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Women Conquering Depression
How to Gain Control of Eating, Drinking, and Overthinking and Embrace a Healthier Life
By Susan Nolen-Hoeksema
Henry Holt and CompanyCopyright © 2006 Susan Nolen-Hoeksema
All rights reserved.
The Toxic Triangle
For Jill, a thirty-year-old account executive at a large bank, there were two distinct parts to each week. When she was "on-duty," from Monday morning to Thursday night, she tightly controlled everything she ate and drank. Breakfast, if she ate it at all, was just a piece of toast with a bit of jam (no butter) and lots of black coffee. Lunch was always a small, pristine salad with no-cal dressing. Dinner was as sparse and low-fat as she could make it and still call it dinner — usually just a frozen diet entree. And alcohol never passed her lips while on-duty, no matter how much she wanted it. Even if she went out with clients to a nice restaurant, she ordered sparkling water, adopting an air of casual self-righteousness about her abstinence from alcohol.
By Thursday night, however, Jill's cravings for food and drink were powerful. The sense of control and superiority that she gained from avoiding food and alcohol all week were overcome by feelings of frustration, longing, and defeat. Why wasn't she more fulfilled in her job? Could she really handle the stresses of her position? When was she ever going to find a man she could really fall in love with? And why did she have to deprive herself all the time just to stay skinny and put in long hours at work?
The second phase of Jill's week, when she was "off-duty," usually began slowly, on Thursday night. She'd come home from work, feeling tired but agitated, desperately wanting a drink. "Just one drink," she told herself, "I deserve it the way this week has gone." She'd pour herself a glass of sauvignon blanc and sip it slowly while she sorted through mail and microwaved her dinner. "Oh damn," she'd say, when the first glass was drained. "I'm not ready to eat yet." Then she'd pour another glass, vowing that two was going to be her max, for sure. By the time dinner was ready and the second glass was empty, Jill was ravenous. And a diet entree out of the microwave was not what she wanted. She put the entree in the fridge and brought out the chips. "I need some starch to soak up this wine," she'd tell herself. Jill then took her chips, and another glass of wine, and flopped down on the couch to watch TV. It felt so good, such a relief, to let go and do what her mind and her body seemed to want to do — eat and drink. Jill spent the rest of Thursday night snacking on junk food and leftovers and drinking more wine, until she collapsed into bed around midnight.
Of course, she felt terrible the next morning. But Fridays were usually absent of meetings, so she could hole up in her office, popping Advil while kicking herself for her indulgences the night before.
By Friday night, however, she was ready to party. It was the weekend, she was off-duty, and she wasn't going to waste a minute of it. From Friday's happy hour with workmates through a party on Saturday night, into Sunday's get-together with friends to watch football, Jill raged. She ate anything she wanted to — hamburgers and fries, fettuccine Alfredo, everything that she forbade herself while she was on-duty during the week. And she drank. Hard liquor, beer, wine, whatever was being served.
Come Monday morning, Jill was back "on-duty," wracked with self-loathing and shame. Why did she do this to her body? She had to stop, she had to be better about controlling her eating and drinking. She felt dirty, defective, diseased.
JILL ISN'T DISEASED but she has entered a perilous zone where millions of women every year find themselves trapped. This toxic triangle is the intersection of three troubles that affect women at alarming rates: yo-yo eating, heavy drinking, and self-criticism and despair. Each of these afflictions does damage on its own. Binge eating and self-starvation ravage a woman's body, increasing her risk of a number of serious diseases. Heavy drinking can wreck a woman's relationships, her career, and her vital organs. Low self-esteem, sadness, and lethargy can stop us in our tracks, preventing us from claiming all that life can provide.
Millions of women play at the edges of depression, eating disorders, and alcohol abuse. They'll take a few steps into the realm of eating disorders, calling their self-deprivation a diet or throwing up a meal every now and then because it "didn't settle right" with them. They'll experiment with how much they can drink before they begin to slur their words. They'll allow themselves a day or two in bed, wallowing in angry thoughts about themselves and others, or just shutting down and not thinking about anything.
These little forays can be insidious. At first, we step over the line just a bit, and pull back relatively quickly. But we are lured to return. The symptoms can feel good — it's such a relief to let go and binge or give up and curl into a little ball. After a while, we find ourselves inside the danger zone for eating disorders, or alcohol abuse, or depression, only this time more often, and for longer. Our symptoms, which were once mild and occasional, have become moderate and more frequent.
More dangerous than either of these discrete realms, however, is their intersection — the toxic triangle. Depressive symptoms, crazy eating habits, and heavy drinking rarely happen independently. As many as 80 percent of women who are drawn into one of these afflictions find themselves crossing the line into at least one of the others. The vortex where all three intersect is a whirling mass of confusing and self-damaging actions and feelings. A woman stuck in the toxic triangle can shift from immobilizing sadness to strength gained from controlling her eating, to shame and frustration from losing that control, and then to the relief of anesthetizing herself through alcohol or binge eating. Her family members and friends may try to help, though the target for their interventions keeps shifting. One day she won't get out of bed, can't get to work, and her voice is pure misery. The next day she seems happier, but she might be drinking heavily. Later, she swears she's stopped drinking, but she's losing (or gaining) weight rapidly.
Why Don't We Recognize the Toxic Triangle?
Although the toxic triangle is both poisonous and prevalent in women's lives, it has been largely ignored both by the lay public and by mental health professionals. One reason is the expectation that mild or moderate symptoms of depression, eating disorders, or alcohol abuse are "typical" for women today, and not terribly dangerous.
We comfort ourselves by saying things like, "Sure I drink, but I'm not a heavy drinker," or "Every woman I know goes on and off diets all the time — I'm no different from them," or "I'm not happy with how my life is going, but I'm not depressed — depression is an illness that you have to take Prozac to get over."
A critically important finding in my own research and other recent studies is that moderate, or subclinical, forms of eating disorders, alcohol abuse, and depression are each in themselves highly toxic and dangerous. These subclinical symptoms chip away at a woman's physical and mental health, harm her ability to function in everyday life, and set her up for more serious symptoms down the road.
Another reason that the toxic triangle has gotten too little attention is that it's just easier to focus on one problem at a time. Scientists tend to study depression or eating disorders or alcoholism, but rarely do they study two or more disorders at a time. We also like to think linearly — that one thing causes another, and then another, and so on. So if a person is suffering from two or more problems, we tend to think that one must have caused the other. In particular, mental health professionals and laypeople often assume that if a woman is both depressed and binge eating or binge drinking, then the depression must be causing her to binge. This is sometimes the case, but not always. Often the binge eating or binge drinking comes before the depression. And relieving a woman's depression through treatment doesn't automatically stop her from bingeing on food or alcohol.
The toxic triangle is not as simple as one thing causing another. It is a place where symptoms of depression, eating disorders, and alcohol abuse play off one another and enhance one another. There are many pathways into the toxic triangle. Some women enter through the path of depression; others through binge eating and self-deprivation; still others through alcohol. Once they are in the toxic triangle, women can find it very difficult to escape.
Taking It upon Ourselves: Women's Tendency toward Self-Focused Coping
At the root of women's vulnerability to the toxic triangle is their tendency to respond to stress with what I call self-focused coping. When women are faced with a difficult situation, they turn inward to control or change themselves rather than focusing outward on the environment and individuals that need to change. Whereas men tend to externalize stress — blaming other people for their negative feelings and difficult circumstances — women tend to internalize it, holding it in their bodies and minds. When something bad happens to women, they analyze everything about the problem — how they feel about it, why it came about, and all its meanings and ramifications for themselves and their loved ones. Women are acutely aware of how their body feels in reaction to a problem — tension, agitation, lethargy, and a sense of being out of control in reaction to a problem. As a result, they are especially likely to do something to change how their body feels.
Many women do self-destructive and damaging things to overcome their feelings. They may binge eat to escape their feelings in the fleeting pleasures of excess or their favorite "forbidden foods." They may refuse to eat, welcoming the feelings of power and control that come with self-denial. They may drink alcohol or take sedatives in an attempt to anesthetize their feelings. Or they may simply remain glued to their feelings and thoughts, rehashing things that have happened in the past, worrying about what will happen in the future, immobilized by a crushing sense of being overwhelmed.
Self-focused coping takes many forms, but each involves managing your internal self in a misguided attempt to manage external situations. Feeling that you can't do anything about your problems at the moment, you turn inward and focus on how you feel or think about the problems themselves. Not all forms of self-focused coping are self-destructive. Employing strategies to quell your anxiety — such as deep-breathing exercises — can help you think more clearly and is a highly adaptive form of self-focused coping.
But when self-focused coping involves hurting your body in some way, or gets in the way of doing something productive to overcome your problems, it becomes dangerous and maladaptive. Indeed, it can help transport you into the toxic triangle — depression, yo-yo eating habits, and heavy drinking. Self-focused coping can lead to depression by amplifying feelings of despair and preventing you from taking action to overcome the true sources of your problems. Self-focused coping can lead to symptoms of eating disorders by causing you to focus on your control (or lack of control) over your body rather than on the ways you can change your life situation. And self-focused coping can lead to abuse of alcohol and other drugs as a way of escaping those troubling thoughts and feelings that it inspires.
Unfortunately, once a woman enters the toxic triangle, the symptoms of depression, disordered eating, and heavy drinking work in lockstep, creating a self-perpetuating syndrome that grows in intensity. Depression leads to attempts at escape, and many women achieve this through drinking or binge eating. But binge eating and drinking lead to more depression. In fact, the cycling of bingeing and drinking changes the way the body metabolizes food and alcohol. Once the cycling starts, it fuels itself, making it hard to stop.
Women can break out of the toxic triangle. This book will help you understand how the toxic triangle emerges in women's lives and will help you use this knowledge to break free from the power it exerts over your life. Women's self-focusing tendencies develop in part because we are attuned to our own emotional lives and the emotions and needs of others. These sensitivities can be used to acknowledge and understand the sources of our stress, and develop more effective ways of dealing with stressors. Stress need not be internalized or taken out on our bodies and minds; instead, we can learn how to use self-focusing skills to develop the kinds of solutions that strike a balance between our own values and the best interests and needs of those we care about.
The Three Pathways into the Toxic Triangle
Each of the three pathways that lead to the toxic triangle has unique characteristics that draw in its victims. To give you a sense of how each pathway looks and feels, and how each converges into an overpowering trap, I will describe them for you here.
"I JUST DON'T CARE ANYMORE"
Depression has been called "the common cold of modern times." Indeed, rates of depression appear to have increased in recent generations. Researchers Myrna Weissman and the late Gerald Klerman of Columbia University examined data from several studies and determined that people born in the latter part of the twentieth century are much more likely to experience depression than those born in the early part of the century. Lots of different explanations for this generational effect have been offered: older people simply may not remember their periods of depression and so don't report having experienced it, or something about our contemporary life — lack of strong family and social ties, a vacuum of common values, materialism — may be making people, particularly young people, more vulnerable to depression.
Just what is meant by depression? It's a word that is used so casually these days, like stress, that it's understood to mean any general feeling of malaise and psychic discomfort. But psychologists and psychiatrists have a specific set of symptoms that they place under the label of depression.
Sadness is the cardinal emotional symptom of depression. You're blue, feel as if you've lost something, as if there's a huge weight on your psychological shoulders. Some people who are depressed don't so much feel sad but it's more like their emotions have been sucked dry and they can't feel anything anymore. What used to give them pleasure now just lands like a dull thud on their consciousness. They watch a favorite movie — one that used to make them smile every time they saw it — and they can't see or hear what used to make them feel so good. They talk with a trusted friend, and instead of feeling relieved or uplifted, they feel dull and drab and lifeless. They go shopping, or go out to eat, and nothing can pique their interest. They really couldn't care less about anything.
The physical symptoms of depression are often confusing because they can swing from one extreme to the other. When you are depressed, you may want to sleep all the time, or you may not sleep at all. You may feel tired, slowed down, heavy, and lethargic, or agitated and unable to sit still.
When you are depressed, your thoughts may be filled with themes of self-blame, guilt, and pessimism. You may feel as though you can't think at all — your powers of concentration and attention have disappeared, along with your ability to make decisions. Writer and researcher Kay Redfield Jamison has described these feelings this way: "It seemed as though my mind has slowed down and burned out to the point of being virtually useless."
One in four women, at some time in her life, will experience symptoms of depression severe enough for a diagnosis of major depression, one of the most severe forms of depression. Milder symptoms of depression, short of such a psychiatric diagnosis, but still painful, plague most women at least occasionally. In one of my own studies, I assessed depressive symptoms in approximately 1,300 adults, half of them women, half men. These people had not sought help for depression or any other psychological problem — they were a random sample of people from all walks of life. Over a third of the women reported experiencing five or more symptoms of depression at the time of the study. Although this may seem like an astonishingly high rate of depressive symptoms, it is well in line with other studies of the general population in the United States, Europe, Australia, and New Zealand.
Excerpted from Women Conquering Depression by Susan Nolen-Hoeksema. Copyright © 2006 Susan Nolen-Hoeksema. Excerpted by permission of Henry Holt and Company.
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