My Two Cents in the Depression Debate

*Warning* This post might be long. I can’t promise it will all be worth reading, but I can tell you that there are at least two links included that are worthwhile. If I bore you (and I might), skip down and click through to the interesting stuff. Noah Rubinstein of GoodTherapy.org and ModernComments Blog write on depression from different perspectives and do a whacking good job of it.

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In the interests of full disclosure, I have never experienced significant depression other than situational dysthymia which was an appropriate emotional response to  circumstance. I have worked with clients living with depression, and with the people who love them, for almost 30 years.

In the aftermath of Robin Williams’ suicide, the Internet has allowed those with an opinion and access to say just what they think about the whole business of depression, its impact, of Mr. Williams, mental illness, treatment, and everything in between. Some of the discussion is excellent (a very small percentage), some of it is helpful (also a very small percentage), and most of it is individual, opinionated, self-focused rubbish. The vast majority of people take their personal experience (or that of someone they know) and generalise it, assuming what is true for them is true for others. This simply isn’t so. (If people wrote from a personal perspective, (the “I” voice), refrained from “you-ing” the rest of the world, and accepted that their own personal experience might not hold true for others, the percentage of excellent discussion and helpfulness would go up exponentially. Conversely there’d be less rubbish to wade through)

I read two quotes yesterday that really resonated with me after all the reading I’ve done since Mr. Williams’ death.

This one from ModernComments’ blog… “Depression is a deeply personal, very individual, and profoundly complex illness.”

and this one on my Facebook feed, today … “It is the mark of an educated mind to be able to entertain a thought without accepting it.” ~Aristotle

I'm fineI have read things about depression recently that I have not heard in my years as a therapist. I know things about depression that I have not (yet) seen written in this flurry of commenting and editorialising. It is a complex, personal, mental illness and its impact on the individual varies according to genetics, life choices, past trauma, and current circumstances. What is helpful to one individual is useless or unhelpful to another. Research – that is empirical data, not anecdotal – has shown multiple times through multiple studies that the combination of medication and therapy is most effective in treating depression.

Notice please, I said “treating.” For some, there may never be a cure for depression. For them, they must learn to manage themselves, understanding the symptoms of their disorder, recognising when additional help or support is needed, and choose to order their lives in ways that maximise resources and minimise distress. The ‘wild card’ in all of this is the individual. As ModernComments tells us, her husband had to make the choice to seek help himself. As Noah Rubinstein points out, this is hard enough for any individual and must be excruciatingly difficult for an individual with a public persona.

Random thoughts (RT) I’ve had as I’ve read through the outpouring of opinion on depression…

RT Most people will acknowledge the truth that mental illness impairs cognitive ability (i.e., Paranoid Schizophrenia), and that choices made while someone is in the grip of a full-blown manic episode (Bipolar Disorder) are unlikely to be rational, but an individual with unremitting, agonising clinical depression is to be blamed for making the “choice” to commit suicide. Matt Walsh, another prolific blogger talked about how Mr. Williams’ “should have hope” and “shouldn’t give up the fight,” and “should choose life” as if these options are on some menu of readily available take-out. It is my opinion (and I have said this to my clients’ families for years), ‘When the pain of NOW overwhelms ALL hope that the future can be different, even the most desperate of choices seems reasonable.’ At the risk of invoking a firestorm of indignation, I admit that what came to mind in this debate about “choice” is 9/11. The pictures of the ‘jumpers’ (no one refers to them as suicides, and rightly so) were mind-numbingly horrifying – at least to me. I’ll bet that most of those people going to work that morning were not contemplating jumping off a building, i.e., they weren’t suicidal. When the extent of the catastrophe became clear, those people were confronted with two options – stay in the building and burn (certain death); or jump and cling to the faint hope that something better (than burning to death) would result. Sitting in our armchairs at home, horrified at the carnage, we think, “Of course they were jumping to their deaths! How could it be otherwise?” But WE WEREN’T THERE. We weren’t faced with those options. No human being picks ‘Option D’ when making a choice. Everyone makes a choice, certain in the moment that they are choosing the best option of whatever choices they believe they have. So it is with depression. It does not matter that I, sitting in my own skin, cannot fathom the depths of agony that would cause another human being to choose suicide. What matters is that in that moment, suicide seems like ‘Option A’ in whatever array of options the individual thinks they have. Could they ask for help? Of course. Is it true that the future has to be the same? No. In the end, though, it is what the individual believes that governs the range of options s/he has. And for someone who has wrestled, struggled, fought with, and despaired in depression for years, there may come a point at which hope of anything changing evaporates, leaving that person with an agony of mind that simply cannot be endured any longer, thereby limiting the choices s/he believes are available.

RT The majority of my clients who are suicidal, have been suicidal, or who have attempted suicide are not seeking ‘death’ per se, but rather relief from the soul tormenting, mental battering that accompanies the biological, emotional, and psychological reality that is depression. They talk of “making the pain stop;” of “finding relief;” of “finally getting rid of the ‘ voices’ that torture them endlessly.” Sometimes they refer to this as death, but not usually. I’ve also had the experience of working with clients who have very nearly completed (we use so many euphemisms these days) and in the moment in which they believed they were actually going to die, regretted it, with every fibre of their being. In that moment, I have been told, they realised that suicide meant DEATH, and that is NOT what they wanted. I’ve also worked with clients who have descended deeper into depression after a thwarted or unsuccessful suicide attempt because to them, it was just one more proof of failure. Depression is an individual, complex, mental illness.

RT Many of the clients I have worked with have been abandoned by other professionals in the course of treatment because of “…non-compliance with treatment regimes,”  “…limited resources,” or being “…unresponsive to treatment.” I’ve worked with clients accused of malingering “…because there’s no reason why you’re not getting better. You must be experiencing some benefit to being depressed.” I’ve had clients report that other therapists have asked them not to come back because they are “…using resources which might be more effective with someone else.” Professionals may become exasperated, uncomfortable, and discouraged when clients with severe depression don’t seem to make any progress in “getting better.” I’ve supervised therapists whose entire case presentation was a rant about a depressed client who was “…simply ‘choosing’ not to get better.” We professionals run out of ideas, techniques, resources, and empathy for severely depressed clients, and suffer a crisis ourselves. Working with clients with refractory depression (unresponsive to treatment) can cause even the most seasoned therapist to feel like a failure. Unfortunately, this attitude often gets passed on to the client, who then adds this ‘failure’ to his/her ever growing list of faults and flaws, along with a sense of abandonment. Psychology professionals are also human beings, and we, too, can be worn down by the reality of depression.

RT People who say they “…don’t believe in depression,” or “Medication shouldn’t be needed to make life liveable” or some such other bilious platitudes make me crazy. Fortunately for the rest of the world, not believing a truth e.g., gravity… or a round earth… or atoms… doesn’t make the truth any less truthful. Depression is a real, measurable, observable, quantifiable, mental illness. People who read the research, follow the studies, keep up-to-date on neurophysiology and neuropsychology know that depression impacts the brain in measurable ways. Promising gene studies are getting ever closer to identifying the genetic factors influencing depression, and evidence-based treatment protocols have the data to prove they WORK.

RT Everyone from Matt Walsh to the Far Right Christian contingent to global Wicca adherents have expressed an opinion on the “spiritual component to depression.” Some contend that spirituality – however one defines that – is an antidote or cure-all for mental illness (“Just pray and you’ll be healed.” “Depression is a lack of faith.” “Depression is a sin requiring repentance.” “Meditation and stillness of the mind cure depression.” “Collecting positive tones from the Universe will cure depression.” “Find a way to be thankful everyday and depression will cure itself.”) Ha! I laugh scornfully. I really do.  Am I dissing the spiritual element of being human? Absolutely not. In fact, one of the strategies I use with a profoundly depressed client is to explore the existential component (or lack thereof) in their lives.

Matt Walsh was skewered, vilified, crucified, and hung out to dry for suggesting that depression has a spiritual component. He was right. There is a spiritual component to life. No matter how one defines ‘spiritual’ or the practice of acknowledging that spirituality, human beings, in order to have hope, also need to hold a long term view of existence. To believe that we have an eternal existence beyond the few short years that comprise our life in time and tangibility; that we have the ability to leave a legacy that remains long after our bodies have been consigned to dust. For some clients with depression, simply tuning into the inner truth that they are connected to something larger, more eternal than themselves is the beginning of a shift in perspective that can help to restore mental, emotional, and psychological equilibrium. Exploring what that spiritual component looks like… feels like… acts like… is a major break in the closed loop of self-examination and hypercritical self-judgment. Spirituality is both inside and outside the individual simultaneously, and that cycle of mental agony breaks …just a little, and light from another source is allowed in. I happen to believe in God. My clients have espoused everything from Islam, to Buddhism, to Shamanism, to Pantheism, to a whole host of other -isms. What is common to any spiritual belief (even atheism) is that I, an individual, am more than just THIS moment. This is a hope-instilling idea for many with depression. (All sorts of peeps probably ought to apologise to Matt Walsh)

I suppose I could carry on here (probably) ad nauseam, but I have to get on with other things. The two blogs I selected out of the hundreds I read are here (Noah Rubinstein) and here (ModernComments).

If  I’ve given you something to think about or an idea to consider, then it was worth taking the time to post this. If not, I apologise for not posting the interesting links at the beginning.

6 thoughts on “My Two Cents in the Depression Debate

    1. I often wish that some of my clients could put words to their experience, but it is often part of the issue that they cannot articulate that internal landscape. Thank your husband from me for being willing to have you share his (and your) journey through the Slough of Despond.

  1. At the risk of being pilloried, people do tend to subjectivise their own experiences and I’m no exception. I felt like a lab rat upon whom my doctor tried a cocktail of different remedies, from drugs which sent me a little crazy, to acupuncture, meditation, gym, and a middle aged therapist whom I genuinely wanted, poor woman, to physically damage. Nothing worked at the time. I was someone who “just got better” for no discernible reason. Except that I gave up drink. Ah.

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