Fortunately, key strategies can reduce and improve these symptoms. “The most important strategy is definitive treatment for the depression with psychotherapy and medication,” said William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

For instance, psychotherapy helps individuals become more aware of their cognitive symptoms, which can be subtle, Dr. Marchand said. It also teaches individuals specific techniques to improve their symptoms. And it helps clients gain a more accurate perspective on their illness.

“Because of the negative thinking associated with depression, there is a tendency to interpret symptoms as personal failings rather than as symptoms of an illness. A therapist can help one see things as they are – rather than through the distorting lens of depression,” Marchand said.

In addition to professional treatment, there are many strategies you can practice on your own to improve cognitive symptoms. Below are several techniques you can try.

Revise Distorted Thoughts

“I think it’s vital to teach any depressed individual how to ‘think happy,’” Serani said. Revising problematic thought patterns is key because they only fuel the fog and despair of depression.

“This approach definitely takes some time, patience and elbow grease, but once [it’s] learned, [it] enhances well-being.”

The first step is to monitor your negative thoughts, which you can record in a journal. A negative thought is anything such as “I’m a total loser” or “I can’t do anything right,” she said.

It’s also important to focus on how a negative thought affects your mood. By and large, it derails it. “Generally, [negative thoughts] will worsen mood, decrease hope and lower self-esteem.”

Next, challenge the reality of your thought, and replace it with a healthier one. Serani gave the following example: “Am I really a loser? Do I really do everything wrong? Actually, I get a lot of things right in life. So I’m not really a loser.”

Finally, review how each realistic thought affects your mood. According to Serani, it “leads to a healthier frame of mind. Now this new, healthy thought replaces the negative one and shifts mood into a less depressive place.”

Use Your Senses

“For helping with executive functioning skills for memory, focus and decision-making, I always recommend using your sense of sight, hearing and touch,” Serani said.

Technology can be especially helpful. For instance, you can set reminders for taking medication, attending therapy and running errands on your smart phone, computer or tablet.

If you don’t have access to technology or prefer pen and paper, Serani suggested placing brightly colored notes with reminders around your home and office. “Using touch to write will track the task more deeply into your memory and the visual cue to ‘see’ the reminder will help you keep your focus.”

Your sense of touch also can help when making a decision, said Serani, who uses this technique herself, “especially if I’m struggling with a significant melancholic mood.” She suggested a grounding practice, which “helps you be in the moment”: Place your hand on your heart, take a deep, slow breath and ask yourself the question you need to know. “Slowing things down and focusing on your sense of self can better help you make decisions.”

Take Small Steps

“Depression has a way of taxing you physical[ly], emotional[ly] and intellectual[ly], so taking smaller steps will help keep your energy reserve from burning out,” Serani said. Break down longer, more complicated tasks into bite-sized steps. This helps you “rest, refuel and re-attend [to your task].”

Have A Cushion

Therese Borchard, a mental health blogger and author of the book Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes, also struggles with cognitive symptoms from time to time. Whenever possible, she reduces her workload. “I’ve always prepared for days like that by working a little harder on the days I feel good, so I have a little cushion.”

Take Breaks

Because depression is so taxing on your brain and body, taking breaks can help. When she’s working, Borchard takes breaks every two hours, or “every hour if I’m really struggling.” Your breaks might include stretching your body or taking a walk around the block.

Be Kind To Yourself

“One of the most important things to do is remember not to be too hard on yourself if you still find you’re forgetful, have trouble focusing or making decisions,” Serani said. “Remember that you are experiencing a real illness.” Blaming yourself and losing patience only adds “to your already full plate.”

As Borchard noted in this piece on working from home with a mental illness, “When I was in the midst of my most severe depression, I couldn’t write at all. For almost a year…I try to remember that when I have a bad day where my brain feels like silly putty and I am not able to string two words together. I try to remember that courage isn’t doing a heroic thing, but getting up day after day and trying again.”

Yet cognitive symptoms are quite common. “[They] are actually significantly prominent in depression,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression.

And these symptoms are incredibly debilitating. “In my opinion, when cognitive symptoms of depression hit, they are more of a pressing concern than physical symptoms.”

Cognitive symptoms can interfere with all areas of a person’s life, including work, school and their relationships. Problem-solving and higher thinking, according to Serani, are greatly diminished. “This can leave a person feeling helpless and without a plan of action to defeat depression.”

Poor concentration can cause problems with communication, and indecisiveness may strain relationships, according to William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

The cognitive symptoms of depression also may get confused with other conditions, complicating diagnosis. Here’s a specific list of symptoms along with similar disorders.

Cognitive Symptoms of Depression

“Cognitive symptoms can be subtle and often go unrecognized,” according to Dr. Marchand. Fortunately, psychotherapy can help individuals become more aware of these symptoms, such as distorted thinking, he said.

Marchand and Serani shared these cognitive symptoms of depression:

• Negative or distorted thinking
• Difficulty concentrating
• Distractibility
• Forgetfulness
• Reduced reaction time
• Memory loss
• Indecisiveness

Disorders That Mimic Depression

“The cognitive aspects of depression usually involve a person’s thinking being sluggish, negative or distorted in quality,” Serani said. However, there are many other disorders that share these similar symptoms, because they, too, inhibit cognitive function. Unfortunately, this means that the “risk for misdiagnosis is high,” she said.

For instance, Serani mentioned attention deficit hyperactivity disorder (the inattentive type), post-traumatic stress disorder and substance abuse.

Co-occurring disorders can add to the confusion. “In many cases there are comorbid conditions such as dementia (in elderly individuals), adult ADHD and generalized anxiety disorder, and it can be difficult to sort out which condition is causing the cognitive symptoms,” Marchand said.

It’s critical to receive a proper and comprehensive evaluation to make sure that you have depression or another condition. Again, psychotherapy and medication can improve cognitive symptoms along with other symptoms of depression. Also, there are many strategies you can try on your own to reduce symptoms and feel better (which are explored in another article).

Some individuals experience a decline in mood with a sense of loss, he said. Others experience a loss of interest or pleasure in activities they previously enjoyed. Still others experience “an increased irritability, impatience or lower tolerance for the normal stresses of daily life.”

Chronic pain also creates many stressors, which can lead to depression, said Beverly Thorn, Ph.D, Clinical Health Psychology Professor and Chair at The University of Alabama whose research focuses on painful conditions. Chronic pain interferes with a person’s daily functioning. It lasts at least three months, more days than not, she said.

“People might be unable to work or work the way they used to.” Consequently, they might have financial problems, and a new role in their family. Patients have told Thorn that not being the main provider has made them feel worthless or like they’re not contributing to their family unit.

Treating Both Conditions

It’s important to treat both chronic pain and depression, Kerns said. “Many people with pain and depression say things like ‘If you had my pain you’d be depressed, too,’ or ‘If you would treat my pain, I wouldn’t be depressed.’ However, reducing pain doesn’t necessarily reduce symptoms of depression, he said.

That’s why Kerns suggested people work with providers who treat each condition (instead of an either-or approach). Some studies suggest that a collaborative and integrative approach is best. This study published in the Journal of the American Medical Association found that a course of antidepressants followed by a pain self-management program improved both depression and pain.

If you haven’t yet, consult a pain specialist for a treatment plan, along with a mental health specialist for a proper evaluation and treatment for depression, Kerns said. It’s also important to communicate regularly with your providers and pay attention to changes, Thorn added.

When to Proceed with Caution

One of the biggest challenges of treating both pain and depression is that feelings of helplessness and hopelessness lead people to try cures that are ineffective and even damaging, according to Kerns. “Continued doctor-shopping is problematic.”

Also problematic is pursuing more and more aggressive pain interventions, which he said only reinforce the “sense of helplessness and hopelessness and demoralization.”

Opioid medication is another concern. According to Kerns, there’s very little evidence that opioids are helpful for chronic pain. Instead, there’s “abundant evidence of the potential harm of long-term opioid therapy.”

For people with pain and depression, “who may be vulnerable to pursue these kinds of interventions,” it’s best to be cautious. Most experts “argue for very limited use of pharmacological agents and support education, encouragement and judicious use of non-opioid, over-the-counter [medication],” along with a healthy lifestyle and self-management techniques, he said.

How Psychotherapy Helps

Experts used to think that the amount of pain a person felt was equal to the amount of damage in their body, Thorn said. Today, however, we know that our thoughts and emotions can influence the perception of pain, making it much worse or less intense, she said. Psychotherapies, such as cognitive-behavioral therapy (CBT), harness this concept “by re-teaching your brain.”

Research has found that CBT is highly effective for managing both pain and depression. (“Some of the strongest evidence supports CBT,” Kerns said. But he also noted that other therapies such as behavioral activation and Acceptance and Commitment Therapy show promise.)

For instance, CBT teaches individuals to pay attention to their thought processes, which can maximize or minimize pain. Thoughts like “This pain has ruined my life, and there’s nothing left to be done,” negatively affect your emotions and behaviors, said Thorn, author of Cognitive Therapy for Chronic Pain: A Step-by-Step Guide. They also make you more likely to get depressed and withdraw. Plus, “If you feel like there’s nothing you can do, you won’t do anything,” which is “really dangerous for someone with chronic pain.”

For instance, one of Thorn’s clients, who has lower back pain, kept saying that his spine was disintegrating because his MRI showed some damage. Thorn asked him how this thought was affecting his emotions and behavior. “It makes me panic, and I’m afraid to do anything.” This thought also spiked his blood pressure, breathing and heart rate. Thorn suggested he find another perspective that’s more realistic and less of an emotional noose. He came up with the following thought: “There’s still some damage to my spine, but no amount of surgeries will help that damage. [However] it is the kind of damage that would be helped with muscle strengthening.”

Today, Thorn’s client plans to work with a physical therapist to strengthen his muscles. “As soon as someone has an empowering thought, they start to feel like they have a little bit more control over their life,” Thorn said. “His spine is damaged. He’s had three surgeries. But does he have control? Yes, he does.”

Paying attention to your thoughts is especially helpful when your pain level rises. For instance, Thorn suggested asking yourself, “What just went through my mind? What am I saying to myself?” If you become aware of a negative thought that’s emotionally laden for you, “stop, breathe and then consider your options.” This helps to interrupt your reflexive reactions, such as lashing out at yourself or your loved ones. It helps you choose a different path, and reminds you that you have more control than you think you do, she said.

In CBT, along with other therapies like behavioral activation, clinicians also help patients discover the kinds of physical activities they can engage in without exacerbating their pain, Thorn said. They also help them make realistic goals and manage defeatist thinking.

For instance, a person who used to run 10 miles might be able to walk for a few minutes today. They might easily think that such a minor activity isn’t even worth it. However, as Thorn said, walking for 5 minutes several days a week adds up. Soon you might be able to walk for five days, and so on. “That kind of gradual increase will build on itself.” Plus, regular physical activity helps to improve mood and energy levels.

Living with chronic pain can be especially debilitating. It can lead to or exacerbate clinical depression. Fortunately, these conditions are highly treatable. The key is to seek treatment for both, and to remember that a fulfilling life is absolutely possible.

Further Reading

Thorn and Kerns both recommended the book Managing Pain Before It Manages You by Dr. Margaret A. Caudill. Kerns suggested John Otis’s Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook.

Also, these are excellent organizations: the American Chronic Pain Association, led by people with chronic pain, and the American Pain Society, Kerns said.

But it’s actually not uncommon for the first treatment to be unsuccessful. In fact, about 40 to 50 percent of people don’t respond to the first antidepressant they’re prescribed, according to Jonathan E. Alpert, M.D., Ph.D, the associate director of the Massachusetts General Hospital Depression Clinical and Research Program and co-founder and co-director of the Depression and Anxiety Group Practice.

Still, the people who stick with treatment do get better. So there is hope – real, tangible hope. Below, you’ll learn why treatment might not work, along with what you can do and how you can advocate for yourself.

Why the First Treatment Doesn’t Work

There are many reasons why the initial treatment doesn’t take. Here’s a selection.

Incorrect diagnosis. The treatment might be ineffective because the person doesn’t have depression in the first place. For instance, medical illnesses such as hypothyroidism can look like depression. Hypothyroidism produces significant fatigue, lack of motivation and difficulty concentrating, Dr. Alpert said.

A person might have another psychiatric disorder such as bipolar disorder. “On average bipolar disorder takes 7 years to diagnose,” said Kelli Hyland, M.D., a psychiatrist in outpatient private practice in Salt Lake City, Utah. Or an individual might have a personality disorder, which doesn’t respond to medication, she said. (In fact, “medication is often contraindicated.”)

Even if the diagnosis is correct, medical conditions can blunt the effect of antidepressants, Alpert said.

Stressors. Sometimes, the person is “living in an untenable situation,” Alpert said. So it doesn’t matter how well the antidepressant is working because the individual is still surrounded by stress – either at home or at work – that needs to be addressed, he said.

Adherence. Some people might stop taking their medication because they’re concerned that it’s habit-forming, addictive or a crutch, Alpert said. Other individuals might stop because they actually feel better. But, as he said, “Once someone responds, they need to stay on medication for a minimum of 6 to 9 months to ensure they don’t have a rapid relapse.”

Another reason people stop taking their medication is side effects, such as nausea, diarrhea, sexual dysfunction or weight gain, he said. (“Many of these side effects can be addressed by switching to a lower dosage or a different antidepressant or sometimes by prescribing a second medication that helps alleviate the side effect.”)

Alcohol or drug use. “Alcohol and drugs interfere with antidepressant response,” Alpert said. Even having a beer or glass of wine at night can mess with your medication, Hyland said.

Other medications. Hyland noted that other medications, such as steroids and hormones, can interfere with antidepressants. (Being perimenopausal or menopausal also can affect efficacy, she said.)

Sleep problems. “I tell my patients that if you’re not sleeping, we can take medication ‘til the cows come home,” Hyland said. “Insomnia exacerbates mood, anxiety and coping.” Treating an underlying sleep disorder or trauma is important, she said.

Severity of illness. With moderate to severe depression, people often do best with medication and therapy, Hyland said. And sometimes two or three medications aren’t enough, she said.

The Next Steps

If your first ineffective treatment was medication, there are several ways physicians proceed. Alpert begins by examining the reasons the medication didn’t work. If he can eliminate the above as culprits, he might increase the dose of the medication. He also might switch the patient to another antidepressant within the same class (such as switching from one selective serotonin reuptake inhibitor, or SSRI, to another). He then might choose a medication from another class.

Another technique is to add a medication to augment the effects of the initial antidepressant, “especially if there is some evidence of a partial response,” Alpert said. In other words, if a person thinks they’re about 20 percent better and they’re tolerating the medication well, the doctor may prescribe a second antidepressant that works on a different mechanism of the brain, he said. An example is combining an SSRI, which targets serotonin, with Wellbutrin, which works on dopamine and norepinephrine.

Physicians also might prescribe an atypical antipsychotic, such as Abilify or Seroquel, to bolster the effects of the original antidepressant, Alpert said.

Psychotherapy, including cognitive-behavioral therapy and interpersonal therapy, is highly effective for treating depression. Therapists help clients learn about their illness, cope with stressors in their lives, identify and change dysfunctional thinking, and take action to get better.

If you’re only taking medication, seeing a therapist can be tremendously helpful. (If you’re solely working with a therapist, it’s also possible that you might need medication.)

Although SAD is not a “standalone” diagnosis in the current Diagnostic & Statistical Manual (DSM-IV-TR), published by the American Psychiatric Association, it has received much attention by the medical community over the past several years.

The most common symptoms of winter-onset SAD are:

• Loss of energy
• Weight gain and an increase in craving carbohydrates
• Anhedonia (inability to experience pleasurable activities)
• Anxiety
• Depressed mood
• Difficulty concentrating
• Social withdrawal
• Hopelessness/helplessness
• Decreased sex drive

The most common symptoms of spring/summer-onset SAD are:

• Anxiety
• Poor appetite
• Increased sex drive
• Insomnia (difficulty sleeping)
• Irritability
• Weight loss

Some believe SAD can be caused by a dysregulation in the biological clock (circadian rhythm); melatonin levels (a hormone that assists in the regulation of mood and sleep patterns); duration of sunlight; and serotonin levels (a neurotransmitter in the brain that affects mood).

Treatment options include:

• Phototherapy (light therapy). Light therapy is an easy way to decrease the symptoms of SAD. Most people can purchase a light therapy box and put it in their homes or office. The light from the light therapy box mimics outdoor, full-spectrum lighting. Some insurance companies will pay for a light therapy box if you have a prescription from your physician.
• Medication. You can speak with your physician, psychiatrist or nurse practitioner about psychotropic medications that may help decrease the symptoms of SAD.
• Psychotherapy. A mental health therapist can assist you in changing your negative thought processes and behaviors that contribute to your overall mood. Therapists understand how difficult it is to manage the stress of life, especially when you are feeling depressed. Therapists treat each person in a holistic manner and guide you along the way to wholeness.

Many researchers have found that a combination of psychotherapy, medication management and light therapy are beneficial to the treatment of SAD. Please speak to your physician or mental health professional if you believe you are experiencing SAD or any other mental health condition.

Other ways to combat SAD include:

• Exercise. Getting any amount of exercise is better than no exercise at all! If you work in a high-rise building then take the steps and if you have steps in your home then use them for 10-15 minutes each day. Join a gym; the cost of memberships this time of year tends to be pretty fair.
• Get adequate sleep. Sleep is vital to regulating your mood and behaviors. Try to get 6 to 8 hours of sleep per night.
• Relaxation. We are bombarded in our world with cell phone calls, text messages, Facebook posts, Twitter, and emails. We go to work each day and are overwhelmed, then come home and the kids need our attention. This week spend 10 minutes alone in your car or a quiet space in your home. Turn off the radio, television and cell phone so you can BE.Become a watcher of your thoughts but do not analyze or react to them at all. Watch the thoughts drift by like clouds in the sky. If you begin to think about the grocery list, then focus on your breath. Some people benefit from counting breaths to keep the mind focused on the number being mentally said instead of their thoughts. If this works for you it is helpful to count to 10 and then return to 1. If you are able to get to 10 with no interruption of thoughts then that is great! Most people begin and only get to 5 or so until they run away with a thought. If this happens, return to 1 and begin again.

  Spend the 10 minutes in being instead of doing. Start off with five minutes if 10 is too much. Your breath will return to normal and your body will get the chance to rest, even for a brief period. Do this once per day and then increase the time if you are able. This simple exercise is best done sitting in a comfortable chair or on the floor in a comfortable position; it is not recommended to do this in bed because your body is already trained to sleep in that space.

• Eat well. You do not need to be a dietitian in order to eat well. Listen to your body and eat what it innately craves. Replace unhealthy “fast foods” with alternatives such as sandwiches and salads.
• Get more sunlight. If it happens to be a nice day, then go outside when it is sunny. It may also help to get more sunlight into your home by opening your blinds up or sitting closer to a window with light coming in.
• Find balance. You can be the best you can be when your body, mind and spirit are aligned. Do not be too hard on yourself. Many people make New Year’s resolutions and often fail. It takes almost one month to change any bad habit, but be gentle with yourself and love yourself. Nobody is perfect and you cannot change every “bad” characteristic all at once. Instead of swearing off alcohol, fatty foods, men, women, cigarettes, or whatever your vice may be, look at your life and ask yourself, “Where in my life am I out of balance?” If you believe you work too hard, then you need to rest a little more. If you exercise too much, then you need to relax more.The adage “what we resist persists” is true. If we focus on the negative, that is what we will receive. For example, the “battle to lose weight” idea focuses on weight loss being a war of some sorts; however, if we shift our perspective to “eating healthy for me” then there is no negative related to thoughts around our food intake. If we believe eating is always going to be a battle, then chances are it will be a battle that we cannot win. So, our thinking patterns do affect our outcomes.

It might be helpful to enjoy a sunrise, spend time in your spiritual place (church, temple, mosque, spiritual home), laugh more, and enjoy the life you were meant to live. Everything is always changing and balance is a healthy way to endure the changes we face. We were not created to be overstimulated and out of balance. Focus on your strengths and positive ways to introduce balance back into your life. Remember that you are whole, complete and perfect — half the battle is in believing it.

I’m just getting to know Michelle. She had her first baby 3 weeks ago and has been sad and irritable ever since. Her pediatrician was worried about her at the well-baby visit this week and sent her to me. She’d had a tough pregnancy (morning sickness that wouldn’t quit for what felt to her like forever), made tougher by the financial stress that came from her husband being out of work for several months. The doctor is worried that she and her baby aren’t getting off to a good start.

Sadly, moms like Michelle often feel alone and guilty. Not feeling what they think they are supposed to feel, they are embarrassed to admit to themselves and others that things aren’t going well. Just when they need help the most, many don’t reach out. Some start to resent their babies and begrudge them time and attention. They force themselves to do what needs to be done but don’t provide their newborns with the nurturing they need.

Still others give up on nursing, or holding their babies when bottle feeding, depriving themselves and their babies with the closeness that comes with the quiet feeding times. Propping a bottle is the best they can do. Overtired, irritable, and sinking into depression, life after birth isn’t at all what they expected.

As hormones shift and settle, it’s absolutely normal to feel what is commonly known as the baby blues in the weeks following birth. One of my clients described the first couple of weeks after her first child was born as PMS times ten. Others feel more emotionally fragile than usual and maybe a little weepy. Still others are surprised that they are on an emotional roller coaster, feeling great one minute and set off into tears by something that normally wouldn’t bother them the next. It’s all because the endorphins from delivery are leaving the new mother’s system and the body is resetting itself.

Different women react differently but normal baby blues are usually accompanied by moments of joy and wonder and happiness about the baby and motherhood. The emotions settle down after a couple of weeks and the routines and rhythms of new parenting get established.

But when those up and downs last more than a few weeks, and especially if they get worse, it may indicate that the new mom is developing postpartum depression (PPD). This happens to between 11 and 18 percent of new mothers, according to a 2010 survey by the Centers for Disease Control (CDC). Surprisingly, it can last anywhere from a couple of months to a couple of years.

Symptoms of Postpartum Depression

Postpartum depression looks like any major depression. Things that once gave the mother pleasure are no longer fun or interesting. She has trouble concentrating and making decisions. There are disturbances in sleep, appetite, and sexual interest. In some cases, there are thoughts of suicide. Many report feeling disconnected from their baby and some worry that they will hurt their baby. Feelings of hopelessness, helplessness and worthlessness immobilize them. Many feel guilty that they can’t love their child, which makes them feel even more inadequate.

In some cases, women develop psychotic delusions, thinking their baby is possessed or has special and frightening powers. Sadly, in some cases, the psychosis includes command hallucinations to kill the child.

Who Develops Postpartum Depression?

There are a number of issues that contribute to a woman’s risk of developing PPD:

• A prior diagnosis of major depression. Up to 30 percent of women who have had an episode of major depression also develop PPD.
• Having a relative who has ever had major depression or PDD seems to be a contributing factor.
• Lack of education about what to realistically expect of herself or the baby. Teen mothers who idealized what it would mean to have a baby to love with little appreciation for the work involved are especially vulnerable.
• Lack of an adequate support system. Unable to turn to someone for practical help or emotional support, a vulnerable new mom can become easily overwhelmed.
• A pregnancy or birth that had complications, especially if mother and baby had to be separated after the birth in order for one or the other to recover. This can get in the way of normal mother-child bonding.
• Being under unusual stress already. New mothers who are also dealing with financial stress, a shaky relationship with the baby’s dad, family problems, or isolation are more vulnerable.
• Multiple births. The demands of multiple babies are overwhelming even with substantial support.
• Having a miscarriage or stillbirth. The normal grieving of loss is made worse by the shifting hormones.

What to Do

In cases of the normal “baby blues,” often all a new mom needs is reassurance and some more practical help. Engaging the dad to be more helpful, joining a support group for new parents, or finding other sources of support so the mom can get some rest and develop more confidence in her mothering instincts and skills can put things back on track. As with any other stressful or demanding situation, new parenthood goes better when the parents are eating right, getting enough sleep, and getting some exercise. Friends and family can help by bringing some dinners, offering to take over with the baby for an hour or so so that the parents can get a nap, or by babysitting siblings to give the parents time to focus on the infant without feeling guilty or pulled in multiple directions.

Postpartum depression, however, is a serious condition that requires more than naps and caring attention. If the problem has persisted beyond a few weeks and has been unresponsive to support and help, the mother should first be evaluated for a medical condition. Sometimes a vitamin deficiency or another undiagnosed problem is a contributing factor.

If she is medically okay, those who care about her and her baby need to encourage her to get some counseling, both for the emotional support counseling offers and for some practical advice. Cognitive-behavioral treatment seems to be especially helpful. Since women who have experienced postpartum depression are vulnerable to having another episode of depression in their lives, it is wise to establish a relationship with a mental health counselor to make it easier to seek help if it is needed in the future. If the mom has had thoughts of suicide or infanticide, the therapist can help the family learn how to protect them both. If the birthing center or hospital offers a PPD support group, the new mom and dad should be encouraged to try it. Finally, sometimes psychotropic medications are indicated to alleviate the depression.

The baby blues are uncomfortable. Postpartum depression is serious. In either case, a new mom deserves to get practical help from family and friends. When that alone doesn’t help a new mom adjust, it’s time to seek out professional help as well.

Managing Depression and Suicidality

It is common for clients with schizophrenia to feel grief and loss due to the myriad life changes that it triggers (Wittmann & Keshavan, 2007). In this sense, during treatment, it is essential for clinicians to help clients navigate through the grieving process. According to Tait, Birchwood, and Trower (as cited in Wittmann & Keshavan, 2007), depression has been found to lead to the abandonment of treatment by clients due to the isolating characteristics of the disorder. Abandonment of treatment poses serious drawbacks for clients.

Wittmann and Keshavan (2007) assert that the grieving process is a necessary component to coming to terms with a new diagnosis of schizophrenia. Due to the sense of loss experienced by individuals newly diagnosed with schizophrenia, it is essential for them to navigate and work through the grieving process (Wittmann & Keshavan, 2007). According to Lewis (as cited in Wittmann & Keshavan, 2007), by doing so, clients will learn to mourn the life and identity changes that have occurred, along with establishing the ability to integrate such change into their lives. It has been shown that counseling can be beneficial in such a situation.

Grief and mourning are a common component in clients diagnosed with schizophrenia (Wittmann & Keshavan, 2007). This is because the diagnosis of a serious, permanent mental disorder is a major life crisis for most. The disorder affects the mind in very serious ways (Wittmann & Keshavan, 2007). In some cases, clients might spiral into psychosis as a means of dissociating, or defending against facing, the losses their disorder has caused (Wittmann & Keshavan, 2007). Clinicians have a major hand in helping clients manage this crisis.

Numerous models exist to explain grief and mourning, and can also help professionals guide grieving individuals. Elizabeth Kubler-Ross (1969) proposed five stages of grief that individuals can experience while grieving. They include denial, anger, bargaining, depression, and acceptance. In contrast, Worden (2002) proposes four tasks, as opposed to stages of grief. These include accepting the reality that loss has occurred, feeling the pain and emotional responses to the loss that has occurred, readjusting to life after the loss, and finding ways to remember the lost individual. Although these models are meant to aid in grieving a person, individuals diagnosed with schizophrenia are, in fact, grieving the loss of the person they once were and will potentially no longer be. In this sense, these models offer a framework that can be used in counseling to help a client adjust to life after their loss of self.

A Safety Plan for the Newly Diagnosed

Clinicians should develop a safety plan for use in the event that a client presents with suicidal intent or depressive symptoms, as these are both common in newly diagnosed clients. One of the first issues to address is the onset of depressive symptoms or suicidal thoughts. A safety plan can involve listing symptoms characteristic of depression, including those characteristic to the client, as well as those that the client has not felt before, but could potentially feel in the future. This would help foster the client’s awareness of their own symptoms.

Along with such a list, clinicians can help clients determine the course of action to be taken if suicidal thoughts or feelings occur. Action plans can include emergency contact numbers, such as a suicide hotline and that of the primary therapist, the psychiatrist and other medical doctors, and family members or other individuals who serve as the client’s support system. One of these individuals could sit with the client and support them through the situation while attempting to contact appropriate clinicians. If the client has no close friends or relatives, suggest that they join an in-person or online support group.

Clients should be asked to keep a list of depressive or suicidal triggers. During sessions, the counselor and client could develop and implement ways for such triggers to be managed.

Clinicians should urge clients to remove from his or her home any items that could be used to self-harm. Making access difficult reduces the temptation to use them. This might be especially useful for clients who have already made attempts, and would also potentially increase the likelihood of them seeking some form of support or following an appropriate plan of action, rather than engaging in self-injurious behavior.

Clients can be encouraged to keep an up-to-date medication list with them at all times. This will help them if they need to seek out emergency services. During a crisis, it might be difficult for them to recall each of the medications they take, as their minds will be preoccupied.

Clinician should keep a current list of service providers to which clients can be referred. For example, if the client’s symptoms become more intense and overwhelming for them, and more in-depth treatment is required, the clinician should be able to make an appropriate referral or direct the client to an appropriate provider. This could further ensure the client’s safety, as he or she would receive the necessary services, especially if more in-depth treatment is required.

Conclusion

A diagnosis of schizophrenia presents serious implications for newly diagnosed individuals in particular. Those with schizophrenia have a vast series of challenges to face, including overcoming and grieving the loss of a sense of self, experiencing a loss of hope for the future, accepting the diagnosis, facing the fact that social, occupational, educational, familial, and romantic arenas might undergo marked change, and integrating new insights, coping strategies, and processes learned on their journey into their life.

Because the diagnosis of a serious mental illness can cause a major life crisis (Wittmann & Keshavan, 2007), clinician support is critical. This is especially true because depression and suicidal ideation are common in the newly diagnosed (Addington et al., 2004). Along with helping the client manage their diagnosis and helping to facilitate his or her grieving process, clinicians can help ensure client safety by establishing and agreeing upon a safety plan for use in the event that the client is experiencing depressive symptoms or suicidal ideations. Not only will this help clients to feel supported and cared for, but it will also potentially help save a life in the event of an emergency or crisis.

References

Addington, J., Williams, J., Young, J., & Addington, D. (2004). Suicidal behaviour in early psychosis. Acta Psychiatrica Scandinavica, 109(2), 116-120.

Kubler-Ross, E. (1969). On death and dying. New York: Scribner.

Wittmann, D. & Keshavan, M. (2007). Grief and mourning in schizophrenia. Psychiatry, 70(2), 154-166.

Worden, J.W. (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed.). New York: Springer Publishing Company.

When Paul Gruchow first started putting Letters to a Young Madman together, he wondered how his disjointed journal entries, quotes, and medical research could work to create something coherent and meaningful. Though every entry contains a different experience, a different thought, a quote that Gruchow could relate to, any reader of this book is able to clearly understand the message that Gruchow is sending.

“To assume sickness as a career, of course, is to resume the role of a child.”

Gruchow communicates with incredible transparency how depression feels. He allows readers to feel his abyss and to empathize with the feeling of waking up in the morning paralyzed and unable to get out of bed for days at a time. He helps the reader understand what it feels like to lose one’s self worth after being put on disability and being defined by what one is unable to do. The reader plunges down with Gruchow, departing from a life in academia and family ties and entering a life spent in a garage and trying to take solace in the fact that it’s not a mental health facility.

“I have been treated by six psychiatrists and by six psychologists. The psychiatrists have all believed that my problem was organic. The psychologists have all believed that my problem was behavior. We see what we are trained to see.”

Gruchow gives a vivid view of problems with our mental health system. He shows exactly where the various treatments and medications he was prescribed failed in their ability to help him recover. He’s able to show through his research that over the course of mental health care history, nothing has really helped, and what we have now isn’t much different. In one entry, he writes that every new treatment is said to experience a 70-80 percent success rate when it first emerges on the market. After a period of time, these treatments lose popularity as people discover they don’t actually work. A new treatment comes out with a high percentage of success to erase the preceding treatment from the market.

“I don’t think we’ll have a truly successful mental health system until the mentally ill become genuine partners in their own healing, and the only way to do that is to make them healers, rather than merely objects of healing.”

Though the book is more of a narrative of Gruchow’s experiences, the author also writes about what he believes may have been able to help him. He bares his unsettling experiences and tells his story in a way that allows the reader to not only understand, but empathize. And that story, though disjointed, leaves no gaps or questions as to what Gruchow was feeling at the time or why.

As a student of psychology, I was struck by how different the patient perspective is from the practitioner perspective when it comes to mental health care. Reading Letters to a Young Madman was an eye-opening experience for me, and gave me some much-needed insight into what we need to change if we really want to help our patients.

More than empathy, Gruchow’s book left me with a clearer idea of what I can do for someone who is going through an episode of depression. Being able to get a glimpse into the mindset of a friend or relative who is suffering from depression can be infinitely beneficial for someone who wants to help but has no idea how to do it.

Letters to a Young Madman can allow professionals in the mental health system to truly see their patients and do more to help. If read widely enough, the book could help ease the stigmas surrounding those with depression.

Letters to a Young Madman: A Memoir
Levins Publishing, September, 2012
Paperback, 209 pages
$14.99

All are good ideas if the problem merely is that you need a jumpstart to the work week. But such suggestions are beside the point if there is a real and important underlying issue that needs to be addressed. Sometimes the resistance to Monday is an inner emotional alarm going off. If that’s the case, taking a cold shower or drinking a cup of coffee won’t solve your Monday Blues any more than taking the battery out of a smoke detector will stop a fire.

Hate Mondays? Maybe you aren’t paying attention to one of these signals:

1. Your job isn’t really “workable.”

Let’s face it: For many, work has become much more demanding in the last 10 years. As companies cut personnel to cut costs, those left are expected to do more and more. Those who have been in their jobs for a long time often have high personal standards for quality that are almost impossible to meet with the increased workload. It’s exhausting and discouraging to feel like “the hurrieder you go, the behinder you get.” It may be appropriate to talk with your supervisor about adjusting your own or the company’s standards. If that’s impossible, it may be time to consider whether you can find a different job.

2. Your job isn’t satisfying.

Only a lucky few have jobs that are thrilling, satisfying, enjoyable, and enriching every minute of every day. Most of us have a whole lot of routine mixed in with occasional periods of excitement, or at least satisfaction. If those moments are few and far between, get busy. You may be able to up the portion of the time that you are happy in your work. Is there a project you could take on that would renew your interest? Is there a way to change your job within the company, either by going for a promotion or through a lateral move that would give you new opportunities? Does the human resources department offer workshops you could take to develop new skills?

3. Your life is out of balance.

“All work and no play makes Jack a dull boy” (or Jane a cranky girl.) It’s an old saying that is never irrelevant. If your life is work, work, work, of course you feel out of sorts. No matter how important our work is, we need to remember to refuel through self-care. That includes developing a hobby or interest, taking time for some fun and vacations (or stay-cations), and doing the usual daily regimen of eating right, sleeping enough, and getting some exercise. If you only take care of yourself on weekends, Monday morning is the beginning of five days of deprivation. Not good. Take the time to reassess how you are managing the balance of your life during the week.

4. Your job is hostile to your relationships.

Jobs that require long hours, or that require you to take work home or put in time on the weekends, are killers to family life and friendship maintenance. It’s sad to see parents at kids’ events who couldn’t leave their laptops at home. Friends get impatient with friends who interrupt a social evening to take a business phone call. Yes, these folks are in attendance, but they aren’t really there. Your discontent with your job may be a signal that you are missing out on too much of the warmth and intimacy you need from your relationships. Take a careful look at how you can manage the demands of your job in such a way that it doesn’t cost you love.

5. Your attitude toward work needs adjustment.

We do get what we expect. For some people, work is a four-letter word. Work is, well, “work.” It’s seen as the opposite of fun, the nasty dinner you have to eat before you get to have dessert. When a person has developed an attitude that any work or chore or required activity is a major distraction from enjoyment, Monday morning is, by definition, a downer. If that’s the case, it’s time for an attitude transplant. Unless you are one of the fortunate few to win the lottery or to inherit a trust fund, you’ll be working a great many hours of your life. Better to find a way to embrace it, and, yes, even enjoy it.

6. You are struggling with depression.

Depression can sneak up on a person. It may not be the job that is pulling you down. It may be that you are becoming clinically depressed. Is your appetite off? Are you having trouble getting to sleep or staying asleep? Has your interest in sex plummeted? Does doing things that used to be pleasurable for you seem like just too much effort? These could be the signs of depression. Consider going to see a mental health counselor for an evaluation. If you are depressed, the counselor will discuss possible treatment options. This may include some medication and some talk therapy to help you get back to your old self.

Before you buy into the notion that Mondays are awful and simply can’t be changed, take another look. It’s important not to ignore the possibility that the awfulness resides in your choices, not in a day of the week. If that’s the case, you do have the option to make it better. Confront the issue, make some changes (and maybe give yourself that splash of cold water and a cup of coffee), and you can make Monday the start of a productive and satisfying week.

• Finances. Not enough money or the fear of not having enough to buy gifts leads to sadness and guilt. The stress of financial hardship during this economic downturn is often compounded by shame. When you can’t afford to celebrate it can feel devastating.
• Stress. The stress of shopping and planning family dinners when you’re already overworked and tired can be overwhelming.
• Loneliness. A whopping 43 percent of Americans are single, and 27 percent of Americans live alone. When others are with their families, it can be very painful for those who are alone. Seventeen percent of singles are over 65, when health, age, and mobility can make it more difficult to enjoy yourself.
• Grief. Missing a deceased loved one is painful at any age, but seniors have more reasons to grieve.
• Estrangement. When you’re not speaking to a relative, family get-togethers can usher in feelings of sadness, guilt, resentment, or inner conflict about whether to communicate.
• Divorce. If you’re newly divorced, the holidays may remind you of happier times and accentuate your grief. It’s especially difficult for adult children of divorce who have to balance seeing two sets of parents. The stress is multiplied for married children who have three or even four sets of parents to visit.
• Pleasing. Trying to please all of your relatives – deciding what to get, whom to see, and what to do – can make you feel guilty and like you’re not doing enough, which leads to depression.
• SAD. Many people experience the blues during gloomy weather due to decreased sunlight, called Seasonal Affective Disorder (SAD).

Much of the planning, shopping, and cooking is done by women, so they carry the greater burden in preparing for family gatherings. Women are at twice the risk for depression than men. After heart disease, depression is the most debilitating illness for women, while it’s tenth for men. To read more on this, see Depression in Women.

Some measures you can take to cope with the holiday blues include:

• Make plans in advance, so you know how and with whom your holidays will be spent. Uncertainty and putting off decision-making add enormous stress.
• Shop early and allow time to wrap and mail packages to avoid the shopping crunch.
• Ask for help from your family and children. Women tend to think they have to do everything, when a team effort can be more fun.
• Shame prevents people from being open about gift-giving when they can’t afford it. Instead of struggling to buy a gift, let your loved ones know how much you care and would like to, but can’t afford it. That intimate moment will relieve your stress and nourish you both.
• Don’t allow perfectionism to wear you down. Remember it’s being together and goodwill that matters.
• Make time to rest and rejuvenate even amid the pressure of getting things done. This will give you more energy.
• Research has shown that warmth improves mood. If you’re sad or lonely, treat yourself to a warm bath or cup of hot tea.
• Spend time alone to reflect and grieve, if necessary. Pushing down feelings leads to depression. Let yourself feel. Then do something nice for yourself and socialize.
• Don’t isolate. Reach out to others who also may be lonely. If you don’t have someone to be with, volunteer to help those in need. It can be very uplifting and gratifying.

The signs of depression are feelings of sadness, worthlessness or guilt, crying, loss of interest in usual activities, fatigue, difficulty concentrating, irritability, social withdrawal, and changes in sleep, weight, or appetite. If these symptoms are severe or continue for a few weeks, more than the holidays may be the cause. Seek professional help.

Or maybe you’re a bundle of nerves. You are so anxious you just want to hide. You’re nervous about your job. You’re scared to speak up even when you know you should and could. You are so anxious that you are anxious about being anxious.

Or maybe the issues are about relationships. You don’t have one or the one you have isn’t the one you want. You and your partner are fighting all the time. Every day seems to be “same fight, different day.” Trust has become a huge issue. Neither one of you can relax into your relationship. You each wonder where the love and sweetness and tenderness have gone.

And then there are family issues: The mother you can’t get along with. The father who expects too much or too little of you. Siblings who are mean-spirited, favored, or so self-centered that you feel constantly taken advantage of. Parents who are fighting. Parents who are splitting. Family you are expected to like but who are entirely unlikeable – and here comes another painful family event.

Any of these types of issues can stretch a person beyond his or her ability to cope. Any of them can challenge the most creative, caring, and responsible person, You’ve tried your best. You’ve tried to look at a brighter side, to be rational, to be smart about whatever it is. But you still can’t figure things out. You still feel alone in your troubles and without the inner resources or the outer supports to change things. This is when people often go to therapy. You wish you could. But you have no insurance and you know it can be costly. The situation seems hopeless.

It’s not. Serious, yes. Hopeless, no.

Inexpensive and Alternative Treatment Options

There are many ways to get the help you need, therapist or no. Before you give up on the idea of getting some therapeutic help, consider these alternatives.

Sometimes therapy is free or low-cost.

Depending on your problem, there may be funded or subsidized therapy available to you. Many communities have women’s centers that offer free services to women who are being abused. Many have free services for adolescents. And an increasing number of communities have men’s resource centers to help men with anger management, relationship or vocational problems. Go online and check.

Employee Assistance Programs (EAP).

Many businesses and companies offer a limited counseling benefit. Usually the company provides three to six sessions. If you need further help, the counselor will refer you to a local therapist. Check with your human resources department to see if there is an EAP counselor at your workplace. Often even a couple of focused sessions is enough to offer some relief.

Sliding scales and free slots.

Many mental health clinics and many therapists in private practice have sliding fee scales so that people can pay what they can afford. Ask your doctor if he or she knows who offers this service. Call some of the therapists in your area and ask. Many therapists keep a number of slots at a lower rate as their way of giving to their community.

Support groups.

Often a support group can be very therapeutic. By talking to people with a similar problem, you will feel less alone. Often there are people in the group who are a little ahead in their healing and who can offer you good practical advice as well as emotional support. Local hospitals, libraries, churches, and schools often offer support groups for grief, parenting issues, managing chronic illness, etc.

PFLAG (Parents and Friends of Lesbians and Gays) offers support to those supporting family members and friends who are coming out. There are also support groups online and in the community for gays, lesbians, and transgendered people who need information and advice.

Parent education classes.

Not all problems are mental health issues. Parenting is difficult. Often people new to parenting or new to a stage of parenting could just use some additional information and the reassurance and advice that can come from parents who have been there and done that. Often such groups are offered through the school system or through local parent centers.

12-step Groups.

Alcoholics Anonymous, Al-Anon (for families of problem drinkers) and Alateen (for teenage family members) offer support to people who are struggling with alcoholism and to their families. Other spinoffs include Overeaters Anonymous, Narcotics Anonymous, Clutterers Anonymous and Parents Anonymous. If you think a 12-step program is for you, search your issue and “anonymous” and you are likely to find a group.

The National Alliance on Mental Illness (NAMI) has chapters throughout the U.S. They often offer support groups for those struggling with mental illness as well as for family members.

Online support groups.

Name a problem and there is probably an online support group for it. Here at PsychCentral, there are over 100 such forums and groups. Members are not professionals. They are people who are grappling with the same issue you are. Their compassion and understanding can help you feel less alone. Often members offer experience and wise suggestions.

Are you a veteran? Every branch of the service has a program for military personnel and their families. Call your local Veterans Administration office for information.

Are you a teen? Many high schools have free counseling available through the guidance department. Often the guidance counselors are themselves counselors and can be very helpful with both individual and family problems. Sometimes they know which therapists in town have free or nearly-free services and where you can go for further help.

Are you in college? Check to see whether the health services at your school include a mental health department. Often the health insurance you pay for at school can enable you to see a local therapist for at least a few sessions.

Hotlines and warmlines.

There are important hotlines and warmlines in almost every country. In the U.S., the National Suicide Prevention Lifeline (1-800-273-8255) is available 24/7. The Boys Town National Hotline is also available 24/7 for teens (girls as well as boys). Google “hotline” and your problem and you are likely to find a number to call.

Houses of worship.

Spiritual leaders often have had training in counseling as well as in the practices of their faith. See if your church or synagogue or house of faith offers such help. If your spiritual leader isn’t comfortable dealing with secular problems, he or she may be able to refer you to someone who can.

Journaling or writing letters you will never send can be an important method for self-help. Don’t get put off by having to put something down. You’re the only one who is going to see it. Writing out what troubles us often helps us put our feelings into perspective. Often enough, a solution will come as you work to make your problems clear.

Bibliotherapy is a fancy name for reading a book. Whatever your problem, someone else has probably written about it to share their journey of healing. Sometimes we learn best from reading how someone else did and did not address issues. Search for your issue at one of the major online bookstores and you can find what you are looking for.

Prayer, meditation, chanting.

Anything that helps you relax and get out of yourself for a bit can do wonders for your state of mind. Turning your problems over to God, your higher power or the universe can help relieve the pressure and begin the healing.

Get off the screens and go outside.

Mother Nature is a great therapist. Stop spinning about your problem with online friends who are in the same spin and go for a long walk instead. Open your senses to the outdoors and you may be able to cut your problems down to a more reasonable size.

Talk to a trusted friend or family member.

You know who they are. Many of us have a friend or relative who is wise and loving and supportive. Don’t waste your time on anyone else. People who are critical or judgmental will make you feel worse. Reach for the people in your life who will listen with their hearts and who will validate your strengths.

Take care of yourself.

Getting enough sleep, eating right, and making sure you get a little exercise each day can do wonders for your troubles. You may not feel like doing any of it. But doing it, whether you feel like it or not, can help you start to feel a bit better. You will have taken a step toward self-care and self-love that is the basis for any therapeutic action.

Blind Devotion: Survival on the Front Lines of Post-Traumatic Stress Disorder and Addiction gives a taste of the Prinsen’s gutsiness at the outset, as she begins by acknowledging that she herself has played a part in her family’s difficulties. In this, her first book, the author tells the searingly honest and remarkably brave story of her family’s battles with mental illness, charting the ongoing chaos they’ve faced following Sean’s service in Bosnia.

After his discharge, Prinsen tells us, her husband returns home to the States and is given a prescription for narcotic pain medication to help him cope with the pain of a neck injury he suffered during military training. It is here that things begin to quickly spiral out of control, as Sean becomes addicted to his pills and begins to self-medicate with additional over-the-counter medications and alcohol. His behavior throws the entire family into disarray.

“Alcoholism is an enigma,” Prinsen writes, “— as complex as it is puzzling. It follows no rules and has no boundaries. Like a giant vacuum, alcoholism goes after everything and everyone in its path. It is a family disease — everyone in the family gets sick.”

Because Sean is reluctant to speak about the trauma he experienced in the military, or to share the truth about his depression with anyone, Prinsen assumes that her husband is simply suffering from addiction. It takes many years for her to understand and recognize the nature of PTSD and to connect the dots between the trauma Sean experienced in Bosnia and his subsequent depression and substance use.

“For so long, in the early stages of Sean’s addiction, I didn’t understand the destructive interplay between Sean’s PTSD, his depression, and his substance abuse,” she writes, explaining:

… Only he understood the desperate need to escape from the crippling flashbacks and the intrusive thoughts that blindsides him without warning, bringing with them the full force of the emotions that he felt in the original traumas. Only he understood the exhausting anxiety that kept him on high alert for ‘danger’ 24/7 and the need for something — anything — to keep that anxiety at bay. Only he understood how the pills helped him get through a night that would otherwise be plagued by the alternating horrors of nightmares or insomnia.

Sean’s PTSD continues to go undiagnosed, until he finally reaches crisis point. One night, in 2007, Sean suffers a complete breakdown and attempts what is known as “police-assisted suicide.” He becomes threatening and aggressive, arms himself with a loaded weapon, and calls the police to the house, almost as a challenge.

Prinsen recalls the horrific events of this evening, as she and her two young children are forced to witness Sean’s breakdown and frightening behavior, fearing not only for his life, but for their own. Sean survives, is arrested, and is subsequently jailed. Then, incredibly, after his release, the same thing happens again exactly a year later, as he suffers a repeat breakdown and once again challenges the police to come and get him, putting his family’s lives at risk in the process. By this point you’d be easily forgiven for wondering why on earth Prinsen doesn’t just leave, but it’s here that the relevance of the book’s title becomes clear. Prinsen adopts the military philosophy of “No One Gets Left Behind” and refuses to abandon Sean, no matter what anyone else tries to convince her, or how tempting it might sometimes seem. Looking back, she realizes that she plays a codependent role in the relationship, too.

But Prinsen doesn’t let her husband off the hook lightly, either, and always holds him fully accountable for his actions. “It took me many more years to fully grasp the reality that abuse isn’t just physical,” she writes. “Sean was a master at manipulating my emotions to get just what he wanted, and as difficult as it is even today to say the words — that is abuse.” Sean also used threats of suicide and self-harm to keep her from leaving or setting healthy boundaries, she tells us, recognizing it as a form of abuse. His “screaming, the holes in the wall, the slammed doors, and the broken objects” are also “definitely abuse.”

Later, Prinsen recounts, with brutal honesty, how she at times longed for her husband’s demise:

Sean stayed in our home, but I was finally starting to understand that Sean would never get help until he hit rock bottom. He needed to fall hard if he was ever going to get up again. I did something then that I’ve since found out is common behavior for the loved ones of addicts: I began to systematically pray for my husband’s downfall. I didn’t want him to get hurt. I didn’t want him to injure someone else and live with the regret. I didn’t want him to suffer lifelong consequences. I just wanted him to suffer enough to want to get help for himself.

It is rare to find these sorts of frank admissions in a personal memoir, let alone a first book, and it is this fearless honesty that makes Prinsen’s story so powerful. One can only imagine how difficult it must have been for her to put all of this into writing, knowing that her husband, friends, and family would all be able to read it. At one point in the story she finds herself wondering, “What will people think when they see this in the newspaper?”

In addition to sharing her own raw experiences, Prinsen also follows every section of the book with a short factsheet, providing the reader with a brief summary of the fundamental topics covered and links to further resources. These factsheets might easily have seemed disruptive or out of place, but Prinsen keeps them concise and informative.

The author also raises some vital ethical and political issues, questioning the morality of a government that puts soldiers in situations that destabilize their mental health, then prosecutes them as criminals. “How can we expect our veterans to come back to their homes and be ‘normal’ again after they have seen humanity at its worst?” Prisen recalls thinking angrily as she and Sean walked out of court one day. She feels sick when considering that Sean, who had never had any trouble with the law before he was deployed to Bosnia, was now a twice-convinced criminal. “What kind of a country is this to condemn and shame its own soul-wounded soldiers in such a way?” she asks. “Why don’t we just help them?”

Blind Devotion lives up to its name as a remarkable testament to the unquestioning power of love against all other odds, including the most destructive forms of mental illness. This is a story of survival, with protagonists who are determined to conquer their personal demons and triumph, no matter what. Prinsen’s writing will appeal to every reader, regardless of whether or not they’ve had to deal with PTSD. For the hundreds of thousands, if not millions, of military families who can relate to her experiences firsthand, hearing Prinsen speak about them so openly and shamelessly will surely be a relief.

Blind Devotion: Survival on the Front Lines of Post-Traumatic Stress Disorder and Addiction
Hazelden, September, 2012
Paperback, 348 pages
$14.95

While the book does tell the story of Zach Schidkunz, a young man convicted of murder, the real heart of it is the author’s journey as he attempts to come to grips with what has transpired. The reader is witness to how a parent can make sense of a world in which his beloved little boy can go from college, to suffering from serious depression, to prison.

We are introduced to Zach as a fairly typical, middle-class child. It’s not until college that he begins to show signs of depression, including self-injurious behavior. Eventually, Zach’s psychiatrist recommends a psychotropic medication — Zoloft. Things seem to be getting better until a shocking incident: Mr. & Mrs. Schmidkunz discover a female shooting victim in their home. Even more shocking, the evidence seems to point to Zach as the perpetrator.

Gail Schmidkunz is, understandably, utterly distraught by this idea, and attempts to piece together the possible causes for this incomprehensible situation. What could possibly drive his son, a young man who had no history of trouble with the law, to suddenly, fatally shoot a female friend? What role did Zach’s history of depression and psychiatric treatment play in the incident? Could Zach be held completely responsible for his actions, or were there mitigating factors on which accountability could fall?

All of these questions have been examined by the justice system as well as by Schmidkunz. The author provides us with a vivid picture of the confusion and torment that the ordeal led to. Not content to leave his son’s fate to the courts, Schmidkunz consults with lawyers and mental health professionals to try to make sense of this terrible situation.

After much investigation, the author arrives at a controversial conclusion. One of the medications that Zach had been prescribed, Zoloft, had reportedly caused bizarre side effects in a select number of people. One of these side effects is aggressive behavior. Perhaps, the father postulates, this medication could have been the underlying cause of his son’s actions. The difficult next step was to convince others that this was a possibility. Schmidkunz discusses his battles with doctors who disagreed with his theory as well as the legal team behind the pharmaceutical company that produces Zoloft.

The questions raised in I Am Not Silent are not necessarily easy to answer. How do we determine to what extent a person’s actions may have been caused by mental illness, or by a medication one was taking for that illness? And if medication does play a part in a criminal act, whom do we hold responsible: the person taking the medication, their doctor, the company who produced the pills? Is there some type of proactive monitoring that can take place in order to prevent stories like Zach’s from happening to others in the future? These are complicated legal and ethical issues to contend with.

Whether or not psychiatric medication played a part in Zach’s actions is certainly up for debate. Though Zach was ultimately found guilty, the reader will have to draw his or her own conclusions about the verdict based on the evidence Schmidkunz presents in his memoir. But whether you agree with the author’s assessment of the situation or not, I Am Not Silent is an intriguing read. Schmidkunz presents a heartfelt, honest portrayal of the difficulties such circumstances can present to a family. Through his and his son’s story, we gain an inside look at the ways the criminal justice system deals with defendants who have a history of psychiatric diagnoses.

There is nothing that can be done to bring back the young woman that the Schmidkunzes found in their home. What caused Zach’s actions may never be fully understood. However, stories such as his can hopefully help us gain a clearer understanding of the effects of psychotropic medication and how to best utilize them in order to help those suffering from psychiatric symptoms. You may or may not agree with Gail Schmidkunz’s conclusion about his son’s crime, but it is nonetheless worth hearing his story.

I Am Not Silent: Oor Zoloft and Depression Story
InspiringVoices (July 9, 2012)
Paperback, 208 pages
$14.99

Religion

All world religions stress the importance of gratitude. In Judaism, prayers of gratefulness are an essential component of worship: Orthodox Jews recite them one hundred times a day. Gratitude was referred to by Martin Luther as a “basic Christian attitude.” The Koran states that the grateful will be given more. Muslim believers are encouraged to give thanks five times a day. Sufi, Hindu, and Buddhist traditions also emphasize giving thanks.

Moreover, religious traditions suggest that you should be grateful notwithstanding your current problems and circumstances – not to deny them, but in addition to and in spite of them. To feel gratitude only when you feel good is considered narrow-minded. In the Bible, Paul teaches, “In everything give thanks.” The Hebrew Midrash instructs, “In pleasure or pain, give thanks!” Islamic tradition says that those who give thanks in every circumstance will be the first to enter paradise.

The purpose of prayer is to open people to the presence of God. When it’s heartfelt, it is life-altering. Prayers of gratitude affirm God’s presence in everything and make our actions infinitely more effective.

Why Be Grateful?

Meister Eckhart, a well-known mystic, believed that thanking God was the most important prayer. Prophets and monks know that gratitude brings you closer to God. Even if you’re not religious, gratitude enables you to see your life in a larger context beyond your immediate troubles. It expands your life experience. It counteracts an ego-centered contraction and preoccupation with losses, fears, and wants. Being grateful only when good things happen reinforces your ego’s demand that good things happen, setting up greater disappointment when things don’t turn out as you desire. This, according to Buddha, is the cause of suffering.

The sages also knew that gratitude actually shifts your perspective from feeling depression, envy, anger, or self-pity to happiness. It can open your heart to joy and generosity, because you begin to feel that you’re blessed. Moreover, how you view your circumstances determines your ability to manage and overcome them. Often it’s worry or anxiety about the future that colors how you see a situation. Negative emotions limit your imagination and ability to cope and solve problems. Hence, your state of mind ultimately is more important than your outer experience.

Cultivating an attitude of acceptance enables you to feel grateful even when you’re in pain. It’s helpful to view all experience is an opportunity to grow and learn. Helen Keller wrote, “Everything has its wonders, even darkness and silence, and I learn whatever state I may be in, therein to be content.” Rather than seeing yourself as a victim of circumstance, accepting reality and developing gratitude for what you do have vs. focusing on what you don’t empowers you to take appropriate action.

Gratitude has only been subjected to empirical research since the advent of the positive psychology movement. What religion has known for millennia, science has confirmed. Numerous studies suggest that grateful people are more likely to have higher levels of happiness and sense of well-being and lower levels of stress and depression. This naturally translates into better physical health.

Developing an Attitude of Gratitude

Gratefulness comes more easily to some than others. When you’re discouraged or weighed down with negative thoughts, there are several things you can do to develop an “attitude of gratitude:”

1. There’s wisdom in the phrase “count your blessings.” Listing the things for which you’re grateful can generate feelings of appreciation and gratitude. It’s often suggested to write them down daily. You can start with the fact that you have a brain, can write, and can read. Add small things, for example, seeing a child smile, receiving affection from a pet or greetings from a co-worker, or accomplishing a task, such as doing laundry or taking a walk. After several days, you’ll begin to look for things to add to your list and find that your mood significantly improves – faster than taking an anti-depressant.
2. Read your list to someone. Sharing your grateful feelings doubles the effect. Arrange to regularly share your gratitude lists and give thanks together. Praying together heightens your sense of connection and well-being.
3. Express thanks daily. Doing so out loud has more power. In the morning and evening, and before meals, recite prayers of gratitude, or just say thank you to your higher power.
4. Thank others. Throughout the day, thank others for their help — particularly people you don’t ordinarily thank, such as cashiers. This is a recognition that you depend upon many people in order to survive and acknowledges your interdependent existence. The same is implicit in saying grace for the labor that goes into food on your table.
5. Compliment people. Giving compliments shows appreciation and lifts others’ mood as well as yours.
6. Write notes. Put them on your refrigerator, mirrors, and computer to remind you to be thankful.
7. Think about people you appreciate. The act of visualizing them with positive feelings opens your heart to gratitude.
8. Write people unexpected thank-you notes. Writing your appreciation prompts loving feelings that engender gratitude.
9. Do small acts of generosity. Give someone your place in line, help someone pay for a purchase, or bring food to a neighbor.
10. Thank yourself at the end of the day for things you did well. List at least three things. They may be small and include the above acts of gratitude.

In time, you’ll notice a change in your mood until your “cup runneth over” – or, at least appear half full rather than half empty.

Why Shame is so Painful

Whereas guilt is a right or wrong judgment about your behavior, shame is a feeling about yourself. Guilt motivates you to want to correct or repair the error. In contrast, shame is an intense global feeling of inadequacy, inferiority, or self-loathing. You want to hide or disappear. In front of others, you feel exposed and humiliated, as if they can see your flaws. The worst part of it is a profound sense of separation — from yourself and from others. It’s disintegrating, meaning that you lose touch with all the other parts of yourself, and you also feel disconnected from everyone else. Shame induces unconscious beliefs, such as:

• I’m a failure.
• I’m not important.
• I’m unlovable.
• I don’t deserve to be happy.
• I’m a bad person.
• I’m a phony.
• I’m defective.

Chronic Shame in Addiction and Codependency

As with all emotions, shame passes. But for addicts and codependents it hangs around, often beneath consciousness, and leads to other painful feelings and problematic behaviors. You’re ashamed of who you are. You don’t believe that you matter or are worthy of love, respect, success, or happiness. When shame becomes all-pervasive, it paralyzes spontaneity. A chronic sense of unworthiness and inferiority can result in depression, hopelessness, and despair, until you become numb, feeling disconnected from life and everyone else.

Shame can lead to addiction and is the core feeling that leads to many other codependents’ symptoms. Here are a few of the other symptoms that are derived from shame:

• Perfectionism
• Low self-esteem
• People-pleasing
• Guilt

For codependents, shame can lead to control, caretaking, and dysfunctional, nonassertive communication. Shame creates many fears and anxieties that make relationships difficult, especially intimate ones. Many people sabotage themselves in work and relationships because of these fears. You aren’t assertive when shame causes you to be afraid to speak your mind, take a position, or express who you are. You blame others because you already feel so bad about yourself that you can’t take responsibility for any mistake or misunderstanding. Meanwhile, you apologize like crazy to avoid just that! Codependents are afraid to get close because they don’t believe they’re worthy of love, or that once known, they’ll disappoint the other person. The unconscious thought might be that “I’ll leave before you leave me.” Fear of success and failure may limit job performance and career options.

Hidden Shame

Because shame is so painful, it’s common for people to hide their shame from themselves by feeling sad, superior, or angry at a perceived insult instead. Other times, it comes out as boasting, envy, or judgment of others. The more aggressive and contemptuous are these feelings, the stronger the shame. An obvious example is a bully, who brings others down to raise himself up, but this can happen all in your mind.

It needn’t be that extreme. You might talk down to those you teach or supervise, people of a different class or culture, or someone you judge. Another tell-tale symptom is frequent idealization of others, because you feel so low in comparison. The problem with these defenses is that if you aren’t aware of your shame, it doesn’t dissipate. Instead, it persists and mounts up.

Theories about Shame

There are three main theories about shame.

The first is functional, derived from Darwinian theory. Functionalists see shame as adaptive to relationships and culture. It helps you to be acceptable and fit in and behave morally in society.

The cognitive model views shame as a self-evaluation in reaction to others’ perception of you and to your failing to meet certain rules and standards. This experience becomes internalized and attributed globally, so that you feel flawed or like a failure. This theory requires self-awareness that begins around 18 to 24 months old.

The third is a psychoanalytic attachment theory based upon a baby’s attachment to its mother and significant caretakers. When there’s a disruption in that attachment, an infant may feel unwanted or unacceptable as early as two-and-a-half to three months. Research also has shown that a propensity for shame varies among children of different temperaments.

Healing Shame

Healing requires a safe environment where you can begin to be vulnerable, express yourself, and receive acceptance and empathy. Then you’re able to internalize a new experience and begin to revise your beliefs about yourself. It may require revisiting shame-inducing events or past messages and re-evaluating them from a new perspective. Usually it takes an empathic therapist or counselor to create that space so that you can incrementally tolerate self-loathing and the pain of shame enough to self-reflect upon it until it dissipates.

You can raise your self-esteem to heal your shame with my e-book, 10 Steps to Self-Esteem: How to Stop Self-Criticism, available at www.whatiscodependency.com/ and online booksellers.