Dealing With DepressionA Brief Guide for Understanding and Healing Depression
Robert Caldwell, M. Div.
An executive, bored by her work, drags herself through another day, just as she has done periodically for several years. Finally, home for the evening, she growls "hello" to her family who seem but one more burden to her. After moping through dinner, she falls exhausted in front of the TV, where she alternately vegetates and criticizes her children for not being appreciative of her needs. She has Chronic Depression.
A graduate student glares disconsolately at the ceiling, possessed in the moment, as he has been for weeks, with dark, desperate thoughts about how badly his life is going--school, dates, friends, job prospects appear unwaveringly bleak. He feels nothing is working for him. He neither sleeps nor eats well. Thoughts of suicide haunt him. He is suffering from Major Depression.
A lawyer goes through alternate cycles of being high and low. When she is "up," she is very up and emits seemingly boundless energy, talks grandiose schemes, and races around from one thing to the next without continuity and completeness; when she is "down," she is listless and without purpose or direction. In days or weeks she fluctuates wildly from one to the other. She has Manic-Depressive Illness or Bipolar Depression.
A middle-age salesman experiences, every winter, significantly reduced energy and diminished enthusiasms. He is particularly gloomy and immobilized by the darkness of winter. He has SAD, or Seasonal Affective Disorder.
A young mother suffers from the "blues" that won't go away, even several weeks after her baby's birth. At the moment she had expected to be the most joyous of her life, she finds she is continually close to tears and can sometimes hardly stir herself to look after even her child's minimal needs. She represents the one in ten mothers afflicted by Postpartum Depression.
An administrator shows agitation in carrying out his new responsibilities. He feels everyone is dissatisfied with his performance. He is gaining weight and sleeping more. Because his symptoms are opposite from ordinary depression, though the underlying dynamic is the same, his dysfunction is called Atypical Depression.
Being depressed is hard living. Hard for the persons depressed; hard for the persons who are around them and who care about them. Depression is more than the blues, or the common feeling of being "down" that can come to us in the course of disappointments and losses that make up ordinary experience. Depression is more insidious and pervasive. It grabs and stifles; it settles in and forgets to make an exit; it begins, commonly enough, as a response to loss that in an inevitable part of life, but hangs around after the loss itself has become a faint memory.
The symptoms for depression are a veritable list of life's most undesirable possibilities: gloominess, a painfully low self-esteem, pervasive sadness, depleted energy, inability to enjoy anything; absence of interest and satisfactions; an overall sense of helplessness; intense feelings of guilt and shame; believing everything is one's own fault, sleeping too little or too much; eating too little or too much; decreased sexual drive; feeling life has lost meaning and is not worth living, contemplating or acting upon suicidal thoughts.
Depression is our body/mind's signal that something has gone very wrong. It is the psychic pain that tells us that our organism is out of whack. Nature has fashioned us to be propelled by liveliness, interest, energy and pleasure--coping with and overcoming inhibition, fear, threat and boredom, as we move through meaningful present experience toward desired goals. Depression is not denial, or spacing out, or freezing our emotions. In depression we have our feelings very available and they tell us that our life is going badly, that we need change--or else. Taking our feelings of depression seriously, we begin to see that there are areas of our life which we must address if we are to return to lively and effective living. Knowledge of the factors that make our depression will yield understanding of our values, involvements, ideals, and sense of personal power. Further, developing an understanding of depression can enable us properly to balance work we need to do in healing our brain and in healing our mind.
Causes of Depression
All of us are both brain (biological) and mind (psychological) creatures. There is no absolute knowledge about how much our depression is caused by chemical imbalances in the brain and how much by psychological dysfunction. Science and instinct tell us that both are involved. In recent years research is helping us understand more clearly how brain and mind work separately and together as creators of depression.
The Brain and Depression
There are ten billion neurons (brain cells) and each one has hundreds to thousands of offshoots to one another which make countless billions of connections a day. And most of this without our even giving it a thought. These connections are made by neurotransmitters. If these neurotransmitters (which include dopamine, norepinephrine, and serotonin), like Goldilock's soup, are "just right," we tend to have a healthy and positive mood, if they are too "cold", i.e. underactive, they tend to produce the deflated mood we call depression; if they are too "hot," their over stimulated state may produce mania.
Evidence has become compelling as to the biological base of some depressions. Many studies show the incidence of depression is higher in families where one of the parents is depressed. The directly related family members of a depressed person have a 20-25% chance of being depressed, compared to an average of 5-6% for the general population. Further bolstering this finding, in one study of identical twins raised apart the rate for depression was 67%.
The Mind and Depression
Our thoughts and feelings take many turns, and too often we direct them painfully against ourselves. Depression is one of those forms of self-torment. Negative experiences of shame and failure, of loss and betrayal can cause us to create a set of burdened, constricted, and hopeless scenarios for living that give us little opportunity to experience a strong and positive mood. This is the sort of dark thinking we get trapped in when we fall, slide, or creep into depression. Working our way out of depression can call forth a willingness to look at patterns that have established themselves over a lifetime of making maladaptions to experiences and creating depressive coping processes, conscious and unconscious, which, while originally attempting to defend us against some more fearful threat, now serve to dampen our mood and subtract the joy from living.
Dealing with Depression
We don't have to be stuck with a mind-numbing, energy sapping, meaning-dampening depression all of our lives. It is possible to deal with depression very constructively. More than 80% of those who approach their depression seriously get relief, many substantially, and some permanently. There are two approaches that match the two causes--medication for the brain and re-education for the mind. There is no necessary either/or. What is effective, of course, is what matches with brain/mind of the particular individual.
Healing the Brain
Human suffering is sometimes a legacy passed through the genes. Though it is established that psychological treatment can sometimes be effective with biologically induced depression, therapy by psychological means in some instances may not provide the optimum hope for cure and renewal.
Edward (Names and identifying data have been changed.) told me he remembered only rarely being without depression. For him this meant that each day life seemed not worth living; a day was a bore to be dragged through with only occasional respites of enjoyment. He had no pleasure in sex and little trust of the possibility of making successful relationships. A few days after he began a Zoloft regimen his feelings about himself and his world began to change. His frigid psychic temperature began to thaw. Edward began to be interested in doing more than just surviving. He became a volunteer in a nursing home, a committed companion to a friend who was losing his sight, and made a connection with a woman he now plans to marry. For about a year he continued in therapy, cementing his new possibilities in behavior changes and shaping a new and more nourishing environment for his life--now that he could live above rather than below the depression line. Then, bolstered by his new mood and setting his life in order, he left therapy.
My orientation as a humanistic therapist, a tradition that sees the patient less as "sick"--and therefore in need of being made well, and more as "blocked"--and in need of being set free, has brought me but slowly and cautiously to appreciate the virtues of medication. Since the advent of Prozac and similar drugs, I have seen patients using these medications become remarkably lightened of the drudgery of their living and released from the chafing and numbing bonds of their own mental prisons. But, the drugs are hardly magical for everybody. Some people with whom I have worked have had little, if any, improvement. With a few persons the medication may even have exacerbated their condition; however the negative effects were immediately reversible with the cessation of treatment.
All in all, the positive effects considerably outweigh the negative ones. Whatever the cause of one's depression, it is important to recognize that some persons are helped in considerable degree by the re-balancing of the chemical process of the mind that modern treatment can offer. I have come to understand that the anti-depressant medicines (Prozac, Paxil, Zoloft, Effexor, Sinequan, Nardil, etc.) re-establish the natural balance of neurotransmitters for the brain's task of maintaining a facilitating mood and energetic attitude so we might best deal with the life tasks at hand. When drugs work, they add-in what nature has missed, and they do it remarkably well. National Institute of Health studies show that medication therapy works with some measure of success for up to 80% of those who try it.
Healing the Mind
Whether the primary cause of depression is genetic or environmental, invariably there is a psychological component. After all, depressed persons live in a world of negative mood and dysfunctional behaviors that, whether they are actually cause or consequence of their depression, contribute toward its maintenance. If we are down, and then cannot get "on top of life," we certainly are living in such a way that our depression can breed more depression. Even when there is dominant biological basis for depression, the illness is often triggered by life experiences in which we feel disrespected, out of control, disappointed, shamed, enraged, confused or failures at relationships. When we are depressed we feel loss, or abandoned, or unable to cope with the difficulties of life--and on top of these feelings of despair and inadequacy, we may also believe that we deserve our wretched state of mind. These feelings can overwhelm us and spiral in on themselves till they implode into serious psychologically created depression, a production of our mind trying perversely to save itself, but constricting itself painfully in its misbegotten process.
We have become so accustomed to being depressed that one of our gravest dangers is that we will be afraid to experiment with lightening-up. Sometimes the mind is rendered so powerless through biological depression that it forgets how to pattern life for interest and success, so when there is relief through medication, the sudden possibilities of a happier life seem more weird than enticing. Other times, persons become invested in their life in which being depressed is so intimate and integral a part they cannot conceive of themselves except as depressed. Depression becomes the organizing principle of their lives. They become so used to being depressed, to the feelings, the reactions, the excuses, the besieged sense of self, that they have no wish to change. They fear the unknown. Inertia may well be the most dangerous of all human realities. Known experience, regardless of how painful, can prompt fierce resistance to the unknown, regardless of its promise.
We are the results of our life styles. Depression often is produced, and always compounded, by the way we live and the way we think about our living. Depression is a dark, numbing state of mind, a painful and destroying mood, that springs from our inter- and intra-personal worlds. What follows are some guides for dealing with our beliefs and attitudes and emotions that bring on and/or sustain depression.
Sort Out Your Grief and Rage
Depression often is the stuck place between grief and rage. It is the incapacity or unwillingness fully to grieve. It is the refusal, the inability fully to express anger. When we have lost a person's love, a precious material object, or a cherished hope, the natural evolution-installed response is to grieve over what has been lost, or to become angry for its being taken, or both.
Often we remain in the grip of depression, rather than accept the consequences of the pain of being bereft. We hold on--in the face of all reason--to the hope that we will get back what is lost, thus postponing facing our deprivation. How many times have we said to friends, as we were telling them good-bye with little hope that we would ever be reunited, "I'm sure we'll be seeing each other soon." Such comments are signs of our refusal to grieve, to let into ourselves the reality of the pain of separation. We are not ready to move into our future by allowing our feelings of being torn away from what was important to us to run their disturbing course.
When we can be ready to grieve, to allow ourselves to experience fully and openly the absence of what is lost, then will we be able to move forward without the regret and the longing that immobilize us. Thus can we accept our pain as part of the total continuum of our lives, and it then becomes background for new and enriched experience.
On the other hand, the experience of loss or diminishment often evokes powerful anger toward the perceived cause of the loss or injury. Depression can be the refusal to discover and make active our angry reaction. The anger comes back upon us. If we experience something taken from us or done harmfully to us--perhaps we are stolen from, perhaps betrayed--the appropriate organismic response is anger. Anger is nature's program for energizing us for action to take care of ourselves. If we fail to cooperate we get in trouble. An assembly-line worker in a computer factory gathered for weeks with his co-workers as they griped together about the lack of support from their supervisor. Finally, he decided to be bold, and with the encouragement of his friends, confronted his boss in a general meeting, expecting support from his prompters for putting himself out on a limb. He got none. Inside, he seethed, but he made excuses for them and was fearful that, if he confronted them, he might lose their friendship. He opted for anger-toward-self, or depression.
Primitive anger is an aggressive and frightening emotional and behavioral response to loss and intrusion, but,anger-transformed is assertiveness and active creativity. Harnessing and directing the energy of our anger can move us far toward building new pathways for achievement, enjoyment, and new human contacts that fill the void of loss and hurt. Grief and anger enable us to complete the cycles of our experiences and move beyond to create anew. If we let ourselves grieve, we are responding to and expressing our need to feel deeply our losses and our pain. Grief carries us into our soul. If we let ourselves acknowledge and express our anger, we will discover and live in our creativity and power. In experiencing grief and anger, we can complete the past and move to making new, and perhaps stronger, attachments.
Challenge Your Helplessness
Depression is often characterized by feeling helpless about controlling one's life. Through detailed research the psychologist, Martin Seligman, has established a relationship between "learned helplessness" and depression. In a famous experiment he placed two groups of dogs, one group at a time, into a "box" with a wall that they could, with some effort, jump over. One group of the dogs was naive--i.e. they were ordinary dogs that had been through no special conditioning to teach them how to be helpless; the other group was conditioned--they had been taught that, whatever they did, they could in no way influence what happened to them in an enclosed area. In the box each group was given a mild, non-harmful, electric shock. The naive dogs barked, dashed wildly about, voided bodily functions and then jumped out of the box to escape the discomfort of the shock. The conditioned dogs barked, dashed wildly about, voided bodily functions and then settled down, whimpering, into the discomfort of the shock box.
Further, Seligman discovered that naive dogs, in addition to jumping out of the box, were able quickly to identify a lever that would cut off the current, and with only one exposure, they learned to do it themselves. The conditioned dogs, even when shown the lever and how it worked, did not learn to use it. Seligman saw that the "helpless" dogs not only were unable to escape the box, but that their learning was impaired so as to make it impossible for them to acquire a simple skill that would have save them frustration and pain.
Seligman maintains that the behavior of these dogs offers crucial lessons for humans in understanding their depressions. We, like the conditioned dogs, have developed certain limited expectations built from our failures to influence our environment. We have learned to be helpless--to believe that, if life administers us the shock of loss, or deprivation, or threat, then there is little more we can do but make the pitiful noises of depression, as we lie passive prisoners of our pain.
However, there is hope also to be drawn from Seligman's experiments. A behavioral therapist assisted in developing a scheme that helped the conditioned dogs escape their painful inertia. After failing to lure the dogs out of the box with Hebrew National Salami (their favorite food), a procedure was introduced whereby the dogs were taken by their collar and gently dragged across and out of the box. It took fifty to two hundred draggings for the dogs to learn that they could escape by jumping out of the box on their own--but learn they did!
Our "helplessness" to take control of our own life is rarely genetic, nor is it so implanted in our learned responses patterns that it is indelible. We learned it, and we can learn something else. A problem many have is that we want our friends and family to pull us out of our depressions "two hundred times." Though the scientists did this with the dogs, few humans will do the same with one another. We will have to learn not to be "dead-weights"--rather, to push when others are kind enough to pull. Perhaps we can learn as well, how to exit our painful boxes of depression as we practice new skills--e.g., meditation, acts that build self-confidence, studying philosophies of hope--that enable us to moderate the painful surges of depression ourselves.
Confront Your Shame
The emotional experience that leads most often to depression--and keeps one depressed--is shame. Shame is the experience that we are not worthy, that we have been "found-out" as being less than we had imagined and presented ourselves to be. Shame is feeling judged as incompetent or unacceptable, or threatened with abandonment. People who have the intense feeling of shame--which includes the physical manifestation often associated with depression, that of caving-in the chest and bowing the head--are feeling many of the characteristics associated with depression. We become depressed because we believe others do not honor us or want us around. We become depressed because we incorporate the shame others put on us into our own criticisms and pejorative self-denunciations. If, behaviorally, depression is linked to learned helplessness, inwardly, depression often is the manifestation of a toxic shame and the accompanying low self-esteem that will not let go. When we are depressed, we often believe we are not worthwhile, not powerful, not interesting, not attractive, not strong, not smart, not skilled, and certainly not important to others. In feeling we have little or no value, our energy is drained and does not revive--this is depression that is the fruit of shame.
We learned from growing up that our caretakers and peers who gave negative and judgmental and abusive messages caused us to believe that we were not OK. In our beginnings, we have plenty of help in creating our shame-bound feelings. Others were willing for us to take the rap for their negative feelings about life and themselves, to make us depositories for the poisons they could not deal with in themselves. We accepted, for resisting and fighting back takes more understanding strength than children can muster. The payoff for our acquiescence was tolerance by our caretakers, the inner consequence for our heart was depression.
The depression that is spawned by shame weighs us down with a self we believe to be unwanted and exposed as inadequate and unacceptable. It is hard not to be depressed when we live under a mountain of toxic shame. Shame--the diminishment of energy, and pride--the expansion of energy, are polar forces and do not inhabit the same psychic space at the same time. To escape from depressions that are caused by shame, we must develop courage to examine and confront our shame history, our relationships with our abusers, and our "comfort" with our low self-esteem. Then will we be ready to entertain and act on the possibility that we can live proudly.
Create Supportive Relationships
Isolated and hurtful relationships are a major cause of depression. In the majority of couples whom I see for marriage counseling, at least one member of the couple is clearly depressed. He or she has become over-burdened with repeated disappointments, recriminations, and non-rewards of their relationship. He has tried; he has failed. She has been stonewalled, or abandoned or abused. And one or both are depressed. For individuals who seek therapy who are not "in relationship," chances are good that they come because they are unsuccessful in making an ongoing connection, either with a lover or with friends or in the workplace. In fact a whole system of therapy, called simply enough, "Interpersonal Psychotherapy for Depression" is being taught to professionals across the country. In one recent study it came out ahead of other psychological therapies as being most effective in the healing of depression. We only need to touch-in with how our relationship issues so often are present in our depressions to understand why.
In addition to intimate relationships, we have lost a sense of belonging to larger groups. There is an interesting study on depression made of the tight-knit and intimately interdependent Amish population of Lancaster, Pennsylvania. It was found that, though their depression rate for almost 100% biologically induced Bipolar or Manic-Depressive Illness was the same as that of New York City residents, their rate for major depression, a condition that has psychological as well as chemical origination, was only 5% of New Yorkers.
With the demise of religious and community institutions, with the dispersion of the family into the far-flung corners of the earth, we have a lost a sense of close bonding with one another. There is no self but the self in relationship--with individuals, with small groups, and larger ones. And when we are not in some degree of harmony and mutual appreciation with others, depression is often the consequence.
We are community creatures. Perhaps "Prozac" will numb enough of our fear so we will be able to get out of the house, but without making significant connections when we are out, no dosage of Prozac will make any appreciable difference in lifting the quality of our lives. Further, we must not wait for our depression to be over so we may then engage the world, we must know that only in venturing into the world of vital and nourishing relationships will we be able to generate and sustain the energy to minimize or transcend depression and develop the habit of being empowered.
Depression is being dominated by the fear of self-expression. Depressed persons have come to believe that if they let themselves say or act out what they feel, then bad things will happen to them. Jerry longs for people to pay attention to him, but he is afraid to insert himself into the stream of human interactions forcefully enough for persons to know he is there and need to interact with him. He is looking for the world to be the good mother and anticipate his needs, responding to him and give him recognition and affection without his needing to ask. Consequently he is perennially disappointed--and depressed.
We need to go through training for expression. Perhaps, we could benefit from activities as varied as dance classes to assertiveness training to taking our turn at the mike at Twelve Step meetings. This does not mean that the mild-mannered should become bulls and the timid, aggressive sales-persons, but only that everyone needs a form of self-expression that fits him or her as their modes of connecting with the world. No-expression equals no-connection and no-connection means the failure to rhythmically interact with the world. Without this, there is depression, for in depression the organism is seeking to survive within itself, by itself. This is a useful and protective position for a very limited time, but sustained over a period, what is a natural withdrawal for resting and renewal, becomes a stuck hide-out which results in depression.
Be Gentle and Patient with Yourself
Depression is a fact of life. Anyone sensitive to life's fluctuations and to their own limitations for keeping-up, anyone capable of experiencing loss and being caught with unprocessed grief or anger will from time to time experience depression. Some are more susceptible than others, having a specific sort of chemical imbalance due to genes or other biological influences. Others suffered so much in growing up that depressed responses to loss and stress became installed in their ways of being. Changing takes time, and effort, and will. We make progress and we regress. Bad enough to fall back into depression without compounding our unhappiness by laying on ourselves expectations of urgency or unattainable ideals. There is nothing depressed people need more than kindness. And we need first to learn how to be kind to ourselves, to embrace ourselves as a worthy cause for understanding, compassion, and the creation of an effective program for feeling good.
I have in my desk a Peanuts cartoon 38 years old. In it Lucy is complaining about being depressed and Charlie Brown is telling her not to be so upset because life has "its ups and downs." Lucy replies that she is not interested in "downs;" she says, "I only want Ups, Ups, Ups." For more than forty years Charles Schultz has been helping us live "up," not Lucy's way, but Charlie Brown's. Charlie has taught us that even though his team never wins a baseball game, he keeps coming back every year, loving the game, surrounded by his so contentious and loyal team. He keeps pitching rain or shine.
Robert Caldwell, M. Div., is a Certified Professional Counselor and has a private practice in Individual, Couple, and Group Psychotherapy in Bethesda, MD. He can be reached at (301) 652-6180.