by Bernard McDowell, lcsw copyright 2003
Feeling in a low mood with low energy...even on days off? To the point that it hurts and it seems hopeless to try making things better? Do you find yourself with few interests or unmotivated to take care of basics like doing the dishes? Or do you frequently feel badly about yourself for failing at meaningful relationships or being stuck in a senseless job? These scenarios describe a few painful symptoms of what is commonly called depression. But wait, doesn't much of the above apply to most of us--at least some of the time? Absolutely! In fact, there's no general agreement about what "depression" is. By recent media accounts, depression is a mental illness while the TV commercials of pharmaceutical companies characterize depression as
This article is intended for orientation in sorting through a maze of possible therapeutic treatments for depression as well as an understanding of the research and theories behind them. There seems to be a different “theory” for every aspect of being human: One emphasizes cognitive processes (thoughts and beliefs), others family background (family of origin, ancestry, and culture), and another behavior (exercising, smiling, and staying active). Other candidates include internal psychological processes, human chemistry (neurotransmitters), and genetics. Despite their claims, none of these theories are well proven or mutually exclusive. However, there is lots of evidence that many people regain their vitality after periods of depression. Here is an overview of different takes on depression. While it reads coherently from top to bottom, you may benefit by forwarding to a section of particular interest by clicking on any topic in the box (above right).
Depressed people may or may not articulate it as such or even recognize it. Some of the superficial signs are indicated by how we talk about our lives. Typically, when depressed, people say they're "down" or "in bad mood". This can spread beyond a few days to the point of pervading much of life. Even on days off, finding themselves in a “fog” half way through the day, depressed people often report wanting to be out enjoying life but unable to identify (or decide on) something they would really enjoy. Frequent self put downs are common along with casual, almost innocent comments, "it doesn't matter to me", or more serious statements about "just not caring anymore". Painful indecisiveness with low self-esteem often oscillates with spells of anger, anxiety, and/or lethargy. Two days worth of dishes pile up in the sink and bills don't get paid on time. Important appointments may be forgotten as the sense of a future is blurred by a bad mood and a sense of hopelessness.
At more extreme levels of depression, people feel inert, "shut down", “numb”, or overwhelmed with feelings of despair. Perhaps, they stop showing up for work, ignore their children, or entertain suicidal thoughts. Very restricted or flat facial expressions are common. Feelings of shame may be easily triggered. Along with very poor self esteem, they typically have difficulty asserting themselves or even knowing what they want. Obviously, any of this may devastate families and finances, though the basic tragedy is the loss of the depressed person's ability to enjoy the marvelous adventure of a fully engaged life (though for a depressed person that seems an extremely remote possibility). Recently the World Health Organization reported that “depression is the leading cause of disability… and the 4th leading contributor to the global burden of disease….” The project that ranking to move to 2nd by the 2020. In treating depression, it is often critical to distinguish physiological conditions of low energy such as hypo-thyroid or post partum hormonal conditions from psychological issues. There are many other factors to consider in a good "differential diagnosis" which distinguish depression described here from other conditions such as bi-polar (manic depression) which are not specifically addressed in this article.
From the perspective of a large bodies of research and theory often referred to as “depth" or "object relations" psychology, the symptoms of depression don't fall out of the sky like some invading virus rather they are simply clues to deeper though common psychological dynamics. Elsewhere on this site, you'll find articles examining those dynamics in much greater depth including how a healthy sense of self grows and how that process can go awry into depression. In brief, those dynamics include glitches in incorporating and/or maintaining the ability to recognize and pursue what interests us.
When people are clearly aware of what really excites them in life (their needs, interests, desires, etc.), they will be in motion towards fulfillment of those needs. Imagine that for some sudden mysterious reason you had no food available to you for a few weeks. Now what will happen if for some odd reason, you happen to come into my office and there is a beautiful buffet of your favorite foods. Of course, most people will go directly for the food! We might say needs (e.g., hunger) seek fulfillment (food in this case). Then is it merely a matter of identifying and asserting our needs to feel fully alive? Well, there's a big catch-22! Some of our needs conflict with other needs we have-most particularly, our needs in relationships. For example, we may want to reach out to someone to make a new friend, but also want to look cool and not look like a needy fool. A child may need connection with a parent who often rages at the child for expressing herself. The child needs individual attention from the parent but may need a peaceful household even more. When presented with the scenario above, really depressed people rarely say they'd go straight for the food. Instead, they wonder if it would be all right if, they “might possibly”, “if it wouldn't be too much trouble” have some food. That is, they are so oriented towards others, it's as if they quickly lose track of their fundamental needs. When we pursue our needs (or what jazzes and excites us), we might find fulfillment but we also risk loss-rejection, failure, etc.. [By the definition used here, losses are any unfulfilled needs.]
Consider a man who doesn't ask someone out on a date or a woman who doesn't try out for a part in a play or apply for a promotion--for fear of embarrassment or rejection. The woman avoids a specific loss but isn't moving with her natural inclination. In fact, both this man and woman are likely to be depressed sitting at home on the couch. Now imagine that the woman did try but failed to get what she wanted; and then swept the losses “under the carpet” while copping attitudes: “I don't care”, “it didn't matter anyway”, or “it hurts too much, I'll never do that again”. Now, she may diminish her hurt or escape the pain of further rejection, but, remember that since losses are unfulfilled needs, she has also pushed her needs under the carpet; that's why she's saying that it doesn't matter.
We might also say she has “self abandoned”-she focuses so much on what others think, that she abandons her own vital desire. In effect, she's pushed her “self” under the carpet. Now, out of touch with her needs and to avoid further loss, she stops asking people out or nurturing her secret dream to be in a play. Perhaps, only half realizing it, she avoids future losses but by not going for what she wants. When such a tendency gets entrenched, depression results. Some people do that and simply grow numb with a flat emotional life. Others know very well that they are hurting, but, in an habitual, though unconscious reference to others' responses, their heart's desires are no longer in sharp relief.
For some, problems maintaining loving connections while asserting needs take root very early in life; but as we'll see the same basic dynamics continue through the life cycle, with pitfalls and potential leaps forward all along the developmental pathway. The emphasis here to begin with focuses on childhood because it's just simpler to explain the basics beginning with early childhood. Hundreds of experiments have been done tracking interactions between mothers and infants by photographs or videos every tenth to every 30th of a second. If, when a baby moves its facial muscles along with `goo-gooing' sounds, the mother `goo-goos' back, then the baby can repeat what it just did by making the same sounds and facial movements. But if the mother doesn't mirror/respond to the baby enough, the baby generally wont' be able to reliably repeat those movements.
Not only our physiological ability to move our facial muscles but also our psychological health is much more like a living system that needs energy inputs as well as creative outputs. Many research studies corroborate the role of mirroring in other aspects of child development including the emotional realm. Imagine a toddler overcome with anger. If the parent yells, “one more word out of you and I'll knock you across the room”, the child either forever inhibits or forever acts out anger trying to come to terms with those overwhelming feelings. On the other hand, if a parent greets the child's tantrum with attunement and, ideally, some calmness, that child learns to name anger and express it appropriately. "Come over here. Hey, you're so angry, that must hurt". Even if begun in an irritated voice, when the parent shifts to a soft soothing tone, the child learns to name it's chaotic feelings as anger and downloads the ability to soothe itself. There are technical psychological terms for that: The child “autonomously incorporates” the ability to "regulate affect"; that is name emotions and calm themselves. These examples address physical and emotional development, but we have yet to highlight how the essential ability to identify what excites or interests us develops-without which we'll feel depressed.
As we grow up, demands to navigate the world on one's own increase and, with that, the need to identify as an independent person intensifies. As with physical and emotional abilities, only with mirroring can children incorporate a sense of self, a sense of choice--to go along with parents' demands or not; to give love and affection or not; or to identify and pursue desires and needs. Parents must certainly give strong directives to younger kids; but without some “mirroring” for their emerging “sense of self” and acknowledgment of their particular tastes and preferences, children will not grow up with a fundamental sense of their unique needs, self-worth, and choice. It is only with a sense of choice that we can truly give and feel vibrant. Acting out of obligation (should, have to, etc.), people feel resentful, drained, and sluggish. Our “identity” grows from the ability to differentiate our needs from others and that is essential for vitality and movement towards goals .
At adolescence other critical challenges come: The need to explore what we like or don't; to experiment, fail, and succeed in determining our needs relative to parents and peers. A classic setup for depression finds an adolescent in the position of care taking for an already overbearing parent. The teen needs the parents approval, financial support, and guidance but now has to suppress her needs in favor of the parent's needs. This teenager doesn't get a chance to go through the typical exploratory phase required to differentiate her thoughts, preferences, and choices for leading her own life. Frequently, a teen in this situation grows into a depressed adult. The point here isn't to focus on particular childhood situations associated with depression but to underscore the dynamics of how children need parental influence and need to distill out their needs from parents' and peers' influences--or very likely suffer depressive consequences. Without the ability to differentiate from peers, adolescents are quite susceptible to bad decisions that their parents call “bad choices”. But from this viewpoint the problem is more fundamental, they really don't yet “have a self” from which to make choices, much less good choices. Keep in mind these examples are given in broad strokes.
Most depressed people don't have nearly as obvious or as dramatic family histories, but any number of subtle interactions with caregivers with the best of intentions may have similar depressive results. Many adults become depressed without any obvious prior history of family dynamics that might predict it. Again, some kind of loss typically plays a major role. It could be a layoff, a death, a child moving away, a rejection for a job or a failing relationship, or a disabling condition. Now logically, it may seem that someone who has made it to adulthood would be able to keep a layoff in perspective. But its not that simple. Rollo May, a famous psychologist, noted that one hundred years ago, people valued themselves through a variety of identifications including their religion, nationality, or family background. In this society the main cultural current places an enormous emphasis on what type of work we do; and how much money we have translates to how independent people perceive us to be. When laid off from an important job, it is a tremendous challenge to stay psychologically differentiated from gravitational field of common cultural sentiments-“why isn't the bum working”. Unemployed people often hate going to parties for fear of being asked "what do you do". Logically they know they are the same worthwhile person, but emotionally it's hard for them not to internalize other people's disapproval onto themselves. Of course, there are many other variations of depression through the life cycle. Suffice it to say that the same issues about differentiating out needs from others as well as issues about loss are usually involved.
Quite often depressed people use the exact phrase, “I can't take another loss”. But if we are in love with life, we will have losses: No matter how wonderful a relationship someone has, there will be important ways that the beloved won't appreciate that person at times-not to speak of inevitability of illness, death, etc.. That's a loss. Without the ability to respond deeply and thoroughly through loss, people close their hearts. Without the willingness to have a loss, no one would ever try something new, travel, apply for a job, or paint a picture. And when people stop following those heartful impulses, its as if they've not only averted loss but abandoned their very self. There is an esoteric saying that a “true person” is a woman or a man with a broken heart. Of course, it refers to a heart broken…open…to the risk of being engaged in life. But who in this world of modern medicine teaches us to grieve. Most of the culture is running from loss as fast as possible with drugs, alcohol, and mindless distractions. Yet the ability to feel a loss is crucial to maintaining self worth. The woman who says yes but with resentment to every request of a family member isn't acting unselfishly; rather she suffers a lack of self. The man who doesn't ask someone out for fear of rejection isn't just sensitive to the other's reaction; he's avoiding loss but also avoiding himself.
The Diagnostic and Statistical Manual
There is no universally agreed upon definition of depression. The least interesting and most shallow take on depression demands our attention first because it has been adopted by virtually the entire insurance industry in the United States. The Diagnostic and Statistical Manual [DSM] lists depression among specific "disorders" of individuals. For major depression, a person must have 5 out of 9 on a list of symptoms for a minimum of 2 weeks and meet a few other criteria [see DSM on this site]. That same list is used as part of the diagnosis of several other “disorders” including “Depression NOS (not otherwise specified)”, a catch-all category often used when a client reports less than 5 symptoms.
The DSM has strengths but also glaring weaknesses--it explicitly refuses any responsibility to determine the causes for depression, yet it storms ahead with its claims to define it properly. On a positive note it provides a standardized base for; researchers all over the world can use the same DSM criteria for depression so that comparisons between different research projects may better fit into a collective understanding.
Social Context Factors
Many social critics, writing in much greater depth about the landscape of modern life, portray depression as a peculiarly modern problem resulting from the alienation of industrial life. A great deal of twentieth century literature portrays that along with a number of major social critics. Indeed, counter to the notion that depression is caused by genes or neurotransmitter imbalances, depression rates skyrocketed 1,000 % in industrialized countries since 1945.
There are many psychologists and writers who stand in stark contrast to the DSM's superficial approach. For example, Thomas Moore notes that clients don't come in with a list of symptoms rated on a 1 to 10 scale; rather they speak of difficult complex issues such as loneliness, inability to get out of bed to go to a meaningless job, gnawing feelings of failure to meet family expectations or manifest their own dreams, or the pain of searching and searching for a relationship that never quite materializes. From that perspective giving someone a diagnosis of depression by using the DSM's list is a disservice; they aren't "disordered" but hurting in the face of normal though painful human circumstances. (From a strictly scientific viewpoint, the “empirical data” is the client's exact wording, “loneliness” or “feeling devastated” after a breakup. A typical managed care approach married to the DSM asks clients to rate their “depression” on a 1 to 10 scale but that actually strays further from the empirical data than speaking about “loneliness” or feeling “devastated”.)
Similar to the examples cited above, “psychodynamic” theories attribute chronic depression to glitches in the development of a healthy self that, in turn, arose within problematic relationships during childhood with caregivers. Yet, a broader context comes from Carl Jung who drew on thousands of years of literature and myth to understand the human psyche. From that perspective, depression can be seen as a central feature of the human psyche; again, not a disease, but a developmental challenge. For example, The Fisher King Myth, hundreds of years old, depicts a king falling into depression along with his whole kingdom. But it also maps out, through the story line of the myth, the elements necessary for the king and the kingdom to regain their vigor. Some believe this is actually a more scientific approach because these stories, told and retold through generations, are less susceptible to distortion by business interest or one particular person's ego. Their difficulty lays in the wide spectrum of interpretation they invite.
Is Depression a Chemical Imbalance?
To add to the mix, the pharmaceutical industry portrays depression as “caused” by malfunctions in neurotransmitters. This vast topic requires the evaluation of much scientific literature as well as an investigation into the politics of health care. Because this is a quite complex topic, this is addressed below along with other therapies.
At first glance, the various explanations of depression touched on here seem at odds, but, again, they are not mutually exclusive. It is useful to think of each of these approaches as originating from a particular predisposition as will be illustrated in the next section on different types of treatment.
Different psychological schools have emphasized entirely different aspects of human experience. Unfortunately, each new school seems to claim the unique and exclusive corner on the truth. Fortunately, many types of therapy have been proven effective. Psychoanalysis typically focuses on early childhood for explanations of how patterns rigidify with the imprints of our parents: In essence, you are you're history. Cognitive therapy assumes that thoughts rule our mood and motivations: In essence, you are your thinking patterns. Popular a few decades ago, primal scream therapy promoted wild and full emotional expression assuming 1) reservoirs of emotions govern us and 2) venting them heals. (Research on anger shows just the opposite). Psychiatric treatments presuppose that you are your chemistry--a chemical soup that "causes" suicidal feelings, feelings of worthlessness, low mood, or any of the other symptoms of depression (according to the Diagnostic and Statistical Manual). So, lets take a closer, though cursory look at some of these.
The largest “effectiveness” study ever done indicated that many types of therapy are helpful. Also, a number of other studies show little difference between different types of therapy while attributing most of the success of therapy to the relationship between client and therapist. The rapport between the client and therapist as rated after the second session predicts the success of therapy better than what the therapist specializes in.
Cognitive Behavioral Therapy
Cognitive therapy relies on the assumption that “moods are created by thoughts”. Each thought gives rise to an emotion. Depressed people think in distorted, “downer” patterns-e.g., “all or nothing” or “expecting the worst”. An isolated, self-berating client might say “I never do anything right” or “I can't go that party, they'll put me down and it'll just be boring anyway”. A cognitive therapist challenges the client to be precise and rectify the distortions in their thinking: “OK, is it really true that you've never done anything right?”, “how do you know for sure that they'll put you down or that they'll be boring tonight?”. Of course, the client might begrudgingly admit they have gotten something right sometime in their life. The theory is that eventually, a person can change deeply ingrained thought habits.
Many research studies compared cognitive behavioral therapy [CBT] to other types of therapy and to antidepressants. In fact, because CBT has been studied so much, it is often proclaimed as the only “empirically supported” therapy. Detractors point out that just because cognitive therapy is simplistic and easily “manualized” to fit a research project protocol comparing therapy to drugs doesn't count as sufficient reason to recommend it as the best approach. It must be noted that most of those studies are paid for by pharmaceutical companies with vested interest in the outcome. In contrast, many therapy theories guide therapists to continuously adapt throughout a session to the client's concerns and, because of that very fact, are not moldable to a standardized lab protocol! The key issue though is that our cognitive functioning is only one aspect of the human psyche. If logic won the day, I wouldn't be seeing a continuous stream of couples both of whom are often lawyers or scientists!
Cognitive behavioral therapy [CBT] adds suggestions for changes in behavior which also “result” in depressed moods. Over the years, some have expanded on the basics of CBT to include the “emotional implications” of our thoughts. Though more sophisticated, those more expanded versions of CBT actually begin to resemble other “interpersonal therapies” and thus detract from the grander claims cognitive theory had to begin with. (To be fair, it is important to note that individual therapists who say they identify with cognitive therapy may use many other techniques to adapt to each client.) In a review of decades of research on therapy, "The Great Psychotherapy Debate", Bruce Wamplold consludes that cognitive therapy works but it's not because of what the theory claims; and further, it works no better than other types of therapy.
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