Depression: denial, help and formal support
Several years ago I sat in a lecture hall expecting to hear an academic lecture on depression. Instead I listened to two very attractive people describe their experience of being depressed. The first speaker, a high powered television executive described how during her journey to work one sunny day she found herself crying uncontrollably for no identifiable reason. She stopped her car and eventually she was able to turn her car around, return home and go to bed. She remained in bed for several weeks. During this time she became familiar with the totally debilitating experience of depression. She had no idea why leaving her bed to go to the bathroom became such a frightening journey. She was diagnosed with clinical depression, and with psychological and medical help she recovered.
The second speaker was a very witty intelligent American, Andrew Solomon. He indicated that he was in remission from the assaults of this cruel invisible illness, depression. He has described his experience of depression in a book entitled ‘The Noonday Demon’. In the opening lines of the book he tells us about the impact of depression on his life:
“When it comes, it degrades one’s self and ultimately eclipses the capacity to give or receive affection. It is the aloneness within us made manifest, and it destroys not only the connection to others but also the ability to be peacefully alone with oneself.”
In the introduction to his book, Solomon gives his desire to understand more fully the nature of his illness as one of the principal reasons for writing it. I share this desire to understand why depression can appear in one’s life and, in extreme cases, destroy life without any apparent warning. A high proportion of those who suffer from depression have experienced loss or trauma. These experiences may have been forgotten, trivialised or relegated to the unconscious, and as a result have not been worked through and may be triggered at any time.
We live in a culture that has ambivalent views about depression. There seems to be on the one hand a silent sympathy and on the other an apparent dismissal of those who suffer from depression, that they are really just ‘malingers’, weak, lacking in character. This attitude seems to persist in spite of the many successful and courageous people who openly admit their propensity to suffer from the illness. I am impressed by the number of people who have spoken out and remind us that the illness attacks the famous and those of us who are unknown. Some famous names include Winston Churchill, Princess Diana, Freddie Flintoff, Robin Williams and Gwyneth Paltrow.
What is depression?
Perhaps it is important to begin with to make a distinction between the occasional bout of the blues that most people suffer from and full on depression. There are different intensities and longevities in depressed moods but the formal definition suggests that the really clinically depressed suffer relentless low mood for at least two weeks. During this time there is a loss of interest or pleasure in nearly all activities. To elaborate: for a person to be diagnosed as clinically depressed they will have a group of symptoms continuously for two weeks. There are nine symptoms noted and these are:
- Depressed mood most of the day
- Diminished interest or pleasure in life
- Significant gain or loss of weight
- Inability to sleep or sleeping too much
- Reduced control over bodily movements
- Feelings of worthlessness or guilt
- Inability to think or concentrate
- Persistent thoughts of death or suicide
Malignant sadness (L. Wolpert)
Anxiety is sometimes treated as a variant of depression, while at other times it is seen as distinct. The imagined fear that something really threatening is going to happen may be accompanied by feelings of social withdrawal, difficulty in sleeping, concentrating or fatigue, but does not necessarily have the other symptoms of serious depression.
Denial of depression
Surely anyone suffering from some combination of these symtoms would know that they were depressed? Surprisingly this is frequently not the case. As stated above there is a huge taboo around any mental disorder; the sufferer is often ashamed and family and acquaintances are too sensitive or worried to talk to the sufferer.
The seriously depressed person may internalise negative cultural attitudes and hide the illness from themselves as well as from others. This denial can delay, if not prevent, seeking help. It would seem that many people adopt the ‘stiff upper lip’ solution, finding a way to persuade themselves that they are really fine. This ‘toughen it out attitude’ is much admired and may result in months if not years of silent suffering until the sufferer is unable to function. We so often find plausible explanations, other than depression, for chronic low mood, loss of energy, social withdrawal, sleeplessness, loss of appetite, inability to concentrate and for other associated symptoms.
It is so important for the sufferer to recognise that there is no more blame attached to depression than there is to having a broken arm or a tooth-ache. It is an illness that comes like a thief in the night, uninvited.
Help with depression
Perhaps the most important help that we can have is the presence of others that we can trust, talk to openly, honestly and without shame about our suffering. It is quite clear that the feeling of support from those around us who can listen, not judge but simply warmly accept us, is a crucial part of the healing process.
It is now well accepted that exercise, yoga and an interest that gives focus and offers an alternative creative way of viewing self and ones life can be helpful. It is also true that without support we may spend our time escaping temporarily into the oblivion of an obsession, e.g. drink, drugs, gambling or anything that will suspend the loneliness and the hopelessness for a short time.
Cognitive Behaviour Therapy
CBT is now widely considered to be the most effective therapy for depression. It points to the interdependence of behaviour, thoughts, feelings, the body and our environment.
This theory draws our attention to the relationship between what we do, what we think, what we feel and our surroundings. It points out that the mind of the depressive is totally biased against itself. The theory points out that the logic of the depressive is fundamentally misinformed, it is false, erroneous.
All our thoughts are accompanied by feelings and visceral sensations; they tell us what to do, how to respond to life. So we set up a circular pattern of negative thought, feelings and actions that feed off each other. For therapy to work this cycle has to be challenged and broken.
To illustrate, with a few examples, how this can work in practice:
- The depressed client claims her mother does not love her anymore because she postponed her promised visit. A negative meaning is given to the mothers action and ignores other explanations which in turn lead to feelings of rejection and abandonment. This in turn can lead to anger and a withdrawal of contact.
- A client complains of being turned down for a date. He then concludes that he is unattractive, a failure and becomes demoralised which in turn can lead to a loss of confidence and avoidance.
- A mother complains that her child is doing badly at school so she believes that she is to blame and that she is a bad parent. Again the thinking is narrow, self-critical and ignores all other explanations.
This destructive, negative, self-critical blaming behaviour is learned and so can be unlearned. Our experience of life has conditioned us to think and feel the way that we do. We have to find a way to decondition ourselves and be free to accept ourselves as we are with love and compassion.
Acceptance of the way we are is the first essential step in change. Only then can we change. The good news from studies of the brain is that what we do actually changes the structure of the brain. If we can find a way to change our behaviour and our thought patterns we change our brains and our lives. Therapy seeks to do this.
There are a number of different models of therapy that can be helpful.
Cognitive behaviour therapy and mindfulness
Some CBT therapists have found the ideas drawn from mindfulness helpful. Mindfulness has developed from Eastern thinking, in particular Buddhism.
When combined with CBT it is a very productive way of gaining an understanding of the problems that get in the way of our lives and help us to accept these problems with love and kindness. The practice of mindfulness meditation helps to switch off the relentless automatic critical mind. It helps to develop clarity in our thoughts. Importantly it helps us to let go, to realise that we can separate ourselves from our depression. These qualities are missing from the depressed mind. In terms of unlearning some of our habitual automatic responses in our daily lives we come to see just how profoundly we have been conditioned.
Psychodynamic therapy assumes that we are deeply influenced by our past and so it helps the client to reflect on early relationships as well as current ones. It is assumed that aspects of our contemporary relationships are unconsciously playing out of forgotten relationships. Some of us are quite aware of this. The woman who states “I cant believe this but I am just like my mother. I swore that this would never happen”. A youngest son returning to the family finds himself taking on that role well into his adult life. It is as if the past is controlling the present.
It is likely that the psychodynamic therapist will include reflections on the past as well as inquiring into current relationships. It is assumed that understanding and helping the client to make connections between life now and the past will help the client to work through the problematic issues.
In practice therapists are likely to use a combination of methods. It is clear that the most important part of therapy is the intimate relationship between therapist and client. When there is a good working relationship based on a warm non-critical acceptance, the therapy is most likely to work.
The drugs that are prescribed will vary with the type and the intensity of the depression. Millions of people are helped to manage their lives with the help of prescribed drugs. It is unfortunately also true that some prescribed drugs bring little relief to the sufferer but can have powerful negative side effects.
If you are suffering from depression do not hesitate to go to your GP for help. If the prescribed drug does not suit, request another. Have the courage to keep experimenting until you find the right one. This is difficult, it requires confidence, determination and a belief that you deserve to be treated with kindness and compassion. Finally you can learn to develop your sense of entitlement which will allow you to seek support without anxiety.
There is no shame or blame in depression but the critical self can make the pain worse by non acceptance and an absence of love.
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