Depression (from a variety of perspectives)
Rees Chapman, Ph.D.
If depression is a disease (as it is regarded by adherents to the medical model, most psychiatrists, drug companies, and statisticians), it is an incredibly complex, dangerous, and often treatment-resistant disorder. Indeed, a severely depressed person is virtually always a wretched pariah, whose self-neglect and self-sabotage place them at serious risk of self-destruction. The DSM diagnostic criteria for a major depressive episode are a catalogue of misery:
- depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
- markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
And there are many theories which attempt to explain the signs and symptoms of depression as originating in some pathological process, biological or mental:
- significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Neurological: decreased limbic neurons lead to slower reactivity and depressive symptoms. Smaller ventromedial cortex, less activity in the prefrontal cortex, deficits of subgenual cingulate region
Neurochemical: imbalances in the brain with regard to the neurotransmitters serotonin, glutamate, norepinephrine, and dopamine
Endocrine: thyroidal and adrenal deficits, decreased estrogen or testosterone, hypothalamic disorder
Genetic: tendency or vulnerability transmitted from generation to generation
Psychoneuroimmunological: diminished hippocampal function compromises immune system, which adversely affects mood
Chronobiological: seasonal affective depression
Psychodynamic: loss, "anger turned inward."
Behavioral: a low rate of positive reinforcement
- disruption of a caregiving relationship with a primary object characterized by feelings of helplessness and weakness (anaclitic)
- depression: sense of failure to meet their own standards or the standards of important others (introjective)
Cognitive Behavioral: maladaptive, faulty, or irrational cognitions take the form of distorted thoughts and judgments
Interpersonal: negative interpersonal behaviors induce rejection, which worsens mood (Coynes)
- negative thoughts, generated by dysfunctional beliefs (Aaron Beck)
- irrational beliefs tend to take the form of absolute statements, "Musterbation" (Albert Ellis)
- external locus of control and a low sense of self-esteem (Julian Rotter)
- self-recrimination and self-blame, low self-efficacy (Albert Bandura)
- learned helplessness (Martin Seligman)
Gestalt: retroflected, unsatisfied needs
Transpersonal: incapable and powerless self-image, "biophilous" loss of energy
Lifestyle: abusing drugs and alcohol, overwork, poor diet (including excess caffeine or sugar), lack of exercise, poor sleep, lack of leisure time as well as fun and recreational activities
Environmental factors: disasters, pollution, etc.
Again, these all reflect the assumptions of the medical model, or some variant that regards depression as a disease and/or a disorder. But what if depression begins as a normal response to the expected crises and conflicts of life, and becomes increasingly problematic and disabling as we respond in maladaptive or self-impeding ways to natural feelings of sadness, disappointment, and loss? What if the very process of denying and numbing ourselves to life's emotional pain exacerbates it, and transforms it into pathology?
When forest rangers stop every minor fire that crops up in a woods, brush and debris accumulate. After many years, any little fire that is not quickly controlled becomes an inferno, and roars out of control to destroy many square miles of forest. In the same way, the naturally occurring bends and curves of great rivers lengthens the time required for ships to travel along them, so the channels are straightened; this renders floods far more destructive as the water - like the ships - rushes much more rapidly downstream.
I have had clients begin therapy when they realize they've had no feelings, neither sadness nor joy, in many years after the death of a loved one. Often, they have been prescribed antidepressants by their family physicians, when their grief has not ended soon enough for them (or their families, or their employers). Indeed, after a few weeks, certain antidepressants will numb the pain of loss, and the person seems to be functioning better. But, upon weaning themselves off the drug, they often find that the grief has not been eliminated - it has merely been rendered dormant - and it returns.
The initial process of depression, wherein our psychic energies diminish and we begin to inhibit and restrict ourselves, is an adaptive response to situations and circumstances which are otherwise unmanageable. When we cannot see a way to solve a problem, our reflexive fight-or- flight reactions kick in, but they are largely ineffective, because the problems which provoke such mood states cannot be fought, not can they be run from. Our best options are to "let our sails luff," to "curl up in a ball" but roll nowhere, to withdraw into ourselves and invest little or no psychic energy into solving problems. But we live in a culture where these natural and beneficial adaptations are discouraged, regarded as evidence of character weaknesses and failure. So, we fight the self-inhibition and passive acceptance in an effort to pull ourselves out of the emotional doldrums. We need to be depressed, but we will not allow ourselves to be. As we battle our own innate depressive processes (and are ultimately unsuccessful), helplessness becomes hopelessness, dysphoria gives way to agitation, and we begin to doubt and loathe ourselves. This is when we are more likely to seek professional help.
Most psychiatrists (and many therapists) have little understanding of the adaptive secondary gain of depression - it's a disease, of course, a disorder to be corrected. They prescribe drugs which interfere with the balance of neurochemicals to disable the self-inhibiting processes. They believe they are "treating the disease," and often they are, in that the depressive process is diminished. But in a minority (but significant) number of cases, the elimination of depression actually provokes even worse psychopathology. For example, a wife who has, for many years, responded with depression to chronic mistreatment from her husband, kills her abusive spouse on an antidepressant; this is regarded as an adverse side effect, but is really her acting on her fight-or-flight reaction which is lo longer inhibited by depression. In another example (more frequent in recent years), a previously depressed teenager becomes more agitated, more hostile, and more impulsive a few weeks after beginning antidepressant medication; the drug is allowing chronic feelings of rage - previously inhibited through depression - to be expressed directly instead of being "bottled up." These are disinhibitive responses to antidepressants, and skilled psychiatrists will ensure that there is no secondary gain from a patient's dysfunctional mood that would manifest as some other even more pathological dysfunction once the depression is disabled, before prescribing such drugs.
Although a large proportion of psychiatrists attribute depression to a "chemical imbalance," and suggest that it is genetically predisposed and biologically driven, this belief is largely contradicted by the fact that a significant number of patients remain emotionally dysfunctional while taking the drugs. It can be argued that the "chemical imbalance" that accompanies symptoms of depression may be more of a consequence than a cause of the disorder. Even more challenging is the empirical evidence, found with some consistency for decades, that depression generally responds as favorably to psychotherapy as to psychotropic medications. And a recent study showed that while 60% of patients receiving antidepressants improve, 40% of those treated with a placebo do as well.
There are psychotherapeutic treatments of depression which regard mood conditions as natural phenomena, not necessarily disordered. In interpersonal therapy (most strongly supported empirically), depression is seen more as an adaptive process gone awry than a disease, and more effective means of adapting are encouraged. Gestalt therapy might invite the client to be more aware (and accepting) of the causes and consequences of his/her mood, and to experiment with other ways of utilizing depression that are more healthy. Forms of Naikan therapy from Japan, in addressing depression, facilitate introspection regarding the benefits that such mood states bring, and how to derive more from their gifts.
When I begin psychotherapy for clients with depression, I assess risk factors (such as suicide potential), and identify signs and symptoms which support the diagnosis. I am likely to use some assessment measures to better understand the dynamics and etiology of the depression. Early on, however, I set aside the medical/disease model and switch to a humanistic view of the person. I might ask the client to imagine how his/her life might be different if he/she wasn't depressed, and I will sometimes ask directly "what might your depression be doing for you?" I invite him/her to try to grasp the "wisdom of your feelings," and to imagine how that wisdom might be better honored, through letting go of unresolvable problems, coping more effectively with crises, or making changes in relationships and/or him/herself. Quite often, this determines the direction of the therapy that follows. If he/she lacks the insight or emotional strength to introspect and take more responsibility for his/her depressive processes, I will initiate more generic therapeutic approaches, and I may refer him/her back to the physician for medication. But if he/she can grasp the concepts of emotional wisdom and recognize it within him/herself, I will support and facilitate further self-exploration, self-acceptance, and self-empowerment.