internist and psychotherapist have urged her to take antidepressants, but she doesn't want to. She's come to me to find a better way.
Theresa knows I view depression differently from how her doctor and therapist do. "Depression isn't a disease," I explained to her on the phone when she called to make an appointment. "It's not the end point of a pathological process. It's a sign that our lives are out of balance—that we're stuck. It's a wakeup call, potentially the start of a journey that can help us become whole and happy, a journey that can change and transform our lives." Before any patients visit my office or pay me a fee, I speak on the phone with them, letting them know who I am, what my perspective is, and how I work, and make sure they want to participate in what I have to offer. I usually suggest that before the first appointment, they read something I've written about my practice, to get to know more about the meditative, eclectic, active, and engaged "Unstuck" approach I'll offer.
The fit between what I'm offering and what my patient is hoping for will be the springboard for all our work. It'll provide the shared vision on which we can draw in the difficulties and challenges that may come in any therapy. Commitment to an integrative approach—and the urgency that may fuel that commitment—help provide the energy that sustains us in meeting the challenges of our work together.
I begin, as any therapist would, by asking Theresa what happened a month ago, right before her depression. She says she'd just ended a relationship, and she tells me that at almost 40, she still doesn't have a man who loves her, and she still doesn't have a child. I listen carefully as she describes the inhibition and despondency that shadowed her childhood; the recent breakup with her boyfriend has plunged her into the same kind of hopeless darkness she remembers from that time. A thousand miles away, she tells me, her mother's arthritis has slowed her to irritated immobility, and her father's sight and vigor are fading. Theresa feels she should be with them, but she doesn't want to, and feels guilty about that. "I carry my whole organization on my back, too" she says ruefully, "women's rights for everybody except this woman."
As I take in what Theresa is telling me, I encourage her to see herself as a student and adventurer, an active participant in our work together. Indeed, she's the one primarily responsible, with my guidance, for helping herself. "Self-care," I often tell clients, "is the true primary care." From our first session, I convey to her my belief that she has within her the resources for her own healing. I begin to help her recognize what she's already doing that's helpful to her. In her case, the morning yoga she still sometimes does gives her energy; and phone calls or visits with her best friend, Barbara, dispel, at least for a while, her loneliness. I write these activities down on a prescription pad, as another physician might an antidepressant drug, crafting "a Prescription for Self-Care" at the end of the first session.
I teach Theresa (and virtually all of my patients) a simple meditation technique called "Soft Belly," involving slow deep breathing in through the nose, out through the mouth, with the belly soft and relaxed. I encourage Theresa to close her eyes as she breathes so as to remove distracting stimuli. I suggest that she say to herself, "soft" as she breathes in through her nose and "belly" as she breathes out through her mouth. If thoughts come, I say, let them come, and let them go.
"Soft belly" is, I explain, an antidote to the fight-or-flight and stress responses, which figure prominently in the development and deepening of depression. Soft belly brings more oxygen to the lungs and stimulates the vagus nerve, which is central to relaxation. Slowly, I tell Theresa, the relaxation of the belly will spread to the other muscle groups also.
I explain to Theresa that though the research studies are most often done on 30 to 40 minutes a day of meditation, just a few minutes several times a day will help balance her physiologically, slow her anxious, pressured thought patterns, and give her a better perspective on her life. Equally important, as she sees she has the capacity to help herself, she'll be overcoming the helplessness and hopelessness that are hallmarks of depression. I add "Soft Belly 3–5 minutes, 3–5 times a day" to Theresa's Prescription for Self-Care.
I do soft belly along with Theresa and with all my patients. It's of course helpful for me to be as relaxed and open as possible in my sessions. It conveys an important message to my patients: "We're on this journey together. I'm not an observer. I'm here with you, learning as well as teaching, experiencing life, and dealing with my own stress along with you." Dealing with depression and its challenges, and with stress, generally, is, I'm recognizing and admitting, not separate from our lives, an extraordinary response to a pathological situation, but an ordinary and ongoing part of them.
Theresa, significantly more relaxed as well as reassured after our first session, felt encouraged and supported by the Prescription for Self-Care. Each week, I ask her about her progress, and I express appreciation for what she's doing well, while not being dismayed by what has been too difficult, or what she's ignored or neglected. Our work isn't about her "good" or "poor" compliance (what an ugly, condescending word!), but about what she can learn from difficulties, avoidance, and defeats, as well as from "success."
Like many depressed people, expecting to get a prescription but not much more in the way of attention, Theresa is afraid of being "left alone" with her depression. I assure her that I myself have been on the journey through and beyond depression, and that I'll be there with her at every step of her journey. I make sure she understands we'll have regular appointments—a usual feature of psychotherapy, but a major departure for people who are used to seldom seen, drug-prescribing physicians. I tell my patients they can call me any time, and find that this reassurance is itself powerful medicine: even though patients know they can call me, that I'm always there, almost no one does.
From the first session on, I give my patients detailed instruction in guided imagery, focusing most often on two images: the creation of a "safe place" where they can find calming sanctuary in difficult, stressful times; and consultation with an "inner" or "wise" guide—an emblem of their intuition and imagination, on which they can call for advice and counsel. I often teach "Dialogue with a Symptom, Problem, or Issue (SPI)," a Gestalt-like exercise, in which a rapid, written dialogue between my patient and her physical, emotional, spiritual, social, or interpersonal SPI often reveals both its origins and possible solutions. I work, too, with journaling, drawing, and movement to express and reveal feelings and release them. The message to my patients is clear and consistent: you can mobilize your own mind and body to help and heal yourself; I'm here to help, to equip you to do it, and to support you as you do.
A spiritual perspective informs my work from my first moments with each person. Not an explicit religious orientation, this perspective encompasses an appreciation for the yet unrevealed potential of each person, a sense of sacred connection within each of us to something larger than ourselves, and moments of inexplicable grace, which can transform each person's work with me and on their own.
Not long ago on a phone call, Theresa reminded me of this dimension of her life and of our work together. She'd moved through her depression in two months of weekly sessions with me, without drugs. She'd continued to see me once every month or two for "refresher sessions" for another three years. Then, two years ago, she moved away to take a position at a law school. I'd watched her grow over the years into a peacefulness that she'd never before known—meditating regularly, doing yoga, taking time for herself. Now we were catching up, and she was looking back on our work together.
"My depression and the sad state of my spiritual life were two sides of the same coin," Theresa reflected. "First, I needed to look at myself psychologically, to see that I was depressed, and that mine were ordinary human problems. I wasn't this bad, immoral woman, sleeping with guys who didn't love me, drinking too much, and smoking pot. I just needed to see how what I did, and the sad, confused way I felt, connected to my childhood—to that lonely little girl with her desperate desire to please. And I needed to get my life on a track that worked for me. But I also needed to feel my spiritual side, and by that I mean the heart, or the soul, or the divine in me."
Through her work with me, as well as meditation, yoga, and dance, Theresa said, she began to develop "some emotional radar to sense what I was feeling—whether anxious, sad, angry—to know if something was off-kilter. I learned that I didn't need to fight it, that it was okay just to let myself feel the pain. It was just passing feelings, and not something fundamentally wrong with me. I no longer have the feeling that I won't get what I want. I have what I want." Here, she emphasizes that wonderful, present-tense word, so different from all the past-tense terms of loss and longing that marked her depression, "I feel whole and happy as I am. If I find a 'significant other,' that would just add to it."
I thank Theresa out loud, and silently, too, for sharing with me what's possible. Freud wrote about replacing neurotic with ordinary unhappiness. Psychopharmacologists praise the restoration of the "premorbid personality." Theresa is showing me, telling us, what it means to move from being terribly, chronically, depressed to feeling blessed every day.
This blog is excerpted from "Educating Theresa" by James Gordon. The full version is available in the January/February 2010 issue, Psychotherapy and the Brain: Are We Entering a New Era of Practice?
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