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Thursday, December 06, 2018
“Four Problem Areas That Could Be Bringing You Down”: An excerpt from FEELING BETTER by Cindy Goodman Stulberg and Ronald J. Frey

For years, the first line of defense for depression has been pharmaceuticals, but in their new book, Feeling Better: Beat Depression and Improve Your Relationships with Interpersonal Psychotherapy, psychologists and authors Cindy Goodman Stulberg and Ronald J. Frey say that it is actually our relationships that offer the most effective path to healing.

Recognizing that depression is an illness as legitimate as any physical ailment, Feeling Better helps readers get clarity around the four main areas in life that can be contributing factors to why people feel sad, blue, down, and depressed: life transitions, complicated grief, interpersonal conflict, and social isolation. We hope you’ll enjoy this excerpt from the book.

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Do you think your mood difficulties are linked to your childhood, your first romantic relationship, your choice to study one subject in college rather than another, the city you settled in, or your career path? Spending time in the past may help you to answer the question why, but it won’t give you the tools to feel better in the present.

The founders of interpersonal psychotherapy saw a pattern among the people they helped with mood difficulties. Their patients, they discovered, were all experiencing problems in at least one of four different areas in their lives at the time they became depressed: interpersonal conflictlife transitionscomplicated grief, or social isolation. These four problem areas aren’t causes, but they are contributing factors to why people feel sad, blue, down, and depressed. At least one of them can almost always be linked to a recent depressive episode.

Interpersonal Conflict: When Relationships Bring Us Down 

There’s no one I know who can honestly say they’ve never had an argument or disagreement with someone. If two people talk about anything more than the weather, one of them is bound to eventually express an opinion or act in a way that the other one doesn’t like or agree with. 

Conflict is a natural and important part of real, meaningful relationships. It’s what happens when we share our true selves with others — because those others won’t always think, feel, or behave the way we do, or the way we want them to. 

Ideally, conflict points out where there’s stress or tension in a relationship, so we can figure out what’s going on and work together on solutions. It’s like a roadside warning sign, telling us to slow down, stay alert, and take action. But sometimes we ignore the signs. Instead of responding responsibly to the sharp curve, icy bridge, or sheep crossing, we maintain speed and hope for the best. Or maybe we follow the signs, but our efforts don’t seem to make a difference. The stress or tension isn’t resolved. Instead, it simmers or grows. 

Conflict takes many forms. It can be with a spouse about how to discipline the kids, a friend who stops calling, an aging parent who refuses to stop driving, or a sibling who manages to ruin every family gathering. Does your boss keep piling work on your desk at 5 p.m., expecting it to be done the next day? Is your teenage son or daughter so belligerent that you yell every day (and cry every night)? Is your neighbor’s behavior making you seriously consider putting your house up for sale? 

There are three types of conflict. In the first, the conflict is out in the open. Often there’s arguing (and maybe yelling and tears too). It’s obvious there’s an issue, and it occupies a lot of our time. We might talk about it with other people. We might raise it with the person we’re in conflict with. We might try — unsuccessfully — to resolve it. We’re experiencing intense feelings of disappointment, hurt, anger, frustration, and maybe even worthlessness, and the cause is clear.

The second type of conflict is below the surface. We ignore each other. We live separate lives. We may even fool ourselves into thinking things are okay, but really we’ve simply given up on resolving the problems in the relationship. We aren’t openly fighting with each other, but the conflict may take its toll in other ways. Maybe we can’t concentrate at work, have a short fuse with our kids, or have physical symptoms that no gluten-free diet, chiropractor visit, or iron supplement seems to fix. 

Sometimes an incident will bring a simmering conflict to the front burner. Maybe a friend leaves her husband, a coworker quits, your girlfriend unfriends you on Facebook, or your teenager says something profound (but probably snarky) about your marriage. Suddenly you’re thinking, “Maybe the future could be different. Maybe I should do something.”

In the final type of conflict, we know the relationship is over, but we may struggle for a long time with how to end it. 

It can help to remember that, in most cases, conflict doesn’t happen because anyone involved is a bad person. You both just aren’t on the same page. Each of you expects something different of the other, and there’s no resolution in sight. 

Life Transitions: Change Is a Four-Letter Word (with Two Extra Letters)

Spencer West spoke at an event at my grandson’s school a few years ago. He’s a motivational speaker who lost both his legs when he was five and has accomplished things most of us with two fully functioning lower limbs would never try, including climbing Mount Kilimanjaro. 

He took questions at the end of his talk and, kids being kids, one little boy asked Spencer if he ever wanted his legs back. Spencer looked straight at him and without a second thought said, “No.” He went on to explain that he was the person he was today because he had lost his legs when he was young, and he wouldn’t change that for anything. 

Now my knee-jerk response (which I kept to myself, of course!) was, “That’s B.S., Spencer. You think your life has been enriched by not having legs, but I don’t buy it.” But I’ve thought a lot about his answer since that day, and now I wonder. Legs would change everything in Spencer West’s life. It’s a strange thing for someone who takes walking for granted to think about, but I had to acknowledge that he might have some difficulty with the transition back to a life with lower limbs. 

Transitions are events that occur throughout our lives marking a change from one role or situation to another, often when we move from point to point in the human life cycle. Most of these life changes aren’t inherently good or bad, and most have both upsides and downsides — though it’s hard for people who have depression to appreciate the upside. 

A change in our physical abilities (losing our legs — or getting them back after a lifetime without them) is a transition. So is any other major change in our health status, living arrangements, employment, or finances. Marriage is a transition. So is divorce. Getting a new job is a transition, as is getting fired from an old one. Bankruptcy? Transition. Winning the lottery? Yup, transition. Going to college, moving to a new city, having a baby, creating a blended family, recovering from an addiction — they’re all transitions.

Transitions aren’t always linked to the start of mood difficulties and depression. But if your life change means adapting to a new, unfamiliar role and you miss your old circumstances a lot, it may be associated with your depression.

Do you feel as though your expectations of the new role aren’t being met? Is the life change supposed to be a good thing, but actually feels bad? Did the change happen in a way you thought it shouldn’t? Do you feel inadequate, unprepared, or as if you’re failing in your new role? Have you lost the support people you used to count on as a result of the change? Has your self-esteem taken a hit? These are all telltale signs that the transition may be connected to your mood difficulties.

When Grief Gets Complicated

I didn’t grieve my mom’s death in the most effective way. I didn’t want to experience such intense feelings of loss, so I ate cookies, ice cream, and chocolate bars instead. I avoided visiting her grave and rationalized it with a shrug, saying, “I’m just not a cemetery person.” Years later, when my mother-in-law’s illness and death brought on unexpectedly powerful feelings of sadness, it took a wise friend to put two and two together for me. My mood difficulties were actually about my mom’s death, and I needed to address that.

Grief is considered a problem area when we can link our depression to the death of someone we care about. It can be tempting to think we’re grieving a job we lost, a friendship that ended, or our children leaving the nest, but these are transitions. We experience complicated grief when someone in our circle has died.

The person we’re grieving could be a parent, close friend, sibling, aunt, uncle, cousin, teacher, mentor, colleague, boss, or neighbor. If they’re a peripheral person on your social circle, you might want to ask if you’re really grieving them or whether their death is reminding you about someone closer to you whom you didn’t grieve fully.

The time frame doesn’t matter — your depression may have started right after the person died or anytime after, even decades later. What matters more than when the person died is whether you can function. Of course, not functioning is appropriate for a period of time after someone close to you dies. But if you want to begin to resume some of your normal activities but you can’t or people who love you are worried that you aren’t coping, this might be your problem area. 

So go back to your social circle. Was there anyone significant in your life who died? 

If the answer is yes, there are some telltale signs that your grief may be complicated. Are your feelings of sadness, guilt, and loss still intense, and even incapacitating, years after the person died? Do you worry that if you let yourself cry, you’ll never stop? Do you feel intense or prolonged sadness every year around the anniversary of your loved one’s death? Do you avoid talking or thinking about your loved one? Did you feel numb when they died? Instead of expressing your grief, are you transferring your feelings to other people or areas of your life? 

Your grief may be complicated because of circumstances at the time of the person’s death. For example, if you weren’t able to see your loved one before they died, if your last interaction was a fight, or you had to miss the funeral, you may be left with feelings of guilt that won’t go away. Guilt is also a common — and very intense — feeling when a loved one takes their own life. You may blame yourself for not doing enough or seeing the signs. Because of the social stigma of suicide, you may also feel that you can’t openly mourn the death and receive support for your loss. Lack of support at the time of a loved one’s death in general makes it harder to grieve someone’s death fully.

Loneliness and Isolation: No One to Lean On

Ron likes to say that people who experience loneliness and isolation are like Mother Hubbard of nursery rhyme fame: they go to their cupboard and it’s bare — not of dog bones, but of meaningful relationships.

If you have had a history of inadequate, unsupportive relationships; difficulty making friends; and challenges maintaining meaningful relationships with family, loneliness and isolation may be your problem area. 

Loneliness and isolation is the least commonly experienced problem area. The symptoms of depression may make you feel socially isolated — you don’t have the energy to make plans and feel no one would want to spend time with you anyway — but loneliness and isolation isn’t likely your problem area unless you’ve had a lifetime of problems connecting with others. 

Ron was treating a stockbroker who worked thirteen hours a day, six days a week, fifty weeks a year. He had no time for his wife, his sons, or his friends. There were a lot of people on his social circle, but he had almost no meaningful contact with them. 

Was his problem area loneliness and isolation? No. Turns out his lack of close relationships was a relatively recent change. He was sacrificing his whole social circle because he had received a promotion at work and was feeling overwhelmed and inadequate. He felt he needed to give everything to his job in order to keep his new position. As a result, it made more sense for him to choose transitions as his problem area. That way he could develop skills to cope constructively with his new role at work and feel confident that he had the time to emotionally reengage with his loved ones. 

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Cindy Goodman Stulberg, DCS, CPsych, and Ronald J. Frey, PhD, CPsych, are the authors of Feeling Better and directors of the Institute for Interpersonal Psychotherapy. Visit them online at

Excerpted from the book Feeling Better. Copyright © 2018 by Cindy Goodman Stulberg and Ronald J. Frey






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