Wednesday, April 24, 2013

Signs of Depression and Disorders of the Self

Most people use the word "depression" to describe many separate and distinct experiences -- grief, disappointment, mild forms of unhappiness, etc. When I use the word here, I mean clinical depression, the sort of mental and emotional suffering that sends people into therapy or to their physician for prescription-based relief. I've seen many men and women over the years who's come in with signs of depression; from my experience, the roots of their suffering usually lie in three common areas. I'd like to offer some thoughts about these varieties depression and their origins. I don't view them as necessarily distinct; they often overlap and mingle in various ways.

Post-Apocalyptic Rage:

Ever since Freud, psychotherapists have noted the frequent connection between anger and depression; you may have heard depression described as "anger turned inward." I'd take this a step further and say that explosive and violent rage often lies at the heart of certain severe signs of depression. I use the phrase "post-apocalyptic" because, with many severely depressed clients, I have felt as if a nuclear bomb has gone off inside them, devastating their minds and laying them waste. Such clients might make it to session but lie inert and mute on the couch; they might say they feel nothing, or describe their body as feeling numb, weighted down by a pressure that flattens all emotion. When I'm in the room with these clients, in close emotional contact, it feels to me as if MEANING has been completely destroyed and the emotional realm is void. Such clients might describe themselves as feeling empty, without interest or motivation to do anything. They often mention intense pressure around their eyes or face.

Re-creating the emotional events that led to this state of devastation takes time and patience. The task is complicated by the fact that the rage is almost always UNCONSCIOUS: the client has no idea that he or she has been raging. Sometimes you might hear hints of it in the client's material when he or she begins to speak; more often, you see it in dreams or simply feel it by intuition. The landscape of the apocalypse often appears in the dreams of depressed people: bleak ghettos, deserts or terrain borrowed from movies such as THE TERMINATOR. If you have a strong empathic link with a client, you may find feelings of rage rumbling inside you during the silence, for no reason you can understand.

This rage may itself be a defense against fears of disintegration, as I've discussed elsewhere on my 'After Psychotherapy' site. Or it may be a kind of omnipotent, destructive reaction to feeling unbearably needy, small or frustrated. In any event, it is a sign of progress (and an emotional challenge for the therapist) when such clients can experience and express rage within their sessions and yet not destroy their treatment in the process. Helping the client to tolerate this kind of rage involves the patient work of years.

The Fragmented Self:

Whatever our theoretical orientation, most of us understand that when mother-baby relationships go awry, for varying reasons, it affects the child's developing sense of self. The more unreliable those early experiences (i.e., the more unavailable or inconsistent the mother), the shakier the child's sense of self. In severe cases, the person may feel as if he or she is constantly in danger of falling into pieces under the pressure of intense emotion. Anxiety may thus be one sign of a shaky core self, where the person feels terrified of disintegration; depression may be another sign, where it may feel as if he or she ALREADY HAS fallen into pieces. Such disintegration may be experienced as a kind of personal psychic death; the depressive feelings that result are akin to mourning, a mourning for the self, full of grief and hopeless despair that anything can be done to salvage the fragmented self.

This kind of client needs the safety of ongoing psychotherapy and a strong empathic connection with the right therapist. I'm not sure I would go so far as to call it "re-parenting", but given the insecurities of their early attachment, such clients need to regress and become emotionally dependent to a significant degree; they almost always need to come more than once a week. Within the context of the client-therapist relationship, they learn to understand and tolerate unacknowledged feelings, helped by the safe holding environment the psychotherapist provides. Again, such work takes years.

The Rejected Self:

In especially toxic environments where parents may be abusive or projectile, evacuating their own feelings of unworthiness or confusion into their children, those children may grow up with intense feelings of shame. Rather than experiencing their selves as if they were in pieces, these men and women feel dirty, damaged, ugly, smelly, disgusting, repulsive, contemptible, etc. They may feel that their authentic self is so thoroughly damaged, in a state of such decay as to be beyond redemption. In these cases, the individual may be highly defended against feelings of depression and unworthiness; they often inhabit a false self organized around the characteristic defenses, evacuating their "depression" into others. They may come across as superior and arrogant; they may feel contempt for others who they perceive as excessively needy or vulnerable. At heart, they feel enormous contempt for their own authentic damaged selves and want nothing to do with them.

The work with such clients -- if they even reach the point of seeking treatment -- is to help them to BECOME depressed. In other words, it is a sign of progress when such clients can experience depressed feelings. They usually don't experience this depression as progress, however, and may break off treatment as a result. A particularly tricky variation is the superficially-devoted client who becomes a major fan of psychotherapy, possibly entering the profession. Such individuals attempt to ward off depression and awareness of damage with a false, pseudo-therapeutic self that uses the LANGUAGE of insight and emotion with fluency but never gets near authentic shame. The challenge with such clients is to bring them into contact with their actual self in such a way that they don't experience it as an unbearable narcissistic injury.

Years. The work always takes years.

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