Chapter 1

New Perspectives on Depression

We cannot solve our problems with the same thinking we used when we created them.

—Albert Einstein

If you’re looking at this self-help book, it’s likely that you’re struggling with serious issues in your life that you haven’t been able to fix. You may be in a bad relationship, maybe even an abusive one. Maybe your job is at a dead end and you haven’t mustered the courage to move on to something else because of the risks involved. You may simply be demoralized by the demands of life and the ongoing stress of it all. Perhaps you’re trying to care for an aging parent while raising your children and pursuing a career. Perhaps you’re having trouble with one or more of your children and can’t find the right way to approach it. Or you might not be approaching it at all because you don’t like conflict. You may be struggling with chronic health problems with no easy solution.

Perhaps you’re fighting a secret or not-so-secret addiction to alcohol, drugs, sex, the Internet, or food—habits that help you escape from and numb personal pain in the short term but lead to more depression in the long run. It may be that you’re so busy reliving your past that you’ve forgotten how to live in the present, or, worse, you’re letting your past dictate the present. You may simply be living by the numbers, hoping that life will cut you a better deal if you follow all the rules. You might even be experiencing a lot of success in your life at the surface level, earning a good salary and having a nice home and lots of “toys” but feel unhappy and out of sorts nevertheless.

At first glance, none of these scenarios seems way out of the ordinary. These types of personal challenges are the bread and butter of everyday living. People fall in and out of love, get divorced, change or lose jobs, and grapple with unwanted events like health problems and the death of loved ones. But people often cope with challenging life moments in ways that don’t work that well. There are almost 24 million people dependent on alcohol and other drugs in the United States alone (Grant et al. 2004), roughly 8.6 percent of the entire population. In particular, there has been a virtual nationwide epidemic of narcotic addiction, due in part to the ease with which narcotics can be legally procured. Narcotic overdose deaths are now the leading cause of accidental death in 29 states, surpassing automobile accident fatalities for the number one slot. The current annual rate of onset of mental disorders in the United States is 27 percent (Kessler et al. 2005; SAMHSA 2013), meaning that every year, one in four Americans will experience a serious emotional health problem.

The overall pervasiveness of mental health and substance abuse problems translates into a substantial lifetime risk of depression: approximately 20 percent for women and 10 percent for men (Kessler et al. 2005). This means that, during their lifetimes, one in five women will experience depression, and one in ten men. Do these numbers suggest that something is amiss in our basic human training? Is depression the common cold of modern living? If so, what’s the pathogen responsible for this epidemic of suffering?

The purpose of this chapter is to present some new perspectives on depression that will help you see it in a different, more approachable way. We will examine depression in a way that is quite different from the traditional biomedical approach. First off, we will introduce you to a powerful, evidence-based treatment for depression called acceptance and commitment therapy (ACT; Hayes, Strosahl, and Wilson 2011). ACT works to promote the ability to:

Closely tied to ACT, but now a separate field of research in its own right, is the general role of mindfulness in the treatment of depression. In the introduction to this book, we mention that mindfulness is not a single skill but rather a group of skills, all of which are included in various ways within the ACT model. Mindfulness training has also been employed with success in other, non-ACT treatments for depression. The bottom line: You can reverse your depression if you learn how to apply mindfulness skills in your daily life.

We will also briefly examine the burgeoning field of affective neuroscience. In studying the nervous system as a basis for our emotions and mood, this area of science has led to a particular interest in identifying the neural mechanisms of depression, as well as in how mindfulness practice affects those mechanisms.

Another encouraging development in the last couple of years is the emerging role of self-compassion in the treatment of depression. We will examine the concept of self-compassion in more detail and show why learning to be self-compassionate is so central to moving through depression.

Next, we will look at depression from the perspective of positive psychology, a relatively new branch of psychology that studies human resilience and the ways that people create sustainable positive emotional experience in daily living. We now know that engaging in positive, emotionally rewarding behaviors on a daily basis creates a positive-emotion “savings account” that makes people more resilient when they run into life challenges or setbacks that, for some, might be a trigger for a descent into depression (Frederickson and Losada 2005).

Finally, we will examine the highly prevalent, somewhat simplified media account of depression as a genetically transmitted, biological illness that is best treated with antidepressant medications. Adhering to this viewpoint leads some people with depression to conclude that using medication is their only real hope of living a normal life. We will introduce you to an alternative way of thinking about depression: the biopsychosocial model (Schotte et al. 2006). This contemporary perspective does more justice to the complex biological, psychological, and social factors that contribute to depression.

After all, if you’re going to focus your energy on getting on top of your depression, we want to help you zero in on the strategies that will give you the biggest bang for your buck. We think equipping you with a new, more complete point of view on what depression is—and what it isn’t—will make moving through your depression seem eminently more doable. You can thus relax; take a slow, deep breath of fresh air; and attack the problem with a newfound sense of confidence and a clear sense of direction.

Five Contemporary Perspectives on Depression

In order to understand depression in a new light, it is important to understand both contemporary theories about it and developments from different areas of psychological and brain research. When you combine these different perspectives, what emerges is a kind of user’s manual for understanding depression and what to do about it. So let’s take a look at depression from the following perspectives, which are the cornerstones of this book:

The ACT Perspective

As we mentioned in the introduction, acceptance and commitment therapy (abbreviated and pronounced like the word “act”) has been shown to be an effective treatment for depression in both adults and adolescents (Bohlmeijer et al. 2011; Hayes, Boyd, and Sewell 2011; Blarrina et al. 2016; Zettle and Rains 1989). ACT holds that depression is but one example of how people suffer when they follow culturally instilled rules about the necessity of feeling good as a major sign of health and well-being. From early childhood, we are trained to believe that natural, important human emotions—feeling sad, angry, rejected, grief stricken, lonely, ashamed, or anxious—are threats to our health and well-being. Therefore, they must be controlled or eliminated via any means possible.

Granted, painful emotions can be very unpleasant and can command our attention. But that doesn’t mean that they are bad for you; they may in fact signal that something important to you is missing or underutilized in your life. At other times, painful feelings might signal the need for you to make a change in your life, like leaving a dysfunctional relationship. At still other times, painful emotions might help heal the wounds of loss, such as when someone close to you dies. Looked at logically, it would be difficult to see emotional experience as the “enemy within,” but that’s exactly what we learn as we grow up.

The other problem with this pervasive social rule is that private experiences such as painful emotions, disturbing thoughts, distressing memories, or unpleasant physical reactions cannot be controlled or eliminated by an “act of will.” Paradoxically, when you attempt to control or eliminate them, they become even more intrusive in your awareness and seem even more out of control. When direct attempts to control or prevent unpleasant emotions don’t work, people begin to hunt for other ways to get the job done, such as using alcohol or drugs to quell their feelings, or sleeping for hours on end to blunt their awareness of what is going on inside. Even more toxic in the long run, people figure out that avoiding situations, events, or interactions that trigger unpleasant emotional experiences is a way to control them.

For instance, you may have stopped participating in activities that trigger unpleasant feelings. You may be avoiding talking with your spouse or partner about painful issues in your relationship. You might be distancing yourself from friends because they seem to be doing better in life than you are, and it makes you feel out of place to get together with them because they are happy and you aren’t. Put simply, you protect yourself from personal pain by withdrawing from or avoiding those things in your life that most matter to you. The reason these situations are emotionally painful is because they do matter to you.

Sadly, most of us don’t even realize we are following rules like this—our behaviors are so well ingrained as to be almost automatic. So instead of trying something completely at odds with the rule, we follow it even more rigidly and forcefully. As we sink into the ooze of this unworkable, self-defeating approach, more and more extreme coping strategies seem warranted. These generally involve either quick-acting strategies designed to numb our awareness of distressing experiences (for example, drinking, drugging, overeating, binging and purging, cutting, or attempting suicide) or slower-acting strategies such as becoming withdrawn, disengaged, or emotionally numbed out (all typical symptoms of depression).

For a moment, think about your current life situation and the emotional challenges it brings. Perhaps you’ve been trained to believe that the goal is to be strong and not allow your emotions to surface. Worse yet, maybe you sincerely believe that having negative emotions such as sadness, anxiety, anger, or fear is a sign that there is something wrong with you. This type of message puts you at odds with your feelings in situation after situation. When you are at war with your own feelings, it will be almost impossible to use your emotions to help guide your behavior. Your instincts and intuitions will not enter into your decision-making process, and this leaves you prone to letting personal problems slide or, worse yet, avoiding dealing with them altogether.

In ACT, we view depression not as a problem to be solved but as an important signal that something isn’t working quite right, that your life is out of balance in some important way We want to use the information contained in your depression to help you create a new life plan that doesn’t involve suppressing how you feel or avoiding important life situations that can determine your overall quality of life. In ACT, we believe that controlling your emotions, avoiding the situations that produce them, is the problem, not the solution.

You don’t get healthier by turning your back on how you feel—that only makes you more vulnerable to the very things you are trying to steer clear of. Avoiding problems in your marriage, family, job, or health doesn’t make the problem go away—it actually makes the situation worse. For instance, if you don’t address important problems in an intimate relationship, you may feel less connected to your partner and start to drift away. As things get worse, your depression will deepen and you may begin to avoid other problems, like the fact that you’re feeling less romantic with your partner. Likewise, if your job is unfulfilling, and your approach is to not think about the fact that your work is losing its meaning, avoidance of the problem can make your work less interesting—and eventually you have to deal with burnout. Or if you have a risky health habit like smoking, drinking too much, or being too reliant on drugs, simply turning your back on the problem doesn’t make it less risky.

And maybe, somewhere in the back of your mind, there’s an intuition that depression is turning you into a person you don’t want to be. Even if it’s unintentional, falling into a pattern of avoiding unpleasant or painful feelings and the situations that trigger them is a major cause of depression.

The Mindfulness Perspective

ACT utilizes a wide range of mindfulness concepts and practices for good reason: because low levels of mindfulness are associated with high levels of depression (Williams 2010). Research has also shown that going through an ACT program like the one we present in this book hones mindfulness skills, like the ability to be present, detached, nonjudgmental, intentional, and values focused (Bohlmeijer et al. 2011). Even more important, positive changes in mindfulness skills are associated with improved treatment results in ACT (Arch et al. 2012; Forman et al. 2012; Zettle, Rains, and Hayes 2011).

One key process leading to depression is overidentifying with socially ingrained rules that emphasize controlling or eliminating distressing, unwanted emotions. The failed quest for emotional control is at the heart of depression. If you are depressed, you are often besieged by thoughts such as, “I shouldn’t be as upset as I am. What’s wrong with me? Why can’t I feel good about myself? Everyone else seems to be happy and self-confident—why can’t I be?” When you overidentify with rules and self-evaluations, they can seem like undisputed truths—and you might forget that they are just inner experiences.

Think about an alternative reality: What would happen if you could see thoughts as thoughts—not as undisputed truths that you must follow? If they produced an urge to act in an unhelpful way, what if you could simply experience an impulse as an impulse, without acting on it? What if you could reliably create a space between your thoughts and your actions, such that you don’t have to do what your thoughts tell you to do?

The reason mindfulness skills work so well in depression is that they help you create a space between you and your thoughts and impulses. This allows you to pick approach behaviors instead of avoidance behaviors. Approach behaviors allow you to engage in important life activities, even if they are emotionally challenging (Barnhofer et al. 2009; Bihari and Mullen 2014; Williams 2008). Avoidance behaviors, while promising you emotional safety, actually remove you from the field of play, so to speak, putting you on the sidelines in your life. This can lead you to feel like your life is passing you by—and that feeling can be downright depressing to just about anyone!

If you get good at the mindfulness skills we will teach you, you could then hear the ongoing chatter of your “mental advisor”—the part of your brain that is constantly evaluating things and telling you what to do—without necessarily having to do what it says! So instead of trying to argue with your advisor, you could simply:

  1. Be aware that the mental chatter is present,
  2. Think about what is really important to you right now, and
  3. Base your behavior on what matters.

How powerful are mindfulness skills in the treatment of depression? A recent study showed that mindfulness-based treatment is clearly superior to more conventional treatments in a sample of depressed primary care patients (Sundquist et al. 2014). An earlier study of depressed patients found that mindfulness training helped 72 percent of the patients significantly reduce their depression levels (Finucane and Mercer 2006). These patients reported that they enjoyed mindfulness exercises, and more than half continued to use these techniques after the study ended.

Another reason that mindfulness is so effective with depression is that it short-circuits rumination (Williams 2010). Rumination is a particularly unhealthy form of depressed thinking that involves replaying past or current life difficulties, excessively analyzing personal flaws and weaknesses, comparing oneself to others, and brooding about one’s inability to “feel right” (Nolen-Hoeksema 2000). Indeed, British researchers have found that people who respond to treatment for depression are less likely to have future problems with depression if they receive training in mindfulness (Teasdale et al. 2000). These researchers also discovered that mindfulness training creates more detachment from and perspective on unproductive ways of thinking, such as rumination (Teasdale et al. 2002). With mindfulness skills in tow, you are far less likely to get drawn into the rumination trap. Specifically, the rumination trap occurs when you get entangled in ruminating, and then, to top things off, you begin to over-analyze why it is that you can’t stop ruminating!

There is one last thing to consider: the benefits of mindfulness don’t stop at helping you address depression. Indeed, a wide variety of other benefits have been associated with practicing mindfulness skills, including increased mental efficiency (Deshmukh 2006), better problem-solving skills (Hankey 2006), increased levels of compassion and altruistic feelings toward others (Weng et al. 2013), and increased levels of self-acceptance (Fennell 2004).

The Self-Compassion Perspective

Self-compassion is a powerful skill you’ll want to acquire on your quest to transcend depression—and on your journey through life in general. Self-compassion involves taking an open, accepting, and nonjudgmental stance with respect to your personal flaws, inadequacies, and life disappointment.

As the old saying goes, “To err is human.” Our hang-up, however, is that when we do mess up, our immediate emotional response is a feeling of alienation, as if we are on an island and are different from everyone else. To compound the problem, the painful feelings that come from failure or disappointment are real—they are not illusions. So how you treat yourself in your moment of pain will largely determine how much you suffer. If you are harsh with yourself, you will hurt even more. If you soften and treat yourself with kindness, and remember that you are part of humanity and are not alone, your emotional experience is likely to hurt far less.

The fact is, if you have been depressed for any length of time, you will likely suffer some negative real-life outcomes, like losing a primary relationship or a job, or being rejected by friends. Many times, depressions start with events that involve interpersonal loss, career setbacks, illness, death of a loved one, and so on. It turns out that how you treat yourself during these moments of suffering directly predicts your risk of depression. If you take a harsh, self-critical, self-rejecting stance, your risk of depression goes up steadily. If you treat yourself with kindness and acceptance, your risk of depression goes down steadily (Leary et al. 2007; Neff 2003; Neff, Rude, and Kirkpatrick 2007). When those inevitable moments of life disappointment or personal setback occur, you have a mindful alternative at your beck and call, in your moment of pain, when you are most tempted to beat up on yourself.

The Positive Psychology Perspective

Positive psychology is the study of how people cultivate an optimistic life outlook and positive mood states, even in the midst of challenging or difficult situations. Positive psychology researchers are finding that, just as depressed emotions are fueled by a downward spiral of isolation, withdrawal, and passive avoidance, positive mood states are produced by upward spirals of pleasant activities, social connections, and approach-oriented behaviors (Frederickson and Losada 2005; Garland et al. 2010).

Simply put, the emotional charge of your behavior (whether it be positive or negative) will tend to control your mood state. So one widely agreed upon, powerful remedy for depression is to persistently engage in positive, healthful activities in your daily life. This includes pursuing hobbies, exercising, doing relaxing leisure-time activities, and making casual as well as closer social connections. There is ample evidence in the depression-treatment literature that engaging in positive, healthy-emotion-producing behaviors has an immediate impact upon depression (Martell and Addis 2004).

The Neuroscience Perspective

Here we are going to put our science geek hats on for a bit and try to explain the important role that neuroscience is beginning to play in furthering our understanding of depression and what to do about it. The field of affective neuroscience studies the brain basis of human emotions, including how we develop emotions in the first place, where they are located in the brain, and how we regulate emotions and learn from emotional experience. Brain researchers investigate the possible neural roots of depression, hoping to locate areas of the brain implicated in depression that could be changed by brain training interventions.

A key concept in neuroscience is neuroplasticity. Neuroplasticity at the general level means that the brain is constantly adapting to environmental challenges and demands through a dynamic process of strengthening existing neural circuitry or, even more intriguing, creating new neural circuitry. Practically speaking, this means that you can strengthen and/or rewire your brain’s neural pathways from the outside in. In other words, the behaviors you practice on a daily basis actually strengthen the neural connections in your brain that support those behaviors. So, for example, if you practice mindfulness and/or self-compassion skills on a regular basis, you will strengthen the neural circuitry in your brain that supports being mindful and self-compassionate (Lutz et al. 2008). For this reason, locating the areas of the brain that are responsible for promoting both positive and painful emotional states is critical if we are to capitalize on the potential benefits of neuroplasticity.

So far, the research on depression has yielded some very interesting results.

Default Mode Network

The broadly distributed neural network in the brain that is implicated in depression is called the default mode network (DMN). Like the name implies, the DMN functions as a kind of “screen saver” for the brain when the brain is at rest. The DMN has been called the “dark energy of the mind” due to its tendency to encroach upon more task-oriented brain behaviors and to gobble up the brain’s finite attention resources (Raichle et al. 2001). Activation of this network is associated with a variety of mental events that are linked to depression, including daydreaming, lapses of attention, reduction in sensitivity to sensory inputs from the body, and increased free-floating memory recall, to name a few (Buckner, Andrews-Hanna, and Schacter 2008; Spreng et al. 2013).

While it is tempting to think of the DMN as a nuisance, it actually plays a valuable role in maintaining our mental health. Accruing evidence suggests that DMN brain systems activated during rest are also important for active, internally focused mental processing, for example, when recalling personal memories, imagining the future, and feeling social emotions with moral connotations (Andrews-Hanna 2012).

Task Positive Network

There’s another major neural network in the brain called the task positive network (TPN). It is responsible for recruiting and applying brain resources needed to complete specific tasks, whether they are internally or externally focused, and whether they are negative or positive. The TPN actively competes with the DMN for the brain’s resources and, in a perfect world, the TPN and DMN would exert natural checks and balances on each other. In other words, from a neuroscience perspective, healthy human functioning is achieved through a dynamic balance between task focus and the ability to rest, daydream, imagine, and reintegrate past memories and experiences (Spreng et al. 2013).

The problem arises when either network becomes chronically overactivated. In the case of depression, it is the overactivation of the DMN that is thought to be the main mechanism of concern. Current treatments generally require the depressed person to get present, pay attention, and engage in specific thinking or behaving tasks. This has the effect of reactivating the TPN so that it counteracts the dominance of the DMN.

Executive Control Network

The executive control network (ECN) (Spreng et al. 2013), as the name implies, is a neural pathway that functions to protect the brain’s limited resources and to distribute them in the most efficient way. It is responsible for managing what is called the brain’s working memory capacity, or the ability to complete tasks even when there are conflicting tasks to attend to, such as sticking with a problem-solving strategy like deep breathing even as you are dealing with intense sadness (Marchetti et al. 2012). Mindfulness practices have been shown to strengthen areas of the brain that are known to be a part of the ECN (Lutz et al. 2008), and this is one mechanism through which mindfulness is beneficial in the treatment of depression.

A Neuroscience Framework for Intervention

What does all this mean for our understanding of depression? First, depression has been associated with overactivation of the DMN and underactivation of the TPN, which seems to be associated with underactivation of the ECN. In other words, depression puts the ECN to sleep, figuratively speaking, and this allows the DMN to gobble up a disproportionate share of brain resources. This explains the “inertia” problem in depression—that is, the way you have trouble starting a new behavior that would help you feel better. The motivation to do things just isn’t there. This is due to the underactivation of the TPN. For instance, you know that you would feel better if you went outside and took a brisk walk in the park, but when you stand up to do it you feel like you’re trudging through mud.

Second, underactivation of the ECN depletes working memory capacity very quickly. This leads to lapses in concentration and immediate memory when you are trying to multitask. In emotionally charged situations, you may feel confused and indecisive, and you might freeze instead of acting affirmatively.

Based upon what we now know, we can create new treatments and start to understand the brain impacts of existing ones (Sambataro et al. 2013; Singh and Gotlib 2014). For example, the ACT perspective holds that getting caught up in thoughts, feelings, or memories makes it very difficult to accept these private experiences for what they are. Instead, we physiologically and mentally react to them as if they were literally real, and we allow them to regulate our behavior. To offset this vulnerability in our hardwiring, ACT teaches us to detach from, or let go of, the impulse to overidentify with distressing, unwanted thoughts, emotions, or memories. Practicing this detached stance directly targets and strengthens areas of the brain responsible for regulating powerful emotions. For example, there is unique neural circuitry in the brain that supports detachment, or the opposite of being caught up in distressing experiences. This circuitry is controlled largely by the ECN—which as we know can be compromised when depression is present. And to make matters even more complicated, the neural pathways responsible for detachment regulate emotional arousal by dampening the amygdala, the part of the reptilian brain that produces emotional arousal (Shiota and Levenson 2012; Sheppes, Brady, and Samson 2014).

Let’s take off the geek hats now and put this in plain English: When you are depressed, it is harder to pay attention to what is going on inside of you and, because of that, it is harder to stay detached when something painful shows up. This leads to becoming overidentified with what you’re feeling, thinking, or remembering, particularly when the experience is painful and is identified as a threat to your safety and well-being. That primes the pump of your primitive emotion pathways, leading to a downward spiral of negative emotional experiences (Joorman and Vanderlind 2014). Taking a detached stance toward negative emotions in a moment of high arousal reverses this destructive process by downregulating the amygdala, thus short-circuiting the neural basis for any further downward spiraling.

If you are a neuroscientist thinking about what to do with this problem, you would likely say, “We need to do something to restore the depressed person’s ability to focus attention and keep it focused.” That is one of the main reasons why mindfulness training has entered the picture so dramatically in affective neuroscience. Recent studies show that mindfulness practices directly impact central neural pathways responsible for paying attention in a flexible, workable way. A recent study examined experienced meditators matched with naive control subjects who were asked to perform three different types of meditation. The results suggest that, for experienced meditators, each type of meditation resulted in reduced activity in the DMN and increased activity among several brain structures thought to be associated with the ECN. No such changes were observed in the naive control subjects (Brewer et al. 2011).

Neuroscience studies of compassion have shown two very compelling results that bear directly upon depression. Subjects in one study practiced compassion prayer thirty minutes daily for just two weeks, and pronounced brain changes were observed (Lutz et al. 2009). The other finding is that compassion training led to far more altruistic attitudes toward suffering in general (Weng et al. 2013). In other words, through compassion training you aren’t just learning how to be compassionate toward someone, you are learning how to be compassionate to the human condition. This is the doorway to practicing self-compassion, because you are a part of humanity, not separate from it.

Neuroscience studies within the realm of positive psychology show that negative emotions have a distinct narrowing effect on attention. When you are depressed, what you pay attention to narrows such that what you are aware of is largely determined by your mood. You are aware of many more negative thoughts than positive thoughts; you remember many more negative events in your life; you experience more strings of negative emotions. When you engage positive emotions, your attention widens—and so does your ability to see your life in perspective. You’ll recall both positive and negative memories with much more ease, and your emotions will tend to be more evenly distributed and restorative (Frederickson and Branigan 2005).

Throughout this book, we introduce you to different skills derived from these perspectives designed to help you move through depression. You can practice these skills at home in the way of brief brain training exercises. We use this term on purpose because you are literally training your brain’s neural pathways to engage in activities that promote your sense of well-being. There is a simple truth associated with the concept of brain training: You are always training your brain to do something; the question is, what are you training it to do?

Combining Perspectives: A New Start

When we combine the five perspectives into a unified biopsychosocial model of depression, what emerges is a completely different view of depression than you may have had when you started this book. Let’s look at three important themes that each perspective has in common with the others:

Loss of Attention Control and Rule Following

Depression involves a disruption in the ability to control attention, preventing us from taking a nonreactive and nonjudgmental stance. In essence, depression interferes with our ability to be mindful. The biggest issue, from an ACT perspective, is that when depressed people lose control of their attention (which happens as a by-product of daydreaming, mind wandering, and rumination), they unknowingly get caught up in the web of their mind’s judgments and evaluations. This leaves them vulnerable to socially instilled rules about dealing with emotions that lead to the use of avoidance strategies. They are then exposed to a steady barrage of messages that are just downright depressing: “You are a loser. You’re destined to fail at the things in life that matter to you. Your mistakes in life are unforgivable. You have so many flaws that no one will ever love you. Even if you succeed at something in life, it is a fluke, and people will eventually see what a fake you are. You need to figure out what’s wrong with you and fix it. Other people are happy and you aren’t. Blah! Blah! Blah!”

Learning to be mindful, to pay attention, to be aware, and to react nonjudgmentally are key to overcoming the rule following that keeps us locked in a depressed state.

Avoidance Promotes Depression

Depression develops because of two types of avoidance that are practiced repeatedly over time. Both avoidant types become engrained in the brains’ neural pathways and become habitual ways of responding to emotional distress.

You might be thinking, “If I am feeling really down, how is avoiding that feeling bad? Why is avoidance such a toxic process?” The short answer is that the life situations that trigger unpleasant emotional reactions in you are also likely to be the situations that matter to you. They might involve issues of intimacy, love, parenting, work, being part of a community of like-minded souls, and so on. These are the issues that come with being alive; they are not threats to your emotional health and well-being, however much they may seem to be. We know from research that life stressors are a trigger for depression at least half the time (Schotte et al. 2006). In fact, one highly publicized study found that at least 25 percent of all cases of clinical depression are really more likely a reaction to some form of interpersonal loss or setback (Wakefield et al. 2007).

Depression is like the “check engine” warning light on your car’s dashboard. It is telling you that something is amiss and you need to take action. Engaging in emotional and behavioral avoidance during challenging life moments is like putting duct tape on the check engine light in your car, because you don’t want to be upset by it. Doing so might keep you calm for a while, but eventually your car is going into the shop, probably with an even bigger problem than when the check engine light first came on. Similarly, if you don’t listen to your body’s warning light, your depression will likely get worse, and the original problem you were facing might escalate out of control. Worse yet, because you are not engaging in activities that matter to you, over time your sense of life direction just fades away. This further impairs your motivation to do things because there is no obvious purpose for doing so. If you avoid the situations that matter in life or the emotional reactions they produce, you have little chance of addressing important growth-producing opportunities.

Depressed Behavior Generates Depressed Mood

This theme is perhaps the most important for our purposes: Depression is not something you have; it is something you do. The behavioral theory of depression holds that people start engaging in actions that feed into depression long before they develop the disabling mental symptoms of depression (Carvalho and Hopko 2011). The neuroscience perspective shows us that many behaviors seen in depression—such as self-isolation, avoidance, passive problem solving, and a sedentary lifestyle—could be viewed as day-in, day-out forms of brain training. Without knowing it, you are actually training your brain to overactivate the DMN and create depressed mood and behaviors!

Similarly, positive psychology research is showing that the opposite is also true: Behaviors that produce positive emotions can spiral upward to create the motivation to perform more and different positive behaviors (Garland et al. 2010; Frederickson and Losada 2005). In other words, your behavior patterns determine your mood state, whether positive or negative. This is actually good news because, while it is very hard to dial up only the emotions you want to feel, you do have complete control over your behavior. Thus, you can choose to behave in healthy, productive ways even if you don’t feel at the top of your game emotionally. It turns out your behavior is a superhighway to producing positive mood states!

The idea that behaviors produce depression is new to a lot of people. But let’s look at an example that will show the commonsense aspect of this idea:

You had a terrible night’s sleep and feel out of energy when you wake up. You decide to cut back on your daily activities, including that walk you were going to take. You feel sluggish midday but power through with caffeine. At the end of the day you feel exhausted, and you also feel guilty for not doing all the things you planned. To feel better, you stay up very late watching TV. No big deal, right? The result is that you don’t get caught up on sleep, and the next day you are even more tired. And so you cut back on activities again, and feel sluggish all day—and the cycle continues! It is the same with depression.

This example isn’t meant to make you feel bad about your behavior patterns. Choosing to behave in healthy, productive ways on a day-in, day-out basis is a challenge for everyone. It is not a problem that is unique to depression. We just want you to understand that there is a way to move beyond depression that is under your immediate control! You can choose to experiment with new behaviors even when you are depressed.

Flaws of the Biomedical Perspective

Now that we have examined depression from the five contemporary perspectives, it might be useful to compare the comprehensive biopsychosocial approach with the traditional biomedical model of depression.

Is Depression a Biological Illness?

The message that depression is a biological illness is virtually everywhere. It has been actively promoted by the pharmaceutical industry, psychiatry, and some consumer advocacy groups. For the pharmaceutical industry, treating an everyday problem like depression as an illness converts into billions of dollars in drug sales. For consumer advocacy groups, calling depression an illness absolves people from responsibility for the problem and presumably reduces the stigma of having a mental health problem. For psychiatry, the belief simplifies the treatment approach to depression by making it a simple matter of finding the right medication.

We can say with confidence that current scientific evidence does not support defining depression as a biological disease. That’s why the World Health Organization, the global body responsible for identifying and describing new disease entities, doesn’t currently recognize depression as a clearly demarcated biological illness.

Is Depression the Result of a Chemical Imbalance?

The second assumption in the biomedical approach is that depression results from chemical imbalances in the brain, which in turn produce depressed mood, thinking, and behavior. This is sometimes referred to as the serotonin hypothesis because serotonin is the neurotransmitter that has been the object of much biologically based depression research over the years. Indeed, most modern antidepressants operate to alter the rate at which serotonin is produced and/or reabsorbed within the nervous system.

Whitaker (2010) reported on the result of an extensive review of all of the biological psychiatry literature pertinent to the serotonin hypothesis since the advent of modern antidepressant medications in the mid-1980s. He concluded that there is scant evidence for the theory that depression is caused by chemical imbalances. Of course, all human behavior ultimately comes down to a matter of biology and chemistry. But it isn’t at all clear that differences in individual brain chemistry cause depression, nor is it clear that chemical imbalances cause the mood, thinking, and behavioral problems associated with depression.

A better way to think about the relationship among brain chemistry, mood, thinking, and behavior is that the arrows of causation point in both directions, not just one direction. Depressed behavior might exert as much influence on brain chemistry as brain chemistry exerts on depressed behavior, to cite one example. This biopsychosocial approach is cause for optimism if you are depressed, because it means there are many potential treatments available that could work, rather than relying on just the use of medication.

Are Medications the Best Treatment for Depression?

A natural result of the biomedical perspective is to regard medications as the first line of treatment for depression. Indeed, this country is awash in psychoactive medications of all kinds. The question is, how well do antidepressants work?

A recent review of the antidepressant medication treatment literature concluded that antidepressants are no more effective than placebos (sugar pills) in treating mild to moderate clinical depression, with mild evidence for the benefit of antidepressant therapy for patients with severe depression (Khin et al., 2011). Lending additional credibility to this review is the fact that it was sponsored by the U. S. Food and Drug Administration, the branch of government responsible for approving new drugs, in response to the growing controversy over how antidepressant drugs are approved in the first place. There is still an intense academic debate over the benefits of antidepressant therapy for severe depressions (Kirsch 2014).

If you suffer from mild to moderately severe depression, your response to an antidepressant likely will be about the same as if you took a placebo. In statistical terms, there is a 40 to 50 percent chance you will respond. And, as we often tell clients that are taking medications, don’t ever underestimate the power of the placebo effect. In reality, it is the most powerful effect in all of medicine. The belief that you are taking something that is going to help you is even more powerful than what you are taking to help you.

There are, at the same time, other factors that go into determining how effective a treatment is for depression. One is what happens when you wean yourself off the medication, usually at about nine months to a year after initiating treatment. People who are treated using only antidepressant medication have very high rates of relapse, in the vicinity of 70 percent. Interestingly, many studies suggest that behavioral therapy is actually more effective over time in terms of preventing future episodes of depression (Paykel 2006). This is important because depression tends to be a recurrent problem. Many people who experience depression have a pattern of recovering and then relapsing again. Often this pattern continues throughout a person’s life. Any approach that reduces the chances of being depressed again is definitely worth exploring.

Do Medications Work Faster?

Another factor worth exploring is how long it takes the treatment to start working. A popular belief is that medications work faster than therapy or self-help programs. However, studies suggest that behavioral and cognitive therapies may actually work faster than antidepressants (Kelly, Roberts, and Ciesla 2005; Mynors-Wallis et al. 2000). Recent studies of behavioral treatments have shown that a significant number of patients show sudden large improvements in their symptoms within the first one to three treatment sessions (Cape et al. 2010; Lutz, Stulz, and Kock 2009).

What Role Do Medications Play?

This leaves us with two very important questions, which you are no doubt asking if you’re already taking antidepressants or considering taking them: What role does the medication play in my recovery? And what roles do the concepts and strategies in this book play?

Our answer (admittedly biased!) is a simple one: Even if you’ve benefited from antidepressants, it’s still wise to practice the strategies we teach in this book. They could help you avoid a relapse into depression in the future.

If you’re currently taking antidepressants, think about them this way: Medications, if they work, might help reduce some of your symptoms, including overwhelming fatigue, loss of energy, lack of sleep, and problems with concentration, any of which can keep you from making positive changes in your life. In this sense, medication can be helpful for some people. It might reduce some of the overwhelming symptoms you experience that make it hard for you to get in gear.

But medications can’t make those positive changes for you—only you can do that. The skills and strategies suggested in this book can serve as a kind of map for when, where, and how to make these life changes. We want to be very clear that we are not opposed to people using antidepressants. Rather, we want you to have the information you need to judge the risks and benefits of using medications. Our intention is to help you take a balanced view of what drugs can do for you, and what you must do for yourself.

Trading Illusions for Actions

Once you understand depression for what it is, rather than what it seems to be, you’re in an excellent position to begin to do something about it. Depression is really a signal that something is out of balance in your approach to living. It is never simply an accident of nature; it is perfectly designed to tell you something important about how your life is going. Rather than rejecting your depression as a blight or just resigning yourself to having it, you can learn to accept where you are at in your life and view depression as a natural consequence of living in very complicated circumstances.

Right here, right now, you can stop beating up on yourself for being depressed and treat yourself with kindness and affection instead. You can redirect your energy toward solving the dilemmas that have you stuck—right now. There is a solution to this problem at your fingertips, and in the remainder of this book we’ll show you how to transcend depression and develop a vital, purposeful life.

Ideas to Cultivate