Barbara Miller, MD
Depression is a withdrawal from life. It is usually felt as a sense of hopelessness, helplessness, low energy, eating and sleeping problems, poor self-esteem, difficulties in relationships, and thoughts that may be preoccupied with catastrophe, self-criticism and death.
Why does this happen? When I’m trying to understand someone’s depression, I think about it from several different perspectives. Its cause may be primarily at the biological, psychological, or spiritual level, or may be a complex mix at several levels.
At the biological level, there may be an imbalance in the neurotransmitters and/or hormones. These imbalances may be inherited, or caused by medical illness, or be the long term result of childhood trauma. Genetically, depression runs in families. For example, if one identical twin suffers from depression, the other twin is at a higher risk of a similar problem–even if they were separated at birth and raised in different families.
Imbalances may also be related to medical problems. Illnesses such as thyroid imbalance, adrenal imbalance, strokes, menstrual disorders, and vitamin deficiencies can be a cause of depression. Certain medications, such as steroids, benzodiazepines (eg. Xanax), and beta-blockers (cardiovascular medications), can cause depression. Drug abuse can be involved in depression. If you are trying to understand someone’s depression, don’t neglect to consider physical health as a possible cause of the problem.
At the psychological level, I think of depression as an inability to grieve: a disturbed mourning process, a defensive reaction to the hurts and losses in life.
What causes this avoidance? What is the difference between depression and grief? In the healthy grieving process, there is the capacity to tolerate and integrate the intense flow of feelings associated with the loss or hurt. Ultimately, there is an acceptance, a letting go, and a hope for life.
A healthy grieving process may carry one through several stages. For example, a person has lost a loved one. That person might initially feel shock, denial, or numbing. This may be followed by protest, a “fighting” against the event. At times, the person drops into periods of despair as a prelude to final acceptance and reorganization.
In healthy grieving, there is a letting go, an acceptance, and an ability to go on in life, to learn from the painful event and go forward. Aggression is not directed toward the self but is an energy used to go forward in life with a faith in growing and learning. The last line of Mary Oliver’s poem Blackwater Woods speaks to this strength:
To live in this world
you must be able
to do three things:
to love what is mortal;
to hold it against your bones
knowing your own life depends on it;
and, when the time comes to let it go,
to let it go.
Depression at the spiritual level may be looked at as the Dark Night of the Soul–a transpersonal experience. It is the struggle to transcend the ego, to face the Emptiness, to surrender to the mystery beyond the self. The longing to transcend beyond the personal self-identity can stir up unresolved fears from childhood. If the ego is strong and healthy enough to tolerate being transcended, the Dark Night is a questing, a searching, not an escaping. It is a movement toward, not away.
In depression, there is a sense of stagnation rather than flow, a “holding on” rather than a “letting go”. The depressed person’s holding on is an avoidance or inability to accept what has happened. The hopelessness actually covers a secret hope (but a false hope) that the awful event can be undone or fixed. An important part of depression is the inability to tolerate pain, sadness, and anger. The result is an experience of deadness, numbing, anxiety, or a flooding of pain or anger. Also, in depression, there is usually a great deal of self-blame and disconnection from others. The energy of aggression is not used positively to move on in life, but is used to reject the reality, and to attack the self or others.
What blocks grief? One idea is the learned-helplessness theory: hopelessness, and hence depression, develops when noxious events occur that are experienced as uncontrollable. A traumatic childhood may activate a persistent stress hormone response that alters brain development, leading to depression later in life. This may help us understand why losses in childhood can lead to adult depression. Three major types of childhood circumstances have been identified as leading to later depression:
1: The child’s parent dies and the child experiences little control over ensuing circumstances. This leads to the experience of hopelessness and despair.
2: The child can’t form a stable secure relationship with the primary caregiver. He sees himself as ineffective, a failure.
3: The parent gives the message that the child is incompetent or unlovable. Later, the child becomes an adult and expects hostility and rejection when in need.
The common thread of these three situations is that the child feels ineffective in actively managing his life, and has not learned how to experience, articulate, and integrate emotions. Both of these skills, called “agency” and “inner affectivity”, are important for a healthy sense of self and are needed in coping with life and being able to grieve the disappointments inherent in all living. Also important is the feeling that people can be turned to and relied upon in times of stress.
The process of healing depression involves looking at any contributing biological factors. Rebalancing the physical may involve life style changes in diet (decrease sugar, check for low folate levels, consider essential fatty acids) and exercise, evaluating medical illness, considering antidepressants, herbal (St. John’s Wort, SAMe), or other physical treatments such as light therapy, vagus nerve stimulation, or ECT.
The therapeutic task at the psychological level involves lifting experiential states back into consciousness, integrating them into awareness and identity, in order to resume the interrupted or never-begun work of mourning. This involves learning to identify and create a holding space for very difficult feelings, and to examine and challenge the negative thinking process of depression.
The process of healing depression means opening to grief, moving from the stagnation and frozenness of depression to an ability to compassionately hold the feelings of pain, loss, and anger, to move from a state of powerlessness to a sense of agency. An example of this process can be seen in the following imagery exercise.
Imagery on Healing Depression
Think of a difficult troubling loss in your life.
How do you defend against it?
Feel that defense in your bodyï¿½in your thoughtsï¿½in your feelings. Let yourself open to this defense, accept it, and then say to it, “Thank you for protecting me but I don’t need you now.”
Now let yourself open to the pain. Know that you are safe, and make space for this experience. Feel the pain in your body…in your thoughts…in your feelings. Allow the pain, and any other feelings, to move through you.
What can you learn from this pain? This pain is your teacher.
Listen with every cell of your body.
How can you carry this new learning with you as you move on in life? Imagine yourself going forward in life. What are you doing? What are you feeling?