Rethinking the Battle Against Depression

medium.com/the-understanding-project/rethinking-the-battle-against-depression-513f84a556

March 31, 2019

Photo by Everton Vila

Why habits, not more pills, may be the best way to fight back against
depression.

Nick Wignall
Apr 1

As a psychologist, I’m frequently often asked a seemingly simple question:

What causes depression?

My answer is always the same:

I have no idea.

At this point, the face of the person asking the question quickly morphs from eagerness to
perplexity. They usually follow up with something along the lines of:

What do you mean you don’t know what causes depression? You’re a psychologist, aren’t you?

Now that they’re sufficiently perplexed — and a bit riled up — I know I’ve got their full attention.
Which is important, because the concept I introduce next is subtle:

It’s true, I have no idea what causes depression because I don’t think there is one cause of
depression. But, I do know what maintains it.

In this article, I want to unpack that explanation, and along the way, accomplish two practical
things:

1. Explain why the question of what causes depression is complex, and why any
simplistic answer should raise serious red flags in the mind of any thoughtful person.
2. Show how two psychological habits — rumination and avoidance — maintain
depression, regardless of the cause(s). Consequently, thinking about depression in
terms of habits is the most pragmatic strategy for most people to begin addressing
depression.

Whether you struggle with depression yourself, have a loved one who does, or are simply
curious to better understand a very misunderstood phenomena, I hope this article will be
useful to you.
The “cause” of depression is far more complicated than we think

Photo by Isis França

What if depression is, in fact, a form of grief — for our own lives not being as they should?
What if it is a form of grief for the connections we have lost, yet still need? —Johann Hari in
Lost Connections

As a society, we’ve been sold (figuratively and literally) the idea that depression is simply a
“chemical imbalance” caused by a deficit in neurotransmitters like serotonin. Consequently,
the simple (and profitable) solution is a drug that increases your serotonin and restores your
brain’s chemical balance.

Nothing to it, right?

Sounds great. The only problem is, there’s little real evidence of any sort of chemical
imbalance at play in depression; in fact, the chemical imbalance theory of depression has
been dead for decades because there’s no actual research to bear it out.

This should dampen our surprise somewhat when we learn that medicine has been trying for
the better part of a century to treat depression with drugs and the results have been tragically
disappointing, often no better than placebo. And when research does suggest a positive
effect over and above what you’d expect from placebo, the effect size is typically quite small,
the duration of benefit short, the side effects significant, and there’s the very grave possibility
of a massive file-drawer effect at play.

My point here is not primarily to criticize the pharmaceutical industry and psychiatric
medicine; in fact, I’m quite glad we have drugs and psychiatrists, even if I think they’re not
always correct in the way they conceptualize mental health.

Instead, I want to set the stage for a broader, more nuanced perspective on depression.

The misuses of neuroscience to explain depression

Photo by Hal Gatewood

As a psychologist who spends hours each day trying to understand the lives of people
suffering from a range of mental health struggles including depression, low serotonin or a
“chemical imbalance” is a shockingly reductive way of thinking about a person’s mental
health struggles.

Even if advances in neuroscience do lead to finer-grained analyses that show reliable

neurochemical changes in the brains of depressed individuals, that simply begs the question:
What caused those changes in the first place?

If you say genetics, proceed directly to jail, do not pass go, do not collect $200.

Any serious bio-medical scientist will tell you that for the past 20+ years we’ve known that — 
when it comes to human behavior — it’s foolhardy to try and think about genetics (i.e. how
genes affect behavior) without also thinking about epigenetics (i.e. how behavior and
environment affect genes).

Far from the one-way street we imagine them to be, genes are better thought of as 12-lane
bi-directional superhighways, almost constantly affecting and being affected by the broader
environment.

All that’s to say, the superficial glamour and psuedoneuroscientific appeal of the biochemical
model of depression have blinded us to the vast and diverse realities of those who suffer
from depression.

We talk excitedly about the latest research into how serotonin, dopamine, and
norepinephrine affect mood, or the newest drug that promised to finally cure depression
(ketamine is the latest “it” drug for depression).

But all the while we turn a blind eye to persistent loneliness and social isolation, abuse and
trauma, poverty and chronic stress, excessive familial and cultural pressures, chronic illness
and disease, substance abuse and addiction, lack of meaning and purpose, deep-seated
regret and shame, as possible causes of depression.

If you give it a few minutes of thoughtful contemplation, it’s difficult not to realize that the
causes of depression are as diverse and multifaceted as the histories and contexts of the
people suffering from it.
No doubt brain chemistry and genetics play a role in peoples’ experience of depression, but
we can’t let this distract us from the obvious social, psychological, cultural, and structural
factors so evidently at play in the lives of those suffering from depression.

Which is why my answer to the question of what causes depression quite intentionally begins
with, I have no idea.

So how should we think about depression?

Photo by Fabrizio Verrecchia

The myriad potential causes of depression for an individual human being with their own
unique history and context presents a matrix of possible causes so complex that a simple
answer to the question of what causes depression rightly seems ludicrous.

Of course, uncovering the causes of depression is important. I work with my clients to do this
in psychotherapy, usually over quite a long period of time.

But unfortunately, most people who struggle with depression don’t have access or resources
to do long-term psychotherapy.

And while it’s possible to discover these causes on your own or outside of a formal
therapeutic context, it’s difficult. What’s more, uncovering the causes of depression is
arguably the “easy” part — it’s making sustained changes to your life informed by your
knowledge of the causes that are profoundly difficult.

So where does this leave us?

Probably slightly discouraged, a sentiment I feel often as a mental health professional given
the complexity of the domains I work in — the intersection of cognition, emotion, behavior,
culture, and society.

Still, even if uncovering the causes of depression and making structural changes to our lives
and environments is beyond the scope of an article like this, I want to suggest a compatible
but alternative way of thinking about the fight against depression.

While there’s a staggeringly vast number of potential causes of depression, in my experience

there are two near-universal psychological factors which tend to maintain and exacerbate
depression.
Addressing these maintaining factors in depression may not be sufficient to completely
eliminate depression in someone’s life. But it can go a long way toward helping people
understand and manage their depression more effectively.

Rumination and Avoidance: The Twin Engines of Depression

Photo by Viktor Forgacs

The great unintended sin of our overly-medicalized approach to depression is that it

encourages people to think about it as they would an infectious disease — as though it were
a malicious bacteria you’ve caught that needs to be eradicated with a strong dose of
antibiotics.

But as I’ve hopefully shown above, far from a virus or bacteria, depression is often a
perfectly understandable psychological response to a vast and complex set of individual-
specific interpersonal, cultural, and societal stressors. If only the causes of depression were
as simple as polio or influenza!

Sadly, when we train people to think of depression this way — as an infectious disease — they
begin to see their own experience of depression as bad, something to be quickly eradicated,
preferably via a pill.

Then, when pills inevitably fail in the long run, we turn to more subtle, but equally unhelpful,
psychological attempts to eradicate the disease. And almost always, these attempts take the
form of two habits: rumination and avoidance, the psychological equivalents of the proverbial
“fight or flight” response.

And while these attempts to fight or run away from our depression may give relief in the
short-term, they inevitably exacerbate things in the long-run.

In the rest of this article, I’m going to explain these two maintaining factors in depression and
offer some thoughts for identifying them and working to lessen their influence by substituting
healthier alternative habits.

What is rumination, exactly?

Photo by Ben White

Rumination is the mental habit of persistent negative judgments about oneself, especially
one’s perceived past failings and mistakes:

If only I hadn’t been such a jerk, she never would have left me. I’ll never be truly
lovable.
I’m just a lazy bum. I’ve always been lazy. I’ll never amount to much anyway.
I can’t do anything right and always screw things up eventually.
Did I come across as rude? I shouldn’t have brought up that story about her mother.
Why do I always put my foot in my mouth?

Read through just a few simple examples like these and it should be obvious how badly
you’re going to feel if this is the kind of self-talk you habitually engage in, day in and day out.

The deeper question is, if we know that habitual negative self-talk and rumination like this
make us feel bad about ourselves (guilty, hopeless, lonely, etc.), why do we do it? Why do
we ruminate when it pretty obviously only makes our depression worse?

Part of the answer is simple conditioning. If you’ve historically associated sadness and
depression with the mental habit of rumination, eventually becoming sad will automatically
trigger the mental habit of rumination. In fact, this is the same process (Classical
Conditioning) that Pavlov discovered with his infamous drooling dogs.

Like any habit — physical or mental — rumination can seem to “come out of nowhere” and be
difficult to resist. Still, if a habit can be formed, it can also be broken.

But for deeply entrenched habits like a lifetime of rumination, breaking out of it can be
difficult, especially if that habit is filling some kind of important but unmet emotional need.

In depression, for example, a common feeling is a lack of enthusiasm and motivation to do

the things you know you should and want to do. In its extreme form, this lack of motivation
can become what psychologist Martin Seligman termed Learned Helplessness, an almost
complete despair of ever doing anything differently in the face of depression.

While many people who struggle with depression often look quite passive, it can be amazing
how active their minds are — specifically, how intensely they ruminate. In fact, it could be that
because they lack so much motivation to physically do anything, rumination temporarily
alleviates this need to take charge of their lives and do something. Like worry in anxiety,
rumination offers the illusion of control and agency in depression.
Of course, while hyper-analysis of one’s past mistakes and flaws is perhaps temporarily
relieving in that it gives you something to do and feel in control of, the negative emotional
side effects only contribute to one’s sense of sadness, shame, despair and apathy in the long
run.

In the next section, I’ll suggest some practical ideas for breaking out of the rumination habit.

Why mindfulness is the cure for rumination

Photo by Aleksandr Ledogorov

You’ve likely at least heard the term mindfulness before.

And while it’s typically thrown around quite casually and loosely as an apparently easy cure-
all for anything that ails you, I’m going to explain why a very specific version of mindfulness
can be not only helpful for dealing with rumination, but in fact, is the exact cure for it.

Fundamentally, mindfulness is the capacity to be aware without thinking. It means learning

how to observe things as they are in the present moment without getting lost in thoughts
about what they mean, how good or bad they are, and what happened or might happen in
the past or future.

More specifically, mindfulness is the ability to control our attention — to notice when our
awarenesses is consumed by thoughts (especially our own self-talk), and then to gently shift
our attention to observing things (including our own thoughts) rather than engaging with
them.

For example: You’re lying in bed and can’t seem to fall asleep. You find yourself obsessing
about that awkward conversation you had on your date earlier in the evening:

Damnit, I always put my foot in my mouth on first dates!

Why couldn’t I have mentioned another topic? Any other topic would have been better
than my last girlfriend!
I’ll never find someone. I should just give up and accept that I’m always going to be
alone.

Thoughts like these are a perfect example of rumination. It’s a kind of highly negative and
judgmental (and usually irrational) storytelling about yourself. And each one of these
negative thoughts generates more negative emotion (self-directed anger, sadness,
hopelessness, etc.).
But how do you stop ruminating? How do you stop thinking? How do you stop storytelling?

Mindfulness is the answer.

Although we rarely recognize it, it is possible to be aware without thinking. By cultivating our
attention muscle via mindfulness, we can learn to more quickly recognize when we’re caught
in unhelpful rumination spirals and then disengage from those unhelpful thinking patterns by
focusing our attention elsewhere.

When we practice mindfulness, we practice noticing ourselves getting sucked into thinking
and then extracting our minds from that thinking back into simple observation (usually of
something physical like our breathing).

For people with depression, the mental habit of rumination is strong. In a sense, it’s an
addiction to a certain self-critical way of thinking.

In order to break out of that habit, we need to strengthen the competing mental muscle. We
need to learn how to shift our attention and remain in observing mode without slipping back
into thinking mode.

Mindfulness is the most direct and efficient way I know of to build that mental muscle and
ability.

Ruminating less won’t cure your depression. But it will go a long way toward lessening your
overall distress and negative emotionality. So much so that when you begin to lift the excess
emotional burden of rumination, you’ll often be amazed at how much easier it is to address
other aspects of your depression.

While it’s beyond the scope of this article to walk you through how to get started with
mindfulness, here are three resources that can help:

How to Start a Mindfulness Practice: A Quick Guide for Complete Beginners (Article)
The Mindful Way Through Depression (Book)
Sit Like a Buddha: A Pocket Guide to Meditation (Book)

Now that we’ve covered rumination, let’s move on to the second maintaining factor in
depression — Avoidance.

What is avoidance, exactly?

Photo by Jose López Franco

Avoidance is the habit of turning down opportunities and experiences that are in some way
difficult or scary but likely to be rewarding and worthwhile in the long-run:

Staying on the couch watching Netflix after work because we’re exhausted rather than
going for a walk or to the gym.
Canceling brunch with a friend because we’re a little anxious and just feel “off.”
Eating lunch in our office instead of going out to eat with colleagues.
Turning down the invitation to join that softball league with our sister-in-law.

Of course, there’s nothing inherently wrong with canceling a meetup with a friend or eating
lunch in your office. In fact, being able to say no to things you genuinely don’t want to do is a
key component of assertiveness.

Turning down opportunities like these become avoidance behaviors and problematic when
they fit two key criteria:

1. They’re habitual. We don’t just occasionally skip out on the evening walk and watch
Netflix, rather, that’s the case more evenings than not.
2. They’re motivated by feelings and in conflict with our values. It feels better in the
short-term to stay on the couch, even though we know that walking regularly is good
for our health (a value) and will actually help us feel better in the long-term.

The reason a habit of avoidance is so detrimental to us — especially when we’re depressed 

— is that it robs us of meaningful and rewarding experiences in favor of short-term
gratification or relief. And it’s this consistent lack of meaningful and rewarding experience
that maintains and even worsens depression.

When we’re depressed, it can seem like the hardest thing in the world to simply get up, get
moving, interact with friends, and do some meaningful work. And yet, those are the things we
need most when we’re depressed.

The challenge, then, is to figure out ways to engage with life and begin to get more of those
rewarding experiences even though every bone in our body tells us we can’t, that we don’t
have the energy or motivation.

Why Behavioral Activation is the cure for avoidance

Photo by Tiago Rosado

You can think about depression like having an empty fuel tank. And obviously, it’s hard to go
anywhere or move at all when your tank is empty, which is very often how people describe
their experience of depression.

While getting a handle on your rumination habit is a good way to stop your tank from leaking
and losing even more fuel, the other “half” of the problem is that you need more fuel in the
first place. That’s where the concept of Behavioral Activation comes in.

Behavioral Activation sounds technical but it’s actually simple: it means doing things you find
rewarding.

More specifically, behavioral activation is a structured plan for incentivizing yourself to

engage in more rewarding (i.e. tank-filling) activities despite not feeling like it or having much
energy/motivation.

On a superficial level, behavioral activation resembles the famous Nike motto: Just Do It.

But of course, if you’re depressed, that’s the whole problem — you don’t have the energy or
motivation to do much of anything. Which is why the secret ingredient to effective behavioral
activation — and what sets it apart from “Just do it” — is the concept of incrementalism.

Incrementalism is the idea that if you’re having trouble making progress on any endeavor,
including engaging in more rewarding activities, the solution is to break things down into
smaller steps and pieces:

Can’t seem to actually meet a buddy for dinner and drinks? How about meeting him for
lunch?
Still too much? How about coffee for 15 minutes?
Still too hard? Try inviting him over to watch a game.
Still too much? Send him a text after the game about the coolest thing that happened
in it.

Once you’ve found a small enough increment, do it until you begin to notice a small uptick in
motivation and energy. Then, go for the next smallest thing on the list. Rinse and repeat.

I had an old supervisor who used to say:

I’ve never seen someone so depressed that they couldn’t go to the bathroom. If they can find the
energy to get into the restroom, that’s a start, something we can build on.
The key to breaking the cycle of avoidance, then, is to combine behavioral activation — a
structured plan for doing things that are personally meaningful and rewarding — with
incrementalism in order to get over the motivation problem.

In fact, the most powerful effect of incremental behavioral activation is to chip away at the
belief that because I don’t feel motivated, I can’t do anything.

By showing ourselves experientially — in very small ways at first — that that belief isn’t entirely
true, we can guide ourselves to ever-increasing levels of activation and therefore reward. We
can start to re-fill the tank.

Perhaps most importantly, in the long-run, we can construct a new belief about the very
nature of motivation itself: Yes, motivation helps me do difficult things, but doing difficult (and
rewarding things) actually leads to more motivation. In other words, we build a more
sophisticated model of motivation and action, one that is bi-directional.

All You Need To Know

Let’s review: There’s an important distinction between the causes of depression and
maintaining factors in depression. While the causes of depression are often highly diverse
and individual-specific, there are two nearly-universal factors that maintain it:

Rumination is the mental habit of persistent negative judgments about oneself,

especially one’s perceived past failings and mistakes. To undo this habit, mindfulness
is the best solution since it helps cultivate the ability to shift our attention away from
ruminative thinking and instead move toward non-judgmental awareness and
acceptance.
Avoidance is the habit of turning down opportunities and experience that are in some
way difficult or scary but likely to be ultimately rewarding and worthwhile. The key to
breaking free from avoidance cycles and re-engaging with life is to use incremental
Behavioral Activation to dispel the false belief that we need to feel motivated in order to
do important things.

For most people struggling with depression, identifying and addressing the structural,
interpersonal, and biological causes of their depression is necessary at some point in order
to truly undo the grip of depression. But no matter what those causes are, anyone who
struggles with depression can learn to undo the habits that are making it worse.

Depression feeds on rumination and avoidance. Starve it of these energy sources, and you
just may turn the tide on your war with depression.

Originally published at nickwignall.com on April 1, 2019.