Almost half of us will suffer from depression
at some point in our lives, but the condition
remains badly misunderstood and therefore
often poorly treated. At the heart of our
collective difficulty with depression is a
confusion about what it actually is - and
in particular, how it can be distinguished
from a state all of us know very well and
with which it is has a distracting number
of similarities, namely sadness. It’s because
we unwittingly tend to apply to cases of depression
a number of assumptions drawn from, and better
suited to, an understanding of sadness that
we end up suffering far more than we should.
There are, on the surface, some notable similarities
between those who are sad and those who are
depressed. Both groups cry; both withdraw
from the world; both complain of listlessness
and a sense of alienation from their normal
lives. But there is one categorical difference
between depression and sadness. The sad person
knows what they are sad about; the depressed
person doesn’t.
Sad people can, without difficulty, tell us
what is troubling them. I am sad that my grandmother
has died. Or that I lost my job. Or that my
friends are being unkind to me. And - though
it might sound strange - this is precisely
what the depressed person is not capable of
doing. They may be tearful and at a very low
ebb, but they can’t conclusively put a finger
on what has drained life of meaning for them:
they simply say it has no meaning per se.
They aren’t depressed about x or y as one
might be sad about x or y. They are, first
and foremost simply depressed.
The inability of the depressed person to account
concretely for their mood can lay them open
to unwarranted charges of faking, malingering
or exaggerating. Friends who begin in a well-meaning
search for a soluble problem can end up frustrated
by the lack of progress. When pushed, the
depressed person may latch on to rather odd
or minor-sounding issues to account for their
state: they might complain that there is no
point going to work because the earth is due
to be absorbed by the sun in 7.5 billion years.
Or they might insist that life lacks all meaning
because they’ve just dropped a glass on
the floor and everything is now completely
hopeless.
At this stage, one can hear it said that if
depression doesn’t have any any sensible
psychological causes, the problem must be
bound up with some kind of imbalance in brain
chemistry, which it would be kinder and more
effective to treat with pills - an idea of
great appeal to the pharmaceutical industry
first and foremost, but also to worried families
and schools and employers who crave rapid
and cost-effective solutions.
But there is another approach to depression
which, though slower and more arduous, may
be a great deal more effective in the long-term.
This stems from insights drawn from psychotherapy,
the discipline that has - arguably - been
able to understand depression better than
any other. The basic premise of psychotherapy
is that the depressed person isn’t depressed
- as they suggest - for no reason. There is
a reason. They are very distressed about something
but that something is proving extremely difficult
to take on board, and has therefore been pushed
into the outer zones of consciousness - from
where it wreaks havoc on the whole person,
prompting boundless feelings of nihilism.
For depressives, realising what they are concretely
upset about would be too devastating, so they
unconsciously choose to remain dead to everything,
as opposed to very distraught about something.
Depression is sadness that has forgotten its
true causes - forgotten because remembering
may generate overwhelming, untenable feelings
of pain and loss.
What might these true causes be? Perhaps that
we have married the very wrong person. Or
that our sexuality isn’t what we once believed.
Or that we are furious with a parent for their
lack of care in childhood. In order to preserve
a fragile peace of mind, one then ‘chooses’
- though that may sound more willed than it
is in reality - to be depressed rather than
to have a realisation. We pick unceasing numbness
as protection against dreadful insight.
To make things yet more difficult, the depressed
person doesn’t typically consciously feel
that they are in fact lacking insight. They
are not aware of a gap in their self-understanding.
Furthermore, they are nowadays often taught
to assume that they are ‘just depressed’,
as one might be physically ill - a verdict
that can be of appeal as much to the pharmaceutical
industry as to certain people close to the
patient with an interest in insights remaining
buried.
There’s another key difference to note between
sadness and depression. Sad people are grief-stricken
about something out in the world but they
aren’t necessarily sad about themselves,
their self-esteem is unaffected by their grief,
whereas depressed people will characteristically
feel wretched about themselves and be full
of self-recrimination, guilt, shame and self-loathing
paranoia that may, at tragic extremes, culminate
in suicidal thoughts.
For psychotherapy, the origins of these violent
moods of self-hatred lie in anger due for,
but unable to be directed towards, someone
else in the world - that has then turned against
the sufferer. Wrathful feelings that should
have gone outwards, towards a partner who
is relentlessly defensive and denies one sex
or a parent who humiliated one in childhood,
are instead driven back onto the sufferer
and starts to attack them. The feeling: ‘X
has horribly let me down’ turns into a very
unpleasant but in some ways more bearable
‘I’m an unworthy and unbearable wretch.’
One becomes self-hating as a defence against
the risks of hating someone else.
Also worth noting in all this is that, in
many cases, depression is associated with
an apparently opposite mood, a kind euphoric
state termed mania, hence the term ‘manic-depressive’.
The mania in question looks, from a distance,
a bit like happiness, just like depression
can look like sadness. But in one area in
particular, the relationship between mania
and happiness is identical to that between
depression and sadness. The common element
is a disavowed self-knowledge. In mania, one
is euphoric, but cannot go into one’s own
deep mind and discover its bitter truths.
Which explains one of the leading characteristics
of manic people: their habit of being in flight
from themselves, talking too fast about nothing,
over-exercising, working continuously or spending
too much - all as an escape from a submerged
grief, rage and loss.
It is from this kind of diagnosis that a suggested
cure emerges. What people in depression need
above all is a chance to arrive at insight.
For this, they will tend to need a hugely
supportive and patient listener. They may
also - used appropriately - benefit from temporary
use of medication to lift their mood just
enough so that they can endure a conversation.
But the assumption isn’t that brain chemistry
is where the problem either begins or ends;
the despair is caused by an undigested, unknown
and unresolved trauma. Far from needing to
be taken through reasons to trust that life
is beautiful, depressives must be allowed
to feel and to remember specific damage - and
to be granted a fundamental sense of the legitimacy
of their emotions. They need to be allowed
to be angry, and for the anger to settle on
the right, awkward targets.
The goal in treating depression is to move
a sufferer from feeling limitlessly despairing
to mourning the loss of something in particular:
the last twenty years, a marriage, a hope
one would be loved by one’s father, a career...
However agonising the insight and mourning
might be, these must always be preferable
to allowing loss to contaminate the totality
of one’s perspective. There are plenty of
dreadful things in every life - which is why
it is wholly normal to feel sad on a regular
basis. But there are also always a sufficient
number of things that remain beautiful and
hopeful, so long as one has been allowed to
understand and known one’s pain and anger
- and adequately mourn one’s losses.
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