On Being Depressed
Depression is a common and highly complex phenomenon. Understanding means listening to both the subjective experience of an individual as well as weaving together the threads that are common to those experiences. It also means looking both within the mind and body of the individual and at the social systems (past and present) they are embedded in —thereby integrating theoretical and research contributions of psychoanalysis and neuropsychology.
Threads of experience:
The two essential elements of the depressive experience relate to a person’s self view/self representation and their mood (Milrod, 1988). When a person is depressed, they are not simply in a state of sadness where they cannot experience pleasure or joy. A depressed or low mood is more pervasive, and gives rise not just to sadness but also guilt, self-pity, hopelessness and anger. It is a mood in which a person cannot access pleasure or gratification in the present, nor remember it in the past or imagine it in the future.
The way people relate to themselves is also impacted. A person in the throes of depression has a very low and negatively toned self-perception, viewing the self as incapable of change, responsible for or deserving of the situation they are in, unloveable and unable to maintain or create relationships. In brief, there are disruptions to the positive and effective sense of self, rather, the self is seen as helpless, failing and worthless (Blatt, 1998).
To begin to understand what is going on inside a person, I pay attention to the nuances of a person’s language, metaphors, silences, physical energy, and what is evoked in me as I listen or bear witness to their pain (all the while trying my best to hold preconceived clinical notions to the side). “To be on the outside looking in”, “to be in the dark depths of a pit I can’t see out of”, “to be adrift at sea” — these are just a handful of descriptions of the lived experience of depression that I’ve heard firsthand or read via first person narratives. These offerings describe the phenomenon more vividly than the DSM, they serve to pull me in to the experiential field and make contact with what is devastating and frustratingly hard to pin down through discourse. Weaving together some of the rich and evocative descriptions, we might begin to understand depression as an illness of isolation, loss and detachment.
Mediating forces:
There is, in fact, a vast body of research and theory that connects depressive feelings and thoughts to the psychology of attachment and social loss. It begins with Bowlby (1969, 1980) who speaks of depression as a form of distorted mourning, where a person grieves the real or imagined loss of an attachment figure (in psychoanalytic terms: “object loss”). He originally theorized that experiences in childhood that make a person vulnerable to depression include never forming a secure early attachment (having a parent who is either unavailable or critical/punitive) and also include the real death of an attachment figure. In both cases we see cognitive consequences — in the development of models of ‘others’ as rejecting or absent and ‘self’ as unlovable or unworthy- and the corresponding affective experience of grieving the actual or imagined loss (i.e. grief for what I never had) of an important other.
Investigation into the neurobiological correlates of depression confirms a central role of attachment/separation neuro-pathways in the experience of depression. Mammalian brain systems that mediate experience of attachment and loss are activated when mammals get separated from attachment figures who are critical to survival (Solms, 2012). When mammals are separated their brain produces chemicals that correlate with feelings of panic and distress, they are driven to protest, engaging in seeking behaviors to ensure reunion with important others. When protesting fails, the evolutionary conserved mechanism shuts down protracted separation distress (“gives up”) because the metabolic cost of panic is too high. The result is lowered motivation or inhibition, despair, helplessness — but this depression like response serves an adaptive function as it protects mammals from behaviors that are potentially dangerous, pointless and unsustainable (Watt & Panskepp, 2009).
There is no known single factor theory of depression. We must consider that multifactorial neurobiological correlates and multifactorial developmental factors account for symptoms and pre-dispose a person to depression. “Traditional biological psychiatric perspectives are almost totally “bottom-up” (neglecting relationships between depression and social stress) and typically cannot explain why depression is such a pervasive problem, or why evolution could have ever selected for such a mechanism” (Watt & Panskepp, 2009). While commonly prescribed medications act on some of the pathways implicated in modulating emotional experience and provide some relief for depression and anxiety symptoms, relative effectiveness of SSRI medications is estimated to be around 50%. We know there is more to the story than brain chemistry so there must be more to the treatment.
Healing the self-in-relation-to-others
Because the experience of depression is shaped by both intra-psychic and interpersonal forces, we might consider that in order to effectively help a person survive the experience we must be working towards repairing what is damaged in human relationships and recovering what is lost.
There is considerable difference in the way psychotherapists working in different modalities conceptualize and treat depression though there are some commonalities. It can be challenging to distinguish between popular cognitive and psychodynamic models of depression because they both claim a manifestation of negative cognitions and emotions relating to the self and other, and both see depression as ultimately connected to attachment and separation, esteem and loss (Zellner, 2012). If we know that early experience of loss makes us more vulnerable to depression and we are evolved to feel bad when we are disconnected from others as a way to enhance survival, we can see the importance of understanding a person’s history of loss in relationships and of creating new patterns of relating in a safe and secure relational context.
Therapy should facilitate grieving or mourning as a way to process real or imagined loss that individuals suffer. Watt & Panskepp (2009) write that the most essential elements of effective psychotherapy for depression involve: “judicious and careful empathic exploration of hurtful losses in which patients feel fundamentally helpless to mitigate the loss or attendant feelings of rejection or abandonment precipitating depressive shutdowns, and the presentation to the patient of realistic options beyond “giving up”.
A supportive relationship may begin to transform the ways a person relates to (thinks and feels) about self and others (which, in depression, is characterized by negativity). Attachments are important building blocks of the self and it is in the context of empathic and attuned relationships that we can begin to explore and create space for new and healthy representations of self and other.
