When Living Hurts

Directives For Treating Depression

Michael D. Yapko, Ph.D.

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317714910
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1994. Some episodes of depression can even be prevented, but the greater focus in this book is on responding to the experience of depression that is already present in the afflicted individual. This book represents an effort to make the extremely complex and subjective experience of depression one that can be better understood and more effectively treated. It does not represent a school of therapy in a singular way. Rather, it promotes the recognition of the diversity of human experience such that an emphasis on anyone approach will seem obviously self-limiting.

Part I

Theoretical Framework

1

When Living Hurts

When Living Hurts is the painful reality of daily life for literally tens of millions of people. There is a very good chance that the reader has directly or indirectly experienced the kind of feelings that make it easy to recognize depression in the way that some of the author's clients have described it:

“A robber in the shadows, stealing my life.”

“An invisible, insidious monster.”

“A suffocating shroud of pain.”

“An evil curse of ongoing agony.”

A couple of years ago the author was affected quite profoundly by a most troubling event that can be described here. It involved a psychiatrist who was a most remarkable man. We had never met, but his excellent work was well known to me. He had attended and graduated medical school in his early twenties, and quickly established himself as a highly visible and noted authority on patterns of behavior change (even co-authoring a well-received self-help book on the subject) and also on forensic issues in psychiatry. His range of knowledge, especially for so young a man, was most impressive. Unfortunately, when his personal life went through a period of crisis due to a failing marriage, his superior knowledge of emotional needs and mental health did not serve him at all. He literally asked colleagues for help because of feeling so out of control, but others apparently found the pleas for help too incongruous with his stature to take seriously. He soon ended up taking his own life with a bullet to his head. He was only in his early thirties, with a life potentially full of significant accomplishments ahead of him.

Perhaps it was the unrealistic expectation that mental health professionals should be more adept at handling life's difficulties that caused this event to stand out in the author's awareness. Perhaps it was some other reason, but whatever the reason, sadly his death was only one of about 30,000 suicides that year (Davison & Neale, 1986). Suicide has been called the “permanent solution to a temporary problem” and perhaps represents the most dramatic risk of painful depression. Why did so well-educated and insightful a man choose suicide? How does depression become so painful to so many that death seems a viable, desirable alternative? How does it become so debilitating that it causes ongoing suffering for those who have the courage, motivation, or tolerance to live with it? What do we as psychotherapists really know about depression and its treatment?

Much research on depression has been done over the years. The body of scientific literature available on the subject is enormous, a testimony to the pervasiveness of the problem and the serious involvement of those who genuinely want to do something to help. From this research have come elaborate theories about the etiology of depression, and a wide variety of ways to intervene therapeutically. Virtually all of the various theories and treatments are of potential benefit to the clinician for developing a comprehensive understanding of the nature of depression, yet paradoxically all are potentially limiting (and may even be harmful to the depressed client) if the multifaceted phenomenon of depression is viewed and treated from only a single perspective.

The mental health profession officially categorizes depression as a mood disorder, and it is so listed in the Diagnostic and Statistical Manual (3rd edition, revised) (American Psychiatric Association, 1987). As will be seen in Chapter 3, there are some specific problems with the diagnosing and classification of depression that can have a significant impact on how the depressed client is treated. Suffice it to say at this early point that the clinical entity termed “depression” is still not fully understood, nor is the treatment of depression consistently effective.

This is not a book about a theory of depression, although it undeniably contains some synthesis of theoretical perspectives. Rather, the emphasis throughout this book is on the treatment of the depressed individual. As a clinical psychologist working with depressed individuals and families, the author cannot help but be deeply affected by the many ways depression robs people of the positive possibilities life has to offer. As a human being subject to the same frailties shared by others living with human bodies and minds, the author also experiences the aches and pains of depression. It is a highly pragmatic orientation that dominates this work: What can one say and do that will have therapeutic value? What tools can be utilized to better facilitate recovery from depression, and catalyze the kind of shifts in the depressed individual's world that will both minimize future recurrences and allow for greater speed of recovery when episodes do arise?

THE NATURE OF THE BEAST

Depression has a long and well-known history, documented from earliest writings and lived out by countless numbers of people (some famous, most not). While specific numbers are hard to come by because of the many cases that go unreported, it is estimated that: 1) a range of 30–40 million Americans now suffer a diagnosable depressive disorder (Newsweek, May 4, 1987); 2) at least one in four Americans will suffer a major depressive episode at some point in their lives; 3) only about one-quarter to one-half of those who suffer major depression receive any therapy for their symptoms; 4) women are diagnosed as suffering clinical depression nearly twice as frequently as men (although the actual distribution of depression by gender appears to be even); and 5) depression occurs in all age groups (Kleinmuntz, 1980; Kolb & Brodie, 1982).

The prevalence of depression in a general epidemiological sense is troublesome enough. To compound the matter, it is well known that many cases of depression are “masked,” hidden behind a host of somatic complaints or other psychological problems. Thus, the problem of depression must be more widespread than general statistics indicate and may be even more widespread than clinicians may realize. If the criteria for a diagnosis of depression are broadened, as will be suggested later, depression may be more accurately assessed for its prevalence, a first step in better knowing the scope of the problem we as a profession face.

The pain of depression is known to some degree by most of us on both personal and professional levels. It seems literally impossible for one to be in clinical practice without encountering depressed individuals routinely. What is the effect of the prevalence of depression? The cost in human lives, suffering, damaged relationships, lost work, and lost personal time, as well as in other areas, is incalculable.

A reference to suicide statistics has already been made. It has been suggested that many of the people suffering depression are channeling their abstract bad feelings into concrete bad physical symptoms. It has also been alluded to that many other psychological difficulties are, in fact, depression in disguise. For example, it seems likely that many of the substance abuse disorders are actually patterns that are primitive attempts to cope with the pain (i.e., anxiety) of depression. Abuse of substances in all their forms are commonly relied on coping mechanisms, which carry mentally and physically unhealthy side effects that may help perpetuate the underlying problem of depression. Treating the alcoholic drinking patterns but not the related depression (when that is the case) is almost certain to generate recurrent episodes of “falling off the wagon.” Other dysfunctional patterns which may, at first glance, seem unrelated to depression may actually be closely related. The later discussion of diagnosing depression according to a broader range of criteria may help clinicians address this issue more efficiently.

Depression is generally a self-limiting phenomenon. If one does nothing and simply lets it run its course, for most people it will eventually fade away. The data on the average duration of a self-limited depression are ambiguous, suggesting anywhere between 4 and 10 months. Statistics further suggest that somewhere between 10–20% of those with a diagnosis of depression will develop a chronic condition (Davison & Neale, 1986).

ETIOLOGY OF DEPRESSION

Conventional wisdom would lead one to anticipate that with a problem as multifaceted as depression there would be no single underlying causative factor. Conventional wisdom is not always correct, but in this case it most assuredly is. In fact, there are quite a few theories describing causes of depression. These theories include biological, intrapersonal, and interpersonal views, and each offers extremely useful ways to think about the etiology of depression. It is assumed that the reader is already familiar with these theories, and so each is given only a cursory description here.

Biological Theories

Derived largely from the effects of certain drugs on the biogenic amines, the major biological theories regarding depression hypothesize that depression occurs when certain neurotransmitters (such as norepinephrine and serotonin) reach too low a concentration in certain areas of the brain. Also falling within the biological realm are those links between depression and physical disorders. The following comprise a partial list of biologically based depressogenic phenomena: certain prescription drugs (including reserpine, some oral contraceptives, antihypertensives, minor and major tranquilizers); some drugs of abuse (e.g., alcohol, barbiturates, stimulants, hallucinogens); neurological diseases; metabolic-endocrine disorders; heart disease; surgery; and diseases of the kidneys, liver, and pulmonary systems (Hollister, 1983).

Depression may be secondary to debilitating illnesses, or vice versa. When depression is observed in tandem with physical illness or dysfunction, it may simply be coincidence, but it may also be a significant finding with strong implications for appropriate treatment. Careful diagnosis is needed in such instances.

The biological framework includes theories regarding the genetic transmission of depression. Studies have shown that a range of approximately 25–40% of depressed individuals have a parent or other first-degree relative with an affective disorder (Clayton, 1983). Owing to the fact that women are diagnosed as depressed twice as frequently as men, some have suggested that depression is linked to an X chromosome transmission, but there is no firm support for this theory to date. Female hormonal influences have also been considered as significant etiological factors (related in particular to the hormonal changes associated with postpartum and menopausal depressions), but firm conclusions in this area have not yet been made. Furthermore, while women may be diagnosed as depressed more frequently than men, the actual distribution by gender appears to be equal. Differences in diagnostic criteria for men and women are thought to be the basis for the larger percentage of women deemed clinically depressed (Davison & Neale, 1986).

Intrapersonal Theories

“Intrapersonal” is the general heading of those theories that emphasize depression as a problem within an individual. This encompasses psychodynamic, cognitive, and the “learned helplessness” models.

The psychodynamic model conceptualizes a sense of “loss” as the chief component of depression. Freud (1917) theorized that some individuals become overly dependent on others for maintaining a sense of self-esteem (arising from too little or too much gratification of needs during the oral stage). Thus, when the object of dependency is lost (perhaps through their death or rejection), the individual feels rage that cannot be directly expressed. Rather, it is “anger turned inwardly,” and becomes the self-blame and self-hatred that are characteristic of depressed people, according to Freud.

The cognitive model of depression, developed primarily by Aaron Beck (1967, 1973; Beck et al., 1979) conceptualizes depression as a product of distorted thinking. In Beck's model, emotions are consequences of thoughts, and if one is depressed it is because one is thinking in negative and unrealistic ways. The negative belief system may have been established early in life and precede episodes of depression that arise later. Perception and subsequent activity involve interpreting ongoing events, and if one's perceptions are consistently negative and demotivating, depression is a fairly predictable outcome. The “learned helplessness” model of depression, developed primarily by Martin Seligman (1974, 1975, 1983), conceptualizes depression as the product of a history of faulty learnings regarding personal locus of control. Seligman's model suggests that when one is subjected to negative events perceived as outside of one's control, one becomes hopeless, passive, and depressed.

Interpersonal Theories

From a systems perspective, individual pathology is viewed as a reflection of the system of which the individual is a part. Thus, the focus in an interpersonal model of depression is one emphasizing the involvement in the therapy of other members of the identified client's social network. The underlying belief is that depression occurs in a social and interpersonal context and arises primarily from depressogenic relationship patterns. These may include stressful social role transitions, social role conflicts, and social consequences of individual choices (Klerman, Weissman, Rounsaville, & Chevron, 1984).

Strategic psychotherapies that are brief and directive in nature are generally systems-oriented approaches that typically make use of the client's everyday social contexts in order to effect change. The systems-oriented approaches of clinicians such as Jay Haley, Paul Watzlawick, Virginia Satir, and Milton Erickson are typical of the emphasis on the antidepressant capability of restoring or elevating a system to its functional capacity.

The various models of depression described so briefly here are each profound in their own way of conceptualizing the nature of depression. For the reader unfamiliar with these models, it is strongly recommended that he or she r...

Table of contents

• Cover Page
• Half Title page
• Series
• Title Page
• Copyright Page
• Contents
• Introduction
• Acknowledgments
• Part I Theoretical Framework
• 1 When Living Hurts
• 2 The Direction of Relief
• 3 The Multiple Dimensions of Depression
• 4 Patterns of Pain
• Part II Treatment
• 5 Therapy: Interrupting Patterns of Pain
• 6 Starting with the Future
• 7 Facilitating Flexibility: Let Me Count the Ways
• 8 In and Out of Control
• 9 Where the Chips Fall
• 10 A Part and Apart
• 11 Never and Always Alone
• 12 Inside Out and Outside In
• Appendix A: Directives
• Appendix B: Case Narratives
• Bibliography
• Index