Different Types of Depression

As I discussed in an earlier post, 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 depressed men and women over the years; from my experience, the roots of their suffering usually lie in three common areas.  I'd like to offer some thoughts about these types of depression and their origins.  I don't view them as necessarily distinct; they often overlap and mingle in various ways.

1.  Post-Apocalyptic Rage:

Beginning with Freud, psychotherapists have noted the frequent connection between anger and depression; you may 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 forms of depression.  I use the phrase "post-apocalyptic" because, with many severely depressed clients, I have felt almost 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.  In the room with these clients, I often feels as if meaning has been completely destroyed and the emotional realm is void.  Such clients might describe themselves as feeling no 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 ghettoes, vast lifeless deserts or scorched terrain borrowed from movies such as The Terminator.  If you have a strong empathic link with your client, you may find feelings of rage rising inside you during the silence, for no reason you can understand.

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Art and the Dread of Experience

Over the years, I've worked with a number of artists -- musicians, a choreographer, several writers -- and dealt with various types of artistic inhibition such as writer's block.  In our work together, my clients and I  struggled with issues that might be familiar to you:  perfectionism, grandiosity of the type described in my post on self-criticism, as well as the self-envy that may lie behind fear of success. With several of my clients, I came to understand another such difficulty in making art, where the original inspiration or emotional charge behind the work of art is killed off in the process of creation.

In an earlier post on anxiety attacks and disorders, I introduced the concept of mind as a container for emotional experience; I discussed how people with "insufficient mind" -- that is, an inability to contain and manage their emotional experience -- often feel terrified that strong feelings will overwhelm and annihilate them.  Several of the artists in my practice fit this description.  One of them was prone to anxiety attacks and states of disintegration; another led a very controlled life, without much human emotional involvement; a third showed symptoms of autism and often tried to shut out a world that stirred up such terrifying emotions.  These difficulties also affected their creative processes.

Over time, we came to think of the work of art -- be it a choreographic work, a song or a piece of fiction -- as a sort of container for their emotional experience.  It's how I think about art in general:  great works of art contain and express profound emotional experiences; optimally, the shape of that container (the individual and unique painting, novel, symphony, etc.) bears an organic relationship to what is contained, adapting its shape to the needs of authentic emotional expression.  I hope that doesn't sound too abstract; as a clinician, I have found it an incredibly helpful way to think about my artist-clients.  The artist works upon his or her "insights" and tries to create a uniquely powerful work of art that will convey powerful emotion (basic human truths) to an audience.

With several of my clients, they started off with a powerful feeling or insight but in the process of creating their work of art, deadened it.  The art they produced (in their own view, not mine) lacked "depth" or "dimension":  dance works felt "constipated", their performers trapped in choreography with constricted movement and little emotion; songs seemed simplistic and boring, without true feeling; characters appeared "flat" and "two-dimensional".  In our culture, we frequently use these exact critical terms:  lack of depth, flat characters, two-dimensional stories, etc.  A vital artistic container has three dimensions and its own sort of life force; it has an interior and a surface or "skin" with which we, as audience, can interact.

Unsuccessful works of art have little dimension.  Rather than containing and conveying powerful emotion, they stifle it.  The artist who is terrified of intense emotion may mis-use his or her art form, employing it to flatten feelings instead of expressing them.  For that reason, the works of art they produce will leave an audience feeling "cold", indifferent or bored.  In short, rather than conveying profound and intense human truths, such art works seek to deny them.

Recently, one of my clients (an aspiring and frustrated writer) brought in a dream that perfectly illustrated this process.  She was treading water in a pond along with some "cowboys".  The pond felt like a whirlpool and they were all in danger of being sucked down into it.  The only way to save themselves -- that is, to keep from drowning -- was to tell one another non-stop stories while treading water.  At the same time, each of them had to hold onto a piece of raw meat that had been vacuum-sealed in plastic.

The cowboys are linked to the Wild West, a frightening way of life without the restraining influence of law and civilization.  Raw meat connects to raw emotion.  The dream shows how my client is terrified of her own raw emotional experience; in order to save herself from being overwhelmed by that experience, she resorts to "art" (telling stories) as a defense.  In the process, she shrink-wraps her experience and makes it safe, no longer raw and vital but hygienically processed, like something you might find in a supermarket meat case.

Finding Your Own Way:

I know that a number of visitors to this site are artists; I'd welcome your input on this subject.  What sort of artistic inhibitions have you struggled with?  Does this description in any way resonate with your own experience?  What about your view of other artists and their work?

As for the rest of us, we might begin with our relation to different art forms and how they affect us.  Think of a movie you found boring and ask yourself why.  Was it because the characters were flat, the story lacking in dimension?  Movies that portray extremely black-and-white characters often leave me cold because they strike me as a denial of a basic truth, that humans are a mixture of good and bad, each of us struggling with unavoidable ambivalence. What about novels you put aside and never finished?  Was it because they failed to engage your emotions?  Did they seem flat and lacking in dimension?

Many of us have artistic urges and never manage to fulfill them.  Maybe it's because we lack time and self-discipline; maybe it's because we don't have the patience to master the needed skill.  Another possible explanation, suggested by this post, is that we grow bored with the process, bored with our own creations, and abandon them.  Sometimes people take up a "hobby", an artistic endeavor that holds meaning, and in the process somehow render the experience meaningless to them; often it's because they simply can't sustain intense emotional involvement with themselves and their art form.

Defenses Against Shame

Over the years of my practice, I've found that most clients who come into treatment struggle on some level with issues of neediness and shame.  In other posts, I've discussed difficulties in bearing need; now I'd like to address in detail three core defenses against the experience of unbearable shame:  narcissistic flight, blaming and contempt.  Denial of internal damage lies at the heart of all three defenses.  Feelings of basic shame also form the core of what is commonly referred to as "low self-esteem".

Narcissism is the primary defense against shame and often goes hand-in-hand with the other two defenses.  When people suffer from an unbearable sense of shame, they often seek to elicit admiration from the outside, as if to deny the internal damage.  Beautiful outside versus ugly inside.  We've all known such narcissistic types.  As friends or acquaintances, they tax our patience and drain us emotionally because of their constant need to draw attention to themselves; their narcissistic behavior makes social interactions dull and one-sided.  Recognizing that these people suffer from unbearable shame may help
us to feel some compassion but it doesn't make the relationships any more satisfying.

The shame-driven client poses a major therapeutic challenge.  If the therapist tries to discuss narcissistic behavior as a defense, to go beneath the "beautiful" outside and get closer to the "ugly" inside, it can easily feel to the client like a narcissistic injury, unbearably painful; rather than feeling that the therapist wants to help them get closer to  something true but unrecognized, such clients often feel humiliated.  I discussed such a client in my post on 'Avatar' and toxic shame avoidance.  As we got closer to the core of shame in our work together, whenever I tried to put him in touch with the damaged David hiding behind his narcissistic Internet encounters, he'd often begin to scream, accusing me of misunderstanding or purposefully humiliating him.  It felt to me as if the shame were so excrutiating that he had to "scream it out," to rid himself of that searing pain and project it into me.  As his therapist, I found the experience deeply painful but at the same time, it helped me understand the degree of his suffering, the intense pain he was constantly warding off.

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The Pleasures of Solitude

In my post on grief and gratitude, I discussed some of the emotions that come to the fore in the termination phase of psychotherapy.  With the client I described in that post, another issue has recently become prominent:   the loneliness of personal responsibility balanced by the pleasures of solitude.

Diane began a recent Monday session by telling me she had the strong urge to fill me in on all the details of her weekend, to spill out her experience in a mindless way very familiar to us.  Throughout her treatment, she would communicate in that fashion because she wanted to feel that I was a part of her experience, as if I were there at her side going through life with her, always available to process that experience and to do her thinking for her.  She knew she felt a little angry and rebellious, as if to spill all those details would be an act of defiance.   In recent months, we've focused on the need to communicate in a different mode:   instead of unloading her experience in a mindless way, she needed to digest that experience first and decide which details should be communicated, what she intended to say and what she felt to be the crucial issues.  In other words, as the end of her treatment approaches, the responsibility to think for herself has shifted increasingly onto her own shoulders.

During that Monday session, she went on to discuss an article she'd read, about the rise of binge drinking among middle-aged professionals.  It made her recognize that her alcohol use had been creeping up lately as she faced various stressful situations in her life; she felt the need to get it more under control. This topic reminded her of early struggles with substance abuse when we first started working together. In those days, she used to carry a moralistic and disapproving "Joe" around in her mind; he held her to very harsh standards with no areas of gray, banning drug and alcohol use entirely, and came down hard when she slipped.  She often felt resentful toward this "Joe", as if she were a teenager and "Joe" the unreasonably strict parent; over time, however, she came to obey his rules.  Now, she said, even though "Joe" still appeared in her thoughts, she didn't believe in him in the same way.  She'd come to feel that the issues weren't so black-and-white.

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Envy and Jealousy

In his collection of essays on the Seven Deadly Sins, Joseph Epstein singles out envy as the most painful of those sins to experience, with none of the ancillary pleasures that go along with, say, lust or gluttony.  As I've discussed elsewhere, nobody wants to feel envious or to acknowledge feeling that way to others.  Like hatred in our culture, it remains a taboo subject.  It might be acceptable to admit you feel "jealous" that a friend has a trip planned to Europe or bought an expensive new pair of shoes; there's a good chance you could one day go on such a trip yourself or add to your own wardrobe.   Jealousy, in this modern sense, means:  "I admire what you have and wish I could have something just like it, too."  Jealousy is the cleaned up, socially-acceptable version of envy.

Almost nobody would say, "I'm envious that you're better-looking than I am."  You can't change the way you or the other person looks.  Few people would admit, "I'm envious that you have a spouse and children while I haven't had a relationship in years."  To admit to such feelings acknowledges a level of hatred most personal relationships can't tolerate.  For the truth is that envy, the green-eyed monster, wants to destroy what it cannot have.  The "solution" to envy -- the way to find relief from the suffering it causes if you can't have what you envy for yourself -- is to make the envied object less worthy of that emotion, by spoiling or destroying it.  Aesop's fable about the fox and the grapes speaks of unbearable desire but also describes a psychic mechanism (spoiling) active when envy comes into play.

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