All the signs were there: pervasive feelings of sadness, inability to eat, insomnia, the sense that he was in a rut and could not break out of it, chronic pessimism, perceptions that he could not solve his problems, the belief that he would always come up “short”. In a word, he was depressed—although initially he bristled at the word “depression.” As he put it, “I don’t think of myself as depressed. I’m just going through a hard time right now.” However, as the session progressed he revealed that he had been feeling this way for months. In fact, he told me that he could not recall a time when he felt otherwise. Although he admitted to feeling depressed for a long time, the event that brought him into therapy centered on receiving a critical performance evaluation. The evaluation triggered a cascade of feelings and thoughts; he wanted to “re-evaluate my whole life” and felt overwhelmed by alternating feelings of sadness, helplessness, and anger.
Depression is most typically associated with a mood—usually sadness, feelings of helplessness and hopelessness. However, other feelings can be present in depression—feelings that, to an onlooker, do not look at all like depression: early in my training I worked with a man who was constantly agitated, irritable, and angry. I recall being surprised when my supervisor remarked that the client had an agitated depression; he certainly did not look depressed to me. However, I began to understand how complex depression really is when I hospitalized him after he became violently suicidal. Indeed, depression is an insidious illness.
Depression often has a particular texture: heaviness, lethargy, lack of energy. Sometimes, the sensations of depression are acutely painful. (This was especially true of the client I hospitalized: after he was stabilized and released from the hospital, he insightfully told me that he had been fighting the feeling of lethargy for quite some time; his agitation and anger had kept him from falling into the "abyss".) The novelist William Styron wrote of “the slowed down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained… depression takes on the quality of physical pain” (from Darkness Visible, 1992). The pain of major depression can become so acute that thoughts of self-harm or even suicide arise. Although the client I described at the beginning of this essay did not report physical pain or suicidal thoughts, he reported a persistent feeling of fatigue, of “being weighted down.” (In Bi-polar disorder, the sensation of lethargy and heaviness alternates with the sensation of manic energy and a kind of pressure to discharge that energy.)
It’s been my experience, though, that a hallmark of depression centers on a particular pattern of thinking. The depressed person’s thoughts are distorted: life events are negatively personalized (e.g., “this would only happen to me” or “she didn’t answer my call; she must be mad at me”); perceived in stark, absolute terms (“only bad things ever happen to me” or “I can’t do anything right” or “I’m worthless”). The negative is accentuated while the positive is filtered out or minimized (“the glass is half empty”). As these distortions take hold, the depressed person loses a sense of communal context and tends to become isolated; the world narrows as the depressed person loses interest in people and activities that previously gave enjoyment or fulfillment.
At the core of these distorted thoughts (made worse, of course, by the physical sensations that can also manifest) are beliefs that are central to depression. Like the distorted thoughts, these belief are distorted and tend to center on self-efficacy, the sense of not having mastered or being able to meet and master life’s challenges, and one’s sense of relatedness: “I can’t do anything right. I am inadequate. I am incompetent. I am unlovable. I will always be this way, and I will always be alone.”
The landscape of depression is different for each person. Likewise, treatment will vary from person to person. Some people may require medication to address the imbalances of their brains’ chemistry and to ameliorate their physical symptoms. It’s important to be evaluated by a psychiatrist or psychopharmacologist for medication—especially when insomnia, changes in appetite, extreme lethargy, physical pain, suicidal thoughts or thoughts of self-harm occurs.
It's important to seek help to treat depression. It's often not a matter of "pulling yourself up by your own bootstraps." Indeed in major depression, it's not physically possible to move yourself out of depression. Moreover since the landscape of depression is typified by distortions in sensation and cognition, psychotherapy is even more critical to becoming well. It often takes a trained professional to spot depression because its signs can be so subtle and insidious. But once depression has been identified, a great deal can be done to treat it. Therapy is typically directed at assessing the patterns of thinking and beliefs that manifest, challenging and correcting the distortions in thinking, and eventually getting at the root causes of the depression.
The landscape of depression is full of shadows and can be dangerous. However, just as there are pathways that lead into the landscape of depression, so too there are pathways that lead out of it. To my mind, a healing relationship is critical to finding the pathway out of depression. Indeed, whatever the specific path one takes to enter the landscape of wellness, having someone who knows and understands the path and can serve as a guide seems key. A therapist can be just that guide.