Addressing The Problem

Where to Begin

A good analogy to major depression is heart disease. Heart disease is caused by a variety of factors, including a genetic predisposition, emotional factors like how we handle stress, and habits like diet and exercise. You don't catch heart disease from an infection. You develop it gradually, over time, just as plaque builds up in your arteries. Once you cross an invisible threshold marked by standards of blood pressure and cholesterol levels, you have heart disease, and you have it for the rest of your life. Depression may be a similar threshold disease-genetic and biochemical factors may determine a different level of stress for each of us that, once reached, puts us over the edge into depression. Childhood trauma, stress, and loss may bring us closer to the edge.

Some stress pushes us over into our first real depression. Once over the line, we can't go back. We "have" depression. We can recover from episodes, we can modify our lifestyles to prevent or moderate future episodes, but we "have" depression.

Unfortunately, a lot more is known about the treatment and prevention of heart disease than depression. You can change your eating habits, your exercise habits, and your stress level and reduce your risk of heart disease. No one seems to know how to reduce your risk of depression. There are many effective medications and some surgical procedures that can reverse the effects of heart disease, restore you to near-normal functioning, and reliably reduce your incidence of another attack. Although there are medications and treatments that help depression, no once knows whether they effectively reduce the risk of future episodes, and opinion is divided whether they can return you to normal.

Since no one seems to really understand depression, everyone feels entitled to an opinion. You have no way of knowing your physician's advice is any better than your wife's, your clergyman's, a mental health professional's, or the guy walking down the street. But the truth is that experienced, open-minded therapists actually know a great deal about how to help people recover from depression.

One of the essential elements of psychotherapy is trust. The patient is open and honest with the therapist in return for an implicit contract that the therapist will use his special knowledge only to help, never to harm, the patient. For many adults, the therapeutic relationship is the only one in which they can let their guard down. Depressed patients are almost always full of guilt and shame. They haven't lived up to their own standards. They feel like failures. They feel that they've let their loved ones down. When the therapist hears the guilty secrets and doesn't run from the room screaming in revulsion, healing begins. The acceptance of the patient as a worthwhile individual, even though he's not perfect, is crucial for the patient to overcome his pervasive guilt and shame.

Another essential element is emotional engagement and support. The depressive sufferer does not usually communicate the depth of his pain and fear to those closest to him. It may be that he wants to protect them; it may be that he fears they will reject him. He bites back on his feelings and tries to pretend they aren't there. If he shows them at all, he usually gets advice from those around him that is less than helpful. Others are quick to give advice because they, like the patient, are afraid of the need and pain.

The good therapist, at this stage, doesn't give advice. He shows by example that the feelings are not to be feared; in fact, he probes and goes deeper. He lets the patient know that depression is a process that has a life of its own, that there is good reason for hope because depression does end, but that feelings are important. Sometimes all the therapist can do is hold the patient's hand, while they wait for the medication to work. Often there is no one else in the patient's life who can do this.

Once trust and support are relatively stable, the healing work of psychotherapy can begin. Many aspects of the individual's functioning can change with treatment. These aspects can be grouped into five major areas: how emotions are experienced; patterns of behavior; thought processes; relationships with others; and how the patient feels about himself. Each of these aspects will be discussed in detail in the coming pages, but here is a brief overview.

Emotions.

People with depression have learned self-defeating ways of handling emotions. Some people seem to be frightened by all emotions, cold, intellectual, and afraid of human contact. Many depressed people have particular trouble with anger. They feel they should never get angry, so they bite back on it until they can't take any more, and then explode. Those nearby can't understand the explosion because they don't know all the little frustrations that led up to it. The depressive then gets even more depressed because he feels he's lost control. In therapy, these emotional patterns must be challenged, and the patient must learn that intimacy doesn't lead to being engulfed and that anger doesn't lead to violence. This is often played out in the relationship between therapist and patient, where the patient feels safe enough for the first time to experience trust and anger without running away or being destroyed.

Behavior.

The depressed person often must also change patterns of behavior that lead to a depressed lifestyle. Most depressed people are perfectionists. They feel that if they don't do a job perfectly, their entire self-esteem is endangered. Often this leads to procrastination. The job is really never begun; outright failure is avoided, but the depressive knows he's let himself down. Then again, depressed people want to make themselves over from the ground up: they want to lose 30 pounds, run five miles a day, quit smoking and drinking, get their work completely reorganized, and have time for relaxation and meditation. It seems like there is so much to do that they never start; or they may start one day in a burst of energy that gets dissipated in so many directions that nothing really gets accomplished, and they are again confirmed in the belief that there's no point trying. We have to learn that attaining more limited, realistic goals is much more satisfying than building castles in the air.

Thought Processes.

Cognition, or the way we think, must be changed. We get some assumptions from our parents, we develop others as we grow up, and we continue to add to and revise our beliefs about what makes things tick into adulthood and old age. Depressed people tend to have certain assumptions in common, which are self-perpetuating and not corrected by experience.  We think that we are responsible for the bad things that happen to us, while the good things are just accidental. We are pessimists, thinking that things left alone will usually go to pieces rather than working out for the best. We think that we have to be in control of things at all times, and if we're not, disaster will happen. These habits of thinking are largely unconscious. They must be brought out into the open, challenged, and changed for the depressive to recover.

Relationships.

Relationships with other people are always difficult for the depressive. We walk around with a vast hurt inside and long for someone to heal it, but we're also ashamed of feeling that way, so we don't let anyone know. We care too much about how others feel and think about us, but we're afraid to let them know we care; consequently we're almost always disappointed. Always expecting rejection, we may reject first as a defense. Our boundaries are too permeable, so that we often assume others know how we feel, and that we know how they feel. Despite the fact that we're often wrong about this, we don't learn from experience and stop making these assumptions.

The Self.

Depressed people don't have inner resources of self-esteem that help them get through trying times. We look to others to replace those resources but know that such wishes are unfair and unrealistic; consequently we are consumed by shame and guilt. We want desperately to be loved, but feel we are unlovable. We haven't been able to determine principles and values for ourselves, nor to guide our lives by rational priorities, because we're so guilt ridden that every detail seems important; we can't afford any mistakes. We can't feel good when we accomplish a meaningful goal because all goals are the same. Depressed people need to learn how to set priorities, to take pleasure in our accomplishments, and to integrate that pride into ourselves.

On the next page we will examine the Emotions of Depression.