Depression and Psychotherapy
Dr Jonathan Haverkampf
Depression usually means feeling low and lacking motivation and energy to do anything enjoyable, but sometimes it may predominantly show in disturbed sleep, a lack of appetite and other diffuse bodily symptoms. Individuals on the outside withdraw from social life, while on the inside they often develop a sense of alienation from their sense of who they are as a person. Stable values and interests become covered up by various negative thoughts and doubts. Helping people with depression also mean uncovering these important concepts again.
It is a condition that can last over a long time, even an entire life, and it often reduces one’s quality of life significantly. It can occur once or reoccur in a number of episodes, with or without an apparent triggering event. Depression has become treatable in most cases, but probably only a minority of those suffering from it seek out help. Severe depression can also lead to suicidal thoughts, which require immediate professional help.
Medication in the form of antidepressants can be of significant help, especially in the early stages of a psychotherapy to facilitate the therapeutic process. Physical exercise has been shown to have a positive effect, as do activities that are enjoyable and take one’s mind off negative thoughts and endless ruminations. Psychotherapy can identify causes of depression, reintegrate the client into the world and help build better patterns of communication with oneself and one’s environment. This potentially lowers the likelihood of a future relapse. Studies have shown that a combination of medication and psychotherapy have the best long-term outcome, while psychotherapy is especially directed at the long-term.
A central problem of depression is that it leads to social withdrawal, which tends to worsen the depression. It cuts a person off from interactions with other people. These, however, are effective in countering the underlying problem in depression, the felt sense of a loss of meaningful communication with the world and oneself. It seems paradoxical that depression leads to a withdrawal something that could help counter the depression, but the reason is that the mind focuses inwards in an attempt to cope with the cognitive deficits and the emotional pain of the condition. Also, depression makes the world appear as a less friendly place, leading to a withdrawal in the sense of a self-defence mechanism. The result is a greater focus on the internal communication, the thoughts circulating in one’s head. But the internal communication is also disturbed because the connectedness with one’s values and interests is reduced. Neurobiologically this can have to do with difficulties in retrieving information and associations from memory. To circumvent this, a strategy is to look with patients at things they enjoyed doing in the past and get them to become more active again. Activity also helps to increase communication between the patient and the environment.
The internal communication in depression can reinforce the negative feelings, leading to a vicious cycle and a worsening depression. It is important to remember that mental conditions are in some ways not that different from somatic conditions. Self-regulatory mechanisms break down. But it has also been argued that there can be an evolutionary benefit of such conditions as depression, schizophrenia and mania. The reasoning is that the focus inside in depression, the different association making in schizophrenia and the invincible feeling in mania can in small doses foster creativity, sensibility and new insights. To me it seems that the healthy version still requires that the individual is connected to the information in the self that makes goal-directed and coherent activities possible. Fundamental values and a sense of one’s interests provide such information, and being disconnected from it can lead into the endless ruminations and loops that make the individual even less active and more separated from the world around and inside.
A biological predisposition makes some people more susceptible in times of stress or heightened psychological pressures. A higher serotonin receptor density, for example, which leads to down regulation of the level of serotonin between the nerve cell endings (synapses) has been implicated in a higher probability to develop depression. It may be one reason why antidepressants which decrease the reuptake of serotonin between the synapses (SSRIs), and thereby increase the level of serotonin between the synapses, are effective in reducing the clinical symptoms of a depression.
The communication between client and therapist is both an indicator for the depression and a tool to treat it. Through the interaction with the client the therapist gets a sense for the depth of the depression. Since the depression impacts a number of functions, which not always have to decrease (as, for example, in the case of an agitated depression), the diagnosis can in some cases be more straightforward than in others. It helps to remember that a depression can have biological, psychological and social factors, that often interact and amplify each other synergistically.
There may be an obvious trigger for the current episode of depression or even the onset of the depression as a whole, but in many cases of the more severe clinical depression there is not. In the latter cases it is often describes as a ‘fog coming out of thin air and settling everywhere’ that makes everything subjectively ‘slow down’. The subjective element is important and underlines that in depression the perception of one’s psychological functions and abilities in the world may be worse than they really are. A depressed state often colours the perceptions of oneself darker. Notwithstanding, concentration and other mental capabilities are often in psychological tests also objectively affected.
Communicating more effectively one’s thoughts and emotions is an important way to make a depression bearable and deal with it effectively. This can lead to greater insights and skills to move forward in overcoming the depression and preventing relapses, but it may not be possible in severe cases and early stages of treatment. Analysing what is underneath the depressed thoughts and feelings, the hopelessness and helplessness, the anger and sadness, or sense of void, often provides a feeling of getting in control again and can be very effective in dealing with the depression in a constructive way.
The depressed thought may give a clue about the things the client values and reflecting on it can facilitate a bridge between the inner world and one’s sense of effectiveness in the outer world. Once a depressed thought is verbalized, it can be understood by another. This makes it less painful and can lead to actual change the client notices. This leads to greater faith in one’s effectiveness and a greater sense of self-confidence.
Sometimes there may be no feeling at all, which, however, normally masks a whole panoply of feelings underneath. One might feel anger about an important person in one’s life, find below that sadness, and further down a helplessness about being ‘dumped’ for no apparent reason, etc. This means restarting one’s interactive capabilities may need a detour into the past, but with a clear sense of the future. Especially under a feeling of void and emptiness there can be a tremendous amount of issues that have never been adequately dealt with. They just cannot yet be communicated to one’s consciousness because they are associated with negative feelings, such as fear or anger.
The present has a special place because it is the only time frame in which actual change takes place. Depression can be a call for change, a property that often leads to fears and therapy avoidance in clients. However, once change looks beneficial, meaningful and relatively safe, the fear often disappears. The early change should be predominantly an internal change. I believe that if change feels good and is done gradually this is already a sign of leaving the depression behind and often a good sign. When clients get their social environment to support change, they already show an ability to interact with the environment that shows greater mental health.
Reintegration with society is important, particularly for those who also suffer from social anxieties, as long as there is a genuine interest in people. Humans need both, the communication with the outside world and the inside world, and the experiences from the interactions in one are used to reflect on the interactions in the other. Since our brains can process information in parallel and in different centres, ‘self-communication’ is possible and happens all the time. Depression is a state of reduced communication on the outside and the inside and facilitating more of it effectively reduces the depression. Communication is meaningful, and thus beneficial, if one sees a relevance to fulfilling one’s values, needs and aspiration. If I am interested in a particular subject and find a challenging course at a local college, this can have an antidepressant effect. A relationship with someone who shares my values can also have an antidepressant effect. It is very much about the feeling to plug into humanity again.
The final step is to solidify the success by reflecting on the path travelled and identifying what helped and what did not. Since we all are different and carry entire worlds of experience and thought inside us it is often only possible to begin with some more general tools that work for most people, and then find what works in the individual case in the therapy sessions.
© Dr Christian Jonathan Haverkampf. All rights reserved.
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This paper is solely a basis for academic discussion and no medical advice is given, nor can it be given. Always consult a professional if you believe you might suffer from a medical condition.