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Is depression a decision?
Psychotherapist touts `directed thinking,' not drugs, as cure.

By Snow Anderson
Special to the Tribune
Published May 15, 2002

"I wake up feeling like I'm going to die in the morning. It's just unbearable. It's agony."

This is how A.B. Curtiss, author and psychotherapist, describes her battle with depression. Yet Curtiss has never taken antidepressants. Instead, she has written a book about her experience, "Depression is a Choice: Winning the Battle Without Drugs" (Hyperion, $24.95).

Curtiss, a California family therapist, mother of five and grandmother of nine, said the genesis of her depression lies in her childhood. Her father was diagnosed with manic depression, as were she and her brother. Her father eventually died in a state of catatonic depression. Her brother has been taking medication for more than 20 years, Curtiss said, but it has not helped him. She went into the field of psychotherapy to help herself find a cure for what was running her life.

When her book came out in October 2001, Curtiss said, she and the publisher were convinced they had a best-seller on their hands. What she has found instead is a hard sell.

"In today's climate it is going against what people fervently believe will save them: the pills, psychiatrists, psychology. So it's a fearful idea that I'm saying these things will not cure you," she said.

Curtiss does not diminish the devastating impact depression can have on people's lives--she shares her own experience openly in the book--but she does insist that drugs are not the answer.

Instead, Curtiss offers "directed thinking" as a way to manage depression. Because the mind can only think one thought at a time, she explained, the trick becomes to distract the mind from thinking about the depression and plug in a different thought.

"There is only one reason we ever suffer with depression," Curtiss writes in her book. "In order to suffer with depression, we must think about ourselves and our pain. If we don't think about ourselves and our pain, there is no way to suffer."

Curtiss' suggestion for not thinking about feeling depressed is to use techniques such as repeating a nursery rhyme, a prayer or mantra. Saying "yes, yes, yes" over and over again, for example, or repeating something as simple as, "Row, row, row your boat." What happens by doing this is that we literally disconnect the message that we are depressed from one part of the brain to another, Curtiss said.

That depression is caused by a chemical imbalance in the brain is a fact that need not frighten us, she said.

"There are two parts of your brain, the neocortex and the subcortex. You produce emotion in the subcortex--panic, fear, whatever. However, the neocortex has to receive the message that you are undergoing those feelings. Neurotransmitters from the subcortex send messages to the neocortex, and you receive cognitively the idea that you are now feeling that feeling."

What she does by inserting the repetitive thoughts, Curtiss said, is block the signal.

"I'm jamming that section of the neocortex that's receiving the feelings that I'm depressed, until such time as the chemistry balance changes and those feelings are no longer produced in the subcortex. I am doing it cognitively, in the neocortex, what the pills [antidepressants] and the electric shock do to the subcortex. They are destroying those feelings. I'm not destroying them, I am distracting that part of the neocortex that is receiving the message that those feelings have been produced."

In order to implement Curtiss' program of directed thinking, a person would have to be motivated to make that choice. Critics would argue that the problem with depression is that it can rob people of feeling they have a choice.

Curtiss disagrees: "They always have a choice, they are never bereft of choice. What they are bereft of is motivation, and that is what needs to be supplied."

She suggests in her book that a program be prepared in advance, so that when a person begins to feel the onset of depression, they already have a plan in place. "It's like a pill, except my pill is motivation. Here's this little bottle and in here is your program of what you're going to do when you get depressed."

Curtiss acknowledged that the person who is experiencing depression is not going to feel like doing this. But the reason to do it, she said, is because "it is the answer to your depression. You decide ahead of time what you're going to do," in a sense, providing your own motivation, though, she explained, it's not really motivation. "It's a substitute for the motivation that you lack. When you do it, it gets you out of depression, and then your motivation will reassert itself."

Chicago clinical psychologist, Dr. Angelique Sallas, said that though Curtiss' theory is plausible, treating depression is far more complex than just applying a mantra, because, she explained, "you don't just find easily something that's kind of pure depression."

Sallas, whose specialty is treating people with eating disorders, said those patients, for example, also have obsessive-compulsive components, depression and anxiety.

"So you really have to look at interaction," she said. "You cannot just say, `Gee, if I just say this mantra I'm going to distract myself and somehow that's going to alleviate my depression. Yes, you can distract yourself if you utilize certain cognitive, behavioral methods to try to cope with it, particularly if it's a milder form of depression, and you can pull out. There are other times that you can't climb out from underneath the covers. And to treat it, you need both [therapy and medication]."

Sallas was practicing long before antidepressants were available, so she learned to work with people without medication. But that, she said, was a tougher road.

"It was harder on the person," she explained. "It doesn't mean that they couldn't get through certain things, but you know, you have a suicidal person, you don't want to play games. You've got to alleviate some of that depression before you can help them behaviorally."

Dr. Brad Saks, an Evanston psychologist concurs with Sallas.

"My experience certainly is that mild to moderate depression can most definitely be managed without medication, using good cognitive therapy. However, I think it's also clear that once you get into more severe cases, when people are experiencing a lot of the vegetative symptoms of depression, where it's hard for them to get out of bed in the morning and they're having a hard time just motivating and activating, that medication in lots of cases is indicated, simply because it provides people with a way to get better faster."

At the same time, Saks sees value in Curtiss' theory.

"I don't know if I agree with all of her model, but I certainly do agree that the mind and body are obviously quite connected and that by talking to yourself differently or by using techniques such as relaxation or meditation, you literally can bring about physiological changes."

Saks made an analogy between his work with patients who suffer from chronic pain and what Curtiss proposes in her book.

"Some of the work on chronic pain is what we call the gate-control theory. What it says is, you have pain responses that are mediated from your body through your spinal cord up into your brain and then they're registered as pain. This theory says if you use things like relaxation, or the saying of a mantra, or something of that nature, or different cognitive techniques, then you can block those sensations, which I think is very similar to what she's saying," Saks said.

Ultimately however, when it comes to treating depression, Sallas said, "If there were one way, and it was the way, the truth and the light, we'd all be doing it. The reality is you have to take into account the individual, the dynamics of that particular individual, their presenting symptomatology and this whole bag of stuff that you draw from, including medication, to try and help that person."

"I think we're ethically bound to use whatever tools are available, and I think a combination of good therapy and medication, particularly for more severe cases, can go a long way toward helping people more rapidly," Saks said.

Curtiss, however, maintains that anyone can be pulled out of depression with enough commitment.

"I've had psychiatrists tell me, `I have people that are so depressed they're in a wheelchair.' Well, my thought would be, you pick that person up out of the wheelchair, you put your arms around them and you make them take a walk. You actually make people physically start moving and that alone will start something favorable happening for them," she said.

Copyright © 2002, Chicago Tribune