Depression has an especially cruel season called relapse. It always happens after the worst seems to be over; hope like sunlight is restored; life without depression is in full bloom. Then suddenly it’s winter again. The more often it happened to me, the more impossible the goal of recovery seemed to become.
I was surprised to read recently in Mindfulness-Based Cognitive Therapy for Depression that relapse has received attention from researchers and therapists only in the last couple of decades.
The focus of most research has been the treatment of acute depressive episodes, and the effectiveness of medication or other therapies has been measured by the ability to demonstrate relief from those symptoms. Most researchers dealt with relapse as requiring more of the same methods of treatment rather than a new approach.
Mindfulness-based cognitive therapy came about specifically as a way to deal with the problem of relapse. I wish I had known about it in the mid-1990s when I had one of my worst setbacks. That experience led me to search for new methods, and the combination of mindfulness and cognitive therapy finally helped me learn how to head off recurrence. Here’s what happened.
An especially bad relapse began a couple of months after I had gotten through cancer surgery on a sustained flow of energy and determination. I had been totally up for taking on the cancer surgery, although the diagnosis had initially terrified me. Worries about cancer had also stirred a depression so deep that I felt like giving up completely. I just decided I was going to live, and the new energy marked a powerful turnaround when it came. I’d swung back from despair and passivity to hope and action. I felt I could take on anything.
That spirit had a lot to do with a rapid physical recovery from surgery and also helped me achieve what I thought was a complete recovery from depression. I stayed on this roll for several weeks after the cancer period was over, but then things changed. I didn’t collapse into deep depression all at once. Instead, I started feeling the low-grade listlessness that’s called dysthymia.
This form of depression often filled in the periods between the major episodes, so recovery never seemed to happen. Those were the blah days, no edge, no excitement to anything. There was little motive to action, certainly nothing like “drive” to get things done. I was mostly aware of the deadening routines that filled each day. There was no surprise or shock or excitement – everything turned into an indifferent hum.
That’s what started happening after the recovery following surgery. I was slow to acknowledge the change. As usual, my wife immediately sensed it and started cautiously asking me about the shifting moods she noticed. I got irritable and denied that anything was different.
The truth is that I had a lot vested in the belief that I had gotten over depression. It became almost an article of faith that I had stopped it and could now be myself again. The problem was that I didn’t have a method for dealing with relapse. When I could no longer deny that depression had returned, I was completely demoralized.
I came to believe that depression simply kept on coming back independently of any external event (that part was true) and that I couldn’t do anything about it (not true). Psychiatrists kept me on the same medications. However, they not only failed to prevent relapse, they also had less and less effect on the major episodes. I kept on with psychotherapy as well – mostly the long-term talking kind, rather than the short-term cognitive varieties so widely used these days. I continued to learn a lot from those sessions, but recurrence remained the big problem.
My exposure to mindfulness and cognitive therapy began at about that time. The learning curve was long and uneven, but eventually this approach provided some of the main techniques I use today to stay healthy. I have to say, though, that these tools did not work that well until I had achieved a more complete recovery than I had ever known before. At that point, just a few years ago, preventing relapse was my deepest concern, and this therapeutic approach proved to be the right one to help me.
I’m no expert in the research-tested methods of mindfulness-based cognitive therapy. I first learned to use mindfulness meditation and then became familiar with the techniques of cognitive therapy even as the MBCT approach was coming into prominence. Much more recently, I’ve been working with MBCT directly, and it’s helping me enormously to refine and extend the techniques that have been most helpful.
The core skill for me has been the ability to step aside from the depressive mindset as soon as it starts to set in. Meditation and mindfulness have helped me observe that mindset as a particular combination of thoughts, feelings, beliefs that accompany depression. This detachment helps me experience it as one possible mindset rather than buy into it as the reality of who I am. Then, instead of simply following that mindset back into depression, I’m able to stop the cycle before it begins. At once I say, as if talking to that mind: I see what’s happening and, no, I’m not going there.
The process can begin at the first sign of a problem. For example, if I hear my mind starting to obsess about some mistake or flop of mine from last week, or, as is often the case, from 30 years ago, I recognize the pattern immediately. I can watch it unfold without giving it any credibility. Or I might notice that I’m walking somewhere, head bent down, feeling out of sorts and seeing only how rotten everything around me looks. I’m able to shake off off that mindset almost instantaneously. But it took a long time to get to that point. I spent about five years and lived through many relapses before learning the method well enough to make it automatic.
Mindfulness-Based Cognitive Therapy for Depression (by Zindel Segal, Mark Williams and John Teasdale) is a great resource for learning the full scope of the approach from which I’ve adapted my basic method.
The primary audience for this book consists of therapists who want to learn the practice, though it offers a wealth of insight for lay readers as well. Another book by the same authors, along with Jon Kabat-Zinn, The Mindful Way through Depression is designed for a general audience and is easier to find. These books have helped me understand mindfulness in relation to depression as no others have. Perhaps they’ll help you as well.
One thought stands out from reading about MBCT. It’s really not about learning a “technique” or “tool.” It’s more about finding a different approach to experience. Rather than isolate thinking as a source of depressive mood, as other forms of cognitive therapy do, it draws together the flow of thoughts, feelings and sensations through your mind and body as an integrated whole.
How have you been able to deal with the recurrence of depression? Relapse is so often a hope-killer. Have you been able to get around the effect of these setbacks and keep going with treatment?