Ruah books

The Holy Longing: The Search for a Christian Spirituality - Ronald Rolheiser

Care of Mind/Care of Spirit: A Psychiatrist Explores Spiritual Direction - Gerald May

   Ruah's back! And I hope to keep up better with the required reading this year.
   When I started the class, I assumed doing the reading would be one of my favorite parts, but I've been disappointed, or I've disappointed myself. Generally I've found the books (some of which I'd read before and deeply enjoyed) boring and frustrating. Overwritten. Uninspired. Blah Blah Blah. I'm projecting my depression onto them, I know! But, still, it's not like I haven't enjoyed other books over the past year.
   I think I'm in a mental and spiritual spot where theology is baloney, sermons are intolerable, nobody knows what they are talking about. I'm in the mood, spiritually, for specific instructions, silence, or riddles.
   All that said, these two books were good, if a bit wordy. Specifically I appreciated Rolheiser's main thesis, that spirituality is how we respond to our deepest desire, our divine madness, our natural maladjustment. We're not happy creatures that sometimes have problems, we're problematic creatures that sometimes get happy. Spirituality is about staying in touch with and channeling this deep longing in healthy ways.
   May's book is helpful in distinguishing between psychotherapy and spiritual direction, while maintaining links between the two. He is all for cross-pollination, but encourages practitioners to hone their specific purposes. Psycotherapy is geared toward identifying and solving psychological problems. Spiritual direction aims to help the directee to hear God in their life.
   May is both a psychiatrist and spiritual director, which is awesome and gives him great tools to write this book. But I'd love to read a book studying spiritual direction techniques and its effects written by a non-religious psychiatrist or behavioral scientist. Are there such books?



notes

Holy Longing

• God-given fire, desire, longing, madness, eros: what we do with that is spirituality, how we channel it
• "energy is not just difficult to access, it is just as difficult to contain once it enters"
• "pray, fast, and give alms"... 4 non-negotiables "a) private prayer and private morality; b) social justice; c) mellowness of heart and spirit; d) community as a constituitive element of true worship"
• "To be a saint is to be fueled by gratitude, nothing more and nothing less"
• "Our loved ones live where they have always lived and it is there that we will find them."
• "John Shea once suggested that the heavenly banquet table is open to everyone who is ready to sit down with everyone."
• "Shower those you love with flowers and affection while they are alive, not at their funerals."
• "To deal with Christ is to deal with church."
• Pascal cycle
• Name your deaths (crucifixion)
• Claim your births (resurrection)
• Grieve what you have lost and adjust to the new reality (40 days of appearances)
• Do not cling to the old, let it ascend and give you its blessing (ascension)
• accept the spirit of the life that you are in fact living (pentecost)
• "When we fail to mourn properly our incomplete lives then this incompleteness becomes a gnawing restlessness, a bitter center, that robs our lives of all delight."
• sexuality as basic fire: lead to creativity, co-creation with God
• "What Janis Joplin is saying is that, in our sexuality and our creativity, we are ultimately trying to make love to everyone."

Care of Mind/Care of Spirit

• "the primary danger in bringing these dimensions together [psychotherapy and spir direction] is that mental and emotional concerns may kidnap the gentle spiritual attentiveness required of both director and directee
• four forces in human spirituality
• longing for God
• God's longing for us
• internal fear and resistance
• evil
• unitive experiences - can't be aware of it in the moment (otherwise wouldn't be "unified"), can't achieve it or cause it 
• "in the absence of clearly identifiable disorder, it is terribly destructive to encourage the dulling or denial of this deepest existential discomfort, for this is one pain we are not meant to anesthetize ourselves to...
• basic trust and mistrust (Erikson)
• self-image
• strength - how stable and defined/fixed is self-image
• quality - how do you evaluate self (good or bad, high or low esteem)
• importance - how attached are you to it; how much do you depend on it
• "we maintain neuroses because hey represent an unconscious "solution" to deeper psychological threats
• attend to relationship between spiritual experience and social/family life
• required physical labor and voluntary exercise usu. have different psychological effects
• dark night experiences usu not associated with loss of functioning (as opposed to depression)
• "it is my belief that the primary task of spiritual directors is to encourage within themselves this moment-by-moment attention towards God as frequently as possible during spiritual direction sessions
• condensation - feelings condense around other feelings
• referals

Drugs, Diagnosis, and Despair

On Depression: Drugs, Diagnosis, and Despair in the Modern World - Nassir Ghaemi

What's the angle?
   Ghaemi is a practicing psychiatrist and researcher, also very well read in the western humanistic tradition. I really enjoyed all the history of psychology and medicine he included. His chapter on Hippocrates was one of my favorites, as was his chapter on Lester Havens, his teacher. 
   On the other hand, his "clinical picture" of post-modernism was vague, watery, a straw-man, so his arguments against it didn't go over well; like a grumpy old-man.

What is depression?
   Ghaemi would like for the mental health field to make a distinction between depression disease - whose hallmark is recurrence - and depression non-disease - perhaps resuscitating "neurotic depression" as an apt term. He doesn't draw a hard and fast line between the two - there must be overlap; but his goal is to distinguish, as far as possible, between biologically based depression and psychologically based depression.
   For depression disease, he identifies genetics and early life environment as the "first" causes (the things that make the disease possible) and adverse experiences or events as the "efficient" causes (the things that trigger the disease).

How do you treat depression?

1. Medicine
   Dr Ghaemi, like many of the authors I've read, think that anti-depressants are being overprescribed, but in principle he is in favor of medicating diseases. The key is accurate nosology, and Ghaemi thinks that the DSM has lumped too much into Major Depressive Disorder. He lays out some good rules of thumb (rule of thumbs?)

• As to diseases, make a habit of two things - to help, or at least to do no harm -Hippocrates. Is the disease curable? help. incurable? do no harm. self-limiting? do no harm. "...a Hippocratic approach would avoid medications as much as possible, except where we can clearly help the natural process of healing and with great attention to side effect."
• Osler's Rule: Treat diseases, not symptoms. "if we reject disease-oriented medicine, we are left at the mercy of social forces tending toward overmedication: patients themselves; the pharmaceutical industry; and doctors' own economic interest."
• Holmes's Rule: All medications are guilty until proven innocent. Medications "need not be proven harmful; they do need to be proven safe and effective."
• Use a diagnostic hierarchy: "certain diagnoses should not be made if other diagnoses are present...mood illnesses can produce not only depression and mania but almost any psychiatric symptom."

2. Psychotherapy
   Ghaemi reminds us that not too long ago psychiatrists primarily practiced psychotherapy. Freud and Kraepelin were the founding tree trunk, and various disciples and heretics branched out with theories and therapies. Ghaemi practices psychotherapy quite a bit, and his chapters on "guides" include many in the "existential" psychotherapeutic tradition.

• Victor Frankl: an abnormal reaction to an abnormal circumstance is normal.
• We must learn to suffer. "We must try to reduce needless evil and horrible suffering where possible, but we also need to learn, not only to accept, but to benefit from, whatever suffering remains.
• Rollo May: the therapist enters the circle of the patient's existence wherever the patient happens to be...Usually, the patient comes with a problem...Whatever the problem is, May teaches that the existential therapist meets it first as a person's experience, not as pathology, nor in any other theoretical way.
• Angst and the awareness of death
• Nudging the patient toward the "I am" experience
• Leston Havens: "soundings," probing comments rather than questions
• "motor empathy," using non-verbal communication to empathize
• hold opposing theories in your head at once
• therapy is "successive acts of liberation, not moving speeches or penetrating insights"
•  "I judge the success of psychotherapy in two ways. Does the patient's appearance change? Does he get new friends?"
• the therapeutic alliance; he was convinced that this relationship was the key treatment

 


notes

• depression a sign that we are at a dead end
• using depression to help understand normal problems
• I think the old term (neurotic) - now discarded for the fancier terms "dysthymia" and "generalized anxiety disorder" - was more true to reality
• depression disease vs non-disease
• recurrence key aspect of disease
• "first cause" - genetics (additive, not Mendelian) and early life environment
• "efficient cause" - life events as triggers
• mental health clinicians should be biased against common sense, because anything that comes their way has already failed to respond to it
• depression expressed as psychic vs physical pain, in diff cultures
• disease process vs clinical picture
• the feeling comes first, the rationalization comes later
• in usa, psychiatrists prescribe meds to 82 percent of patients
• psychiatric drugs second most profitable class (cardiology 1st)
• hippocrates - nature wants to heal, physician should aid nature,
• galen - illness is lack of humoral balance, always intervene
• Osler's Rule - treat diseases, not symptoms
• Holme's Rule - all medications are guilty until proven innocent
• recent study: half of people diagnosable with mental illness not in treatment, and half of people in treatment not diagnosable
• history of DSM and depression
• Frankl - an abnormal reaction to an abnormal circumstance is normal
• learn to suffer
• Havens - goal of therapy is "successive acts of liberation"
• Havens - work with comments, empathy, rather than questions
• Havens - "just as conventions and expectations can fix a lethal straitjacket on individual differences, so standards of health on the basis of admirable traits ignore the way human situations an call up the need for the most bizarre qualities"
• "norm" - what is typical in a group
• "normal" - absence of pathological
• "ideal" - theoretical standard
• Havens - "hold your formulations lightly, and let your imaginations grow, remembering that all formulations used to be imagination"

Conquering Depression

Heavenly Wisdom from God-illumined Teachers on Conquering Depression - St. Herman of Alaska Brotherhood

What's the angle?
   The library office at Richmond Hill has a dozen or so books from the press of St. Herman of Alaska Brotherhood, mostly Russian Orthodox stuff, or things based on the Philokalia. Really cool. 
   This book begins with a very brief testimonial about Maria of Gatchina, who, during a paralyzing illness, was blessed with the spiritual gift of "consolation of the sorrowing." People from all around came to her for illumination, comfort, and counsel. Later she was imprisoned for her faith and died a martyr.
   The rest of the book is made up of teachings and prayers about depression from the Orthodox tradition, from Paul, early Greek writers and desert fathers, on up to the 20th century. The bulk of the excerpts come from 18th-20th century Russian monks.

What is depression?
   I loved both the unity and variety of this book. Depression, dejection, despondency, insensibility, sorrow, grief, despair, gloom: the authors witness to all these and more. Is this depression in the modern, western sense? Definitely so, at least by DSM criteria.
   Mostly what the monks address are prolonged periods (weeks, months, or years) of low or sad mood, a feeling of spiritual disconnection, a loss of the hope or sensitivity to life, loss of energy for their normal activities, feeling like their lives are pointless, overwhelming guilt or shame. The only criterion that doesn't appear here is suicidal ideation or attempts (except when in reference to Judas).
   Despondency may be the word most used in this collection. I'm not sure, maybe dejection or depression. I'm guessing "acedia" or a Russian version of that is the key orthodox term in play.

What causes depression?
   Again there is diversity, with common threads. Here are some diagnoses:

• the devil or a demon of gloom is attacking you, draining you, clouding your spirit and dulling your mind, trying to convince you to give up the monastic life
• God is punishing or disciplining you for some sin
• God is testing your faith; will you love God in the bad times as well as the good?
• God is forming you with the hammer of suffering and deprivation
• you're thinking too much about yourself, about what you lack, or about your past sins.
• it's part of the natural up's and down's of monastic life

Practically, it might be your fault, it might be the devil's fault, or it might be God's fault, but one way or another depression is always defined or explained vis-a-vis God. For the monastic, God is the ultimate reference point, and every experience is caused or allowed by God and, to the eye of faith, leads to God.

How do you "conquer" depression?
   You don't. According to most of these writers, if you live right, then eventually it goes away, or God sends you consolation in the midst of it. I'm not sure why the editors chose "conquer." "We are more than conquerors." It fits with the spiritual battle language, but "resist" or "endure" appear more often here. Here are some treatments:

• Repent! Drop to you knees and pray for forgiveness and begin again. Perhaps you know you have sinned or been forgetful of God. Perhaps God will reveal a hidden sin to you. (this seems a dangerous tack for someone who is depressed, but I guess it worked for many of these folks) In any case, the monk's life is one of constantly (re)turning to God.
• Resist! Don't give into the despair. Don't leave your cell, or abandon your calling. Keep up your prayers, even in the sorrow or pointlessness. Eventually you will come out of the dark cloud.
• Be humble. Bear your cross patiently. "By your endurance you will save your souls." Jesus has "sanctified the road of suffering with his feet."

A Very Short Introduction

Depression: A Very Short Introduction - Mary Jane Tacchi and Jan Scott (2017)

What's the angle?
   Tacchi is a psychiatrist and Scott is a psychologist, both hailing from Newcastle. They begin the book with a history of melancholia, from Hippocrates to Avicenna to Freud, and even provide a quick glance into traditional Islamic, Indian, and Chinese views of depression. Then they present the leading theories on the causes, risk factors, and solutions to depression. In the final chapters they discuss controversies in the study of depression and estimates of its social and economic costs.

What causes depression?

   historic theories
- an imbalance of the humors, or too much black bile
- misperception or misunderstanding of life events
- demons or possession
- punishment from God or spirits
- imbalance or disturbance of the doshas (similar to humors, in Ayurveda medicine) caused by difficulties of mind, difficult life experiences, or difficulties of the environment
- internal blockages disrupting the flow of Qi/Chi
- "mechanical theories" in 18th and 19th centuries hypothesized a disturbed flow of internal fluids (blood, lymph, nerve fluid)
- Freud - melancholia is like bereavement, but mostly unconscious grief over the loss of an "ideal object"

  contemporary theories
- monoamine hypothesis: monoamines - norepinephrine, dopamine, and serotonin - are a subset of neurotransmitters. In the 50's it was discovered, incidentally, that a drug which tended to decrease monoamine levels sometimes had depression-like side-effects, and a drug which tended to increase monoamine levels sometimes had anti-depressant side effects. Further study confirmed that there is a significant correlation between low levels of serotonin and depression. Is it cause, or effect, or bidirectional, or none of the above?
   The hypothesis is that one of the major drivers of depression is 1) low serotonin (because not enough is produced, or it is broken down too fast, or re-uptaken too quickly) or 2) low receptor sensitivity to serotonin.
    However, not all drugs that effect monoamines also effect mood in the expected direction, and anti-depressant medications which target serotonin have a hit-or-miss record (about 20% effective, when the placebo effect is accounted; they said that's not great, but not terrible when it comes to drug effectiveness). And little is known about how the 30-some-odd neurotransmitters really interact with each other, or how their relative levels are related to mood disorders.

- neuro-endocrine hypothesis: disturbances in several hormones have been linked to depression, and people with endocrine disorders are often at higher risk for depression. Most depression related research has been done on the hypothalamic-pituitary-adrenal (HPA) axis, which is the main stress regulator. The hypothesis is that the system kind-of gets stuck in a chronic stress mode, even when there aren't recognizable stressors. Childhood trauma can have a similar effect. Cortisol levels remain high, which can undermine mental and physical health.
  However, not all people with HPA abnormalities have symptoms of depression, and not all people with depression are shown to have HPA abnormalities.

- Aaron Beck's hypothesis: this is the basis of cognitive behavioral therapy. Beck maps a path backwards from feelings to thoughts, from thoughts to beliefs, and from beliefs to our experience, especially early experience. Basically, he hypothesizes that if we're depressed, there's a good chance it's because we're thinking (cognition) lots of negative things, almost automatically, about ourselves. And if we're thinking lots of negative things, it's probably because we have developed certain beliefs (cognitive schemata) that lead to those thoughts. And we have probably generated these beliefs through (mis)interpretation of negative experiences, often early in life.

-Brown and Harris' social hypothesis: Hari (Lost Connections) also dives into the research of George Brown and Tyrell Harris, which they began in the 70's. They didn't make a specific hypothesis, but they demonstrated correlations between social stressors, which they called risk factors, and depression. And these social stressors display a dose-effect: the more stressors, the more likelihood of depression. Certain stressors, like experiences of humiliation or entrapment, were particularly high risk factors. So basically, their hypothesis is that social stress is a major driver of depression.

-the biopsychosocial hypothesis: everything causes depression! No, Tacchi and Scott write that most researchers and medical professionals believe that there are or can be multiple overlapping "causes" of depression. One way to express that is with a stress-vulnerability model, where stressors can be bio, psycho, or social, and the vulnerabilities can as well. Abnormally low serotonin might be a vulnerability, and losing your job might be a stressor. On the other hand, being unemployed might be a vulnerability, and then having a disruption with your monoamines might be a stressor. I think.

What are the treatments for depression?

  historic treatments
- purging
- bloodletting

- exercise
- herbal teas
- bathing, rest, sunshine
- Avicenna recommended persuasive talking
- the first known care facility for mental illness was established in Bagdad, 705ce
- exorcism
- witch-hunts
- sedatives
- brain surgery
- spinning rapidly in a chair! (Benjamin Rush believed it would help with inflammation)

  contemporary treatments
- Electroconvulsive treatment (ECT); they say this has developed a lot since One Flew Over the Cuckoo's Nest. It's primarily used in cases when other treatments aren't helping, or when there is a medical emergency (like the patient won't or can't eat). When it does help, it often helps immediately.


- Transcranial magnetic stimulation; using magnetic fields to stimulate brain nerve cells.

- Brain surgery is still practiced for desperate cases of depression. Stereotactic surgery is the newest practice, which places small electrodes in certain places associated with emotional control.

- Vagal nerve stimulation; originally designed for treating epilepsy, it has also shown some effectiveness in treating depression.

- Drug therapies; the most common are SSRI's and lithium. 

- Psychotherapies; Interpersonal therapy and Cognitive Behavioral Therapy are two of the most recommended therapies.

What other research is being done about depression?
The authors briefly introduce some promising research on the relationship between circadian rhythms and mood disorders, as well as the immune system (particularly inflammatory markers) and mood disorders. They also mention further exploration of neuroplasticity, and the potential ways neuroscience can help study the effectiveness of psychotherapies.

In their final chapter I was particularly impressed with a couple studies estimating the work costs of depression. In the U.K. one team estimated that a depressed person loses an average of 22 work days per year, and another study in the U.S. estimates an average of 5-8 hours per week of work lost.

I've often wondered how I could quantify or describe how much more productive I am when I'm feeling well as opposed to depressed. Eight hours, or a day per week, is probably accurate. Because I spend a lot of time depressed yet functional, and because my work isn't particularly interested, when I'm feeling up at work, it's almost a magical experience. I'm more motivated, alert, and lighter on my feet. It's so much easier to start or change tasks, to change direction mentally and physically. I can rebound from failure more quickly, mistakes don't shackle me, while success is more pleasing.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _

notes

• Hippocrates - melancholia characterized by despondency, aversion to food, sleeplessness, irritability, and restlessness (too much black bile)
• Galen - certain personality types may lend themselves to certain problems
• Avicenna - both body and soul affected by melancholia, persuasive talking
• Benjamin Rush's spinning chair
• bipolar vs unipolar
• Freud
• topography of mind: conscious, preconscious (accessible), unconscious
• personality: id, ego, superego
• sexual development: oral, anal, phallic
• Freud - Mourning and Melancholia, melancholia like grief, except the loss is of an "ideal object" and the loss is partially unconscious
• one-year rate of depression (american study) highest among 18-25yr olds
• 2x higher in women
• symptoms of "post-natal depression" can begin before birth
• about 1 million suicides each year, globally
• monoamine hypothesis; monoamines (a subgroup of neurotransmitters): norepinephrine, dopamine, serotonin
• neuro-endocrine hypothesis: trouble with the regulation of stress responses within hypothalamic-pituitary-adrenal axis; chronic stress or adversity different from usual reaction; cortisol levels remain high, etc
• Aaron Beck (CBT): event-thought-feeling-behavior; cognitive structures/schemata (thoughts and beliefs) and cognitive mechanisms (reasoning)
• events/feelings of humiliation and entrapment esp. associated with depression
• stress vulnerability model (biopsychosocial)
• identical twins more likely 46% to both have depression than fraternal twins 20%
• Baghdad 705AD, first record of asylum, historically Islam very compassionate toward mental illness
• evolution of treatments: sedatives, electroconvulsive treatment (ECT), transcranial magnetic stimulation (TMS), antidepressants, lithium (7-up started as a lithium tonic!)
• therapy - not as much funding for studying, also harder to set-up studies; CBT and IPT (interpersonal therapy)
• chronic disease management models - like diabetes and hypertension
• only group shown to consistently benefit from antidepressants - severely depressed
• monoamine and stress hormone systems connected - also bidirectional influence to genetic, psychological, and environmental factors
• possible link between circadian rhythms and mood disorders
• link also to immune system (higher levels of inflammatory markers, higher risk of depression)
• absenteeism and presenteeism
• estimate 5-8 hours of work lost per week
• mental capital: general abilities, how flexible and efficient at learning; emotional intelligence, such as social skills and resilience under stress

Lost Connections

Lost Connections: Uncovering the real causes of depression - and the unexpected solutions - Johann Hari

What's the angle?
   Hari is a journalist and writer, and most of his book is built on interviews with psychologists and sociologists and stories about their work. Like Rottenberg (The Depths), he weaves in some of his own experience with depression.
   His general conclusion is well expressed by a quote he includes from the World Health Organization, "mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual, solutions." 
   Disconnection and re-connection - this was his key metaphor for the problem and solution of depression. "Only connect!" I'm surprised he didn't riff on that famous line from Howards End. Maybe he thought it overplayed? However if I remember correctly, "only connect" doesn't always work so well for the Schlegel sisters. Or did it? I can't remember. I guess they connect some dots, just maybe not all the dots they hope to.

What causes depression?
   He writes that most mental health guidelines recognize interlocking biological, psychological, and social causes of depression (the bio-psycho-social model). Hari summarizes all his findings as Disconnection. Hari breaks it down into nine areas.

1. Disconnection from Meaningful Work. He cites a 2011-2012 Gallup poll across 147 countries that really struck me. Only 13% of people reported being engaged in their work (looking forward to it and positive). 63% reported being not engaged (like, going through the motions or apathetic). And 23% reported being actively disengaged (like, hatred). Snap.

2. Disconnection from Other People. Loneliness, alienation, isolation. And technologically simulated connections aren't helping much, rather they may be hindering the kinds of tribal or "mutual aid and protection" connections that we need.

3. Disconnection from Meaningful Values. Basically, we are way too materialistic. Most of this chapter focused on the study of intrinsic vs extrinsic motivations and values. Intrinsic values would be the "deep" stuff like love, respect, power, pleasure, security. Extrinsic values are things or goals that (sometimes) help us attain those intrinsic things. The diagnosis is that we're tangled up in a knot of extrinsic values. We're really good at convincing each other that we can't be happy or adequate with out this or that product.

4. Disconnection from Childhood Trauma. In this section he tells the story of Vincent Felitti, who began to study obesity at the request of an insurance company, and found a trail all the way back to childhood trauma. He and others created and, through the same insurance provider, deployed the ACE survey, Adverse Childhood Experiences, the seminal study in the effects of childhood trauma on adult physical and mental health.

5. Disconnection from Status and Respect. Generally speaking, the lower status you have in a hierarchy, the more your risk for anxiety and depression. And insecure status is an even bigger risk factor. Another study found that highly unequal societies have greater levels of depression.

6. Disconnection from the Natural World. We have a natural "biophilia" and need to act on that love.

7. Disconnection from a Hopeful or Secure Future. Here he works backwards from the observation that depressed patients often have a difficult time thinking about the future, making plans, imagining change. Hari also cites a Canadian study that found a close correlation between the level of autonomy for First Nations and their rates of depression and suicide. The more self-governance, the less depression.

8 & 9. Genes and Brain. Your genes and brain can make you more or less susceptible to depression. That's pretty certain. 
   And it's probable that for some people, depression is mostly caused by a chemical or biological glitch. Like, your neurotransmitter system starts tripping up. But based on Hari's interviews and investigation, that is a small slice of the depressed population.

How do people recover from depression?

   I assumed Hari would simply mirror each disconnection chapter with a reconnection chapter, but he takes a slightly different tack. First he uses two fulcrum chapters to display multiple reconnections in action at once. 
   He tells the story of a doctor and a depressed man, in a Cambodian rice farming region, whose leg had been blown off by an old land mine. Together they found a way to reconnect him to his community and to meaningful work by raising money to buy a cow, so that he could become a dairy farmer. 
   Then, in his longest chapter, he tells the story of the Kotti neighborhood in Berlin, which rallied around an elderly Turkish immigrant who'd become suicidal when faced with her continuing isolation and potential eviction, then rallied around other vulnerable members of their community, and ultimately managed to organize long enough and well enough to protect their community from displacement.

1. Reconnection to Other People. You have a better chance of being happy if you think of, and pursue, happiness as essentially a shared experience, rather than something you can achieve for yourself.

2. Social Prescribing. Here he describes the work at the Bromley-by-Bow Center in East London, where the core of their treatment is connecting patients to social programs, volunteering, support groups, nature excursions, "one of over a hundred ways to reconnect."

3. Reconnection to Meaningful Work. He explores how the same work can be more or less meaningful depending on how the workplace is structured. He advocates for more democratic work environments.

4. Reconnection to Meaningful Values. In surveys of "what's most important to you," relationships and personal growth most often score at the top of the list. It takes effort but groups working together can resist being over-saturated in extrinsic values.


5. Sympathetic Joy, and Overcoming the Addiction to the Self. This is mostly about meditation, altruism, and loosening the grip of ego. Spiritual stuff. He writes about Roland Griffith, who, in an effort to understand the effects of meditation, recently resurrected the study of psychedelics.

6. Acknowledging and Overcoming Childhood Trauma. Children are quick to blame themselves and hold on to that shame and guilt into adulthood. However trauma can be addressed and worked through. Adverse childhood experiences are risk factors but not determinants.

7. Restoring the Future. Here he advocates for a universal basic income as a way to decrease inequality, increase security, and balance the power of ownership with more leverage (stability and choice) for workers.



_ _ _ _ _ _ _ _ _ _ 

Notes

• depression and anxiety "like cover versions of the same song by different bands"
• depression and anxiety "are only the sharpest edges of a spear that has been thrust into almost everyone in our culture
• when giving a medical treatment, you are giving the treatment, but also a story about how the treatment works
• proportion of people on antidepressants who continue to be depressed is b/w 65-80 percent
• all want a story about why we are in pain
• the grief exception, or dilemma, in the DSM
• Joanne Cacciatore - call it emotional health
• depression as grief over our own lives
• biopsycosocial model
• "disconnection"
• broad Gallup poll, 147 countries, 13% engaged in work, 63% not engaged, 23% actively not engaged (hatred) 
• derealization - feeling like nothing you do is real or authentic
• disconnection at work can carry over into home life, and vice versa
• loneliness raises cortisol levels
• loneliness, "an adverse state that helps us to reconnect"
• "micro-awakenings" during sleep happen more when people feel lonely or anxious (or depressed)
• to end loneliness, you need to have a sense of "mutual aid and protection"
• difference b/w being on social media and being physically present is similar difference b/w pornography and sex
• intrinsic vs extrinsic motives and values
• materialism associated with depression
• high satisfaction in "flow states"
• ad angle - make people feel and believe they need something; make them feel inadequate without your product
• a "vocabulary to understand why they feel so bad"
• relationships and personal growth - usu the top two on surveys about what people value most
• ACE Study (started with interviews about obesity, then led to study early trauma)
• being treated cruelly by parents biggest driver of depression
• dose-response effect of trauma
• big social stressors: low status and insecure status
• the more unequal you society, the more prevalent all forms of mental illness
• depression and anxiety in animals held in captivity
• e.o. wilson - humans have natural biophilia
• all over world, people show preference to images of savanna
•  depression - lose sense of future
• from proletariat to "precariat"
• suicide lower in first nations with more autonomy
• a brain scan is a snapshot of a moving picture
• "ask not what's inside your head...ask what you head's inside of"
• "it's no measure of health to be well-adjusted to a sick society" Krishnamurti
• a different kind of antidepressant
• Kotti neighborhood in Berlin, powerful story
• Brett Ford, "the more you think happiness is a social thing, the better off you are"
• altruism as antidepressant
• social prescribing, Bromley-by-Bow Center in east london
• ask less, "what's the matter with you?" and more "what matter's to you"
• average american exposed to up to five thousand ad impressions a day
• sympathetic joy mediation (you plant seeds during your meditation, and it flowers throughout the day)
• depression as a constricted consciousness
• psilocybin and mediation (connection, walls of ego dissolve)
• humiliation, shame, childhood trauma
• WHO - "mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual, solutions"

When A Parent Is Depressed

When a Parent is Depressed: How to protect your children from the effects of depression in the family - William Beardslee (2002)



What's the angle?

   Beardslee is a psychiatrist in Boston, specializing in child psychiatry, who also teaches at Harvard. He views depression as a complex disease, like heart disease, that has many causes, risk factors, and treatment options. His book is steeped in the case histories of families where one or both parents have severe episodes of depression, and his advice is based mostly on the experience and research of his team at Boston Children's Hospital. His goal is to help the whole family deal with depression and come out stronger on the other side.

What causes depression?

   In his section on the causes of depression, he describes depression from a biological and chemical point of view - trouble with neurotransmitters, like serotonin, in the brain; diminished blood flow in certain areas of the brain; oversecretion of hormones from the hypothalamic pituitary system (disturbance in the fight-or-flight response system). He doesn't say what causes these things.

How do you treat depression?

   With all available resources! And keep trying until you find something that works. "While our objective reality may be to prevent depression, our method is to promote resilience." He writes that with regard to children, but he seems to apply it to parents as well.
   Specific treatments he mentions are cognitive therapy, cognitive-behavioral therapy, medication, and interpersonal therapy.

What are the risk factors for depression?

• mood disorders in the family
• loss of loved one
• chronically dissatisfying job or relationship
• chronic medical disorder
• suffering or witnessing abuse or violence
• having had depression before
• tendency to brood or ruminate
• recurrent sense of helplessness and hopelessness (isn't that one of the symptoms of depression?)
• being female
• living in poverty

What are risk factors specifically for childhood depression?

• depression in one or both parents
• alcoholism or anxiety in parents
• other difficulties or developmental delays in early childhood

How can parents with depression help their children?

   Beardslee is full of encouragement for parents, and full of examples of parents who have been floored by depression yet continue to be loving, dedicated parents. His number one advice is to get help, quickly; use all the resources available to you - medication, therapy, friends, religion, family. 
   The next step is to talk about depression - "break the silence" - within the family, beginning with a planned family meeting. What is depression? What does it feel like? What's been going on for the parent? How do the kids feel when the parent is depressed? What questions do they have? Let them know that they are not to blame. Let them know that they can ask questions about the behaviors, the disruptions, and the treatment. Keep the conversation lines open. 
   This will begin to create a new family story, a mutual understanding, that includes the depression episodes, but isn't silently dominated by them. The parent's mental health crisis is part of a larger story.
   Then Beardslee turns to resilience, building strengths and building on strengths already present. He highlights several keys for a child's resilience when a parent is depressed:

1. To understand depression, to have a realistic idea of what they are dealing with.
2. That they are not to blame.
2. To develop and maintain positive relationships within and without the family.
3. To develop strategies to deal with the effects of the parent's depression.
4. To develop and maintain positive activities outside the home.
5. To reflect on what they have gone through, and what the family has gone through.
6. To know (especially through experience) that their actions make a difference in their own lives.

Comparison to The Depths 

   Beardslee's definition of depression is different from Rottenberg's (disease vs adaptation), but his vision of mental health is similarly holistic and bold. The goal of treatment should be well-being, in the individual and the family. "The health of the child is inseparable from the health of the parent."
   For many of the parents in Beardslee's case histories, "breaking the silence" and helping to develop the resilience of their children was a major part of their own recovery. They were able to connect more deeply to family members, and were able to see their depression in a broader, more optimistic family story.


_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 
notes

• while our objective reality may be to prevent depression, our method is to promote resilience
• being able to construct a meaningful story together
• family treatment 6 steps
• sharing a history together
• apply knowledge of depression and resilience
• address needs of the children
• plan how to talk to the children
• break the silence together as a family
• continue the family dialogue
• signs of depression start as extensions of normal feelings...symptoms tend to appear gradually
• there's less energy to do tasks, so fewer tasks get done
• depression especially disrupts the memory of what's been positive and what's been accomplished...
• consider what it is you want help with most
• well-established risk factors
• mood disorders in the family
• loss of loved one
• chronically disatisfying job or relationship
• chronic medical disorder
• suffering or witnessing abuse or violence
• having had depression before
• tendency to brood or ruminate
• recurrent sense of helplessness and hopelessness
• being female
• living in poverty
• single most important area to focus on in protecting you, your spouse, and your children is promoting healthy and open relationships within the family and among extended family, friends, and the larger community
• childhood depression often goes undiagnosed because the symptoms mimic other common symptoms - being withdrawn or sleepy, having stomachaches, or being irritable. That's why it is key for parents and caregivers to ask directly about being depressed, about feeling sad, and even about having thoughts of suicide.
• treatment - ct, cbt, medication, interpersonal therapy, other therapy styles
• resilience in children with depressed parents
• realistic about the issue, and also realized they were not to blame
• aware of and could articulate strategies to offset the effects of the illness on them
• they believed their actions made a difference, and they took action based on their understanding
• the effects of positive experiences accumulate over time, gradually helping children develop deep inner strengths.
• risk factors for depression in children
• depression in one or both parents
• alcoholism or anxiety in household
• other difficulties or developmental delays in early childhood
• combine warmth and support with effective limits - help establish resilience
• three things to help protect children
• help them to develop and maintain relationships
• be positively engaged in activities outside home
• help them reflect on and understand what they've undergone in the family
• change comes both from broad understanding and from continuing to take small specific steps
• draw on all available resources to get through depression
• as is true in developing resilience, a central quality in being able to deal effectively with depression is optimism, or confidence that one's actions do make a difference
• take action quickly in a crisis
• review actions and strategies that work and use those again
• fitting the ongoing struggle with depression into the context of other vital shared beliefs
• part of healing for many families was no longer seeing depression as the central part of their lives, but as just one of the many things they had to deal with
• often, trying to talk simply introduces the idea that it is okay to talk, even though actual back-and-forth interchanges do not take place
• each time you need help,  you may have to rediscover how to get it
• above all, dealing with depression means finding and connecting with many resources at different times - community, religious faith, caregivers, friends, and family.
• ...mental health care and physical health care are inseparable
• the health of the child is inseparable from the health of the parent. care must be available for both.
• who would not forgo those few dollars for a guarantee that all of our children, all of our grandchildren, would never be without health care?

The Depths

The Depths: The Evoluntionary Origins of the Depression Epidemic  - Jonathan Rottenberg (2014)

What's the angle?
   Rottenberg is a psychologist who studies mood, "mood science." As I understand it, mood is somewhere between temperament and emotion. If temperament is the climate zone in which you live, mood is your seasonal weather, and emotion is your daily weather.
   He says that mood "is the great integrator." It sums up internal and external information to create an emotional attitude; it prepares you to behave in a general way. Anxious mood prepares you for threats and primes the emotions that help you respond to threats. Positive mood prepares you for exploration and seeking, priming the emotions that go along with that.
   What's the evolutionary function of depressed mood? Some guesses are:

1. De-escalate conflict and get out while you can: like an antidote to anger in social conflict; be sad instead, give-up fighting, especially if you are losing.
2. A "stop mechanism:" when you're in an impossible situation or have set unreachable goals, depression saps your motivation and helps you to give up. [sadly, two common tests of antidepressant medications are the "tail suspension test," where they hang a rat by its tail and see how long it struggles, and the "forced swim test," where they drop a rat into a bucket of water to time how long before it stops scratching the bucket walls and simply floats with its nose above water. The goal is to design a drug that will increase the amount of time the rat struggles to escape.]
3. Sensitivity to social risk: like loneliness, depression is the result of disconnection, and highlights the need to reconnect.
4. Depressive Realism: positive mood can lead to over-confidence; low mood sometimes gives you a more realistic assessment of your situation.
5. Grief/Bereavement: this like a combination of #2, 3 and 4; the death of a loved one brings on the impossible goal to reconnect; however it can bring the group together and help them assess what went wrong, if anything.

What causes depression?

   Rottenberg says that no one has identified the basis of depression as a "disease" or "disorder," as defined by the DSM, whether biological or psychological. There is a correlation between depression and high levels of the stress hormone cortisol and proinflammatory cytokines. And there are well-studied psychological and social risk factors that contribute to the likelihood of depression. [He doesn't even mention the serotonin based explanation.]

  He thinks that depression is simply an adaptation that, as our lifestyles have rapidly changed in the past few centuries, has become maladaptive for certain situations.

What are the psycho-social risk factors for depression?

• neurotic/anxious temperament
• trauma, especially early in life
• chronic stress, especially unpredictable, uncontrollable, or unexplained stressors
• loss events; loss is the big psychological theme
• lack of exposure to daylight
• lack of consistent and adequate sleep
• Overcommitment theory: based on the "stop mechanism" idea, this sees depression as a response to "overcommitment" toward impossible or hazardous goals (for example, saving your abusive spouse, pleasing your hyper-critical parent, so forth). Perfectionists are more likely to become depressed.
• "Sinking through thinking" or "rumination;" circular worrying.
• Happiness-Obsession: our culture has set happiness goals too high, and pursuing happiness as an end in itself often backfires.
• The biggest risk comes from the double whammy of serious loss plus no way forward.

How do people recover from depression?

    Three treatments have shown some degree of effectiveness: antidepressant medications, cognitive-behavioral therapy, and interpersonal therapy. However, about a third of depressed people will recover quickly on their own, or recover more quickly than can be attributed to treatment. Rottenberg hopes to study this group, but has three hunches as to why they recover quickly: 1) they have fewer complex life problems, 2) they have secret weapons, like a nimble mood system or a very healthy lifestyle, or 3) they are lucky - they have good things happen to them, like a fresh start or multiple positive turns-of-events.
   Rottenberg insists that the goal of recovery should be well-being, rather than an elimination of symptoms. Very shallow depression, too shallow to meet the DSM criteria, or lingering effects of depression, greatly increases the likelihood of repeat depression. "Mood-congruent memory" - the tendency to remember things that match your mood - can combine with "memory elaboration" - the process of creating a story or a web of memories - to trap you in sad thoughts and memories. And the more times we experience depression, the more easily our mood system is able to recreate that experience. People suffering with depression need ways to get well, stay well, and bounce back from the depressed moods that will inevitably accompany loss events.


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Notes

• the WHO projects that by 2030 the amount of worldwide disability and life lost attributable to depression will be greater than for any other condition, including cancer, stroke, heart disease, accidents, and war. 2
•  Two-thirds of those treated with antidepressants continue to be burdened with depressive symptoms. 7
• moods are internal signals that motivate behavior and move it in the right direction 13
• the mood system is the great integrator 13
• anxious mood narrows the focus of attention to threats 14
• good moods broaden attention and make people inclined to seek out information and novelty 14
• theoretical explanations of low mood 23
• helps de-escalate conflicts, helps one side yield
• a "stop mechanism," discouraging effort in situations in which persisting in a goal is likely to be wasteful or dangerous
• help sensitize people to "social risk" and helps them reconnect when they are on the verge of being excluded from a group
• enables people to make better analyses of their environments (depressive realism) 24
• If we had to find a unifying function for low mood across these diverse situations, it would be that of an emotional cocoon, a space to pause and analyze what has gone wrong. 28
• We return to a glaring problem with defect models: no one has identified the basis of the disease, the underlying defect in the  mind or brain that causes deep depression. 32
• two mouse tests for antidepressants - the tail suspension test and the forced swim test (how long will they struggle to escape, vs give up and conserve energy) 47
• chronic stress, esp chronic but unpredictable stress cause depressive symptoms in mammals
• social situations are the strongest drivers of mood (in mammals) 54
• no evidence has emerged to suggest that bereavement-related depressions are substantially different from other depressions 66
• the theme that most consistently predicts depression is loss 67
• talk therapies usually seek to address or uncover loss events in clients 69
• we recover more quickly from a bad event if we can readily explain it. We would expect, then, that events that generate mixed feelings and/or confusing thoughts would be a powerful impetus toward persistent low mood. 83
• the most important and well-studied depression-prone personality trait is neuroticism 87
• light exposure and sleep schedule 89
• sinking through thinking; rumination 98
• the perils of persistence; overcommitment theory; depression occurs b/c we can't let go of certain goals that we can't/aren't reaching; "inability to disengage from efforts from a failing goal" 104
• perfectionists are more likely to become depressed 105
• what may be most important for exposing humans to the risk of depression is that they are able to pursue highly abstract goals and to set goals in domains where programs is difficult to measure 106
• our culture has set happiness goals too high; and achieving positive mood states is difficult as an end in itself; rather it usually accompanies the achievement of other goals 110
• the strongest depression-inducing situations present a double whammy: serious losses and no route (or an overly hazardous route) forward 121
• emotion context insensitivity - depressed people react less to emotional stimuli 121
• depressed people showed less moment-to-moment change in emotional behavior than nondepressed people 131
• research on the stress hormone cortisol indicate that many depressed people chronically overproduce this hormone 132
• on average, an episode of major depression last about six months 132
• like cortisol, proinflammatory cytokines are high in depression 137
• why do some people come out of depression more quickly and fully
• hunch 1 - early improvers face fewer complex life problems
• 2 - early improvers have secret weapons against depression (nimble mood system, good life habits)
• 3 - early improvers are lucky (fresh start events, multiple positive events)
• depression symptoms are usually lost in reverse order to that in which they were acquired 155
• chronic depression has a greater power to alter a person's self-concept than briefer episodes do 159
• residual depression symptoms are one of the strongest predictors of the return of deep depression 160
• one reason we're not winning the fight against depression is that our available treatments leave so many in partial recovery limbo 167
• evidence that the mood system has an easier time going from limbo back to deep depression than it did getting there the first time 169
• mood-congruent memory - increased ability to think of content that matches our current mood state
• memory elaboration - creating a story, connecting memories into your identity; deep depression strengthens the web of sad mood 173
• we need to understand how the experience of well-being might help people do things that keep them well 191
• Barbara Fredrickson: broaden-and-build model of positive affect focuses on the ways that it functions to broaden attention and build resourses. The functions of positive mood are in essence the opposite of the functions of low mood and negative emotions. 191
• inert placebo pills are about 82 percent as effective as antidepressants 197