In the Shadow of Depression

How Can We Manage to Stay Well?

Magazine Issue
July/August 2018
A sad woman holds a pillow to her chest

When I reflect on my last bout of depression, which seized me by the teeth and chewed up nearly two years of my life, I can still feel its ferocity. I’m better now, and have been for some time. But back then, the darkness gripped me so hard that I began to speak only when necessary. Thoughts would wander into my head, but I couldn’t summon the motivation to say them out loud. My hopelessness was impervious to internal efforts to correct my distorted thinking, the company of caring friends and family members, or a succession of meds.

For a while, therapy could do no more than help me stay on the planet—a profound contribution, but one I could barely appreciate at the time. It made no difference that my actual life was bountiful, that I had rewarding, creative work and many people who loved me. It only made me feel more desperate. I had everything, and yet here was my life, so much dust.

That was the depression. Then there was the accompanying anxiety, fierce in its own right. Among other difficulties, it made me afraid of my computer. By sheer force of will, I approached the looming machine each morning and answered benign email, my heart clattering against my rib cage. To say that this anxiety was free-floating seems to me a gross misuse of language. Free-floating suggests a pleasant experience, like a dream of flying. This anxiety flung me to the ground.

A couple of months into my most recent bout, I caught my reflection in the mirror and saw that my mouth had actually changed location. My lips were skewed to one side, a rictus of fear. Peering into the mirror, I tried to reposition my lips into a straight line at the center of my face. No luck.

In my worst moments, I hoped for late-stage cancer. Having watched people die of the disease, I knew how slow and agonizing it was. But I could stand that kind of pain, I told myself, because of its ultimate reward. I told no one of these thoughts, because part of me recognized how sick they were. But another part of me believed they made grim sense. Just get me out of here.

Somehow, I held on. I saw two therapists concurrently, both skilled and enormously caring. Ever so slowly, the blackness began to lift. The road back was long, but now I was able to recognize it as a road. Gradually, I began to breathe a little better. One morning, I startled myself by feeling thankful to be alive. Even now as I think of this, tears come to my eyes. Because, even now, it feels like a miracle.

After Therapy, What Then?

But it’s a miracle with a catch. Treatment had worked, and I’m grateful beyond words, but it hadn’t addressed an urgent question, one that seems fundamental for both clients and therapists: how can people stay well once they’ve emerged from their most recent bout of misery? Most clinicians know that if a person has suffered one episode of depression, he or she is much more vulnerable to another. In my own life, I’d already slogged through several.

Yet my therapists and I didn’t talk much about this—how to stay healthy after we parted ways. I didn’t bring it up, and I don’t remember any of them doing so, either. We didn’t talk about how healing is only partly about gaining new skills and self-compassion. It’s also wrapped up with the client’s experience of the therapist’s presence—the almost overpowering sense of relief you feel as you’re greeted by a person who’s a thousand percent in your corner, whose face lights up at the sight of you, even though you feel profoundly unlovable. Slowly, under the dependably warm gaze of your therapist, your wretchedness starts to melt.

Clinicians and clients alike experience the magic of this phenomenon. But what’s left largely unspoken is what happens for a client once therapy ends. Even though you’re feeling better, and maybe even excited by the prospect of trying out your wings, you also confront the flip side of therapeutic constancy—the persistent and utter absence of your healer. You no longer have that guardian angel watching over you. You’re now your own angel. Good luck with that.

In my own case, I needed more than luck. I needed some kind of program, post-therapy, to help me keep thriving. Because I had to stay well. After my last, lengthy depression, something inside me had given way; I wasn’t sure I could survive another encounter with despair. So, for the last few years, I’ve been practicing my own, jerry-built plan for keeping myself on an emotional even keel. It’s loosely based on the research on modifiable risk factors for recurrent depression. My thinking is that if there’s a personal risk I can significantly ratchet down, I’ll be less vulnerable to a next bout of misery.

Yet the makeshift, hope-for-the-best nature of my project makes me wonder why more clinicians don’t take a far more active role in helping clients put together programs for staying well. Of course, some clinicians do this. But many do not, perhaps because at the time of parting, the client seems so genuinely and markedly better. Regardless, I wish my own therapists had talked with me directly about how to stay healthy over the long haul; I know I would’ve benefited from that extra measure of wisdom and support. Instead of having clients cobble together their own post-therapy wellness programs—or sail off with none at all—it seems vital that therapists work actively with departing clients to help them fend off future despair.

The Problem of Recurrence

Yet, given what we know about the recurrence of depression, is this even a realistic goal? Every bone in my body wants the answer to be yes. But research indicates that staying well after depression can be tough going. In a meta-analysis of 10 studies (seven of them longitudinal), University of Minnesota psychologists Stephanie Burcusa and William Iacona found that some 50 percent of those who recover from a first episode of depression will go on to have another one. With each successive spell, the risk for recurrence climbs. If you’ve had two bouts of depression, your chances of having another one increases to 80 percent. On average, a person with a history of depression will suffer between five and nine separate episodes in his or her lifetime.

With major depression comes the very real risk of suicide. The public has become far more aware of the severity of this risk in the wake of the recent high-profile suicides of celebrities Kate Spade and Anthony Bourdain. Both had battled recurrent depression, though few media reports highlighted this aspect. Surveys indicate that depressed people are 20 times likelier to kill themselves than those in the general population: a stunning rate that climbs still higher for those who’ve endured multiple bouts of despair.

Recurrent depression is generally defined as two or more episodes of depression, each of which takes place after a full recovery. Additionally, each episode must occur at least eight weeks after the one before it, though most people get a longer respite. That fits my experience. From the age of 20 on, I’ve weathered numerous periods of major depression, each lasting at least a year and usually separated by a few years.

Looking back, I suspect that these episodes may have started even earlier in life, though in gentler form. At age nine, I began to suffer spells of what I then called “my sadness,” when I’d hole up in my bedroom and cry from loneliness and some other inner ache that I had no words for. I’d keep close watch on the door, hoping that my mother would notice my absence and come up to my room to comfort me. She must have, a few times. But my mother had three other kids to ride herd on. I never went to her and said, “Mom, help me.” I don’t think she ever knew.

The Myth of “One-Off” Depression

Recurrent depression is a universe of its own. I suspect that the general public doesn’t know a lot about it, because the popular imagination tends to envision depression as an either-or illness. You’re either a chronic “depresso”—like Hamlet or Eeyore or Blanche DuBois—or you weather a single bout and you’re done.

The one-and-done version of depression is generally assumed to be typical. You feel terrible, you see a therapist for a while, and then you’re ready to roll again for the duration. This is roughly true for about half of those who’ve weathered one depression. But the other half—several million people each year—slide back into the slough.

Really, though, who wants to think about recurrence? For most people, it’s unpleasant to focus attention on problems that repeat themselves, possibly ad nauseam, when it’s so much more gratifying to imagine a one-time slip and a permanent cure. It’s nicely in step with the American creed of self-determination, in which you can achieve anything you put your mind to if you work hard enough and just want it enough. If you fall short of your aims, well, come on, whose fault is that?

The trouble with the popular “one-off” assumption is that many people who endure recurrent depression believe it, too. Until my most recent episode—the sixth or seventh of my life—I had no idea that I was apt to have any further ones, even though I’d written about mental health for most of my adult life. Whenever I recovered from a particular bout, I was sure it was my last one. Then, when it wasn’t, I was horrified, and then swiftly contemptuous of myself. Really, AGAIN? That’s pathetic! At the same time, I was frightened. Is therapy basically useless, then? If so, is there no help for me?

I was as ready as anyone to believe in a bifurcated doctrine of depression, split between the one-shot type (most typical and wished-for, relatively speaking) and the chronic variety (rare and scary). This artificial divide left little room for me to become aware of the considerable “space between,” the wide terrain of recurrent depression where I periodically and unknowingly resided.

Who’s at Risk?

Why one person and not another? There’s a lot to untangle here. Researchers are discovering that risk factors for onset of depression are not identical to those for recurrent depression. We’re learning, too, that repeat depressions are likely to have more negative long-term consequences in both the emotional and cognitive realms. These back-end risks make it all the more urgent to learn about what makes people vulnerable to recurrent depression, and to help clients recognize and circumvent these danger zones.

The enormous challenge is that many of these zones of vulnerability can’t be modified. People are stuck with certain risk factors for recurrent depression because they’ve already happened or because they’re an immutable part of that individual. For example, the severity of a person’s initial depression has been consistently linked to recurrence. Similarly, certain disorders that coexist with a first depression, such as long-term anxiety or substance abuse, increase the likelihood of later depressive episodes. These risks are already realities. We can’t go back in time and nudge a serious depression into a case of mild discontent. It will remain a component of risk forever.

Then, there’s the matter of family history. As therapists well know, few emotional disorders are immune to its influence, including repetitive depression. In a study of 1,242 relatives of people with recurrent depression, University of Pittsburgh psychiatrist George Zubenko and colleagues found that first-degree relatives were approximately eight times likelier to have experienced depression than relatives of people who’d never encountered it. Other research has linked individuals’ recurrent depression with co-occurring disorders in relatives, including anxiety and addiction.

I recognize this vulnerability in my own family. Several of my relatives have suffered episodes of depression and/or anxiety. One of my brothers, who endured spells of despair and misused various substances, died of an accidental drug overdose at age 33. My father’s sister, who was visibly depressed, drank four or five 12-ounce martinis daily starting at 5 p.m. sharp, when my uncle, a cheerful enabler, would announce, “I believe the sun’s over the yardarm. Could I interest anyone in a toddy?” Then there was an older relative of my mother’s, a man who’d lived in her Indianapolis hometown. Mom knew just one thing about him: “One day, he walked into the White River and never came out.”

The specific ways that family history influences depression recurrence continue to be vigorously researched. We know that the genetic roots of depression run deep, and they’re particularly formidable for recurrent despair. A meta-analysis of studies involving more than 400,000 subjects, published in the April 2018 issue of the journal Nature Genetics, reported that 44 gene variants—triple the number previously known—raise depression risk. Naturally, environment counts, too. In the burgeoning field of epigenetics—the study of changes in gene expression in response to psychosocial factors—some molecular scientists propose that certain genetic material, otherwise quiescent, is roused into action by trauma and other serious stressors, and in so doing, boosts the risk for major depression.

While the subtle interplay of genetic and environmental factors will continue to be studied for a long while, the bottom line is that none of it can be changed. We either have a strong family history of emotional trouble, or we don’t. And if we have that history, we’re at increased risk for repeat depression.

Thinking Dark and Light

Fortunately, immutable factors aren’t the only ones in play. Having a risk factor for recurring depression—or even several of them—doesn’t doom anyone to repeat misery. Evidence is growing that for many people, certain vulnerabilities can be modified. It’s not a simple project. But with certain components in place, including the cultivation of a tenacious spirit, ongoing support, and self-help approaches that are carefully matched to an individual’s personality, staying well after therapy is in the realm of the possible.

Most therapists recognize that chronic negative thinking is a risk factor for depression onset. As early as the 1970s, psychologist Martin Seligman found that people who tended to view stressful life events as personal (It’s my fault), pervasive (I’m going to screw up in every situation), and permanent (I’ll always blunder this way), are likelier to get depressed. More recent research suggests that negative thinking predicts depression recurrence as well. Some 20 years ago, I took Seligman’s legendary optimism test, hoping against all evidence and common sense for a satisfactory grade. Instead, I scored “Moderately Pessimistic”—and just barely. I was just two points away from “Very Pessimistic,” the most hazardous way to respond to life’s vicissitudes.

But if one is prone to pessimism, or what’s clinically termed “a negative cognitive style,” it’s not necessarily a fixed entity. At first, it might look that way. Some part of the tendency toward negative thinking is rooted in inborn temperamental traits, including high reactivity to new situations and one’s default disposition—cheerful or cranky, friendly or wary. But some researchers are finding that the propensity for negative thinking can be moderated in some people.

In a randomized study by psychologist John Teasdale and his colleagues at the Cognition and Brain Sciences Unit of the University of Oxford, an eight-week, group-based approach called Mindfulness-Based Cognitive Therapy (MBCT) was found to significantly reduce the risk of depression recurrence over the following 60 weeks for people who’d already suffered several episodes. As one might expect, MBCT buttresses traditional cognitive therapy with mindfulness practice, focusing especially on the principle of viewing negative thoughts as merely that—thoughts—and letting them go. This particular integrative approach, in the context of group support, hasn’t been well studied yet as a self-help tool for preventing future depression episodes, but it seems to be a model worth watching.

Of course, no particular approach works for everyone. Every clinician who’s ever practiced knows that effective therapy must be tailored to individual proclivities. Even those who subscribe to a particular therapy model will tinker and tweak until they find the version that works for the client in front of them. The same goes for strategies for staying depression-free after therapy. For what it’s worth, I’ll share one of my own most fruitful strategies for tempering negative thinking habits. I doubt it’s been tested for protection against depression recurrence, but it’s been powerful enough to keep me on an even emotional keel since my last episode, nearly three years ago.

First, a bit of background: I’ve spent most of my adult life steadfastly in my head, including the times I’ve found myself sliding toward depression and anxiety. The trigger for the slide has typically been a storm of self-castigation for the most recent relational crime I’d committed—usually something I’ve done that’s made an important person in my life angry or gravely disappointed, either in reality or perception. (A possible negative cognition right there.) Once I’d felt the first pinch of proto-depression, I’d zoom into combat mode, believing I needed to kill my scary emotions before they obliterated me. (Another negative cognition, ably assisted by my amygdala.) Next, I’d try to wrestle myself back into cheerfulness, per the advice of my self-help books. “You don’t need to be perfect!” they exhorted. “Validate yourself!” But I couldn’t do that. Another failure. (Negative cognitions never take naps.) And I’d attack my already battered spirit with renewed vigor.

A couple of decades ago, a friend told me about mindfulness meditation, and I began to practice it most days. After seven years of this, I found myself in the dentist’s chair one afternoon, telling him about it. Intrigued, he asked, “So how do you think it’s been helpful to you?” I had to think. Finally, I said, “I think it’s made me more compassionate toward other people.” It was true, and I felt good about that, but I realized I couldn’t honestly tell my dentist that my practice had made me gentler toward myself. Except for the moments when I was actually meditating, I remained as furiously self-critical as ever. And, periodically, as depressed as ever.

All along, I kept searching for something that would quiet my scathing inner voices and the misery they engendered. I tried classic psychodynamic work, cognitive behavioral therapy, several holistic models, and untold other approaches. Each one helped, but after I’d left therapy and no longer had the benefits of weekly skill-building and the loving presence of my therapist, the steadying effects slowly faded. At some point, I’d become depressed and anxious again.

Then, a few years ago, I took a weeklong workshop on a practice that began to quietly reshape my inner landscape. The approach centers on locating a bodily sense of whatever difficulty I’m struggling with, rather than my customary approach of inspecting the contents of my mind. It works something like this: once I find and name a felt sense—“a constriction in my throat,” for example, or “a hot stone in my stomach”—I greet it. It can be just a few words, like “Hello, I know you’re there.” Then, I wait.

Often, before long, my tightened throat or roiling stomach begins to morph into a visual image of a small, cowering girl. Guess who. She occasionally asks for wisdom or validation, but usually she just wants a loving arm wrapped around her by the adult, compassionate part of me. Until I started this practice, I didn’t know I had that part. But she emerges, readily, in response to this small girl. I feel about this child the way I feel about my daughter or my granddaughter—wanting fiercely to protect her and make sure she feels loved. As I continue to sit with that little one, I typically experience a shift in my body, a less burdened, more spacious quality. The change isn’t necessarily dramatic. But I can feel it.

Some readers may recognize this practice as Focusing, an approach developed in the 1960s by Eugene Gendlin, a University of Chicago philosopher who worked closely with Carl Rogers. I’m not prescribing this practice for anyone else; I know only that it’s a great fit for me. Part of that is because it gets me in touch, quickly and powerfully, with the stringy-haired little kid who doesn’t deserve my depression-inducing scorn—only love and listening. Without effort, I move out of my negative mindset. Unlike mindfulness meditation, which also honors making contact with the body and accepting what emerges, Focusing invites me to dive deeply into whatever I’m struggling with and stay with it a while, rather than simply returning to my breath. Apparently, I need to dive.

For me, perhaps the most remarkable aspect of Focusing is that it’s such a good match for the bigger goal I’m working toward: staying well after therapy. I’ve experienced many body–mind therapeutic approaches in my time, some of them helpful. But the catch is that for most of them, I need a professional appointment. Now that I’m doing well and out of therapy, I need a home-based practice to help me sustain my gains. Focusing fits the bill partly because it’s designed to work as a self-help method as well as a therapist-led one. I practice it twice a month with a friend, as well as most mornings on my own. After I’ve spent this brief time with myself—typically no more than 15 minutes—I get up from the sofa and begin what’s usually a pretty good day. Not necessarily a conventionally pleasant one, but fundamentally good, even if I woke up troubled. The reliability of this shift pretty much blows my mind.

Love, Actually

When it comes to preventing depression recurrence, building a dependable network of support would seem beyond obvious. We know that friendship is salutary and that “bowling alone” is a bad idea. But it may be worthwhile to reflect freshly on social support, especially its role in thwarting repeat depression. Research thus far suggests that only a few risk factors for recurrence are amenable to change, and solid social support is one of them. That sustenance can come in many forms, from one-on-one bonding to varieties of communal comfort. What seems to matter is regularly interacting with one or more people with whom you feel a genuine connection and feel you can call upon for help.

Some years ago, I joined a support group, an outgrowth of a personal development retreat I’d participated in. The group is entirely self-led, though it helps that we have two therapists among us, along with two professors, two business owners, and me. During meetings, each of us in turn shares whatever currently concerns us, from job issues and relationship challenges to full-on emotional crises. We impose only a couple of constraints on ourselves: first, that we share something that matters to us, and that in so doing we strive to be real; second, that we respond to others as empathetically as we can.

When I joined the group, I was in the grip of a serious depression. Week after week, each member listened compassionately as I despaired. If anyone quailed internally, he or she never showed it. When people gave me feedback, they managed to convey caring and hope without sugar-coating my situation. Some of them phoned between meetings to make sure I was okay. Slowly, this group—in conjunction with my therapist and a few family members and friends—helped me rediscover ordinary happiness.

These days, I’m noticing how powerfully this group helps me do something equally essential—sustain my gains. I think of a time, several months ago, when I was beginning to connect with my first grandchild, Simone. Along with my daughter and son-in-law, she’d come to our home for a visit. The last time I’d seen her, she was a cuddly, sleepy-eyed eight-week-old; now, at four months, her little self shone with exuberance. I witnessed her mother, father, and my husband, Dan, make silly faces and ridiculous noises for her, spurring her to wave her tiny arms and legs and explode in delighted yelps.

But when I tried to be that raucous and vivacious grandmother, Simone just looked at me impassively. Sometimes, she’d turn her face away. At best she seemed to tolerate me, like a dinner-party guest she’d had the bad luck to be seated next to. I felt my granddaughter’s apparent indifference as a physical pain. I was sure I was doing something wrong, being someone wrong, for my beloved Simone. Moreover, introvert that I am, I found the whole rambunctious thing exhausting. I felt a shadow pass over me, something gray and heavy.

I took my distress to my next support group meeting, which took place a couple of weeks after my family’s visit. Until then, I’d told no one of my sorrow, because I was ashamed of Simone’s coolness toward me, and then further ashamed that I was so miserable about it. By and large, my friends seemed to revel in their bonds with their grandchildren. “It’s the best thing ever,” they’d crow. “It’s amazing to have someone in your life who loves you so much!” Even people in my support group bubbled in this way.

Yet, shame notwithstanding, I knew I had to talk about this. My connection with Simone was the most important concern in my life right then. The tightness in my chest wasn’t going away. So when it was my turn to speak, I told them about my granddaughter and me. “I can’t do what her parents or Dan can do—get her to giggle and wriggle,” I said, my voice clogging a bit. “When I try to be that way with her, she doesn’t like it.” I felt the shadow hovering.

When I’d finished my story, someone asked if I’d like feedback. I did. Two men who were grandfathers weighed in, each sharing an experience of his own felt disconnection from a grandchild, and how the relationship had begun to blossom over time. They expressed hope and confidence that mine would, too. Then a woman who knew my family and had spent some time with Simone, spoke up. “I think your granddaughter needs more than just laughter and rowdiness and being tossed in the air,” she said. “She needs a quiet, loving presence, too. That’s what you have to give her.” The others chimed in: yes, absolutely.

All at once, I remembered something that I’d managed to shove below my consciousness. Sometime during that weeklong visit with Simone and her parents, Dan and I had spent an afternoon babysitting. She’d been put down for a nap, and not long after her parents left, she awakened and began to wail. “I’ll get this,” I told my husband. I walked into my granddaughter’s room, stood quietly over her portable crib, and smiled down at her.

“Hello, Simi,” I said. Immediately, she stopped crying. Then she smiled back—not her go-for-broke, face-splitting grin, but a kind of serene, I’m-safe-now smile. Something made me lie down on the rug beside her so we could see each other face-to-face through the fine mesh of the crib. I began to sing to her. It was the Malvina Reynolds song “Turn Around,” about a baby girl who grows up, so fast, into a young woman. As I sang, Simi and I gazed at each other steadily, smiling. More than that: I’d say we were glowing.

For reasons I still only partly understand, I’d managed to bury that luminous moment. It was as though I’d stuffed it into a mental file called “Anomalous Event, Therefore Irrelevant.” But my group helped me see that my particular capacity to love Simone in a tranquil way was one of my granddaughter’s fundamental needs, and an avenue to deep connection with her. After that group session, I felt the shadow lift. And the next time Simi visited, something paradoxical happened. I found myself giving her not only the quiet time she seemed to drink in, but also my own brand of goofiness. Before, I’d been straining to be somebody I wasn’t, and my granddaughter, smart girl, knew it.

As I write this, Simone is nearly 10 months old. She and my daughter are visiting here again. My grandchild and I sit on the floor together and page through her farm-animal picture book, bang on her xylophone, play with her plastic blocks, and then babble-sing. When we’re apart and she sees me on FaceTime, she often goes into full wiggle-giggle mode. But even when she doesn’t, I feel fine. Unshadowed. I’m thrilled to be a grandma. I believe that’s what good support can do.

Depression-Proofing: An Evolving Art

We don’t know everything about how to stave off recurrent depression, and it’s a good bet we never will. But so far, there’s pretty good evidence that changing negative thinking patterns and getting good social support can be helpful. This knowledge has important implications for therapy. Once clients have recovered from depression and are moving toward termination, clinicians can brainstorm with them about incorporating versions of these self-care practices into their daily lives.

Clearly, there are numerous ways to develop a more positive perspective and to get meaningful social support. The ones that sustain me aren’t going to work for everyone, or maybe even most people. For some, a better match for changing negative thinking patterns may be an MBCT-type approach, a loving-kindness meditation, or a daily run—or maybe all of these. For social sustenance, one person may prefer getting together regularly with a friend for coffee, while someone else may choose to connect with a church community. I have a friend who joined an improv group a few years ago, and there she found her tribe. “When I’m doing this stuff and everybody’s so kind and encouraging,” she says, “I’m just happy.”

Of course, combating negative thinking and getting social support aren’t the only routes to staying well. Without a doubt, there are other useful practices that just haven’t been rigorously studied yet—and probably never will be. I know that I’m happier whenever I walk in a perennial garden, avoid overwork, sing Motown (especially The Chiffons), or listen to Ira Glass’s mellifluous voice on NPR’s This American Life. These everyday mood-boosters fit my own idiosyncratic personality, and I don’t care whether they’ve been subjected to randomized trials or even the smallest pilot study. Clinicians can encourage clients to consider post-therapy practices that are likely to work best for them, possibly including a continued medication regimen and periodic therapy tune-ups. Each person will create his or her own mosaic of resilience because, as Lord Byron put it, “We are all differently organized.”

Having “The Talk”

Solid depression-proofing measures may work for a time—even a long time—but perhaps not forever. Virtually all clinicians make clear to departing clients that they’re welcome to return to therapy at any point. But for clients with recurrent depression, that may not be enough. I propose that before termination, therapists talk with clients candidly about the possibility of another episode of suffering down the line. People leave therapy with certain triggers still in place. The amygdala never quits. Clients who’ve weathered depression need to know that recurrence is possible and that they can get well again, with the help of therapy and other avenues of support.

This is a complex and delicate proposition. No therapist wants to present a perspective that might become a self-fulfilling prophecy for a departing client. Of course, the conversation will need to be tailored to a particular client’s make-up and current state of mind. It may be challenging to find the balance between discussing the recurring nature of the disorder—especially if a client has already suffered a repeat bout—and transmitting confidence that, in the face of a subsequent slide, the client can recover once again.

Yet, while this conversation may be harrowing, I believe it’s vital. Without it, a person may wait too long before returning to therapy, wrongly hoping she can cope with her latest depression on her own. I’ve certainly been there. Another person might avoid returning to therapy because he imagines his therapist will be disappointed or judgmental about his latest collapse. Still another individual may decide that therapy is useless because here she is again, drowning in misery when she was supposed to have been cured.

Any of these conclusions is potentially dangerous. Working with clients to process their long-term vulnerability—along with their ultimate resilience—may be lifesaving. As part of this learning experience, clients also need to know that while depression may return, there are specific ways to increase their odds of staying well. Before leaving, the client and therapist can co-create a concrete plan. For me, numerous times over the last three years, a few simple, tailored practices have brought me back from the cliff. To say I rely on them is an understatement.

But here’s the thing: I know I’m far from home free. No amount of steady practice and self-knowledge assures that I’ll never slide again. I’ve been a mostly happy person for quite a while now, but I can’t predict my state of mind two months from now, or two years, or at any point in the future. I know only that right now, at this very moment, I’m glad and grateful to be here.

Recently, I read something that deepened my awareness of the immense container that holds our lives. Here it is: whatever situation you find yourself in—a daily circumstance, a committed path, an emotional state—don’t imagine that it’s marked by a period. It may feel like it is, but it’s not. For as long as you breathe, there will be no period. Only a comma.

I find that terrifying and hopeful, both.


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Marian Sandmaier

Marian Sandmaier is the author of two nonfiction books, Original Kin: The Search for Connection Among Adult Sisters and Brothers (Dutton-Penguin) and The Invisible Alcoholics: Women and Alcohol Abuse in America (McGraw-Hill). She is Features Editor at Psychotherapy Networker and has written for the New York Times Book Review, the Washington Post, and other publications. Sandmaier has discussed her work on the Oprah Winfrey Show, the Today Show, and NPR’s “All Things Considered” and “Fresh Air.” On several occasions, she has received recognition from the American Society of Journalists and Authors for magazine articles on psychology and behavior. Most recently, she won the 2021 ASJA first-person essay award for her article “Hanging Out with Dick Van Dyke” on her inconvenient attack of shyness while interviewing. You can learn more about her work at