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Psychotherapy & Couples Counseling 
Bernard McDowell, lcsw
Psychotherapist & Licensed Clinical Social Worker
  811 NW 20th Avenue, Suite 104, Portland, Oregon 97209

503-234-9904



Depression:  General Considerations

by Bernard McDowell, lcsw copyright 2003

     Feeling in a low mood with low energy...even on days off?  To the point that it hurts and it  seems hopeless to try making things better?  Do you find yourself with few interests or unmotivated to take care of basics like doing the dishes? Or do you frequently feel badly about yourself for failing at meaningful relationships or being stuck in a senseless job?  These scenarios describe a few painful symptoms of what is commonly called depression.  But wait, doesn't much of the above apply to most of us--at least some of the time?  Absolutely!  In fact, there's no general agreement about what "depression" is.  By recent media accounts, depression is a mental illness while the TV commercials of pharmaceutical companies characterize depression as
 “caused” by brain chemistry malfunction though there are no clinical lab tests for it.  Other perspectives portray depression as everything from a common psychological reaction to normal developmental challenges to a malady of the industrialized world.  Some scientists have argued that its simply a “behavioral” failure to exercise facial muscles to smile often enough.  There's still active research in that vein. 
 GO TO SPECIFIC TOPICS IN THIS ARTICLE:
   Recognizing Depression  
Deeper Dynamics Of Depression
Defining Depression
Comparing Treatment Approaches
Summary Concerning Depression
Intro To My Therapeutic Approach

     This article is intended for orientation in sorting through a maze of possible therapeutic treatments for depression as well as an understanding of the research and theories behind them.  There seems to be a different “theory” for every aspect of being human:  One emphasizes cognitive processes (thoughts and beliefs), others family background (family of origin, ancestry, and culture), and another behavior (exercising, smiling, and staying active).  Other candidates include internal psychological processes, human chemistry (neurotransmitters), and genetics.  Despite their claims, none of these theories are well proven or mutually exclusive.  However, there is lots of evidence that many people regain their vitality after periods of depression.  Here is an overview of different takes on depression.  While it reads coherently from top to bottom, you may benefit by forwarding to a section of particular interest by clicking on any topic in the box (above right).  
Back to Top

 Recognizing Depression:  How Depressed People Speak About Their Lives

     Depressed people may or may not articulate it as such or even recognize it.  Some of the superficial signs are indicated by how we talk about our lives.  Typically,  when depressed, people say they're "down" or "in bad mood".  This can spread beyond a few days to the point of pervading much of life.  Even on days off, finding themselves in a “fog” half way through the day, depressed people often report wanting to be out enjoying life but unable to identify (or choose) something they would really enjoy.  Frequent self put downs are common along with casual, almost innocent comments, "it doesn't matter to me", or more serious statements about "just not caring anymore".  Painful indecisiveness with low self-esteem often oscillates with spells of anger, anxiety, and/or lethargy.  Two days worth of dishes pile up in the sink and bills don't get paid on time.  Important appointments may be forgotten as the sense of a future is blurred by a bad mood and a sense of hopelessness.

     At more extreme levels of depression, people feel inert, "shut down", “numb”, or overwhelmed with feelings of despair.  Perhaps, they stop showing up for work, ignore their children, or entertain suicidal thoughts.  Very restricted or flat facial expressions are common.  Feelings of shame may be easily triggered.  Along with very poor self esteem, they typically have difficulty asserting themselves or even knowing what they want.  Obviously, any of this may devastate families and finances, though the basic tragedy is the loss of the depressed person's ability to enjoy the marvelous adventure of a fully engaged life (though for a depressed person that seems an extremely remote possibility).  Recently the World Health Organization reported that “depression is the leading cause of disability… and the 4th leading contributor to the global burden of disease….”  The project that ranking to move to 2nd by the 2020.  In treating depression, it is often critical to distinguish physiological conditions of low energy such as hypo-thyroid or post partum hormonal conditions from psychological issues.  There are many other factors to consider in a good "differential diagnosis" which distinguish depression described here from other conditions such as bi-polar (manic depression) which are not specifically addressed in this article.

 Deeper Dynamics Of Depression

From the perspective of a large bodies of research and theory often referred to as “depth" or "object relations" psychology, the symptoms of depression don't fall out of the sky like some invading virus rather they are simply clues to deeper though common psychological dynamics.  Elsewhere on this site, you'll find articles examining those dynamics in much greater depth including how a healthy sense of self grows and how that process can go awry into depression.  In brief, those dynamics include glitches in incorporating and/or maintaining the ability to recognize and pursue what interests us.  

When people are clearly aware of what really excites them in life (their needs, interests, desires, etc.), they will be in motion towards fulfillment of those needs.  Imagine that for some sudden mysterious reason you had no food available to you for a few weeks.  Now what will happen if for some odd reason, you happen to come into my office and there is a beautiful buffet of your favorite foods.   Of course, most people will go directly for the food!  We might say needs (e.g., hunger) seek fulfillment (food in this case).  Then is it merely a matter of identifying and asserting our needs to feel fully alive?  Well, there's a big catch-22!  Some of our needs conflict with other needs we have-most particularly, our needs in relationships.  For example, we may want to reach out to someone to make a new friend, but also want to look cool and not look like a needy fool.  A child may need connection with a parent who often rages at the child for expressing herself.  The child needs individual attention from the parent but may need a peaceful household even more.  When presented with the scenario above, really depressed people rarely say they'd go straight for the food.  Instead, they wonder if it would be all right if, they “might possibly”, “if it wouldn't be too much trouble” have some food.  That is, they are so oriented towards others, it's as if they quickly lose track of their fundamental needs.  When we pursue our needs (or what jazzes and excites us), we might find fulfillment but we also risk loss-rejection, failure, etc..  [By the definition used here, losses are any unfulfilled needs.]  

     Consider a man who doesn't ask someone out on a date or a woman who doesn't try out for a part in a play or apply for a promotion--for fear of embarrassment or rejection.  The woman avoids a specific loss but isn't moving with her natural inclination.  In fact, both this man and woman are likely to be depressed sitting at home on the couch.  Now imagine that the woman did try but failed to get what she wanted; and then swept the losses “under the carpet” while copping attitudes:  “I don't care”, “it didn't matter anyway”, or “it hurts too much, I'll never do that again”.  Now, she may diminish her hurt or escape the pain of further rejection, but, remember that since losses are unfulfilled needs, she has also pushed her needs under the carpet; that's why she's saying that it doesn't matter.  

     We might also say she has “self abandoned”-she focuses so much on what others think, that she abandons her own vital desire.  In effect, she's pushed her “self” under the carpet.  Now, out of touch with her needs and to avoid further loss, she stops asking people out or nurturing her secret dream to be in a play.  Perhaps, only half realizing it, she avoids future losses but by not going for what she wants.  When such a tendency gets entrenched, depression results.  Some people do that and simply grow numb with a flat emotional life.  Others know very well that they are hurting, but, in an habitual, though unconscious reference to others' responses, their heart's desires are no longer in sharp relief.

A Quick Tour of  Depression Through the Life Cycle

     For some, problems maintaining loving connections while asserting needs take root very early in life; but as we'll see the same basic dynamics continue through the life cycle, with pitfalls and potential leaps forward all along the developmental pathway.  The emphasis here is on childhood because it's just simpler to explain the basics beginning with early childhood.  Hundreds of experiments have been done tracking interactions between mothers and infants by photographs or videos every tenth to every 30th of a second.  If, when a baby moves its facial muscles along with `goo-gooing' sounds, the mother `goo-goos' back, then the baby can repeat what it just did by making the same sounds and facial movements. But if the mother doesn't mirror/respond to the baby enough, the baby generally wont' be able to reliably repeat those movements.  

      Not only our physiological ability to move our facial muscles but also our psychological health is much more like a living system that needs energy inputs as well as creative outputs. 
Many research studies corroborate the role of mirroring in other aspects of child development including the emotional realm.  Imagine a toddler overcome with anger.  If the parent yells, “one more word out of you and I'll knock you across the room”, the child either forever inhibits or forever acts out anger trying to come to terms with those overwhelming feelings.  On the other hand, if a parent greets the child's tantrum with attunement and, ideally, some calmness, that child learns to name anger and express it appropriately.  "Come over here.  Hey, you're so angry, that must hurt".  Even if begun in an irritated voice, when the parent shifts to a soft soothing tone, the child learns to name it's chaotic feelings as anger and downloads the ability to soothe itself.  One technical psychological term holds that the child “autonomously incorporates” those abilities.  These examples address physical and emotional development, but we have yet to highlight how the essential ability to identify what excites or interests us develops-without which we'll feel depressed.
A Crucial Aspect Of Depression :: How We Identify Ourselves

      As we grow up, demands to navigate the world on one's own increase and, with that, the need to identify as an independent person intensifies.  As with physical and emotional abilities, only with mirroring can children incorporate a sense of self, a sense of choice--to go along with parents' demands or not; to give love and affection or not; or to identify and pursue desires and needs. Parents must certainly give strong directives to younger kids; but without some “mirroring” for their emerging “sense of self” and acknowledgment of their particular tastes and preferences, children will not grow up with a fundamental sense of their unique needs, self-worth, and choice.  It is only with a sense of choice that we can truly give and feel vibrant. Acting out of obligation (should, have to, etc.), people feel resentful, drained, and sluggish.  Our “identity” grows from the ability to differentiate our needs from others and that is essential for vitality and movement towards goals .  

     At adolescence other critical challenges come: The need to explore what we like or don't; to experiment, fail, and succeed in determining our needs relative to parents and peers.  A classic setup for depression finds an adolescent in the position of care taking for an already overbearing parent. The teen needs the parents approval, financial support, and guidance but now has to suppress her needs in favor of the parent's needs.  This teenager doesn't get a chance to go through the typical exploratory phase required to differentiate her thoughts, preferences, and choices for leading her own life.  Frequently, a teen in this situation grows into a depressed adult.  The point here isn't to focus on particular childhood situations associated with depression but to underscore the dynamics of how children learn to distill out their needs from others' influences or very likely suffer depressive consequences.  Without the ability to differentiate from peers, adolescents are quite susceptible to bad decisions that their parents call “bad choices”.  But from this viewpoint the problem is more fundamental, they really don't yet “have a self” from which to make choices, much less good choices.  Keep in mind these examples are given in broad strokes.  

     Most depressed people don't have nearly as obvious or as dramatic family histories, but any number of subtle interactions with caregivers with the best of intentions may have similar depressive results. Many adults become depressed without any obvious prior history of family dynamics that might predict it.  Again, some kind of loss typically plays a major role.  It could be a layoff, a death, a child moving away, a rejection for a job or a relationship, or a disabling condition.  Now logically, it may seem that someone who has made it to adulthood would be able to keep a layoff in perspective. But its not that simple.  Rollo May, a famous psychologist, noted that one hundred years ago, people valued themselves through a variety of identifications including their religion, nationality, or family background.  In this society the main cultural current places an enormous emphasis on what type of work we do; and how much money we have translates to how independent people perceive us to be.  When laid off from an important job, it is a tremendous challenge to stay psychologically differentiated from gravitational field of common cultural sentiments-“why isn't the bum working”.   Unemployed people often hate going to parties for fear of being asked "what do you do".  Logically they know they are the same worthwhile person, but emotionally it's hard for them not to internalize other people's disapproval onto themselves.  Of course, there are many other variations of depression through the life cycle.  Suffice it to say that the same issues about differentiating out needs from others as well as issues about loss are usually involved.

     Quite often I've heard very depressed people use the phrase, “I can't take another loss”.  But if we are in love with life, we will have losses:  No matter how wonderful a relationship someone has, there will be important ways that the beloved won't appreciate that person at times-not to speak of inevitability of illness, death, etc..  That's a loss.  Without the ability to respond deeply and thoroughly through loss, people close their hearts.  Without the willingness to have a loss, no one would ever try something new, travel, apply for a job, or paint a picture.  And when people stop following those heartful impulses, its as if they've not only averted loss but abandoned their very self. There is an esoteric saying that a “true person” is a woman or a man with a broken heart.  Of course, it refers to a heart broken…open…to the risk of being engaged in life.   But who in this world of modern medicine teaches us to grieve.  Most of the culture is running from loss as fast as possible with drugs, alcohol, and mindless distractions.  Yet the ability to feel a loss is crucial to maintaining self worth.  The woman who says yes but with resentment to every request of  a family member isn't acting unselfishly; rather she suffers a lack of self.  The man who doesn't ask someone out for fear of rejection isn't just sensitive to the other's reaction; he's avoiding loss but also avoiding himself.  

 Defining Depression:  Practical, Psychological , Chemical?

The Diagnostic and Statistical Manual

     There is no universally agreed upon definition of depression.  The least interesting and most shallow take on depression demands our attention first because it has been adopted by virtually the entire insurance industry in the United States.  The Diagnostic and Statistical Manual [DSM] lists depression among specific "disorders" of individuals.  For major depression, a person must have 5 out of 9 on a list of symptoms for a minimum of 2 weeks and meet a few other criteria [see DSM on this site].  That same list is used as part of the diagnosis of several other “disorders” including “Depression NOS (not otherwise specified)”, a catch-all category often used when a client reports less than 5 symptoms.  

     The DSM has strengths but also glaring weaknesses--it explicitly refuses any responsibility to determine the causes for depression.  The latest version published in 2012 was fraught with controversy among the authors and professional organizations . Then in December 2013, the National Institute of Mental Health disaffiliated their research from the DSM on the basis that it wasn't scientific enough. 

Social Context Factors
     Many social critics, writing in much greater depth about the landscape of modern life, portray depression as a peculiarly modern problem resulting from the alienation of industrial life.  A great deal of twentieth century literature portrays that along with a number of major social critics.  Indeed, counter to the notion that depression is caused by genes or neurotransmitter imbalances, depression rates skyrocketed  1,000 % in industrialized countries since 1945.   

Other Views
      There are many psychologists and writers who stand in stark contrast to the DSM's superficial approach.  For example, Thomas Moore notes that clients don't come in with a list of symptoms rated on a 1 to 10 scale; rather they speak of difficult complex issues such as loneliness, inability to get out of bed to go to a meaningless job, gnawing feelings of failure to meet family expectations or manifest their own dreams, or the pain of searching and searching for a relationship that never quite materializes.  From that perspective giving someone a diagnosis of depression by using the DSM's list is a disservice; they aren't "disordered" but hurting in the face of normal though painful human circumstances.  (From a strictly scientific viewpoint, the “empirical data” is the client's exact wording, “loneliness” or “feeling devastated” after a breakup.  A typical managed care approach married to the DSM asks clients to rate their “depression” on a 1 to 10 scale but that actually strays further from the empirical data than speaking about “loneliness” or feeling “devastated”.)

      Similar to the examples cited above, “psychodynamic” theories attribute chronic depression to glitches in the development of a healthy self that, in turn, arose within problematic relationships during childhood with caregivers.  Yet, a broader context comes from Carl Jung who drew on thousands of years of literature and myth to understand the human psyche.  From that perspective, depression can be seen as a central feature of the human psyche; again, not a disease, but a developmental challenge.  For example, The Fisher King Myth, hundreds of years old, depicts a king falling into depression along with his whole kingdom.  But it also maps out, through the story line of the myth, the elements necessary for the king and the kingdom to regain their vigor.  Some believe this is actually a more scientific approach because these stories, told and retold through generations, are less susceptible to distortion by business interest or one particular person's ego.  Their difficulty lays in the wide spectrum of interpretation they invite.

Is Depression a Chemical Imbalance?
     To add to the mix, the pharmaceutical industry portrays depression as “caused” by malfunctions in neurotransmitters.  This vast topic requires the evaluation of much scientific literature as well as an investigation into the politics of health care.  Because this is a quite complex topic, this is addressed below along with other therapies.

      At first glance, the various explanations of depression touched on here seem at odds, but, again, they are not mutually exclusive.  It is useful to think of each of these approaches as originating from a particular predisposition as will be illustrated in the next section on different types of treatment.  

 A Few Notes Comparing Treatment Approaches

      Different psychological schools have emphasized entirely different aspects of human experience.  Unfortunately, each new school seems to claim the unique and exclusive corner on the truth.  Fortunately, many types of therapy have been proven effective.  Psychoanalysis typically focuses on early childhood for explanations of how patterns rigidify with the imprints of our parents:  In essence, you are you're history.  Cognitive therapy assumes that thoughts rule our mood and motivations: In essence, you are your thinking patterns.  Popular a few decades ago, primal scream therapy promoted wild and full emotional expression assuming 1) reservoirs of emotions govern us and 2) venting them heals.  (Research on anger shows just the opposite).  Psychiatric treatments presuppose that you are your chemistry--a chemical soup that "causes" suicidal feelings, feelings of worthlessness, low mood, or any of the other symptoms of depression (according to the Diagnostic and Statistical Manual).  So, lets take a closer, though cursory look at some of these.

      The largest “effectiveness” study ever done indicated that many types of therapy are helpful.  Also, a number of other studies show little difference between different types of therapy while attributing most of the success of therapy to the relationship between client and therapist.  The rapport between the client and therapist as rated after the second session predicts the success of therapy better than what the therapist specializes in.

Cognitive Behavioral Therapy
     Cognitive therapy relies on the assumption that “moods are created by thoughts”.  Each thought gives rise to an emotion.  Depressed people think in distorted, “downer” patterns-e.g., “all or nothing” or “expecting the worst”.  An isolated, self-berating client might say “I never do anything right” or “I can't go that party, they'll put me down and it'll just be boring anyway”.   A cognitive therapist challenges the client to be precise and rectify the distortions in their thinking:  “OK, is it really true that you've never done anything right?”, “how do you know for sure that they'll put you down or that they'll be boring tonight?”.  Of course, the client might begrudgingly admit they have gotten something right sometime in their life.  The theory is that eventually, a person can change deeply ingrained thought habits.

     Many research studies compared cognitive behavioral therapy [CBT] to other types of therapy and to antidepressants.  In fact, because CBT has been studied so much, it is often proclaimed as the only “empirically supported” therapy.  Detractors point out that just because cognitive therapy is simplistic and easily “manualized” to fit a research project protocol comparing therapy to drugs doesn't count as sufficient reason to recommend it as the best approach.  It must be noted that most of those studies are paid for by pharmaceutical companies with vested interest in the outcome.  In contrast, many therapy theories guide therapists to continuously adapt throughout a session to the client's concerns and, because of that very fact, are not moldable to a standardized lab protocol!  The key issue though is that our cognitive functioning is only one aspect of the human psyche.  If logic won the day, I wouldn't be seeing a continuous stream of couples both of whom are often lawyers or scientists!

     Cognitive behavioral therapy [CBT] adds suggestions for changes in behavior which also “result” in depressed moods.  Over the years, some have expanded on the basics of CBT to include the “emotional implications” of our thoughts.  Though more sophisticated, those more expanded versions of CBT actually begin to resemble other “interpersonal therapies” and thus detract from the grander claims cognitive theory had to begin with.  (To be fair, it is important to note that individual therapists who say they identify with cognitive therapy may use many other techniques to adapt to each client.)  In a review of decades of research on therapy, "The Great Psychotherapy Debate", Bruce Wamplold consludes that cognitive therapy works but it's not because of what the theory claims; and further, it works no better than other types of therapy.

Exercising
     Several studies show that when people exercise vigorously for a number of months, they have a better and longer lasting outcome than when on antidepressants.  So, is treating depression as easy as prescribing vigorous exercise?  Well, there's another glitch! Though “loss of interest” is just one of the symptoms of depression according to the DSM-IV, it's at the very core of the problem as outlined in the section above on the “deeper dynamics of depression”.  In fact, depressed people frequently report how they've fallen out of their workout habits.  That's one of the very symptoms of their depression!  So prescribing exercise is virtually like saying stop having that symptom!  Stop being depressed!  There is a similar problem with the basic premise of cognitive therapy.  Extremely intelligent, logical people, e.g. trained as engineers,  may remain depressed though they've heard for years to stop putting themselves down and to think and plan for a positive future--but the logic of cognitive therapy doesn't motivate these otherwise very logical people to stop their illogical distortions about themselves.  Many researchers conclude that it's not the logic of cognitive therapy that heals but the relationship with the therapist that enables a person to take another perspective.  And that's where a deeper, integral look at the psyche is needed.

Psychodynamic Theory
     There isn't just one psychodynamic theory.  However, there are many similarities across a number of  theories, so I'll speak of them here in the broad strokes as one.  Generally, they focus on how our sense of self develops.  This thing we call “I” is a deeply conditioned imprint that forms in our relationships with others; in a sense it's a coordinating center for how we think (cognitive), make moral decisions, form a body image, and develop our particular tastes (aesthetics). Rather than assume “depressogenic” thoughts are the “cause” of depression as cognitive theory does, psychodynamic interventions assume there's a fairly stable way we represent our self to our self--and that serves as a self fulfilling prophecy.  People who missed some important mirroring as children will have internalized an image of themselves as defective, hopeless, a screw up, or not important enough to be heard; that “I” then continues to produce depressogenic thinking patterns:  “no body is interested in anything I have to say, so why bother”.

     Given the overwhelming demand on a child to adapt to the parents, a child necessarily forms a somewhat distorted sense of self which then is then maladapted to the rest of the world outside the family.  Alice Miller, author of the Drama of the Gifted Child, argues that healing from depression requires recovering an “authentic” self.  Along with quite a few prominent psychologists of the last century, she postulates that everyone grows a kind of “false self” over the years to meet the most basic needs of pleasing parents and avoiding their disapproval, wrath, etc..  For physical and emotional survival, kids necessarily adapt to parents' needs, moods, etc. just as a plant bends towards sunlight.  That in itself doesn't constitute a “false self”; however, when a child is overly oriented to parents' needs to the neglect the child's particular interests, the child's own needs simply don't come into consciousness for the child.  
 
     So, how is this “false self” explicitly traced back to depression?  Complicated theories aren't necessary to appreciate this.  Popular culture provides endless examples.  Sports pages chronicle how a father pushed his football playing son to the extreme until that gifted player fell into depression and drugs.  Several recent movies portray parents imposing their agenda on children with a gift for music--but the children then struggled to grow in that atmosphere dismissive of their needs.  The parents in these cases were almost cartoon caricatures of people imposing their will on young kids who could barely breathe much less assert themselves.  But we've all had difficulty asserting ourselves at times even to the point of being depressed or self hating for not standing up for our self to a parent, a boss, a spouse, a store owner, a doctor, etc..

     Let's review a crucial chain of concepts linking “needs” to depression as detailed in the section above.  When hungry we seek food.  That's a simple illustration that “needs seek fulfillment”.  When our needs (what excites and interests us) are obvious to us, we are engaged in life.  But though all children have needs, a child's ability to recognize their unique interests takes time to grow. There is a great deal of research indicating that happens through the process of parents “mirroring” (acknowledging) the child's interests.  Again, unless a mother mirrors an infant's facial muscle movements, the child can't repeat the very movements it initiated.  Psychological qualities only take birth into a self image through mirroring.  A child only knows herself as persistent through being “seen” from others.  Of course, no parent mirrors every child perfectly in every way and there are pitfalls outside family life as well.  Thus, we are all somewhat hungry to be seen in a special way throughout life.  Some people tend to act that out while others withdraw to protect the wounds of not being seen.

     Even very active and seemingly self motivated people can become depressed.  The dynamics of their depressive processes do, however,  entail a similar loss of recognizing vital interests which they somehow lost track of.  A classic example is a very successful person at mid-life beginning to feel the hollowness of their success.  They may not recognize how they had been guided by others' motivations internalized long ago--dad's, an influential teacher, or the cultural rewards for their performance; but now dissatisfaction sets in.  In a process that occurs under the radar of consciousness for virtually everyone, they hadn't distilled our their uniqueness from the cultural, family force field.  Another way that happens is through an obvious loss--someone who has a failure in a relationship or a series of losses whether at work or home.  Again, by the DSM definition, lack of interest is just one of many symptoms of depression, but from the psychodynamic viewpoint lack of interest is virtually synonymous with being out of touch with needs closely entwined with a highly valued sense of identity.  

     That's a little on understanding about what psychodynamic theory concludes makes people tick, but what does the psychodynamic approach suggest for change? for healing the depression of this “false self”?  Decades ago, “psychodynamic” therapists typically took a passive role with their clients.  The therapist said very little and offered no analysis to the client for months or even years.  Such models relied heavily on the assumptions 1) that clients benefit from gaining insight into how they acquire their problems and 2) that the therapy affords the client a chance to rework unhealthy parent/child patterns through the relationship with the therapist.  

     But numerous therapists value the core insights of psychodynamic theory while utilizing a whole range of other interventions borrowed from other therapy practices.  These include such basics as giving empathy and freely admiring a client's accomplishments. But, at another turn, it could take the form of challenging a client to take responsibility for feelings they project with anger onto a spouse or boss.  The process might be characterized as a mutual inquiry into how the sense of self is still subtly blurred into parents and culture while helping the clients distill out their own feelings, opinions, and intuitions.  Milton Erickson, M.D., known for medical hypnosis, story telling, and assigning tasks to clients, is considered the founder of “brief therapy”, often characterized as the extreme opposite of psychodynamic therapy.  However, Erickson argues that his assessments of clients are properly considered “psychodynamic” though he recognizes that his techniques of helping clients achieve their goals are outside of traditional psychodynamic interventions. (More on my own personal approach to working with clients can be found at the end of this article.)

     Alice Miller's antidote to depression is to “grieve” the loss of our authentic vitality.   Initially, that may seem an odd tack.  Why focus on how we disempower ourselves? And grieving doesn't sound like a cure for anything!  But consider the opposite-a man angry and depressed over a spouse, a parent, or “society”.  He sees the other as the “cause” and himself as “at the effect of” that other.  This can be quite healthy to a point: The anger says “don't tread on me”. But if he only stays angry, the spouse, parent, et al remains the “cause” while he stays in the victim position.  The same is true for the depressed perspective, “it's hopeless, there's nothing I can do to change and I don't really care that much anyway”.  When focused on how others or life's circumstances disempower him, such a man is at best a leaf in the wind.  If, however, he shifts attention to how he betrays himself, he has the possibility of stopping that pattern.  When he examines how he didn't listen to his own intuition, how he went along with others' decisions to avoid loss, or how he incorporated others' put downs, then there is a possibility of reorienting towards learning the skills (building the psychological muscle) necessary to do something else.

     Of course, it isn't useful and doesn't make sense to imply that children betray themselves because they are only growing a psychological sense of self.  Similarly if a woman is, e.g., sexually molested, it's not appropriate to suggest she disempowered herself. However, as an adult it becomes a useful concept to recognize “self abandonment”, all the ways we disempower ourselves, when it's a regular part of a pattern of interactions with others.  

     Yet understanding how we disempower ourselves doesn't necessarily translate into ways to do something different.  Those self betraying patterns are usually deeply grooved reflexes from early in our lives.  When people do notice their “self abandonment”, they often say, “I'm so angry at myself” or even “I hate myself”.   These reactions bring attention to the pain but have relatively low power to heal.  They even reinforce a not so subtle harmonic of self betraying energy.  If a parent lectures an angry acting out child who says, “I hate you mommy”, the child's behavior just got negatively reinforced (conditioned) while the child is left even more insecure.  If the parent quietly replies, “that's so sad, it must be awfully hard to hate your mommy, what's going on?”, the parent's accepting (unconditional) response deconditions the child's acting out and opens a dialogue.  Similarly, as long as we react in anger to ourselves, we trap ourselves in the very dynamic we want to escape.  
 
     More healing responses may be thought of on various levels e.g., cognitive, emotional, or “spiritual”.  Perhaps, the ultimate healing response comes with the cultivation of compassion.  Compassion is free flowing attention that embraces whatever is arising in consciousness.  When that free attention meets suffering, it simply meets it--without a predetermined agenda that the suffering must end.  In the ancient myth of the Fisher King, the King finally gets up from depression when the Knight Parceval simply looks at the King's pain and feels it without rushing to judge the King as defective or to make the pain go away.  Similarly, the parent who acknowledges her child with sadness and an open question sees and invites the child's pain…and the unfolding of it (for life is forever changing).  The reactive, lecturing parent implicitly tells the child that their feelings are invalid, but inadvertently locks the child into a bind of either hating the parent or themselves for being mean spirited.  

     On an emotional level, sadness and then grief are more often the appropriate healing channels for letting go of our old wounded patterns.  Again, internalized anger offers a little healing but more often than not has the implicit structure of holding someone or something external as the “cause” of our pain.    For depressed people, it's often of critical importance to learn the difference between grieving and depression.  As noted before, in depression people are often pushing away their pain by pushing away their desires so that a typical attitude is “it doesn't matter that much” or “I don't care”.  In grief, we're hurting but we're acutely aware that vital needs are going unmet.  Then, when the grieving storm has passed through, our needs are right out in the open and we go back to life naturally pursuing our needs as they arise…fully engaged.   In Alice Miller's view, after the grieving this tendency to self abandon, a sense of self is left that more readily identifies its needs and feelings and, thus, can navigate through the world in a healthy, vital, adaptive way.  

Therapy vs. Drugs for Depression
     Extensive research on antidepressants will not be reported here for several reasons.  First, there have been thousands of studies done and the interpretation gets very technical.  In a short essay it is difficult to give a fair hearing to all sides.  Also, the media swamps us daily with advertising and distorted summaries of research--the New York Times seems to report a scandal on the advertising or reporting of pharmaceutical research every few weeks.  Therefore, I prefer to personally discuss this issue with clients or refer them to original relevant literature directly.  One good thread of rather recent research on antidepressants can be found online by searching for an article originally published as joing venture of the American Psychological Association and the American Psychiatric Association at  "The emperor's new drugs: An analysis of antidepressant medication data" and the January 17, 2008 New England Journal of Medicine for an article on Publication bias, or the February 26, 2008 issues of PLOS (available online) to get an idea of the complexity and scope of research challenges and the range of interpretations.  Some of these articles summarize up to two decades of meta-analytical studies which review up to thousands of other studies.  

 Summary
 
    There are many tools to help people caught in the knots of depression.  The philosopher, Ken Wilber, makes a compelling case that  many different psychological theories were built on a limited perspectives that do not contradict each other except in their claims of being the exclusive truth.  Indeed, research on therapy supports that the type of therapy is much less important than the therapist and, more precisely, the rapport between the therapist and the client is the best predictor of the outcome of the therapy.


 An Introduction To My Approach To Therapy

Understanding vs. Skills for Changing
      As I studied many different psychological theories, I found it critical to distinguish between theories for understanding clients' unique problems and theories and prescriptions for intervening to help them make the changes they seek.  It is crucial to have understanding, a map of the territory, but the vehicle to move around that territory (the skills for intervening with people) is an entirely different phenomena.  “Psychodynamics” (as introduced above) is an exquisite tool for gaining insight (understanding) into how people form their patterns of relating, competencies, coping styles, etc..  One particular take on the "psychodynamic" approach is known as "object relations theory" which can now boast the support of 60 years of scientific observation and experiments.  I rely on those insights as well as those of Carl Jung who many consider to be the greatest and most comprehensive psychologist of the last century.  Jung drew on mythology, religion, literature and art of many different cultures for deep insight into the human psyche.  The work of contemporary philosopher, Ken Wilber, more than any other one source, captures in broadest strokes my understanding of what makes people tick.

     However, for all psychodynamic theory offers in insight, the actual methods it prescribes to therapists for intervening with clients were historically rather passive.  Therapists were taught not to react or say much while presuming the client will reenact early parent-child relationship patterns.  A major tool is asking the client to explore reasons. "why". they came to have the problems they did.  But "why"  does not automatically lead to a desired change!!  If there's a hole in the catalytic converter of your car, you may know why it's belching smoke and noise, but not know how to weld in a new one.  Similarly, depressed people are usually only too aware of their difficulty in asserting themselves, but they can't describe much less demonstrate five good ways to maintain their self esteem when slighted or put down.  In fact, several relatively recent trends in psychoanalytic practice do promote more active interventions.  

     In contrast, there are a number of approaches--gestalt therapy, neurolinguistics, "strategic family therapy", psychosynthesis, etc.--that put less emphasis on understanding and more on models and methods for desired change.  When done with respect and towards a client's goals, a whole gamut of dynamic, catalytic, playful, emotional, and educational interventions are invaluable.  In recent decades, marvelous and complex models of human communication and more precise therapy techniques have been developed.  These are not at all incompatible with deep insight into how our relationship patterns formed.  But these techniques do provide a better vehicle for navigating through the understanding given by the "depth psychological" approaches towards making the changes that clients want.  In my approach, therapy is often primarily a joyful, creative healing and learning process--alternatively surprising, demanding, humorous, or simply educational.