Active Treatment of Depressionby Richard O'Connor
Depression, a chronic, recurring illness, affects twenty percent of the population.
O'Connor, a therapist who suffers from depression, shows that depressed people have trouble digging themselves out of one episode or warding off the next because they have become adept at the "skills of depression," such as denying, procrastinating, and intellectualizing.
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Depression, a chronic, recurring illness, affects twenty percent of the population.
O'Connor, a therapist who suffers from depression, shows that depressed people have trouble digging themselves out of one episode or warding off the next because they have become adept at the "skills of depression," such as denying, procrastinating, and intellectualizing. Actively playing mentor, coach, cheerleader, and nurturer, therapists can engage patients' emotions, mitigate the effects of shame, and help them see connections between what happens in their lives and how they feel inside.
- Norton, W. W. & Company, Inc.
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EXCERPT FROM CHAPTER 1: What is Depression?
Three months ago, 24-year-old Jessica was hospitalized after an abortive suicide attempt. Today, she sits in my office, the picture of despair. Tense and worried, she has intrusive thoughts of hurting herself or of other impulsive actions, which she tries desperately to control. She feels guilty and inadequate, hopeless and helpless. Despite medication, she wakes up every morning at 5 A.M. after a few hours of sleep. She's lost 20 pounds. She's had to reduce her responsibilities at work, where she cannot concentrate or make decisions. She constantly asks others for reassurance. Although she goes through the motions of living, she's unable to enjoy any activity. This all seemed to come out of the blue. Jessica had a fight with her mother and decided it was time to leave the nest. She confidently made plans to find her own place until early one morning the impulse to hurt herself—for no reason that she can understand—suddenly overcame her and she slashed her wrists.
Roger is a man in his fifties who works in an autobody shop. Roger joined AA and quit drinking about two years ago, and it's made his life smoother but not much happier. He works steadily and does everything he can to support his wife and children, but takes no pleasure in it. He never has any energy or shows any excitement. He's quiet and unassertive, and gets picked on at work. His rotten self-esteem is made worse by his virtual illiteracy, a result of undiagnosed dyslexia. This also makes him rely on his wife to make all the important decisions about the family. Roger has been unhappy and in the background almost all his life, since his mother died when he was 9. He started drinking and drugging in his early teens, but when he was a young man it was important to him to have a family and be a responsible adult; he's done the best he could, just never enjoyed it.
These are the two principal subtypes of depression. Jessica is diagnosed with major depression. The formal criteria as spelled out in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association, 1994) for her diagnosis include a depressed mood or a loss of interest or pleasure in ordinary activities most of the day and nearly every day for at least two weeks, accompanied by at least four of the following symptoms:
1. significant weight loss when not dieting, weight gain, or change in appetite
2. insomnia or hypersomnia nearly every day
3. psychomotor agitation or retardation (activity level slows down or increases)
4. fatigue or loss of energy
5. feelings of worthlessness or excessive guilt
6. diminished ability to think, concentrate, or make decisions
7. recurrent thoughts of death or suicide, suicidal ideation, or a suicidal plan or attempt
Roger's diagnosis is dysthymia. In the DSM-IV, the essential criterion for this diagnosis is a depressed mood for most of the day, for more days than not, for a period of at least two years. In addition, there must be at least two of the following symptoms while feeling depressed:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
Strictly speaking, almost all the new developments in psychopharmacology for depression apply to Jessica but not to Roger. Major depression has the advantage of being researchable. It is usually characterized by rapid onset, and most patients can be expected to get better within a reasonable amount of time. But we conveniently ignore the fact that most people like Jessica are permanently damaged by their experience with depression, and are likely to have more episodes as their life goes on. As far as Roger is concerned, no one wants to fund research lasting the amount of time to treat dysthymia adequately. But that doesn't stop Roger's doctor from prescribing the same type of antidepressants for him. In fact, they seem to be working better for Roger than for Jessica right now.
There is room for a great deal of discussion, some of which we will explore, about whether Roger and Jessica have two different but related diseases, or two manifestations of the same process. Whichever position we take, it's important to recognize that for both Roger and Jessica depression represents at least four things all at the same time: an adaptation, an illness, a communication, and a vicious circle. I make no apologies for this state of affairs; if light can be both a wave and a particle and an electron can be in two places at once, we can surely think of something as complex as depression as having several coexisting manifestations. In fact, we can avoid a lot of argument and misunderstanding about depression if we make it clear which aspect we are talking about. In order to treat depression successfully, we must keep all aspects in mind, but may want to emphasize one or another at any given time depending on the needs of the patient.
- From Active Treatment of Depression, Copyright 2001 by Richard O'Connor. Published by W.W. Norton & Company.
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Richard O'Connor, who lives in Lakeville, Connecticut, also wrote Undoing Depression.
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The reading public seems to have become well aware that Richard O'Connor's book "Undoing Depression" is a truly excellent and very helpful approach to understanding and dealing with that powerful negative force -- depression. I want to add a related point, which concerns O'Connor's "Active Treatment of Depression." Although this book is aimed at therapists, I would recommend it also as a follow-up for any reader who appreciated "Undoing Depression." Reading his 2 books in sequence is a doubly helpful process. As psychologists become more aware of how depression is usually embedded in a broader pattern of negativity -- worry, anxiety, pessimism -- readers can benefit from those broader, related insights. For example, The Positive Power of Negative Thinking by Julie Norem updates traditional cognitive therapy with new understanding of 'constructive pessimism' as a cognitive-emotional experience. And, as other reviewers have pointed out, the cognitive therapy classic Feeling Good is still useful today. So don't miss O'Connor's 2 books, and related titles may help with the broader psychological context.
I bought O'Connor's first book, 'Undoing Depression,' in hardcover when it came out, and I found it immensely helpful at a time when I was suffering and struggling a lot. I have since recommended that book to many others dealing with depression who wanted to learn more about the disorder and what they can do to get better. When this second book came out, I glanced at it, noticed that it was written for mental health professionals, and put it back on the shelf. Some time later I picked it up again and to my pleasant surprise found that most of the material is appropriate and accessible for educated laypeople. In fact, for me, this may be an even better book than 'Undoing Depression' because it has a clearer, narrower focus, i.e. the 'active treatment' of depression, it omits some of the more general background material found in the first book, it squarely emphasizes what the depressed person can 'do' to get better, and because O'Connor's writing and voice are more polished and self-assured. The parts of the book that are directly applicable to the depressive himself or herself are well-written and sensible. The reader comes away from the book with a clear sense of what he or she can do to feel better, and how to deal with the things that get in the way of a person doing what needs to be done, and doing it consistently. For example, O'Connor explains how and why part of the patient doesn't want to get better, and how that problem can be addressed. O'Connor also recognizes that non-directive therapy creates problems for many depressives, and he understands that we often need help from a therapist with structure, organization, prioritizing, and simplifying and getting started on tasks. But the parts written for the therapist reader can be equally helpful. For example, in reading sections on how and why patients resist doing the things they need to do to get well, the lay reader is likely to recognize some of his or her own tendencies, and armed with a better understanding of those barriers to successful treatment the reader is in a better position to benefit from therapy and self-help. This is not a book for non-professionals who have no background in depression. There are other, better books for 'beginners,' including O'Connor's first book. But, for sufferers who want to move beyond the basics and take a seriously active role in their own treatment, I don't think there's a better book on the market.