Dear Friends,

I composed this Open Letter to Meeting late last year, but it could not be shared easily until recently.

As I’ve mentioned during Meeting, the Morbidity and Mortality (suffering and death) caused by Depression world wide is second only to that caused by Heart Disease (per WHO*). This may seem surprising, but the WHO Morbidity and Mortality ranking process considers loss of productive life for each type of disease. Depression is common and, as both depression and suicide often afflict younger people, the cumulative measure of loss is high.

I appreciated a message given by Jim Downton at meeting recently. He described how he loses confidence after dark, and he suggested that most people who are depressed also suffer from a loss to their “confidence” – albeit one that is more generalized and persistent.

There is a useful clinical construct, related to Jim’s insight, known as Self Efficacy (created and popularized by Stanford University psychologist Albert Bandura).  Self efficacy is an internal state that characterizes ones sense of agency (whether one anticipates future personal success in a particular endeavor or not).  Unfortunately, the internal state of each individual is very complex, and it is this internal state that determines ones self efficacy, which is integral to both mood and behavior.

This is one reason why it is so difficult to help people who are despondent.  In order to make a real difference, a parent, a friend, or a therapist has to impact the internal state of the sufferer.  But the internal state is often largely unconscious, and therefore resistant to even the most sincere and energetic efforts to be of assistance.

My understanding of the interpersonal dynamics that are involved in depression, despondency and suicidality prompts me to address two audiences – those who have suffered the loss of a friend or a family member to suicide, and those who wish to be prepared, should they be concerned for the safety of someone they know.

It’s normal to feel sad or have depressed mood on occasion.  It is normal to suffer after a loss.  And losses come in all sizes and flavors.  Many adolescents suffer due to peer relationship problems, especially the loss of romantic love.  The Social Work Life Change Index lists Death of Spouse and Divorce as the two most stressful life events for adults – on their list of forty three common stressors.  But for adolescents, peer relationships are usually paramount, especially romantic relationships.   

Everyone has their own context of meaning which drives their emotional life.  In my opinion Cognitive Therapy, created by Albert Ellis (psychologist) and Aaron Beck (psychiatrist) in the 1950’s, is the most useful Western method to understand human emotional life and behavior.  Beck realized that our ideas and beliefs drive our behaviors.  Ellis understood that our beliefs actually generate our emotions.  This insight was very profound, as most people place great value in their emotions, and often chart their life course based on them. 

Both men developed techniques that help people identify their “structures of belief” and how those beliefs generate their emotional response to events.  A skilled therapist can help the client identify which beliefs are dysfunctional and can usefully be modified or jettisoned.  That’s why these forms of therapy are so very effective with people suffering depression spectrum disorders.  Cognitive therapy helps people identify the beliefs that underlie their struggles.  The Ellis school of cognitive therapy is called REBT (Rational Emotive Behavior therapy).

These ideas are well understood by Buddhists who utilize a Garden of the Psyche analogy to explain the functioning of the heart, mind and soul.  The Buddhist garden analogy suggests that, as one goes through life, many seeds (ideas and beliefs) are planted in ones garden.  This process happens throughout life, but particularly when we are young.  The primary task as an adult, on the path to enlightenment, is to become aware of the contents of ones garden and to weed and prune as necessary.  With enlightenment meaning to lighten ones burden in life.

Jim Downton kindly reviewed this essay and here’s what he said about depression: 

In working with depressed students, I learned that “normal, everyday depression” is caused by making up negative stories – and then believing they are true.  When you help people become aware of those negative stories, you give them the power to change their thoughts which reduces their depression.  The problem with saying that depression is the result of unconscious processes that are hard to change is that it takes away our confidence and power to make a change.  I think someone with a deep depression may be run by unconscious problems – – but for “normal everyday depression” it’s the conscious mind that needs retooling – – (which) can be done without more drastic measures like taking an (anti-depressant). 

I would add that even in despondency – and even when deeply unconscious processes are at play – “retooling” – (Cognitive Therapy) – is the most effective therapeutic approach.

Like most human characteristics, depression is best understood as a spectrum.  Normal mood oscillation includes periods of sadness – and this represents the mild end of the depression spectrum.  On the severe end of the spectrum are chronic and persistent despondency and suicidal behavior.  In between are the various grades of depression from mild and transient to severe and chronic – the latter blending into despondency.  Despondency can be considered Depression on Steroids.

Despondency is the result of psycho-spiritual processes that are complex and persistent – and that are almost always unconscious.  Which means the sufferer usually has difficulty understanding their internal struggles – which can lead him or her to suicide.   Once someone becomes truly despondent, it’s very difficult to successfully intervene.

People who have lost someone to suicide can benefit to know that suicide is hard to predict – and even harder to prevent.  But, like the suffering of a despondent person who chooses to commit suicide, the suffering of survivors is often driven (in large part) by certain ideas and beliefs, especially related to what they could or should have done, to try to prevent the suicide.  Cognitive therapy can also be very useful for suicide survivors.

However, there is an up side to this story.  Because the suffering of depression is usually a very private process – an effort to help can sometimes bring the situation into the Light.  The rule should be, when in doubt, speak your mind.  Express your concern.  It is far better to be wrong – and speak your mind – than to be right – and hold your peace.  The usual reticence that most people feel when considering whether to interfere with someone else’s “business” should be set aside when addressing concerns of despondency and suicidality.

Depressed people are usually sensitive to what other people think.  This can be useful for those who are trying to help.  Social Workers in Emergency Departments often contract for safety with despondent patients.  This means that they try to get a commitment from such patients, that they will communicate with family and/or friends should they become suicidal.  Such commitments can disrupt the solitary quality of their suffering, and it can help them to recognize their importance to others.  While this tactic is not perfect, it can be effective.

Any Friend who wishes to communicate about this issue may contact me –

Charlie Janney FNP/MSW

* The WHO M&M rankings separate out the various cancers by type.  Cancer would be ranked 2nd on the M&M ranking list – after heart disease – if all forms of cancer were lumped together.