Today is Bell Let’s Talk Day in Canada ~ a day to raise awareness and reduce stigma around mental illness by having conversations.
As a creativity coach, I work with many writers and artists who have dealt with depression, and today I wanted to talk to someone who comes at depression from the therapeutic side.
I’m joined by Dr. Marna Zinatelli, who has a PhD in Psychology and has been practicing for almost twenty years. Marna is a long-time friend of mine ~ we met at church in Ottawa and served on the music team together ~ and she was the first person I called when I realized that I was depressed back in 2002. At the time, I didn’t know where to start or what to do. Should I go to my family doctor, a psychiatrist, or a therapist? Marna answered my questions with love and encouragement, and specifically pointed me toward cognitive behavioural therapy and The Feeling Good Handbook by David D. Burns.
[Interview transcript has been edited for clarity and readability.]
Alison: Thanks for being here today, Marna, and diving into this conversation with me!
Marna: My pleasure! It’s very important to talk about these issues that impact so many people.
How do I know I’m depressed?
Alison: Let’s start at the beginning. I have found that a lot of people still may not recognize when they are dealing with depression. What can you say about some of the classic signs and also about things that we would not necessarily connect with depression, and how someone can know that’s what they’re experiencing?
Marna: One of the challenges in recognizing depression is that it does express itself differently. We all have our own personalities and our own way of interacting with others in living our lives. Depression will be expressed more so in some people with their sleep issues, and they won’t connect problems with sleep and mood issues. For other people, it will be more of a social withdrawing. Someone may not even notice that they’re spending less time with people ~ it’s the people around them who might say, “Gee, you’re not coming out, you’re not returning my calls, you’re not connecting with us.” In other people, it might actually show up in more physical ways. They may feel very tired or have trouble getting out of bed.
There’s quite a long list of symptoms that can be associated with depression, and they’re easy to look up and read about. [Here are symptoms for Major Depression and Persistent Depressive Disorder (previously dysthymia).] The difficulty is that most of my clients don’t come because they want a diagnosis, although it’s useful for people who need to be medicated and for insurance companies. My clients just want relief from the symptoms. And part of the challenge is that depression is overlapping with anxiety symptoms, which makes it hard at times for people to recognize it. Another challenge is that symptoms can come and go. They can be worse during certain periods and then improve, and that also makes it harder for people to be really clear that this is something they’re struggling with.
Alison: So what you’re saying is that it’s not always an obvious presentation. And I think there’s still a certain stigma around acknowledging or look at the possibility that “Maybe I’m dealing with a mental health issue.”
Marna: There’s no doubt. I think there are efforts being made to address that. I saw this very interesting ad where someone gets hit in a motor vehicle accident and everyone runs to help the victim, and then you see a message, “Imagine if we responded to mental health issues like this.” And I thought, that really captures it well. Because with an accident there’s an instant compassion and response, but with mental health, people don’t have something like a bleeding leg. It’s not obvious at all.
Alison: I’ve heard people ask, “How do I tell the difference between what’s just normal sadness or the ups and downs of the human condition vs. something that would get diagnosed as a clinical illness?”
Marna: Again, it’s not always straightforward, and that’s why books like The Feeling Good Handbook are useful, because right in the beginning there are questionnaires where a person can assess themselves. People are often surprised and say “I thought I was depressed but actually I’m anxious,” or “I thought I was anxious but actually I’m more depressed.” And sometimes there’s a combination of both happening, or other things as well. Some of these instruments will ask you to look at just the previous week, because of course it can change from one week to the next. And with diagnostic categories, if you go beyond a certain point score, for example, then you have the diagnosis, but if you are under next week, does that mean you no longer have the diagnosis? That makes it confusing for people.
Marna: From my perspective, I ask people questions about what they would like their life to look like and when was the last time they felt that way.
Then people can start to have a better sense of “It was at this point in my life that I noticed things changed.” When you have a baseline to go back to, then it’s more clear. “I used to get up in the morning with all kinds of energy. That was six months ago.” “I used to joke and laugh. That was six months ago.” “I used to have a smile on my face and look at people in the eye.”
There are so many things that people tell me about their experiences that help them recognize when the change happened. It’s not usually the case where one day you have it and the next day you don’t, and that makes it more complicated. And yet, most of us have a sense of what it means to have quality of life, and when you are depressed, your quality of life is compromised. You could be mildly depressed, or moderately depressed, or severely depressed, but all of that means that life is not what it could be. And that may be a more useful way of looking at it for people.
Can you have mild major depression??
Alison: There are all sorts of terminology around specific expressions of depression, and there are lists of symptoms in the diagnostic manual. Are the labels and categories useful or can they muddy the waters?
Marna: There’s a lot of debate, and it depends on who you’re talking to and what their point of view is. I tend to be more of a big picture thinker ~ I like to look at the forest and see how all the trees connect. So when I think in those terms, the body-mind connection is a very important way of capturing the trees. There are reasons why someone is not well, and those reasons have to do with specific trees, but the big picture is that a person’s not well. There’s a physician in western Canada, Dr. Gabor Maté, who wrote When the Body Says No, and he talks a lot about the body-mind connection. He doesn’t make a big deal about whether someone has a physical illness or a mental health concern, whether it’s depression or whether it’s migraines. He talks about the body speaking. Depression is one way that the body speaks, and it’s speaking through what’s happening in your brain cells. That has a cascade effect in terms of the rest of the body.
So to me, diagnosis is more of a tree issue. Some practitioners are not happy about the direction of the diagnostic manual because it’s becoming more and more detailed. And we begin to wonder how much that is helpful in terms of getting relief. However, it’s a tool, it’s there, it’s used, diagnosis is important, and we can’t ignore that.
Where do I start with treatment for depression?
Marna: We also want to look at what people are looking for when they want treatment and when they want to feel better. And if we stay with the big picture, then we look at things like, how do we go from the forest to what’s happening within the trees and how they connect. So medication, where does that fit in?
There’s a book called Anatomy of an Epidemic by Robert Whitaker that’s very interesting. He looks very closely at why more and more people are becoming depressed ~ it’s not a contagious disease. So given that’s the case, you can become very curious. Whitaker has done a lot of research looking at the role of medication, and he seems to conclude that medication’s very useful in the short term, but that there could be issues in the long run. So then you have to ask, why is that?
There are also talk therapies ~ there’s cognitive behavioural therapy and David Burns’ Feeling Good Handbook is one example of that. In that book he talks at the very end about the various medications, and what’s nice is that people now have options. I’ve seen many people just with talk therapy be able to move forward constructively and learn how to manage their depression, recognize when it’s coming back, and take steps that are appropriate and helpful.
Then we slip back into the big picture, which is “what are these people doing?” There are whole categories of lifestyle changes that people can look at that can be helpful in managing depression. And that can be done in combination with medication.
Another really exciting new avenue is nutrition. Patrick Holford in the UK wrote Optimum Nutrition for the Mind, and in the US there’s Mark Hyman’s UltraMind Solution, and they link to Terry Wahls, who successfully treated her own multiple sclerosis. Through diet change she was able to change her status from having the diagnosis to now where she’s biking to work and back. And with MS, we’re talking about neurology, so some of these things begin to overlap.
If we go back again to body-mind connection, what is the role of nutrition? According to Patrick Holford, with nutrition you can actually feed the brain cells, and when they’re properly fed and nourished, people who are going off their medication don’t have discontinuation syndrome. He has evidence of very high percentage success rates with schizophrenia over the last fifty years using just nutritional interventions.
All of these pieces can come together.
For more examples of treatments that work with the body-mind connection, very well-respected practitioners are talking about yoga, awareness through movement, qi gong, and all kinds of body treatments like somatic experiencing. How do these things link? When your body is relaxed and in parasympathetic mode from a nervous system perspective, your cells open, toxins leave, nutrients enter, and all healing happens in the parasympathetic mode. So it seems that no matter which avenue you’re pursuing, a person has to find peace, find relaxation, find ways to allow the body to heal. Because no matter what the intervention, the body heals itself. We’re just facilitating that in whatever we do. And that’s back to the forest, the big picture.
Alison: It sounds, what you’re saying and what my experience has been is that the only concern in pursuing treatment is to be focused on just one avenue to the exclusion of others.
Marna: Especially now, because we have so many exciting new options. Natasha Campbell-McBride has done research on autism. She cured her own child of autism by understanding that the gut flora is really huge. She has all kinds of reasons for why autism is happening more, people don’t have proper microbiome status in their current health profile. And what’s quite fascinating is not only was she able to treat autism but also depression, schizophrenia, ADHD, all of these then begin to be linked in some way and what do they have in common?
Another approach being used is neurofeedback, where you see your brain mapped and then you interface with a computer where you can change your brainwave patterns. When you do that, all kinds of healing happens, it’s fascinating. Again we’re back to body-mind and big picture, because when you meditate, what happens to your brainwave frequencies? You’re definitely changing them.
No really, where do I start?
Alison: But you see how this can be problematic for someone who is experiencing depression; they’re not thinking clearly and they are tired and sad and then they’re faced with an array of …
Marna: Overwhelming choice.
Alison: Yes, and where does someone start?
Marna: What’s great is, if we go back to the forest and trees, it probably doesn’t matter very much where you start. If you affect one tree, the whole forest starts to improve. So I see it as either you’re moving in the direction of health, or you’re moving in the direction of disease. As long as you move in some healthy direction, then other possibilities open up. Many of my clients are not open to the idea of neurofeedback until they have a working relationship with me and they start seeing some progress. Once you get a little bit of relief, then you’re a little better. And when you’re a little better, you can think a little more clearly. When you can think a little bit more clearly, you can trust your judgements about what’s easiest, what’s convenient, what’s affordable ~ because not all of these treatments are easy to link with.
And I haven’t even finished my list! Allergies is an interesting one, because there’s now research on inflammation that links to the gut flora. The theory behind it is there’s some kind of allergic reaction to a biochemical happenings within the body. So then treatments that can affect what’s happening with allergies can be useful and important.
We can also look at things like energy medicine, which is a very exciting new area. There are Harvard scientists looking at the impact of Emotional Freedom Technique on trauma.
It’s very exciting to see where these possibilities can bring people. There’s lots to choose from, and now we also have the ability to access information; the Internet is great. Yes, it can be too much information, but as someone is looking for solutions that work for them, they can experiment with what works and make judgements about what helps. They will know what helps because when you’re working with instruments that you can self-assess, you can measure and people know. If they get up in the morning and they have more energy, if they can concentrate better, it becomes obvious when they’re getting well and they know what works for them.
The role of meaning in depression
Alison: And of course my area of speciality has been in connecting with meaning, creating a life and activities that feel meaningful, and addressing the existential pain that can come from feeling that your life doesn’t matter or that you’re not doing something important. Is that something you’ve seen in your clients or done investigation of?
Marna: My feeling is that whether that’s the topic that’s being discussed directly or not, it’s all about that. Why get up in the morning unless there’s something meaningful to do? And I think some people can have that discussion more directly, they have the language for it and they think in those terms because of their personality or because of what they do in their life.
Whether it’s something that’s discussed or not, meaning is always there. It’s always behind this. This is where we go back to the biggest picture, which I would say is that meaning picture. That’s really the forest, because if you’re not engaged in something that is important, if you’re not connected with the community or with family life, then what is the point, really?
There are some interesting debates and research around addictions in particular. This week a client sent me an interesting article [“The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think” by Johann Hari] about how a rat alone in a cage will ingest water laced with heroin or cocaine until it dies because it is so gratifying. But when they put toys and other rats into the cage, usage goes down. And when you look at Vietnam vets who came back, a lot of them used drugs heavily, and after they came back only 17% had addiction issues. So why is that? Because the rest, I’m guessing, linked with their families, their communities, and had meaning in their lives.
How do we lose that sense of meaning? Well, we live in interesting times. A sense of community is something that a lot of my clients talk about. They say, “I feel lonely, I don’t have friends, I moved here for a job but I can’t link with anyone at work.” Community is where we find meaning. And of course spirituality is a huge part of that. I find it’s interesting as a culture that mindfulness has become a little more popular to talk about but what does that really mean? How can you talk about mindfulness without becoming somehow spiritual about it? I guess you can, but for me the two are very much linked.
“You just call out my name”
Alison: So what do you think helps people make it in terms of being successful in healing or recovering from depression? What kinds of things do you think they need to do or remember or find in order to make it to the other side of that experience?
Marna: That question comes right after we talked about community. I think that’s where we begin. Ask someone you feel you can trust for help. That’s extremely important. Because even if you don’t get help from the first person or the second person or the third person – hopefully you get it from the first! But unless you live all alone and never talk to anyone ~ which is an extreme case and some people live that challenge ~ there are human beings around. The likelihood is high that someone in your circle will care, and if not, in many cases there are compassionate strangers, there are kind people walking on the street every day. This is what many clients tell me – when they begin to get well, they say, “I now know that I can ask people for help and no matter where I am or where I go, even if I leave the city, if I leave this country, there can be someone who can be there for me. I just need to ask.”
I think that’s an important beginning. When you start asking for help, you often discover that there’s more there than you can imagine. And yes, I think when you’re really feeling down, it’s hard to do that. It’s very very difficult. There are many blocks. This is where I think self-help material is useful, because those books were written by human beings. Sometimes people can feel like, yes, the author of this book understands, and there are lots of books written. This is why I think what you’re doing is so wonderful, [see my memoir, Pilgrimage of Desire] because you shine this light that gives people permission to talk about depression and to know that even if they feel alone, they’re not alone in their aloneness.
Alison: That’s beautiful, Marna. Thank you so much for talking to me today and sharing all of that great information and the sense of hope that this is not something that people need to surrender to or be stuck in. There are many people and many ways to get back to health.
Marna: Absolutely. This is in fact a nice way to sum up. The most hopeful thing is the research on neuroplasticity. Norman Doidge writes about neuroplasticity, which means that anything that’s stuck or not working about our brains is absolutely changeable, much more changeable than we ever imagined. If that isn’t hopeful, I don’t know what is ~ the idea that when things are not working as they should in our brain cells, not to worry, because that’s changeable, fixable, not necessarily easy or simple but very doable.
Want to join the conversation about depression? What’s your experience? What questions do you have? Please let us know in the comments. We’d love to hear from you.