by Bernard McDowell, lcsw copyright 2003
Feeling in a low mood
with low energy...even on days off? To the point that it
hurts and it seems hopeless to try making things better?
Do you find yourself with few interests or unmotivated to
take care of basics like doing the dishes? Or do you frequently feel
badly about yourself for failing at meaningful
relationships or being stuck in a senseless job? These
scenarios describe a few painful symptoms of what is commonly called
depression. But wait, doesn't much of the above apply to most
of us--at least some of the time? Absolutely! In
fact, there's no general agreement about what "depression" is.
By recent media accounts, depression is a mental illness
while the TV commercials of pharmaceutical companies characterize
“caused” by brain chemistry malfunction though there are
no clinical lab tests for it. Other perspectives portray
depression as everything from a common psychological reaction to normal
developmental challenges to a malady of the industrialized world.
Some scientists have argued that its simply a “behavioral”
failure to exercise facial muscles to smile often enough.
There's still active research in that vein.
GO TO SPECIFIC TOPICS IN THIS ARTICLE:
Dynamics Of Depression
To My Therapeutic Approach
is intended for orientation in
sorting through a maze of
possible therapeutic treatments for depression as well as an
understanding of the research and theories behind them. There
seems to be a different “theory” for every aspect of being human:
One emphasizes cognitive processes (thoughts and beliefs),
others family background (family of origin, ancestry, and culture), and
another behavior (exercising, smiling, and staying active).
Other candidates include internal psychological processes,
human chemistry (neurotransmitters), and genetics. Despite
their claims, none of these theories are well proven or mutually
exclusive. However, there is lots of evidence that many
people regain their vitality after periods of depression.
Here is an overview of different takes on depression.
While it reads coherently from top to bottom, you may benefit
by forwarding to a section of particular interest by clicking on any
topic in the box (above right).
| Recognizing Depression: How
Depressed People Speak About Their Lives
Depressed people may
or may not articulate it as such or even recognize it. Some
of the superficial signs are indicated by how we
talk about our lives. Typically, when depressed,
people say they're "down" or "in bad mood". This can spread
beyond a few days to the point of pervading much of life.
Even on days off, finding themselves in a “fog” half way
through the day, depressed people often report wanting to be out
enjoying life but unable to identify (or choose) something they would
really enjoy. Frequent self put downs are common along with
casual, almost innocent comments, "it doesn't matter to me", or more
serious statements about "just not caring anymore". Painful
indecisiveness with low self-esteem often oscillates with spells of
anger, anxiety, and/or lethargy. Two days worth of dishes
pile up in the sink and bills don't get paid on time.
Important appointments may be forgotten as the sense of a
future is blurred by a bad mood and a sense of hopelessness.
extreme levels of depression, people
feel inert, "shut down",
“numb”, or overwhelmed with feelings of despair. Perhaps,
they stop showing up for work, ignore their children, or entertain
suicidal thoughts. Very restricted or flat facial expressions
are common. Feelings of shame may be easily triggered.
Along with very poor self esteem, they typically have
difficulty asserting themselves or even knowing what they want.
Obviously, any of this may devastate families and finances,
though the basic tragedy is the loss of the depressed person's ability
to enjoy the marvelous adventure of a fully engaged life (though for a
depressed person that seems an extremely remote possibility). Recently
the World Health Organization reported that “depression is the leading
cause of disability… and the 4th leading contributor to the
global burden of disease….” The project that ranking to move
to 2nd by the 2020. In treating depression, it is often
critical to distinguish physiological conditions of low energy such as
hypo-thyroid or post partum hormonal conditions from psychological
issues. There are many other factors to consider in a good
"differential diagnosis" which distinguish depression described here
from other conditions such as bi-polar (manic depression) which are not
specifically addressed in this article.
| Deeper Dynamics Of Depression
From the perspective
of a large bodies of research and theory often referred to as “depth"
or "object relations" psychology, the symptoms of depression don't fall
out of the sky like some invading virus rather they are simply clues to
deeper though common psychological dynamics. Elsewhere on
this site, you'll find articles examining those dynamics in much
greater depth including how a healthy sense of self grows and how that
process can go awry into depression. In brief, those dynamics
include glitches in incorporating and/or maintaining the ability to
recognize and pursue what interests us.
When people are
clearly aware of what really excites them in life (their needs,
interests, desires, etc.), they will be in motion towards
fulfillment of those needs. Imagine that for some
sudden mysterious reason you had no food available to you for a few
weeks. Now what will happen if for some odd reason, you
happen to come into my office and there is a beautiful buffet of your
favorite foods. Of course, most people will go
directly for the food! We might say needs (e.g., hunger) seek
fulfillment (food in this case). Then is it merely a matter
of identifying and asserting our needs to feel fully alive?
Well, there's a big catch-22! Some of our
needs conflict with other needs we have-most particularly,
our needs in relationships. For example, we may want to reach
out to someone to make a new friend, but also want to look cool and not
look like a needy fool. A child may need connection with a
parent who often rages at the child for expressing herself.
The child needs individual attention from the parent but may
need a peaceful household even more. When presented with the
scenario above, really depressed people rarely say they'd go straight
for the food. Instead, they wonder if it would be all right
if, they “might possibly”, “if it wouldn't be too much trouble” have
some food. That is, they are so oriented towards others, it's
as if they quickly lose track of their fundamental needs.
When we pursue our needs (or what jazzes and excites us), we
might find fulfillment but we also risk loss-rejection, failure, etc..
[By the definition used here, losses are any
Consider a man who
doesn't ask someone out on a date or a woman who doesn't try out for a
part in a play or apply for a promotion--for fear of embarrassment or
rejection. The woman avoids a specific loss but isn't moving
with her natural inclination. In fact, both this man and
woman are likely to be depressed sitting at home on the couch.
Now imagine that the woman did try but failed to get what she
wanted; and then swept the losses “under the carpet” while copping
attitudes: “I don't care”, “it didn't matter anyway”, or “it
hurts too much, I'll never do that again”. Now, she may
diminish her hurt or escape the pain of further rejection, but,
remember that since losses are unfulfilled needs, she has also pushed
her needs under the carpet; that's why she's saying that it
We might also say she
has “self abandoned”-she focuses so much on what
others think, that she abandons her own vital desire. In
effect, she's pushed her “self” under the carpet. Now, out of touch with her needs and to avoid further loss,
she stops asking people out or nurturing her secret dream to be in a
play. Perhaps, only half realizing it, she avoids
future losses but by not going for what she wants.
When such a tendency gets entrenched, depression results.
Some people do that and simply grow numb with a flat
emotional life. Others know very well that they are hurting,
but, in an habitual, though unconscious reference to others' responses,
their heart's desires are no longer in sharp relief.
|A Quick Tour of Depression
Through the Life Cycle
some, problems maintaining loving connections while asserting
needs take root very early in life; but as we'll see the
same basic dynamics continue through the life cycle, with
pitfalls and potential leaps forward all along the
developmental pathway. The emphasis here is on childhood because it's just
simpler to explain the basics beginning with
early childhood. Hundreds of experiments have
been done tracking interactions between mothers and infants
by photographs or videos every tenth to every 30th of a second.
If, when a baby moves its facial muscles along
with `goo-gooing' sounds, the mother `goo-goos' back, then the baby can repeat what
it just did by making the same sounds and facial movements.
But if the mother doesn't mirror/respond to the baby enough, the baby
generally wont' be able to reliably repeat those
Not only our
physiological ability to move our facial muscles but also
health is much more like a living system that needs energy inputs as
well as creative outputs. Many research studies corroborate the
role of mirroring in other aspects of child development
including the emotional realm. Imagine a toddler overcome
with anger. If the parent yells, “one more word out of you and
I'll knock you across the room”, the child either forever inhibits
or forever acts out anger trying to come to terms with those
overwhelming feelings. On the other hand, if a parent greets
the child's tantrum with attunement and, ideally, some calmness,
that child learns to name anger and express it appropriately.
"Come over here. Hey, you're so angry, that must
hurt". Even if begun in an irritated voice, when the
parent shifts to a soft soothing tone, the
child learns to name it's chaotic feelings as anger
and downloads the ability to soothe itself. One
technical psychological term holds that the child “autonomously
incorporates” those abilities. These examples address physical
and emotional development, but we have yet to highlight how the
essential ability to identify what excites or interests
develops-without which we'll feel depressed.
A Crucial Aspect Of Depression: How We
As we grow up,
demands to navigate the world on one's own increase and, with that, the
need to identify as an independent person intensifies.
As with physical and emotional abilities, only with
mirroring can children incorporate
a sense of self, a sense of choice--to go along with parents'
demands or not; to give love and affection or not; or to identify and
pursue desires and needs. Parents must certainly give strong
directives to younger kids; but without some “mirroring” for their
emerging “sense of self” and acknowledgment of their particular tastes
and preferences, children will not grow up with a fundamental sense of
their unique needs, self-worth, and choice. It is only with a
sense of choice that we can truly give and feel vibrant. Acting
out of obligation (should, have to, etc.), people feel resentful,
drained, and sluggish. Our “identity” grows from the ability to
differentiate our needs from others and that is essential for
vitality and movement towards goals
At adolescence other
critical challenges come: The need to explore what we like or don't;
to experiment, fail, and succeed in determining our needs relative
to parents and peers. A classic setup for depression finds an
adolescent in the position of care taking for an already overbearing
parent. The teen needs the parents approval, financial support, and
guidance but now has to suppress her needs in favor of the parent's
needs. This teenager doesn't get a chance to go through the
typical exploratory phase required to differentiate her thoughts,
preferences, and choices for leading her own life. Frequently,
a teen in this situation grows into a depressed adult. The
point here isn't to focus on particular childhood situations
associated with depression but to underscore the dynamics of how
children learn to distill out their needs from others' influences or
very likely suffer depressive consequences. Without the
ability to differentiate from peers, adolescents are quite
susceptible to bad decisions that their parents call “bad choices”.
But from this viewpoint the problem is more fundamental, they
really don't yet “have a self” from which to make choices, much less
good choices. Keep in mind these examples are given in broad
Most depressed people don't have
nearly as obvious or as dramatic family histories, but any number of
subtle interactions with caregivers with the best of intentions may
have similar depressive results.
Many adults become
depressed without any obvious prior history of family dynamics that
might predict it. Again, some kind of loss typically plays a
major role. It could be a layoff, a death, a child moving
away, a rejection for a job or a relationship, or a disabling
condition. Now logically, it may seem that someone who has
made it to adulthood would be able to keep a layoff in perspective.
But its not that simple. Rollo May, a famous
psychologist, noted that one hundred years ago, people valued
themselves through a variety of identifications
including their religion, nationality, or family background.
In this society the main cultural current places an enormous
emphasis on what type of work we do; and how much money we have
translates to how independent people perceive us to be. When
laid off from an important job, it is a tremendous challenge
to stay psychologically differentiated from
gravitational field of common cultural sentiments-“why isn't the
bum working”. Unemployed
people often hate going to parties for fear of being asked "what do you do".
Logically they know they are the same worthwhile person, but
emotionally it's hard for them not to internalize other people's
disapproval onto themselves. Of course, there are many other
variations of depression through the life cycle. Suffice it
to say that the same issues about differentiating out needs from others
as well as issues about loss are usually involved.
Quite often I've
heard very depressed people use the phrase, “I can't take another
loss”. But if we are in love with life, we will have
losses: No matter how wonderful a relationship
someone has, there will be important ways that the beloved won't
appreciate that person at times-not to speak of inevitability of
illness, death, etc.. That's a loss. Without the
ability to respond deeply and thoroughly through loss, people close
their hearts. Without the willingness to have a loss, no one
would ever try something new, travel, apply for a job, or paint a
picture. And when people stop following those heartful
impulses, its as if they've not only averted loss but abandoned their
very self. There is an esoteric saying that a “true person” is a woman
or a man with a broken heart. Of course, it refers to a heart
broken…open…to the risk of being engaged in life.
But who in this world of modern medicine teaches us
to grieve. Most of the culture is running from loss as fast
as possible with drugs, alcohol, and mindless distractions.
Yet the ability to feel a loss is crucial to maintaining self
worth. The woman who says yes but with resentment to every
request of a family member isn't acting unselfishly; rather
she suffers a lack of self. The man who doesn't ask someone
out for fear of rejection isn't just sensitive to the other's reaction;
he's avoiding loss but also avoiding himself.
| Defining Depression:
Practical, Psychological , Chemical?
Diagnostic and Statistical Manual
There is no
universally agreed upon definition of depression. The least
interesting and most shallow take on depression demands our attention
first because it has been adopted by virtually the entire
insurance industry in the United States. The
Diagnostic and Statistical Manual [DSM] lists depression among specific
"disorders" of individuals. For major depression, a person
must have 5 out of 9 on a list of symptoms for a minimum of 2 weeks and
meet a few other criteria [see DSM on this site]. That same
list is used as part of the diagnosis of several other “disorders”
including “Depression NOS (not otherwise specified)”, a catch-all
category often used when a client reports less than 5 symptoms.
The DSM has strengths
but also glaring weaknesses--it explicitly refuses any responsibility
to determine the causes for depression, yet it storms ahead with its
claims to define it properly. On a positive note it provides
a standardized base for; researchers all over the world can use the
same DSM criteria for depression so that comparisons between different
research projects may better fit into a collective understanding.
Many social critics,
writing in much greater depth about the landscape of modern life,
portray depression as a peculiarly modern problem resulting from the
alienation of industrial life. A great deal of twentieth
century literature portrays that along with a number of major social
critics. Indeed, counter to the notion that depression is caused by genes or neurotransmitter imbalances, depression rates skyrocketed
1,000 % in industrialized countries since 1945.
There are many
psychologists and writers who stand in stark contrast to the DSM's
superficial approach. For example, Thomas Moore notes that
clients don't come in with a list of symptoms rated on a 1 to 10 scale;
rather they speak of difficult complex issues such as loneliness,
inability to get out of bed to go to a meaningless job, gnawing
feelings of failure to meet family expectations or manifest their own
dreams, or the pain of searching and searching for a relationship that
never quite materializes. From that perspective giving
someone a diagnosis of depression by using the DSM's list is a
disservice; they aren't "disordered" but hurting in the face of normal
though painful human circumstances. (From a strictly
scientific viewpoint, the “empirical data” is the client's exact
wording, “loneliness” or “feeling devastated” after a breakup.
A typical managed care approach married to the DSM asks
clients to rate their “depression” on a 1 to 10 scale but that actually
strays further from the empirical data than speaking about “loneliness”
or feeling “devastated”.)
Similar to the
examples cited above, “psychodynamic” theories attribute chronic
depression to glitches in the development of a healthy self that, in
turn, arose within problematic relationships during childhood with
caregivers. Yet, a broader context comes from Carl Jung who
drew on thousands of years of literature and myth to understand the
human psyche. From that perspective, depression can be seen
as a central feature of the human psyche; again, not a disease, but a
developmental challenge. For example, The Fisher King Myth,
hundreds of years old, depicts a king falling into depression along
with his whole kingdom. But it also maps out, through the
story line of the myth, the elements necessary for the king and the
kingdom to regain their vigor. Some believe this is actually
a more scientific approach because these stories, told and retold
through generations, are less susceptible to distortion by business
interest or one particular person's ego. Their difficulty
lays in the wide spectrum of interpretation they invite.
Depression a Chemical Imbalance?
To add to the mix,
the pharmaceutical industry portrays depression as “caused” by
malfunctions in neurotransmitters. This vast topic requires
the evaluation of much scientific literature as well as an
investigation into the politics of health care. Because this
is a quite complex topic, this is addressed below along with other
At first glance, the
various explanations of depression touched on here seem at odds, but,
again, they are not mutually exclusive. It is useful to think
of each of these approaches as originating from a particular
predisposition as will be illustrated in the next section on different
types of treatment.
| A Few Notes
Comparing Treatment Approaches
psychological schools have emphasized entirely different aspects of
human experience. Unfortunately, each new school seems to
claim the unique and exclusive corner on the truth.
Fortunately, many types of therapy have been proven
effective. Psychoanalysis typically focuses on early
childhood for explanations of how patterns rigidify with the imprints
of our parents: In essence, you are you're history.
Cognitive therapy assumes that thoughts rule our mood and
motivations: In essence, you are your thinking patterns.
Popular a few decades ago, primal scream therapy promoted
wild and full emotional expression assuming 1) reservoirs of emotions
govern us and 2) venting them heals. (Research on anger shows
just the opposite). Psychiatric treatments presuppose that
you are your chemistry--a chemical soup that "causes" suicidal
feelings, feelings of worthlessness, low mood, or any of the other
symptoms of depression (according to the Diagnostic and Statistical
Manual). So, lets take a closer, though cursory look at some
“effectiveness” study ever done indicated that many types of therapy
are helpful. Also, a number of other studies show little
difference between different types of therapy while attributing most of
the success of therapy to the relationship between client and
therapist. The rapport between the client and therapist as
rated after the second session predicts the success of therapy better
than what the therapist specializes in.
relies on the assumption that “moods are created by thoughts”.
Each thought gives rise to an emotion. Depressed
people think in distorted, “downer” patterns-e.g., “all or nothing” or
“expecting the worst”. An isolated, self-berating client
might say “I never do anything right” or “I can't go that party,
they'll put me down and it'll just be boring anyway”.
A cognitive therapist challenges the client to be
precise and rectify the distortions in their thinking: “OK,
is it really true that you've never done anything right?”, “how do you
know for sure that they'll put you down or that they'll be boring
tonight?”. Of course, the client might begrudgingly admit
they have gotten something right sometime in their life. The
theory is that eventually, a person can change deeply ingrained thought
Many research studies
compared cognitive behavioral therapy [CBT] to other types of therapy
and to antidepressants. In fact, because CBT has been studied
so much, it is often proclaimed as the only “empirically supported”
therapy. Detractors point out that just because cognitive
therapy is simplistic and easily “manualized” to fit a research project
protocol comparing therapy to drugs doesn't count as sufficient reason
to recommend it as the best approach. It must be noted that
most of those studies are paid for by pharmaceutical companies with
vested interest in the outcome. In contrast, many therapy
theories guide therapists to continuously adapt throughout a session to
the client's concerns and, because of that very fact, are not moldable
to a standardized lab protocol! The key issue though is that
our cognitive functioning is only one aspect of the human psyche.
If logic won the day, I wouldn't be seeing a continuous
stream of couples both of whom are often lawyers or scientists!
therapy [CBT] adds suggestions for changes in behavior which also
“result” in depressed moods. Over the years, some have
expanded on the basics of CBT to include the “emotional implications”
of our thoughts. Though more sophisticated, those more
expanded versions of CBT actually begin to resemble other
“interpersonal therapies” and thus detract from the grander claims
cognitive theory had to begin with. (To be fair, it is
important to note that individual therapists who say they identify with
cognitive therapy may use many other techniques to adapt to each
client.) In a review of decades of research on therapy, "The
Great Psychotherapy Debate", Bruce Wamplold consludes that cognitive
therapy works but it's not because of what the theory claims; and
further, it works no better than other types of therapy.
Several studies show that when
people exercise vigorously for a number of months, they
have a better and longer lasting outcome than when on
antidepressants. So, is treating depression as
easy as prescribing vigorous exercise? Well,
there's another glitch! Though “loss of interest”
is just one of the symptoms of depression according to
the DSM-IV, it's at the very core of the problem as
outlined in the section above on the “deeper dynamics of
depression”. In fact, depressed people frequently
report how they've fallen out of their workout habits.
That's one of the very symptoms of their
depression! So prescribing exercise is
virtually like saying stop having that symptom!
Stop being depressed! There is a similar
problem with the basic premise of cognitive therapy.
Extremely intelligent, logical people, e.g.
trained as engineers, may remain depressed though
they've heard for years to stop putting themselves down
and to think and plan for a positive future--but the
logic of cognitive therapy doesn't motivate these
otherwise very logical people to stop their illogical
distortions about themselves. Many researchers
conclude that it's not the logic of cognitive therapy
that heals but the relationship with the therapist that
enables a person to take another perspective. And
that's where a deeper, integral look at the psyche is
There isn't just one
psychodynamic theory. However, there are many
similarities across a number of theories, so I'll
speak of them here in the broad strokes as one.
Generally, they focus on how our sense of
self develops. This thing we call “I” is a
deeply conditioned imprint that forms in our
relationships with others; in a sense it's a
coordinating center for how we think (cognitive), make
moral decisions, form a body image, and develop our
particular tastes (aesthetics). Rather than assume
“depressogenic” thoughts are the “cause” of depression
as cognitive theory does, psychodynamic interventions
assume there's a fairly stable way we represent our self
to our self--and that serves as a self fulfilling
prophecy. People who missed some important
mirroring as children will have internalized an image of
themselves as defective, hopeless, a screw up, or not
important enough to be heard; that “I” then continues to
produce depressogenic thinking patterns: “no body
is interested in anything I have to say, so why bother”.
Given the overwhelming demand on
a child to adapt to the parents, a child necessarily
forms a somewhat distorted sense of self which then is
then maladapted to the rest of the world outside the
family. Alice Miller, author of the Drama of the
Gifted Child, argues that healing from depression
requires recovering an “authentic” self. Along
with quite a few prominent psychologists of the last
century, she postulates that everyone grows a kind of
“false self” over the years to meet the most basic
needs of pleasing parents and avoiding
their disapproval, wrath, etc.. For physical and
emotional survival, kids necessarily adapt to parents'
needs, moods, etc. just as a plant bends towards
sunlight. That in itself doesn't constitute a
“false self”; however, when a child is overly oriented
to parents' needs to the neglect the child's particular
interests, the child's own needs simply don't come into
consciousness for the child.
So, how is this “false self”
explicitly traced back to depression? Complicated
theories aren't necessary to appreciate this.
Popular culture provides endless examples.
Sports pages chronicle how a father pushed his
football playing son to the extreme until that gifted
player fell into depression and drugs. Several
recent movies portray parents imposing their agenda on
children with a gift for music--but the children then
struggled to grow in that atmosphere dismissive of their
needs. The parents in these cases were almost
cartoon caricatures of people imposing their will on
young kids who could barely breathe much less assert
themselves. But we've all had difficulty asserting
ourselves at times even to the point of being depressed
or self hating for not standing up for our self to a
parent, a boss, a spouse, a store owner, a doctor,
Let's review a crucial chain of
concepts linking “needs” to depression as detailed in
the section above. When hungry we seek food.
That's a simple illustration that “needs seek
fulfillment”. When our needs (what excites and
interests us) are obvious to us, we are engaged in life.
But though all children have needs, a child's
ability to recognize their unique interests takes time
to grow. There is a great deal of research
indicating that happens through the process of parents
“mirroring” (acknowledging) the child's interests.
Again, unless a mother mirrors an infant's facial
muscle movements, the child can't repeat the very
movements it initiated. Psychological qualities
only take birth into a self image through mirroring.
A child only knows herself as persistent through
being “seen” from others. Of course, no parent
mirrors every child perfectly in every way and there are
pitfalls outside family life as well. Thus, we are
all somewhat hungry to be seen in a special way
throughout life. Some people tend to act that out
while others withdraw to protect the wounds of not being
Even very active and seemingly
self motivated people can become depressed.
The dynamics of their depressive processes do,
however, entail a similar loss of recognizing
vital interests which they somehow lost track of.
A classic example is a very successful person at
mid-life beginning to feel the hollowness of their
success. They may not recognize how they had been
guided by others' motivations internalized long
ago--dad's, an influential teacher, or the cultural
rewards for their performance; but now dissatisfaction
sets in. In a process that occurs under the
radar of consciousness for virtually everyone, they
hadn't distilled our their uniqueness from the cultural,
family force field. Another way that happens is
through an obvious loss--someone who has a failure in a
relationship or a series of losses whether at work or
home. Again, by the DSM definition, lack of
interest is just one of many symptoms of depression, but
from the psychodynamic viewpoint lack of interest is
virtually synonymous with being out of touch with needs
closely entwined with a highly valued sense of identity.
That's a little on understanding
about what psychodynamic theory concludes makes people
tick, but what does the psychodynamic approach suggest
for change? for healing the depression of this “false
self”? Decades ago, “psychodynamic” therapists
typically took a passive role with their clients.
The therapist said very little and offered no
analysis to the client for months or even years.
Such models relied heavily on the assumptions 1)
that clients benefit from gaining insight into how they
acquire their problems and 2) that the therapy affords
the client a chance to rework unhealthy parent/child
patterns through the relationship with the therapist.
But numerous therapists value the
core insights of psychodynamic theory while utilizing a
whole range of other interventions borrowed from other
therapy practices. These include such basics as
giving empathy and freely admiring a client's
accomplishments. But, at another turn, it could
take the form of challenging a client to take
responsibility for feelings they project with anger onto
a spouse or boss. The process might be
characterized as a mutual inquiry into how the sense of
self is still subtly blurred into parents and culture
while helping the clients distill out their own
feelings, opinions, and intuitions. Milton
Erickson, M.D., known for medical hypnosis, story
telling, and assigning tasks to clients, is considered
the founder of “brief therapy”, often characterized as
the extreme opposite of psychodynamic therapy.
However, Erickson argues that his assessments of
clients are properly considered “psychodynamic” though
he recognizes that his techniques of helping clients
achieve their goals are outside of traditional
psychodynamic interventions. (More on my own personal
approach to working with clients can be found at the end
of this article.)
Alice Miller's antidote to
depression is to “grieve” the loss of our authentic
vitality. Initially, that may seem an odd
tack. Why focus on how we disempower ourselves?
And grieving doesn't sound like a cure for anything!
But consider the opposite-a man angry and
depressed over a spouse, a parent, or “society”.
He sees the other as the “cause” and himself as
“at the effect of” that other. This can be quite
healthy to a point: The anger says “don't tread on me”.
But if he only stays angry, the spouse, parent, et al
remains the “cause” while he stays in the victim
position. The same is true for the depressed
perspective, “it's hopeless, there's nothing I can do to
change and I don't really care that much anyway”.
When focused on how others or life's circumstances
disempower him, such a man is at best a leaf in the
wind. If, however, he shifts attention to
how he betrays himself, he has the possibility of
stopping that pattern. When he examines how he
didn't listen to his own intuition, how he went
along with others' decisions to avoid loss, or how he
incorporated others' put downs, then there is a
possibility of reorienting towards learning the skills
(building the psychological muscle) necessary to do
Of course, it isn't useful and
doesn't make sense to imply that children betray
themselves because they are only growing a psychological
sense of self. Similarly if a woman is, e.g.,
sexually molested, it's not appropriate to suggest she
disempowered herself. However, as an adult it
becomes a useful concept to recognize “self
abandonment”, all the ways we disempower ourselves, when
it's a regular part of a pattern of interactions with
Yet understanding how we
disempower ourselves doesn't necessarily translate into
ways to do something different. Those self
betraying patterns are usually deeply grooved reflexes
from early in our lives. When people do notice
their “self abandonment”, they often say, “I'm so angry
at myself” or even “I hate myself”. These
reactions bring attention to the pain but have
relatively low power to heal. They even reinforce
a not so subtle harmonic of self betraying energy.
If a parent lectures an angry acting out child who
says, “I hate you mommy”, the child's behavior just got
negatively reinforced (conditioned) while the
child is left even more insecure. If the parent
quietly replies, “that's so sad, it must be awfully hard
to hate your mommy, what's going on?”, the parent's
accepting (unconditional) response deconditions
the child's acting out and opens a dialogue.
Similarly, as long as we react in anger to
ourselves, we trap ourselves in the very dynamic we want
More healing responses may be
thought of on various levels e.g., cognitive, emotional,
or “spiritual”. Perhaps, the ultimate healing
response comes with the cultivation of compassion.
Compassion is free flowing attention that embraces
whatever is arising in consciousness. When that
free attention meets suffering, it simply meets
it--without a predetermined agenda that the suffering
must end. In the ancient myth of the Fisher King,
the King finally gets up from depression when the Knight
Parceval simply looks at the King's pain and feels it
without rushing to judge the King as defective or to
make the pain go away. Similarly, the parent who
acknowledges her child with sadness and an open question
sees and invites the child's pain…and the unfolding of
it (for life is forever changing). The reactive,
lecturing parent implicitly tells the child that their
feelings are invalid, but inadvertently locks the child
into a bind of either hating the parent or themselves
for being mean spirited.
On an emotional level, sadness
and then grief are more often the appropriate
healing channels for letting go of our old
wounded patterns. Again, internalized anger offers
a little healing but more often than not has the
implicit structure of holding someone or something
external as the “cause” of our pain.
For depressed people, it's often of
critical importance to learn the difference between
grieving and depression. As noted before, in
depression people are often pushing away their pain by
pushing away their desires so that a typical attitude is
“it doesn't matter that much” or “I don't care”.
In grief, we're hurting but we're acutely aware
that vital needs are going unmet. Then, when the
grieving storm has passed through, our needs are
right out in the open and we go back to life
naturally pursuing our needs as they arise…fully
engaged. In Alice Miller's view, after the
grieving this tendency to self abandon, a sense of self
is left that more readily identifies its needs and
feelings and, thus, can navigate through the world in a
healthy, vital, adaptive way.
Therapy vs. Drugs for
Extensive research on antidepressants will not be reported here for
several reasons. First, there have been thousands of studies done
and the interpretation gets very technical. In a short essay it
is difficult to give a fair hearing to all sides. Also, the media
swamps us daily with advertising and distorted summaries of
research--the New York Times seems to report a scandal on the
advertising or reporting of pharmaceutical research every few weeks.
Therefore, I prefer to personally discuss this issue with clients
or refer them to original relevant literature directly. One good
thread of rather recent research on antidepressants can be found online
by searching for an article originally published as joing venture of
the American Psychological Association and the American Psychiatric
Association at "The emperor's new drugs: An analysis of antidepressant medication data" and
the January 17, 2008 New England Journal of Medicine for an article on
Publication bias, or the February 26, 2008 issues of PLOS (available
online) to get an idea of the complexity and scope of research
challenges and the range of interpretations. Some of these
articles summarize up to two decades of meta-analytical studies which
review up to thousands of other studies.
There are many tools to help
people caught in the knots of depression. The
philosopher, Ken Wilber, makes a compelling case that
many different psychological theories were built
on a limited perspectives that do not contradict each
other except in their claims of being the exclusive
truth. Indeed, research on therapy supports that
the type of therapy is much less important than the
therapist and, more precisely, the rapport between the
therapist and the client is the best predictor of the
outcome of the therapy.
| An Introduction To My Approach To
Understanding vs. Skills
As I studied many different
psychological theories, I found it critical to
distinguish between theories for
understanding clients' unique problems and
theories and prescriptions for intervening to
help them make the changes they seek. It is
crucial to have understanding, a map of the
territory, but the vehicle to move around that
territory (the skills for intervening with people) is an
entirely different phenomena. “Psychodynamics” (as
introduced above) is an exquisite tool for gaining
insight (understanding) into how people form their
patterns of relating, competencies, coping styles, etc..
One particular take on the "psychodynamic"
approach is known as "object relations theory" which can
now boast the support of 60 years of scientific
observation and experiments. I rely on those
insights as well as those of Carl Jung who many consider
to be the greatest and most comprehensive psychologist
of the last century. Jung drew on mythology,
religion, literature and art of many different cultures
for deep insight into the human psyche. The work
of contemporary philosopher, Ken Wilber, more than any
other one source, captures in broadest strokes my
understanding of what makes people
However, for all
psychodynamic theory offers in insight, the actual
methods it prescribes to therapists for intervening
with clients were historically rather passive.
Therapists were taught not to react or say much
while presuming the client will reenact early
parent-child relationship patterns. A major tool
is asking the client to explore reasons. "why". they
came to have the problems they did. But "why"
does not automatically lead to a desired
change!! If there's a hole in the catalytic
converter of your car, you may know why it's belching
smoke and noise, but not know how to weld in a new one.
Similarly, depressed people are usually only too
aware of their difficulty in asserting themselves, but
they can't describe much less demonstrate five good ways
to maintain their self esteem when slighted or put down.
In fact, several relatively recent trends in
psychoanalytic practice do promote more active
In contrast, there are a number
of approaches--gestalt therapy, neurolinguistics,
"strategic family therapy", psychosynthesis, etc.--that
put less emphasis on understanding and more on models
and methods for desired change. When done with
respect and towards a client's goals, a whole gamut
of dynamic, catalytic, playful, emotional, and
educational interventions are invaluable. In
recent decades, marvelous and complex models of human
communication and more precise therapy techniques have
been developed. These are not at all incompatible
with deep insight into how our relationship patterns
formed. But these techniques do provide a better
vehicle for navigating through the understanding given
by the "depth psychological" approaches towards making
the changes that clients want. In my approach,
therapy is often primarily a joyful, creative healing
and learning process--alternatively surprising,
demanding, humorous, or simply educational.