Out of the Tunnel: A Series on escaping the path of depression—Part 2

What happens when you ask your depressed client to help you map out not only the contours and geography of their suffering but also their competence and better moments? You get a new strategy for treating depression: marbling.

Written by Bill O’Hanlon, MS, LMFT


In the first part of our series on marbling depression, we explored three techniques to reflect in the past tense, localize global thoughts and validate perceptions. Now we will explore another method of marbling depression: Inclusion.

Inclusion

A while ago, I heard a story about a study of people who’d jumped off the Golden Gate Bridge, intending suicide, but had been rescued or survived the attempt. The researchers were searching for something that might help them identify people at risk and prevent future suicides. They found one commonality among the survivors: on the way down from the bridge to the frigid waters below, almost all of them had some variation on the thought Maybe this wasn’t such a good idea. That indicates to me that very few people are 100 percent hopeless, even in the moments before their imminent death (or perhaps they’re even more ambivalent when things have gone so far).

The inclusion method tries to acknowledge and capture this complex experience using three techniques.

1. Permission

In addition to feeling depressed, many people who experience depression feel that they’ve done something wrong, or are feeling the wrong feelings, or are thinking the wrong thoughts, or are just basically “wrong” in some fundamental way. One way to help them with this sense of wrongness is to give them permission to feel, be, or think the way they do-and not to feel, be, or think the way they don’t.

This means that there are two kinds of permission that can be helpful with people who are depressed: “Permission To” and “Permission Not To.” These two types of permission are reflected in the following statements: “It’s okay to feel depressed” and “You don’t have to have hope right now.”

Now I want to be clear here that the permissions I suggest are mostly about experience, not actions. For example, I wouldn’t say to someone, “It’s okay to kill yourself,” but instead, “It’s not unusual for people feeling as bad as you do to think about killing themselves. It’s okay to think that. It doesn’t mean you’ll act on it.” So there’s no permission for self-harming actions or actions that might hurt someone else.

Here are some examples of suggested permissive responses.

Depressed person: “It’s all meaningless.”

Possible responses: “It’s okay not to have meaning right now.” “You don’t have to know what it all means right now. We’re just working on how to get you feeling better today and tomorrow.”

Depressed person: “I feel hollow.”

Possible responses: “It’s okay to feel hollow.” “Feeling hollow is pretty common for someone who’s depressed. You don’t have to feel any other way right now.”

2. Inclusion of Opposites

The next way to give permission is more complex and nuanced and may be especially helpful for people who are depressed. It involves giving permission to have two opposite feelings or to be two ways at once. For example, someone may feel like dying and also want to live. Or he may feel like killing himself but not want to hurt his family and friends by killing himself.

This technique, then, involves giving the depressed person permission to include, feel, or be those contradictory things simultaneously. One major way to communicate this is to connect the two contradictory aspects with the conjunction and. The word and signifies inclusion of both, whereas the conjunctions but and or imply one or the other.

“You felt as if you couldn’t get out of bed today, and you got up and came to see me.”

“You wanted to give up, and you wanted to keep going.”

“You feel as if there’s is no end to this, and you think you’ll come out of it.”

“You can’t find your sense of meaning, and you think you’re going through this depression for a reason.”

“You don’t want to die, and you don’t want to live like this.”

You might have to stumble around with this before you hit on the inclusive reflection that really moves the person, helps him feel both understood and validated at a deep level, and perhaps helps him shift in some way. This technique can be challenging because this isn’t a logical way to speak or think.

3. Oxymorons

In the English language, we have a natural way to use inclusion called the oxymoron. This is when two opposite concepts are put together in a two-word phrase, such as sweet sorrow or exquisite suffering. A more expanded way of using oxymorons is to spread them apart in a sentence or phrase; this is called the apposition of opposites.

“It’s important to remember to forget certain things and not to forget to remember other things.”

“It seems that you’ve spent so much time in darkness that your eyes have adjusted and can see things in the dark that others can’t.”

“You’re hoping against hope that this depression will lift.”

As you can see from the above examples, there can be a place for using oxymorons in therapy to emphasize that it’s okay and even beneficial to have conflicting perceptions and experience opposing ideas. One last application of the inclusion of the opposites technique is to include the negative with the positive by using tag questions. Tag questions are little questions added on to the end of a statement that seem to say the opposite.

Milton Erickson once told me, “If you can’t say the ‘no,’ the patient has to say it.” He regularly used these tag questions. Here are some examples:

“You don’t think you’ll get better, do you?”

“You’re not feeling better, are you?”

“You’re starting to feel better, aren’t you?”

If you think of the Asian symbol of the yin yang, you will get this technique. There is a yes in the no and a no in the yes, and they complete each other to make a whole. The point of this method is to help people become more integrated, including all their aspects, so they feel less fragmented or troubled by the disparate aspects of their experience, feelings, or personalities. Without this integration, clients often feel ashamed or torn in two directions, which can increase their emotional distress and deepen their depression.

Exceptions

Very rarely is someone always depressed, or always empty, or always without energy, or always suicidal. If you and the person you’re helping explore exceptions to the usual problem, feeling, or thought, you can usually find moments when it’s not occurring. A lot can be learned from these exceptions that may be helpful in finding relief from the depression, so here we’re just trying to do some marbling by acknowledging that there are exceptions to the rule of whatever the person’s complaining about or isn’t working for him. For example, he has no energy (except when he does). Or he can’t get out of bed (except when he does). He feels bleak (except when he doesn’t). He never laughs anymore (except when he does).

Here’s an example of a client-therapist interaction in which the client talks about his depression but indicates that there’s more to the story than just depression.

Client: “Sometimes I just feel so hopeless. I don’t know if I’ll ever come out of this hole I’m in. Maybe getting this new job will help. My old job just sucked.”

Therapist: “When you’re afraid you won’t come out of it, it seems hopeless, but when you think about this new job, you get some sense of hope.”

One specific way to discover and highlight exceptions is to listen for and acknowledge moments of non-depression. Perhaps the person got absorbed in a movie and “forgot himself” for a few hours. Perhaps he spent time with a friend or family member and felt better for a time. Perhaps there was a time in the recent past when, inexplicably, his depression was better for a day, a week, or longer.

Another way to find exceptions is to find out about what happens when the depression starts to lift that’s different from what happens during the depressive episode. Maybe the person starts to become more social, or listens to music more, or goes out of the house or eats different foods. Of course, one way to find out what happens when the depression starts to lift is to listen for reports of those times, but you can also elicit such reports by asking about them directly. Here’s an example of such a direct elicitation: “I’m curious. You’ve been through these times of depression before and have come out of them. What happens when you start to emerge from that darkness and begin feeling better?”

One last way to discover exceptions is to investigate why the depression isn’t worse or the person isn’t less functional. This is sort of a backward way of discovering exceptions. For example, you might ask your client, “How have you been able to go to work or visit with friends when some people with depression haven’t been able to do those things?” Or, “What’s stopped you from acting on those suicidal thoughts?” Or, “Why haven’t you given up on seeking help?” The answers to these and similar questions can contribute to the marbling.

Here’s an example of the kind of inquiry you might make: “I was a little surprised to hear that you finished that big project at work even though I know you’ve been feeling like hell. If I were talking to someone else who was depressed and had a similar kind of project in front of them, what would I tell them about how you were able to pull that off even though you felt so impaired?”

Depression as a Bad Trance

I learned hypnosis many years ago when I began to recognize some similarities between a hypnotic trance and what I began to think of as a “symptom trance” or “problem trance.” Both types of trances often involve a narrowing of the focus of attention, and the induction of both involves rhythmic repetition. In Sense and Nonsense in Psychology, Hans Eysenck tells a story about a young English surgeon, just about through with his training, who was drafted into the army during World War I and sent to fight on the fields of France. On the battlefield, he came across a French soldier severely wounded by a mortar shell, writhing in pain and doing further damage to himself. The soldier was in imminent danger of dying unless the Englishman could get him to stay still until he could get him back to the surgical tent for treatment.

In desperation, the Englishman remembered a demonstration of hypnosis he’d seen during his medical training and decided to try what he remembered of hypnotic induction. But he didn’t know much French, so the best he could do was repeat again and again to the writhing Frenchman the only French words he could conjure up: “Your eyes are closing. Your eyes are closing.”

To his amazement, the Frenchman stopped writhing and his breathing slowed. He appeared to be in a trance that lasted long enough to get him back to the medical tent, where the British surgeons did indeed save his life. After the operation, the medical student told the British surgeons the story of his hypnosis. They all began laughing and told the baffled student that what he had really said was “Your nostrils are closing. Your nostrils are closing.”

What the story illustrates is that it was the repetition, not necessarily the correct words, that had the hypnotic effect. In a more insidious way, a similar process happens in depression. The depressed person repeats the same thoughts, activities, feelings, and experiences again and again and begins to become entranced. Only the trance is not a healing trance, a therapeutic trance, but a “depression trance,” which induces more and more depression as it’s repeated. Marbling can be an invaluable tool in breaking the depression trance.


For the past 30+ years, Bill O’Hanlon, MS, LMFT, has given over 2,000 talks around the world and was awarded the Outstanding Mental Health Educator of the Year in 2001 by the New England Educational Institute. He is a Licensed Mental Health Professional, Certified Professional Counselor, and a Licensed Marriage and Family Therapist. An accomplished author, Bill is known for his storytelling, irreverent humor, clear and accessible style and his boundless enthusiasm for whatever he is doing.


This post is based on an article originally brought to life by our partner, Psychotherapy Networker.

The full article, “Out of the Tunnel: Escaping the Trance of Depression” written by Bill O’Hanlon, appeared in the Nov/Dec 2014 issue of Psychotherapy Networker magazine.

Out of the Tunnel: A Series on escaping the path of depression—Part 1

What happens when you ask your depressed client to help you map out not only the contours and geography of their suffering but also their competence and better moments? You get a new strategy for treating depression: marbling.

Join us for part one of our two part exploration of “marbling” from expert Bill O’Hanlon.

This if the first part of our series on depression treatment written by Bill O’Hanlon, MS, LMFT


In recent years, we’ve learned that repeating patterns of experience, attention, conversation, and behavior can “groove” the brain; that is, your brain gets better and faster at doing whatever you do over and over again. This includes “doing” depression, feeling depressed feelings, talking about depression, and so forth. Thus we can unintentionally help our clients get better at doing depression by focusing exclusively on it.

To counter this effect, I like to use a method that I call “marbling.” My father owned several meat-packing plants, and early on I learned that marbling refers to the fat streaks embedded in the leaner meat in a cut of steak. It gives the steak more flavor. In a similar way, but with less cholesterol, in therapy I suggest marbling discussions and evocation of non-depressed times and experiences in with discussion of depressed times and experiences. By going back and forth between investigations of depressed and non-depressed experiences and times, the person who’s been depressed is reminded of resources and different experiences, and often begins to feel better during the conversation.

In this three part series, we will explore various ways of incorporating marbling to discover more about your clients individual depression map.

One Foot In

Working with people who are depressed requires a delicate balance. They’re usually lost in their depressive experience and perspective, so you have to join them in that experience and let them know you have some sense of what they’re going through. At the same time, you have to be careful not to get caught up in that discouragement and hopelessness along with them.

I think of it as having one foot in their experience and one foot out. I call this Acknowledgement and Possibility. It involves acknowledging the depressed person’s suffering, validating his felt sense of things, and inviting him out of that experience.

When people don’t feel heard, understood, or validated in their experience, they often appear “resistant” and uncooperative in therapy. On the other hand, if all one offers is acceptance and validation, it’s all too easy to help the sufferer wallow and stay stuck in his depressive experience.

I remember a client I had early in my psychotherapy career who’d come in week after week soaking up my kind acceptance, unconditional positive regard, and empathy. She’d get her weekly support session and then go back to her miserable life. During one session-it was probably about our 22nd-I heard myself saying, “So, you’re depressed again this week.” And realized I wasn’t really helping her.

Around that time, I began to study with the psychiatrist Milton Erickson, who had many creative ways of challenging the most difficult patients to move on and change. I began to incorporate some of his methods into my work and noticed that my clients were changing much more quickly than they had before. But I still liked the warm, kind, active listening I’d learned in my elementary counseling training and didn’t want to lose that respectful approach. So I combined the best of both worlds and created this Acknowledgment and Possibility method. It not only respectfully acknowledges the person’s painful and discouraging experiences, but also gives him a reminder that he isn’t always and hasn’t always been depressed. It can illuminate and prompt skills, abilities, and connections that can potentially lead the person out of depression or at least reduce his depression levels.

I came across a letter that Abraham Lincoln wrote during his presidency that illustrates his deft combination of joining and inviting. (Lincoln suffered from a lifelong tendency toward depression, or what was called melancholy in those days. He’d been close to suicide during two major depressive episodes in his younger years.) He found out that Fanny McCullough, the young adult daughter of one of his generals who’d been killed during the Civil War, had fallen into a depression that was lasting much longer than the usual grief period. She’d taken to her bed in despondency, and her loved ones were worried about her.

When Lincoln heard of her plight, he sat down and wrote the following letter. (Note: I’ve italicized some of the Acknowledgment and Possibility parts of the letter to highlight them.)

Dear Fanny,

It is with deep grief that I learn of the death of your kind and brave Father; and, especially, that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares. The older have learned to ever expect it. I am anxious to afford some alleviation of your present distress. Perfect relief is not possible, except with time. You cannot now realize that you will ever feel better. Is this not so? And yet it is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you some less miserable now. I have had experience enough to know what I say; and you need only believe it to feel better at once.

What’s so moving about this letter is the kind and powerful way Lincoln joins with Fanny’s grief and validates her suffering while simultaneously inviting her out of it.

Three Techniques of Acknowledgement and Possibility

How do you join while simultaneously inviting? Here are three simple methods for putting one foot in and one foot out when talking with people who are depressed.

1. Reflect in the past tense. This technique may seem too simple, but it can have a subtle and helpful impact. It involves reflecting what the depressed person is telling you as if it has happened previously but is not necessarily occurring now. For example, if a person says, “I don’t want to see anyone,” you might respond, “You haven’t wanted to see anyone.” If the person says, “I’m suicidal,” you might say, “You’ve thought seriously about killing yourself.” In each of these responses, you’ll notice that the reflection is couched in the past tense.

Here are two statements that a depressed person might make, along with some sample “reflect in the past tense” responses.

Depressed person: “I’m afraid I’ll never come out of this darkness.”

Possible responses: “You’ve been really afraid.” “You’ve been feeling pretty discouraged.” “You’ve been worried you’ll never feel better.”

Depressed person: “Nothing will help.”

Possible responses: “Nothing has helped.” “You’ve tried a lot of things and haven’t felt better.” “You’ve been thinking that nothing will help.”

2. From global to partial reflections. The next technique for acknowledging and inviting at the same time is to reflect the depressed person’s generalized statements as more partial. When the person says something like “always,” “never,” “nobody,” “nothing,” “everybody,” or another global term, you can reflect her statement or the feeling she’s conveying but using more limited words, such as usually, typically, rarely, almost nobody, very few people, little, most everyone, and so on. Your task here is to help her feel understood, but at the same time to introduce a little space into the stuck place she feels herself to be in.

Your reflections can be less global than the person’s original statement in both time (lately, recently, these days) and quantity (most, very few, almost everyone, little, rarely). For example, if the depressed person says, “Nothing is helping,” you might respond with, “You’ve tried most everything and it hasn’t worked much.”

3. Validating perceptions but not unchanging truth or reality. To use this technique, acknowledge and validate the depressed person’s perceptions without accepting the fixed, objective truth or unchanging reality of those perceptions.

When people are depressed, they often have an unrealistically pessimistic view of life, so agreeing with that pessimistic perspective may further discourage them. But we can’t just dismiss the person’s felt experience and tell her that her point of view is wrong. This technique involves finding a crucial balance by joining with and validating the person’s felt sense of the way things are while separating those views from accepted reality.

To do this, use phrases such as your sense; as far as you can see; as far as you remember; the only way to handle this, in your view, was; and so on. The goal is to help the person feel heard and understood without joining in her distorted or discouraged conclusions.

Here’s another example of a statement a depressed person might make, along with some suggested responses.

Depressed person: “I’ll never get better.”

Possible responses: “You think you won’t get better.” “Your sense is that there’s not much hope.” “As far as you can tell, nothing’s been working and you’re afraid nothing will.”

Combining All Three Techniques

Of course, as you get more practiced at these techniques, you can combine two or three of them in the same reflection. For example, if the person says, “I’ve just got to kill myself. I can’t take this anymore,” you could use all three techniques in your response by saying, “So, you’ve really been so discouraged lately and suffering so much that killing yourself seems the best possibility for relief right now.”

However, if the person gives you the sense that she feels invalidated or that your response minimizes her experience or suffering, you can switch to another of the techniques or return to pure acknowledgment for a time, leaving out any of the possibility elements.

For instance, suppose the person says, “I can’t get up and going,” and you use the partial reflections technique and respond with, “Sometimes getting going is really hard for you.” What do you do if the person comes back with, “Not sometimes. Every damn day! You just don’t get it, do you?”

You could respond with, “Sorry, I didn’t mean to minimize what it’s like for you to struggle with this. And you’re right, I probably don’t fully get how things are for you. So, your sense is that you can’t get going pretty much every day.”

The person will often respond with something like, “Well, on the days I see you, I manage to get up, but the other days it just feels too hard.” And that is the beginning of possibility. Your task in using these techniques is to stay close to the person’s experience while introducing small openings into her discouragement and sense of hopelessness. She’ll let you know when those possibilities start to become viable and real for her when she begins talking about possibilities and change herself.


Coming soon: The finale to our exploration of marbling depression.


For the past 30+ years, Bill O’Hanlon, MS, LMFT, has given over 2,000 talks around the world and was awarded the Outstanding Mental Health Educator of the Year in 2001 by the New England Educational Institute. He is a Licensed Mental Health Professional, Certified Professional Counselor, and a Licensed Marriage and Family Therapist. An accomplished author, Bill is known for his storytelling, irreverent humor, clear and accessible style and his boundless enthusiasm for whatever he is doing.


This post is based on an article originally brought to life by our partner, Psychotherapy Networker.

The full article, “Out of the Tunnel: Escaping the Trance of Depression” written by Bill O’Hanlon, appeared in the Nov/Dec 2014 issue of Psychotherapy Networker magazine.