Easing the burden of depression with resilience training
Dr. Henry Emmons
In 2003, Todd Stitt was able to deal with his depression. The 37-year-old computer programmer from Minneapolis worked as a contractor. “I was clear with my employer that I had depression. When I worked, I got paid. When I didn’t work, I didn’t get paid,” Stitt said.
But then everything fell apart. Overwhelmed by depression, he could no longer work. “I think I got out of bed every day. But there were days when that’s all I did,” Stitt said. “I didn’t have any energy.” And his depression was so severe, he depended on family and friends to do the basics — shop, clean, and do his laundry.
Stitt saw a psychiatrist who prescribed a combination of medications that eventually started to help. He began meditation and mindfulness, the practice of calm awareness, as ways to manage his depression. And although able to work part-time in 2006, he still felt hopeless and continued to struggle. “I was dealing with my mind not working well, and I got frustrated with that,” Stitt said. “Everything seemed monumental — making phone calls, even getting out of the house.”
Then he heard about the resilience training program at the Penny George Institute for Health and Healing in Minneapolis. The program, inspired by holistic psychiatrist Henry Emmons, blends nutrition, exercise, and mindfulness meditation to manage depression, anxiety, and stress-related mental health conditions.
“The program changed my life,” said Still, who is now working full time, exercising regularly, and feeling more connected to everything around him. “I have better life skills…and I think that’s a lot of what resilience is about — developing healthy habits. So, when there are challenging times, a person can cope.”
Resilience training (RT): an approach that works
After working for more than 20 years as a psychiatrist, Dr. Emmons realized the traditional approach to treating depression and anxiety wasn’t very effective. Treatment as usual for depression and anxiety — that is medications sometimes combined with therapy — leaves a lot to be desired, Emmons said. “It’s not sufficient to the problems people face and it’s not very effective at helping lead them to recovery. Rates of recovery [from depression] are really poor.”
Indeed, data show that fewer than 10 percent of people diagnosed with depression are better to the point of remission a year later, according to Minnesota HealthScores (www.mnhealthscores.org), a non-profit Web site that provides information on the quality of health care in Minnesota and surrounding areas.
But outcome data from the RT program are remarkably better.
A recent study that used the same depression survey reported by Minnesota HealthScores, found that more than 60 percent of RT participants achieved remission at the end of the eight-week program. Equally impressive, these remission rates persisted twelve months later.
“We’re not increasing medications. Sometimes we’re reducing them,” Emmons said. “But we’re offering people skills that they can take with them. And we’re seeing people, even those who have had depression for years, even decades, reaching full recovery.”
“Medications tend to lose their effectiveness the longer people take them,” Emmons said. “With this program, the benefits hold for people in this program who practice what they’re taught.”
In his book, The Chemistry of Joy, published in January 2006, Emmons described holistic ways to overcome depression. But after his book was released, he saw the next challenge — creating a program that would help people practice and apply his recommendations.
Emmons envisioned a more integrated way to help people with depression. Rather than focusing solely on brain chemistry, psychology, or spirituality, he wanted a holistic approach that recognized the impact of depression on the whole person.
The subsequent RT program, first offered in 2007 at the George Institute, embraces three key principles — fitness, nutrition, and the psychology of mindfulness. It includes eight weekly group sessions with a trained facilitator along with individualized guidance from a psychiatrist, clinical nutritionist, and exercise physiologist.
RT participants: experiences and goals
Most people in the program have a major depressive disorder, several have chronic anxiety, and almost everyone is on medication therapy. The majority has struggled with depression and anxiety for years and has not gotten better. “They’re usually feeling as though there’s no where else to turn — that they’ve tried everything,” Emmons said.
Although medications are not the main problem interfering with recovery, medications are often part of the problem. The medications may hold them back and make them a little worse, Emmons said. Medications can make people tired, flatten the mood, or interfere with sleep.
At the beginning of the program, participants usually have one of two goals in mind — they want their depression to get better or they want to get off their medications.
“I almost never recommend that [participants] stop their medications or come off them completely, but very often I will have suggestions about how to simplify or fine tune their medication regimen,” Emmons said.
Mary Jo Keefe, a 66-year old office worker from Bloomington, Minnesota, has struggled with depression, anxiety, and an eating disorder for decades. After more than 10 years of medication therapy, she saw the RT program as a way to get off her medications. But after going through the program, her outlook changed. “I finally got the message — that some people need to be on medications and not to be hard on ourselves if we need to stay on medications,” Keefe said.
It’s common for people to want to get off medications. And I almost always try to change that goal for them, Emmons said. My goal is to find the lowest effective medication dose, reduce medication side effects, and get medications working again by adding other holistic changes.
When Stitt started the program, he wanted to get off his medications. But he had a bigger goal in mind — he wanted to be cured of his depression.
“I distinctly remember thinking, ‘Okay, we have eight weeks. When I get out of here, I want to be cured, fully functioning, and ready to work full time,’” Stitt said. “Then halfway through the class I remember thinking, ‘Boy, I don’t know that I’ll be fully functioning by the end of eight weeks.’” And as his depression improved, he realized his goal was changing.
“I’m learning to live with depression, not be free of it,” Stitt said. “That desire to be fully cured — I still go through that sometimes. But I’m more balanced. Some people need to live with diabetes and some people need to live with other challenges [like depression], and they do. And I am.”
Learning resilience: an integrative model
When Emmons started this area of work, he thought of resilience as the ability to endure stressful events and bounce back to baseline. Although he still believes that’s part of resilience, his definition has expanded.
“I think that one of the deficits of the medical model is that we focus exclusively on disease and recovery from disease,” Emmons said. “But when it comes to depression and anxiety, one of the things that is most preventive is to live in a way that is so full and vital that depression has little chance of coming back.”
Central to this approach is self acceptance and creating connections with others.
“The notion of self care is usually that a person has to do everything right — they have to exercise, they have to eat right, they have to take their supplements — it’s a lot of work,” Emmons said. “But I think it’s more preventive to feel as though you’re living your life in a way that gives you a sense of fullness and vitality. It’s having a strong sense of connection and community…We try to help people go beyond having a sense of recovered, to a sense of living more fully than they perhaps have before.”
The RT program is unique in that it combines eastern and western approaches to health, said Susan Bourgerie, a licensed psychologist who has worked as a RT group facilitator for more than three years. “It really is the only program that I know of in the country that integrates of all the pieces — the body, physical, emotional, social, and spiritual.”
And Emmons has found a way to make the eastern ideas very western friendly, said Bourgerie, who has cared for people with depression and anxiety for more than 25 years. “[Participants] get it in a way that both opens their mind to something new but is not so foreign that they feel put off by it.”
Components of a comprehensive program
The RT program provides tools, practices and education to support resilience. It’s an integrative skills building program that embraces nutrition, fitness, and mindfulness.
“At first glance, I think that it can be a little overwhelming to people,” said Carolyn Denton, a licensed nutritionist who works with the program. “But, we stress that we’re trying to lay out some strategies that you can come back to. And in fact, that’s what life is all about. You get derailed. The most important thing is how do you get back on track…and the program provides some solid strategies.”
At the beginning of the program, many people don’t see the relationship between food and depression, Denton said. “Many people have alcohol dependence or it’s in their family. Many people are hooked into the sugar. And some people aren’t eating enough or aren’t getting enough protein…A lot of it is trying to simplify things for them so that they can get started on something — to make one change.”
Food, exercise, and down shifting out of a stress response are like a three-legged stool, said Denton, who meets individually with program participants and talks about nutrition and sleep during one of the group sessions. If exercise and meditation are in place, but food choices are sabotaging them, the other two legs of the stool will be wobbly. Nutrition fits in as a piece of a larger strategy that has to be simultaneous, Denton said.
Susan Masemer, an exercise physiologist who meets with each program participant, tries to understand people’s thought processes and their relationship to physical activity. Some people are afraid to exercise. Some have had bad experiences with exercise. And some have used exercise as punishment, Masemer said. “I do a lot of work helping them reframe exercise as something that’s more nurturing.”
At the beginning of the program, most people are not exercising on a regular basis, Masemer said. Often they’re not exercising because they’re depressed and don’t have the energy to exercise. She starts there — helping them understand that if they exercise, they will probably have more energy and feel better.
And after the initial 90-minute fitness session, everyone leaves with a plan. “The key is meeting them where they’re at and motivating them to do just a little more,” Masemer said. “We want people to have a very high quality, joyful, productive life. And I’m just one those pieces that can help people accomplish that.”
Mindfulness is the third critical component of the program.
“I think the most important part of the program is the different relationship people now have to their mind, their thoughts,” Bourgerie said. “They feel much more empowered to see that landslide of thought and emotion, and not get all consumed by it or descend into the depths with it.”
For Stitt, mindfulness and meditation has become a powerful way to deal with his depression. “Some mornings I wake up and think, ‘Wow, this is going to be a horrible day.’ And then I meditate and shift that thought pattern — I come out of it feeling energized and alive.”
The more we reinforce unhealthy patterns of thought, the stronger it gets. And if we stop unhealthy patterns of thought, they get weaker and have less control over you, Emmons said. “We might not be able to stop the thoughts, but [people] can learn to notice the thought, stop ruminating, and not let it control them…The brain is very resilient — it’s very good at making new connections as long as we do other things to help it.”
“I always felt as though we were on to something from the beginning with this program. I really believed in this integrative approach,” Emmons said. But there were two things that I didn’t really appreciate were as important as they are — self acceptance and the importance of community.
The biggest stumbling block for real recovery from depression is self derision — where people hold themselves in a very harmful way with how they think and feel about themselves, Emmons said. “And it is such a turning point for people, if they can honestly get to that point of accepting themselves more fully.”
Feeling connected to a community is also powerful, Emmons said. Probably the most healing element of everything we’re doing happens because we are bringing these people together and creating a safe and open sense of community where they can talk about depression with others. They learn they’re not alone. Depression is not unique to them.
“It’s strengthening to be with others in the group,” Stitt said. “You don’t have to explain depression to others who are experiencing it. You learn about tools you didn’t consider in the past, like supplements. You hear other people’s successes. And there’s a unique bond.”
Before starting the program, Keefe felt isolated. And meeting with others in the resilience group helped her deal with the isolation. “I didn’t have to explain what I was going through with depression,” Keefe said. “I look around in that group and everyone’s struggling with it. It’s very clearly not our fault. We didn’t do something that caused this. And that’s the beauty of a group. Nobody gets it like they do. And everyone has so much to offer. We’re so different and yet we’re all alike.”
This sense of community is so important that Stitt and Keefe attend a monthly follow-up group that provides ongoing education and for people who went through the RT program.
Challenges to resilience training participation
Despite success of the RT program in helping people with depression and anxiety, barriers can get in the way of participation.
“It’s kind of a cruel irony that depression, really recovering from it, requires so much good self management and yet the illnesses itself really knocks out the motivation to do it,” Emmons said. “Being ready for change and then sustaining the motivation over the long term is a real challenge.” And although the program is designed to help with this, the lack of motivation that often accompanies depression is a stumbling block for many people.
The other issue is financial. Currently, the program is not covered by most insurance plans. “We’ve made it as affordable as we can. But the cost is still substantial — $900 total. [Cost] is a barrier for some,” Emmons said. “But I have been surprised at how many people will make it happen. Even if it’s a stretch, because they are so hungry for something like this.”
Paying for the program was a stretch for Stitt, and he was able to do it only because his older sister helped him. “At that point, I was living on money that I was borrowing,” Stitt said. “It would be nice if everyone who could use the training could get it without worrying about the finance part.” Beginning 2011, the cost of the program will be less of a barrier for some — it will be a covered medical benefit for employees of one major Minnesota health care organization, Allina Hospitals & Clinics. This benefit change occurred because the program is cost-effective, according to a recent unpublished study. In the study, a workplace productivity and impairment questionnaire measured presentessism, that is being present at work but not productive, in employees with moderate depression. A 59 percent decrease in presentessism was seen in employees who completed the eight-week RT program compared to a 25 percent increase in employees who did not participate. The estimated cost savings from improved presentessism was more than $1,600 for each RT participant.
Resilience as an approach to life
Stitt finished the RT program in June 2007. He returned to full-time work six months later and was married in 2009. Today, he takes medications for his depression, attends the monthly RT follow-up group, meditates, exercises and practices others skills he learned.
“The RT program teaches a lot of techniques and tools, but the practitioner needs to incorporate these into their life,” Stitt said. “Exercise only works if you get out there and do it. Diet is the same way. Using meditation to work with the mind — you need to practice it. And it takes a lot of patience and practice.”
And he sees resilience as a way to approach life. “It’s not about making ourselves perfect, [it’s about] living with the situation we have. Not giving up. Life doesn’t have to be perfect,” Stitt said. “Life is challenging for everyone — even for people who on the surface seem to have a great life.”
Resilience training is a way of life that enables people to live with the suffering that comes with being human, Bourgerie said. It’s not just self improvement, symptom relief, or relapse prevention. And this program can help anyone, not just people with depression, to have more resilience and more ability to live.
You can extend the span of your life
“You can extend the span of your life by only so much. With meditation, however, you can expand the scale of it- two-, three-, fourfold. So, if you live for 60 years but you lived twice as “big” in each moment – it will be like living 120 years. This is not some impossible state of attainment. It is something that any ordinary person can do.” ~Shinzen Young