Deconstructing Depression

This article first appeared in the November/December 2010 issue.

Psychotherapists probably see more cases of depression than anything else in their practices, but it remains one of the most challenging conditions to accurately assess and treat. Part of the problem, no doubt, is that “depression” is a broad, poorly defined diagnostic category, which embraces a daunting range of symptoms, including cognitive and physical lethargy, mental rumination, loss of concentration, chronic negativity and pessimism, feelings of worthlessness, and unremitting sadness. Furthermore, the symptoms themselves can block response to treatment. Lethargy, hopelessness, negative thought patterns, and refractory negative mood all interfere with useful interventions. To get beyond or around the powerful drag of inertia in depression, therapy needs to quickly nudge clients into action, help them take charge of their cognitive habits, instill hope, and reduce negative mood.

Rather than seeing depression as some kind of monolith, I’ve found it useful to see depressive symptoms as falling into four basic clusters, each reflecting a different underlying cause—neurobiological, traumatic, situational, and attachment related. By immediately addressing the attitudes and distinctive vulnerabilities that lie at the core of each cluster, treatment can begin to bring about a shift in brain function that makes longer term work easier. In what follows, you’ll find a brief description of how to begin treatment with each cluster, with a particular emphasis on how to enhance the likelihood of initial engagement.

Endogenous Depression

People who complain of low cognitive energy—”I just can’t think about that now,” or “I just sit and look at the work”—and persistent negative mood, irritability, and limited pleasure or interest in daily life are most likely suffering from endogenous depression, a condition assumed to be biologically, and probably genetically, based. They tend to be passive and unmotivated: their attitude toward therapy can be summed up as “What’s the use?” Despite the neurochemical factors implicated in their depression, you can still nudge these clients into a more active, positive state of mind by engaging their power to make small decisions that will briefly override their low energy. By deliberately shifting away from their negativity and consciously acting in opposition to it, they can begin to make changes in their lives to provide just enough positive reinforcement to boost them a little way out of their trough of despondency.

Angel had suffered from depression most of her life, and had to exert tremendous energy just to get through a day of doing a minimal amount of housework and taking care of her child. She berated herself for being so unpleasant and bad-tempered to people. “Kindness is a fatality of depression!” Angel exclaimed, telling me how short and critical she’d been to her mother the previous week. She still felt irritable and guilty about it.

In my initial work with her, I asked her to recall any act or gesture of kindness, no matter how small, that she’d given to her mother. She easily came up with some examples, and then followed immediately with, “But that doesn’t count!” When I asked “Why not?” she replied, “Because the bad moments are so many, why should I count good ones? I’m just not a good person.” Angel was trapped in the habitual pattern of thinking, common to people with this kind of depression, that bad moments deserve more attention than good.

I explained to her that, given the way neural networks process information, once she got into the mental habit of thinking negatively, her mind frequently became like a runaway train of pessimism, tapping into an ever-growing network of negative thoughts—different versions of “all things wrong.” Forcing her mind into a different network—”at least some things right” would require cognitive commitment. In short, Angel needed to train her brain to identify and rehearse positives to shift her default setting away from negativity.

One of my favorite ways to practice the positive is to get into the habit of giving the “Virginia Report.” My friend Virginia has had much to be depressed about—losing an adult child to cancer, seeing her family break down from the consequences of grief, having cancer twice herself, and suffering severe, debilitating side effects from treatment. Yet you’ll never encounter Virginia without hearing her tell you about an experience she just had that was absolutely “the best!” She just had the best sandwich she ever ate, the most fun she ever had, she laughed harder than ever before. In the “Virginia Report” everything today is better than anything that came before.

Asking Angel to give the “Virginia Report,” about her prior week forced her to say something out loud about what was positive. She wasn’t unconscious of good things; she simply believed they didn’t count. So I wanted to enhance the sense of importance of each positive. She agreed to make a daily record of at least one good action or experience. Then, therapy helped her practice expressing it as “the best” to inject a note of eagerness, enthusiasm, and hopefulness into daily life. She felt awkward using superlatives while telling me about a restaurant meal, so we jokingly exaggerated it. The rigatoni was “sooooo tender” and the meat “sooooo succulent” and the gravy sooooo “intensely garlicky”; she “never had any meal as amazingly fabulous as that meal!” After the laughter, she admitted that she felt great, but quickly added, “Of course, the dinner wasn’t really as good as I just said.” In that moment, she saw how she continually robbed herself of good feelings. She described the meal again and noted the pleasure derived from her positive perspective. She was able to see that describing her dinner as “the best ever” reinforced an attitude of upward comparison she could use whenever thinking about her experiences.

Charlene presented a different kind of lethargy typical to endogenous depression. Sitting slumped in her chair, she told me that she had unopened mail piled up from the last two weeks, groceries purchased two days before still bagged and sitting on the kitchen table, and unwashed laundry heaped on the floor. The clutter of old newspapers, dirty dishes, toys, and stuff covering every surface of the family room made it nearly impossible for her two kids to find a seat. Since contemplating the task of cleaning all this up was overwhelming to her, I asked if she could clean for just three minutes. She agreed that she could do that, but asked, “What’s the point?” adding that things would still be an unholy mess.

I knew she needed to mobilize, and one way was to “prime the energy pump” by doing the work in small, manageable bits—returning one phone call, answering one e-mail—and then rewarding herself for the effort. Like so many low-energy clients, Charlene came home from work and immediately turned on the TV—what she called her “reward” for getting through another day on the job. I suggested she take “commercial breaks” to literally “break” up her pattern of comatose sitting. She should get up and do some tidying just during the commercials, and then sit down to her show again—an immediate reward for about three minutes of effort.

She doubted this would work, but agreed to try it. I helped her make a list of discrete tasks that she could accomplish with brief interludes of work—empty the dishwasher, fold laundry, put away food, and throw out junk mail. I suggested that she pick one item from the list and work on it during commercials until that one task was done. Then, she could move on to the next task. When she returned to therapy the next week, she was amazed and feeling quite a bit more hopeful. She’d gotten both the kitchen and family room tidied up in the space of just one week of commercials! By the following week, she’d even got her son to pick up after himself, and for the first time in months, the floors were clear enough to vacuum.

Because summoning up the energy to move forward is so difficult for people with endogenous depression, they need intrinsically satisfying and meaningful goals. I then asked Charlene to list every single activity in the course of a day and then follow up with a forced-choice question about each: “Was that pleasurable or unpleasurable?” I wouldn’t accept the answer, “I can’t tell because I’m too depressed.” I insisted she pick one or the other although I accepted a grumbled, “Okay, pleasurable. But not much!”

Next, I asked her to make a list of only the pleasurable activities and use that list to find natural motivations to enhance them. I asked her about each item, “How can you make the good moments even better?” For instance, if taking a morning shower is pleasurable, can it be even more pleasurable if you make it two minutes longer, or play music in the bathroom, or add some fancy shower gel? This enhancement technique works with almost any activity, like meeting a friend for coffee (make sure to order a specialty coffee you enjoy), taking a short walk (notice the color of the sky or the neighbor’s flower garden or remind yourself how many calories you burned), talking to the kids after school (review in your mind your child’s smile after the chat is over), and so on.

With these clients, the next step is to put the more-pleasure plan into effect, to do something that increases the pleasure, which is surprisingly easy if the enhancements are small steps to increase enjoyment of what depressed clients are already doing. This extended attention to what feels good is a powerful anti-depressant itself and stirs motivation to have more of that pleasure. When skillfully applied, this incremental approach enables clients to spend more time having pleasurable moments and, more important, paying attention to them, leading to a powerful shift in mood and activity level.

Post-Traumatic Depression

Post-traumatic stress is another source of depression that can manifest itself in sudden feelings of intense helplessness, often set off by emotional or environmental events, which the client may not even recognize as triggers. Trauma victims can experience disproportionately powerful mental and physical states from even seemingly minor stressors, especially when they somehow evoke a version of the helplessness and sense of danger they felt during the initial trauma. They have a hard time believing anybody can help them, far less that they’ll ever be able to help themselves.

Mike was the kind of client often referred to as “high functioning,” but it was clear from our first session that he didn’t think treatment would do him much good. He was a member of a small engineering company that relied on his specialty to round out their team. He wasn’t happy at work, but said, “I know I’m stuck at this job for life.” At age 50, he felt he was “too old” for anyone to allow him to change jobs. And he was sure that his colleagues would try to get rid of him if he didn’t show more optimism for their new business plan. In fact, he’d come to see me only because they complained so much about his negativity and indecisiveness that he worried that he might be fired. To my first remark, that he didn’t seem to hope for much, he rolled his eyes and wondered aloud why he should hope for anything. “No offense,” he said, “but every time I’ve hoped that things would change, they got worse.”

For Mike, the sensation of hope immediately evoked memories of loss, disappointment, and pain. He’d been verbally and physically abused throughout his childhood, and told that the abuse was his fault. No academic or athletic achievement won parental praise, and no amount of good behavior gave a reprieve from the abuse. For him, hope was a trickster—positive feelings of hope were entangled with negative expectations. He became tearful when he said he’d hoped he could have more in life—more peace, more love, and more feelings of being good enough—but he expected it would never happen. He was afraid even to try therapy because he had no hope that it would work—it would only result in more disappointment and pain.

I realized that to help him instill a sense of hope, it had to be modest in scale, so that it didn’t trigger memories of loss and fear. Consequently, we made a plan for him to focus on small hopes—for a good dinner with his kids, or a pleasant afternoon at work without worrying about next week’s meetings. I asked him just to note whether these small hopes actually were realized, so he could do a reality check to see what happened when he allowed himself to hope for small, everyday things. To his surprise, he discovered that allowing himself small hopes actually contributed to their realization. True, hoping for a good life was just too much for now, but it no longer scared him to hope for a nice evening or enough quiet time to get a report written. Bringing those small hopes to conscious awareness made him less fearful of hope itself.

Since remembering the past took Mike into negative, miserable territory, and thinking about the future made him anxious, I introduced the concept of mindfulness as a way to help keep him calm and anchored in the present. He practiced watching his breath and eating an orange with complete attention to the sense of the peel in his fingers, the fragrance of the burst fruit, the texture of one segment, the taste as he slowly chewed. He caught on immediately and found that he could remind himself numerous times every day that, “this day, at this moment, all is well.” While Mike is still not ready to hope for big changes, these moment-to-moment exercises in mindfulness have made him feel less afraid of hoping and trying.

I also addressed his chronic sense of helplessness by asking him to become aware of how often he described negative aspects of his life with the coda, “I can’t do anything about that.” No matter the topic, from controlling his anger to reviving his children’s desire to spend time with him, he essentially shrugged verbally, indicating his unrecognized feelings of helplessness.

We know from neurobiological research that language—coming from the left prefrontal cortex—modulates emotion by exerting control over the limbic system. So, helping Mike change his language—making it less about his inability to do anything, and more about his personal agency—could actually reduce his feelings of helplessness. I pointed out the times he said “I can’t,” until he himself became aware of how often he used this phrase. I then suggested he substitute “I won’t” for “I can’t” and notice how the change made him feel. He found that while saying “can’t” made him feel helpless, “won’t” reminded him that he was, in this moment, simply not choosing to try to change it. His internal discourse thus became less about helplessness and more about rationally appraising situations and his motivation to change them.

Situational Depression

Situation-induced depressions may result from serious personal losses (job, spouse, death of a loved one), work burnout, or exhaustion from long-term care of a sick family member. In addition to causing sadness, discouragement, or a sense of meaninglessness, these stressful situations can engender physical lethargy and emotional isolation, which tend to be self-reinforcing: exhaustion and isolation breed more exhaustion and isolation. Furthermore, this kind of depressed client doesn’t just need to change an attitude, but also the situation itself by doing something about it.

Paul was sent on a year-long job assignment to the other side of the country. Since his wife preferred remaining close to her two adult children and several grandkids, he went by himself. Lonely and cut off from his normal routines, he worked long hours—often 10 to 14 a day—to fill the void. When he finally returned home to his former job, his old world had changed: he’d been replaced as captain of his bowling team; he decided not to rejoin his men’s club and church; his young grandchildren barely remembered him. In addition, his wife generally kept busy with activities that didn’t include him, such as gardening, book clubs, and a women’s golf league. Feeling even lonelier and emptier, he filled his hours with work, which at least gave him some sense of being useful, if not important. His increasing exhaustion and detachment made him irritable with everyone and disinterested in social activities; he grew aloof even from his wife and children.

Finally, his wife suggested they separate, which prompted him to seek therapy. In a classic case of burnout, like Paul’s, working becomes a substitute for feelings and relationships. The adrenaline rush of nonstop activity or meeting deadlines creates the sensation of having feelings, temporarily obscuring an otherwise painful awareness of underlying emptiness and isolation.

Clients suffering burnout tend to complain about their intense responsibilities and the ensuing stress, but they don’t see the depression lurking beneath the surface. Paul needed first to cool down his burnout, by taking straightforward, practical steps to restore his overall health—eat better, exercise more, improve his sleep habits. He needed to remember what he used to like to do for fun and begin doing it again. For example, he reinstituted a lunchtime basketball game with work friends, and the camaraderie and exercise together began to raise his energy. He slept better once he started getting some exercise, and even lost a few pounds—which made him feel less sluggish.

During his year away, he’d developed no social life, and spent his evenings watching TV alone until bed. It was a habit he kept up when he returned home, so his family finally stopped talking with him. He seemed to interact only when he was with his grandchildren—which wasn’t often because he was too emotionally depleted and apathetic to initiate social contact with them. Such self-reinforcing isolation isn’t unusual: depressed people show limited interest in others, who then lose interest in them.

To end isolation, Paul agreed that instead of waiting for his kids to become interested in him, he’d act as if he were interested in them. He thought that he could get up enough energy to call and invite them to come over once a week or a couple of weekends a month. Because his mental lethargy made it hard for him to think of activities at the moment, we planned specifically what he’d invite them to do—walk to the park or play a new video game—activities that he couldn’t readily excuse himself from doing.

Isolated people often find that it takes less energy to stay isolated than to make the effort to connect with other people, even though the latter makes them feel better. Because Paul was genuinely devoted to his grandkids, he felt more responsibility to try hard for their sake. Interacting with his grandchildren gave him more opportunity to talk with his adult children about their mutual interest in the kids—beginning a cycle of self-reinforcing meaningful contact.

Attachment or Abuse-Induced Depressions

Depression stemming from attachment problems often manifests as a default attitude of negative expectations about the world and an inability to soothe oneself in adversity, which often results in a plunge into despair when the person confronts even minor upsets. A child who’s repeatedly left uncomforted by adults when distressed first becomes frantic, then resigned and hopeless, ultimately shutting down emotionally. A child suffering from this kind of chronic neglect or even more severe attachment failure (physical and emotional abuse, for example) becomes an adult who tends to feel generally hopeless, with low expectations of self and others, and susceptible to sudden plunges into psychological despair. These clients exhibit dramatic shifts of mood, quickly descending from relative equanimity to abject misery as if “falling off a cliff.”

Shawna had a history of neglectful parenting—her father was absent, her mother depressed, and neither offered her much warmth as a toddler or later protected her from bullying and abuse from a neighbor. As an adult, her mental default mode was set on “life is deeply unfair, and much more unfair to me than to others.” My therapeutic goal was to help her balance her chronic sense of disappointment and victimization with more positive experiences of other people.

To refocus her attention and reset her automatic default from hopelessness to a more neutral wait-and-see attitude, I gave her several assignments. One was to “Say five positives” every day—find five good things about others’ character or behavior, and then tell them. Besides being an antidote to the assumption that everyone else is unfair and mean, this exercise sets up a positive feedback loop: others, in response, are likelier to live up to your positive remarks than down to your low expectations. During several months, Shawna began to see some good in the world and feel slightly more trusting that people wouldn’t always disappoint her.

Shawna had a tendency to make even the smallest setback a catastrophe. If a friend cancelled weekend plans or her boss told her that they had to discuss a problem, she’d regard it as a sure sign that the friend intended to dump her and the boss to fire her. Unable to tolerate such intense dread, she’d tranquilize herself by spending the weekend compulsively eating or drinking too much or losing a lot of money gambling. It’s virtually impossible for these clients to prevent such impulsive reactions when they’re primed, as Shawna was, to instantly dive into hopelessness. The ability to “put on the brakes” before emotionally crashing requires a cognitive recognition of what’s happening and a capacity to forestall it through conscious self-soothing techniques. Having never been comforted as a child, Shawna simply didn’t know how to comfort herself.

Such clients need to learn ways to put on the brakes consciously when their moods begin to slip, until that process eventually becomes an automatic reaction. Without support, clients like Shawna can’t even get to this point. If, however, consistent support from someone else is available, they can learn fairly quickly to call for help before going over the edge into despair. Together, Shawna and I made a plan to call a lifeline. When on the verge of an emotional nosedive, she agreed to call either me or a good friend.

With Shawna’s permission, I talked to her best friend and we agreed that instead of just offering sympathy, she’d refocus Shawna’s attention to the possible positive interpretations of any situation that seemed desperate to her. If her boss told her they had to discuss a problem, the friend could say, “Your boss may want to brainstorm about the problem, rather than blame you for it.” We also wrote “lifeline notes” that she could read when no one was available to talk. One, for example, reminded Shawna to identify three potential positive outcomes to a situation before assuming the worst would happen. This helped put the brakes on her tendency to get carried away by assuming the worst.

As time went on, she became more able to avert the plunge to despair. A notable turning point was when a colleague from work told her she didn’t want to join her for their regular Friday lunchtime walks anymore—she wanted to keep her time “flexible” so she could sometimes join other friends. Instead of falling into despair, Shawna got mad at what she felt was a betrayal. Getting mad wasn’t an ideal reaction, but it was better than depressed and full of self-blame! Indeed, her anger actually seemed to lift her depression and allowed her some energy to decide what to do about taking care of herself at lunchtime without her friend’s companionship. With that step to anger instead of despair, Shawna turned the corner in the direction of self-care.

What I’ve described isn’t a therapy of dramatic moves, but of small steps—a kind of microtherapy—that focuses on subtle shifts in behavior patterns and daily attitudes. With time, it can create profound change in clients who staunchly resist interventions that seem too bold and threatening. This carefully calibrated type of therapy is, of course, always grounded in the clinician’s attunement with clients’ worldviews and an appreciation of the degree to which their actions can be influenced initially. But those who recognize the crucial differences among the many varieties of depression, and who have the patience to work carefully, will discover that being slow and steady is an underrated therapeutic virtue.