In my last post, I provided a functional perspective of depression acting as the emergency shutoff switch for our human hardware, our brains and our bodies. In this post, I will be providing some of how I work with clients on preventing and recovering from a shutdown.

Working with clients on recovering from a depressive episode and/or mitigating depressive symptoms can be challenging in a number of ways. Any preventative work that can be done prior to a complete shutdown is a worthy and urgent undertaking for both client and clinician. Even a mild to moderate depressive episode will often leave clients feeling thoroughly walloped and devoid of the motivation and energy needed to restore their previous levels of functioning, making the necessary work feel like trudging uphill through the mud. Additionally, some clients experience depressive episodes as abrupt changes in their moods and energy levels that at best may only loosely correspond to adverse events happening in their lives, or events that have happened long ago. It is often surprising to see how long some people can carry on white knuckling it through life, avoiding a shutdown until long after many of the environmental causes have gone away. I find this lack of a clear causal link to a depressive episode often complicates generating the insight I believe is crucial in making lasting behavioral changes.

The insight or awareness of what is causing the depressive episode/symptoms is one of the two spectrums I seek to gauge clients on when they come into my office, the second spectrum being the level/severity of the episode/symptoms. I establish these important treatment benchmarks through the use of validated symptom measures and also by listening to how clients describe their experiences. Regarding the severity of the episode/symptoms, clients typically come into the office somewhere between fully shut down (severe irritability, sleep disturbances, hopelessness, possible suicidal ideation) and partially shut down (slight irritability, some sleep issues, increased substance use). It may be important to note which direction clients in a partial state of shutdown may be headed, some are doing their level best to stave off a shutdown and others may be struggling to bring multiple facets of their functioning back on line as they move out of a shutdown.

The level of awareness a client has about their predicament can often be recognized in the words that clients use to describe their experiences and seems to create a spectrum between limited and mostly aware. Although a moderate to severe depressive episode may be hard to miss, a client with limited awareness may not have recognized some of the warning signs along the way. A partially shutdown client with limited awareness might present as somewhat ambivalent and may say things like, “I’m so agitated all the time,” and/or, “I don’t feel much these days,” versus a mostly aware client who may say things like, “I’m holding on by a thread,” and/or, “I don’t know what will happen if things don’t change.” The latter verbalization points to another complication, the difference between knowing why something is happening and knowing what to do about it. Awareness then becomes the first directive in my approach and focuses on causality, identifying deficits in coping, moving away from guilt and shame, and making an action plan (action being a necessary counterpart to insight/awareness).

As it is often the most difficult aspect of the awareness directive, I usually start with addressing guilt and shame. As I stated previously, evidence shows that depressive periods are mainly the result of environmental factors (loss of a loved one, unemployment, relationship and financial issues, etc.) and inadequate coping. It seems logical that accepting these facts, the results of decades of research on depressive disorders, would effectively absolve clients of the responsibility they often feel for the conditions they find themselves in. Sadly, this is not the case and many clients instead struggle with an intense, demoralizing disappointment that often accompanies depressive episodes and symptoms and which they have internalized as a personal moral failing of their own making. It doesn’t help that there are sometimes others who are at worst accusing clients of the same (being lazy, ungrateful, pessimistic, etc.), or who are at best offering unhelpful suggestions that the client only needs to, “cheer up,” or, “look at the bright side,” which points to the same basic conclusion that the client is not doing enough to extricate themselves from the doldrums.

On the other side of the guilt and shame equation is the possibility that a client’s past or current actions have contributed to feelings of sadness and hopelessness. Acting outside of one’s character/integrity/values can leave a person feeling down on themselves and is worthy of exploration in therapy. Relevant guilt is not in my opinion an overtly negative state of being, it is in fact prosocial if that guilt is prompting us to repair damage we may be responsible for and not causing us to retreat from supportive others. In my clinical experience however, I find that clients are more often struggling to live up to the expectations of others or are shouldering responsibility for adverse and sometimes traumatic experiences that have been imposed on them. I would call the latter emotional state misplaced guilt and/or shame.

When addressing lingering and seemingly misplaced feelings of guilt and shame in my office, I like to use a guided visualization and escort clients on an allegorical visit to the Responsibility Garment Store. I ask clients to visualize with me a small garment store, lined with shelves that surround the space we are in, save for a small counter in the middle of the room where a clerk waits patiently. All of the store’s merchandise has been prepackaged in identical boxes, which line the shelves surrounding us. As the client approaches the register, the clerk selects a box from the shelves and places it on the counter. The client is informed that on this initial trip to the store, they are not permitted to select their own box and must instead take the box given to them. Additionally, they are not to open their box until after they have left the store and arrive at a safe and private location where they could try the garment on. The clerk lets the client know that if they do not like the fit of the garment after trying it on, they may bring it back to the store and exchange it for a garment of their choosing. Finally, the clerk informs the client of what they might find in their package, one of four garments available. The following are their names and brief descriptions:

The first garment is guilt. The guilt garment says of the wearer, “I have done something wrong and am not living according to my values.”

The second garment is a variation of the first and is called misplaced guilt, some call it false guilt. The misplaced guilt garment says of the wearer, “Someone will be upset with me because I’m not living up to their values.”

The third garment is shame. The shame garment says of the wearer, “Something is wrong with me, I don’t have any value.”

The fourth and final garment is called exoneration and is the most desirable item in the collection. The exoneration garment says of the wearer, “I have value and am living according to my values.” 

At this point, I invite clients to leave the garment store and rejoin the session. Assuming that the therapy session is a safe and private place, I then ask clients to describe what came in their box and to try it on to see how it fits. Now, in order for a garment to fit properly and not need to be returned, a client would not only need to offer credible evidence for why the garment is the correct one but also be fully comfortable wearing it. In my experience the client will describe receiving one of the first three boxes and will not be happy with the fit, at which point I will go over the return policy. 

For a client to exchange their garment for the exoneration garment, they must take two actions specific to the garment they received. It may be important to note that for clients who find more than one garment in their box, the garments may be returned together or individually, depending on the client’s needs.

A client who has received guilt and has in fact done something to warrant the garment must reconnect to their values and cease living outside of their own integrity. They must then do their best to make amends and repair relationships. Once a client has completed these steps to the best of their ability, they can exchange guilt for exoneration and be forgiving of themselves.

A client who has received misplaced guilt will need to reconnect with their values, with respect to their life goals and principles for living. They will then need to find a way to check in with themselves regularly to ensure that they continue to live a life that is according to their own core principles and satisfying to them.

Finally, a client that has received shame (haven’t we all), will need to reconnect to their intrinsic value as a human being, their strengths and positive attributes, their faith and their right to self-determination. They will then need to find ways to remind themselves regularly about what makes them a valuable person.

The work a client does in therapy to claim an exoneration garment, to acknowledge their intrinsic value and live according to their values, is a wonderful springboard for developing positive self-talk and generating motivation (see my past blog on motivation for some more help with this). Additionally, a practical, stress reduction approach that includes adequate sleep, nutrition, supportive relationships, and decreased substance use, is advisable to incorporate out of the gate, as any therapeutic effort requires the stability that this approach often provides. As I stated in my blog about anxiety, generating positive inner dialogue and shifting to healthier perspectives requires practice and specificity. In my experience, positive self-talk and reframing often need to be tailored to a client’s particular concerns and may require the help of a supportive professional. If you are struggling to address your depression on your own, or are worried about someone you care about who may be struggling with depression, please reach out to a trusted professional like your family doctor or a counselor for help.

What to say about depression?

Well, for starters, it sucks! I can’t think of a better place for shame to reside than in the depths of a depressive episode. Spend a few days, weeks, months, feeling sad and hopeless, struggling to get out of bed or sustain any kind of forward motion, isolated from your family and friends, ruminating about past injuries and mistakes, and see how you feel about yourself. Hopefully, you will have identified the previous sentence as sarcasm and know that I don’t wish for anyone to spend any time in depression if you can avoid it, it’s awful.

The last two years have brought with them an increase in depression and the damaging behaviors that sometimes accompany it, substance abuse, self-harm, suicide, etc. Recognizing that this time period corresponds to a global pandemic lends further credence to the idea that depression is mainly an environmental condition. I can’t imagine that it’s difficult for anyone to understand how widespread loss of loved ones, livelihoods, and meaningful connections with others, are linked to intense feelings of sadness and a fear that life will not get better.

Therapists and other health workers may have a special window into the broader impact of the pandemic and other environmental causes considering that many of us are meeting with upwards of seventy different people every two weeks, representing hundreds of their and their family’s experiences. For myself, I see this as a double-edged sword. I get to be a part of clients’ major life changes and get to see their strengths, resilience, and humanity first-hand. Sometimes this also means that I get to hear about all of the terrible things people are capable of and do to each other. Consequently, many of us who have remained in the profession have been struggling with feelings of sadness and helplessness right alongside our clients.

The second thing I will say about depression is related to my general statement about therapists and depression and it is that I am regrettably familiar with, and in what I am certain is an unhealthy way, somewhat comforted by occasional periods of despondency. I often feel a sense of safety in the isolation my melancholy brings me, wrapped in a cocoon of grievances about the world, how it works (or doesn’t), and how I’m treated. Although the truth is more complex, at times I think I lack the mechanism that would help me identify times when my brain and my body need a break and it is here that I think what may be the function of depression is revealed. What often happens for me is that a well-intentioned desire to help, coupled with an excessive seeking of validation from others, exert sufficient pressure to have me ignore the signs that would signal an impending breakdown, necessitating my brain and body to hit the emergency shut-off switch to prevent further damage from occurring.

In a previous post, I compared the onset of a depressive episode to the emergency shut-off mechanism one might find on a conveyor belt or other potentially dangerous piece of production equipment. The comparison I offer is not meant as a cure for depression but simply as a frame for viewing depression that may alleviate the shame associated with depressive episodes. I find that a functional lens helps refocus on the practical aspects a depressive episode may be providing clients, outcomes that may be achievable with less debilitating consequences. Success in identifying the conditions that necessitate the abrupt shut-down of our human equipment, our brains and our bodies, may provide us enough time to slow down whatever process we’re undertaking and prevent the intense stops and starts that rob us of our energy and hinder our progress.

When I conceptualize depression in this fashion, I am reminded of a time when I worked for a major shipping company, unloading packages from their planes at the airport. It was a relatively, straight-forward operation. The packages would come off the plane in large crates, shaped like a cross-section of the plane’s fuselage. The crates would then be transported from the plane behind a towing tractor and brought to the hangar where the package handlers were waiting to unload them onto a conveyor belt where they would be further sorted and distributed to the awaiting delivery trucks.

Although the unloading and distributing of the packages took the most time each day, some time was spent each morning on preparing and checking the equipment to ensure that there were no issues that would prevent their smooth operation once the planes arrived. There was a collective recognition that despite the unknowns regarding when and what would arrive with the planes, starting the process with worn-out or faulty equipment was inefficient at best and dangerous at worst. By comparison, any time spent evaluating our own coping strategies and our energy levels before facing our daily challenges, has tremendous value in preventing our human equipment from needing to be shut down before it has finished whatever task we have asked it to complete.

Once the packages hit the conveyor belt, there are many issues that can arise. Perhaps the most obvious would be an object or worse becoming lodged in the belt and causing it to stick. A conveyor belt that had become stuck would quickly burn out the equipment turning it. Much like in the production line, there are many situations in life that may cause us to feel stuck. Injuries and chronic illness can be exhausting. Relationships that continually overwhelm us and circumstances that we just can’t seem to change no matter how hard we try (think financial challenges, body image issues, dead end jobs, unemployment, complicated grief, etc) can quickly sap us of our energy and optimism, and burn us out.

Another issue would be the pace and consistency with which packages come down the conveyor belt. Packages at the airport came in waves. There would be short periods of inactivity while waiting for a towing tractor to dump its contents on the belt, and then a surge of packages piled on top of one another when it did. Similarly, a package might come down the belt that represents an acute challenge, it may be much heavier than the other packages or oddly shaped and difficult to move without assistance. At the airport, we had two methods of dealing with this condition, a speed setting on the belt that could slow the packages down, and an empty crate at the end of the belt to catch any packages that did not get sorted in the first pass. The lesson here for avoiding a shutdown is that when life is sending stressors your way faster than you can handle them, it can be helpful to slow your pace and to let some stressors pass you by. You can remind yourself that appealing as they may be, not all of the packages (stressors) that come down the belt are meant for you, and if they are, they are likely to come back around.

Although all of the previous metaphors point to strategies for preventing one, sometimes, despite our best efforts, shutdowns still occur. Similar to the pain and swelling that correspond to a physical injury, a depressive episode may be our brain and body’s way of requiring us to rest and recover after an injury to our psyche. And just like a physical injury, it will take time and effort to fully recover our mental and emotional capacities.

In the production line, two or three shut-downs in a row, or a lengthy period of time standing idle had a demoralizing effect on us package handlers and would make it difficult to maintain or recover momentum. Additionally, there could be the frustration of knowing that you had a part in why production was shut down or even worse, you could be aware of the frustration of others pointed in your direction. Many of us have a tendency to beat ourselves up over what we believe are avoidable mistakes. Therapists recognize this as shame and strive to help clients move beyond self-punishment. The lessons to be learned after a shutdown are only valuable in preventing future mistakes, insight does not turn back the clock. Fixating on the past beyond allowing it to inform us of what not to do in the future, is wasted energy, and being frustrated over the time it takes to get started again often prolongs it. Our best bet is to allow ourselves the time needed to fully recover from our emotional injuries, learn from past mistakes, make adjustments, and then start putting one foot in front of the other until we find that we’re moving forward again.

As with any mental health concern, if you or someone you care about is in the midst of a depressive episode, or struggling to prevent one, you may need to seek help from a trusted professional like your family doctor or a counselor to help address these issues and to help let others know how to be supportive.

In my last post, I provided a structural framework for anxiety that I share with clients to reduce shame and conceptualize treatment. Before I shift focus and begin outlining a structural concept of depression, I wanted to share some of the ways that I approach the treatment of anxiety and panic with clients in my practice. My approach to treating anxiety builds on the concept I outlined prior of anxiety as the threat detection system within the body and focuses on fine tuning this system in two areas, distress tolerance and stress reduction, a two-pronged approach if you will.  

Distress tolerance is the first prong and foundational to any effort in reducing anxiety. The goal is simply teaching the brain to maintain or regain a state of calm during stressful situations and encounters. This calm state is accomplished through the practice of deep breathing, muscle relaxation, and grounding exercises. 

Deep breathing helps to alleviate anxiety by redistributing oxygen to parts of the brain responsible for rational decision-making and away from the part of the brain responsible for emergency responses (aka fight, flight, or freeze). Grounding exercises help to reconnect the internal and external sensory systems, which may not be communicating effectively with one another due to long-term activation of the sympathetic nervous system. Regular practice of deep breathing and grounding exercises work like a fire drill for the brain. Practicing what we want our brains to do in an emergency will increase the likelihood that we will be able to remain calm and make rational decisions when those emergencies arise and will help us gauge between conditions that are stressful and ones that are true crises.

Stress reduction is the second prong and is the practice of reducing or eliminating stressful interactions and situations from our lives, or reframing them in a way that makes them appear less threatening. A large part of a stress reduction approach is in practical application. A very simple representation of a practical stress reduction approach might be taking a different route to work if your current route is filled with potholes and traffic, or unplugging from social media when you find yourself obsessing over keeping up with the Joneses. There may be many stressors that could be removed from your life with minimal effort or consequence.

Additionally, there are preventative measures that can be practically taken in a stress reduction approach. These measures may consist of improving sleep hygiene, getting more exercise, reducing or eliminating substance use, and reconnecting with or building an adequate support system of friends and family members. Another part of a stress reduction approach is philosophical in nature and has to do with boosting one's self-confidence through utilizing positive self-talk and facing stressful encounters with courage and optimism, also through reframing, the taking of a different perspective that sees stressful encounters as opportunities to practice skills and boost effectiveness.

When it comes to building self-esteem, I do recognize that challenging oneself and attaining goals is an important part of this development. However, much like my perspective on motivation, my experience has been that clients do not seem to have difficulty pushing themselves. Quite the contrary, I see many of my clients excessively focused on achievement/success, to the point of burnout, and constantly comparing themselves to others. I’m all for doing one’s best and striving for excellence. However, too much focus on achievement often has the opposite effect on self-confidence than intended, as a client’s self-valuation becomes solely about what they can do, instead of being about who they are.

It is here that I begin a conversation about self-worth, often in true dad joke fashion, by pointing out that we call ourselves human beings and not human doings. After clients either laugh or groan (I get more groans than laughs), I focus on instilling what I believe is foundational to any effort to establish healthy self-worth and self-esteem, an acceptance of oneself as intrinsically valuable. A person’s worth does not come from their ability to complete tasks, people are not tools that we use to achieve some other outcome. This would be a description of instrumental value, or value based on the capacity to help us achieve something else. An example of instrumental value might be one’s car, as its worth is based on its ability to get us from point A to point B and not just in being a car (sorry car enthusiasts).

Conversely, a person’s worth is not based on what they can achieve, it flows from their unique inner experience. A person is not a means to some end, people are an end unto themselves. This is in no way meant to diminish or dismiss the achievements of anyone. Many of us have found great fulfillment in our personal achievements, as long as those efforts and goals are meaningful to us. Achievement for achievement's sake or as an obligatory exercise for gaining someone else’s approval are paths to less fulfillment and an inaccurate perspective of one’s own worth. Alternatively, if we can build a foundation of intrinsic self-worth, we can then begin to develop confidence and esteem through challenging ourselves appropriately about the conditions that cause us worry, anxiety, and fear.

Much like increasing distress tolerance, generating positive inner dialogue and shifting to healthier perspectives requires practice and specificity. In my experience, positive self-talk and reframing often need to be tailored to a client’s particular concerns. Sometimes a supportive professional will be needed to help identify negative thinking and offer alternative perspectives. If you are struggling to address anxiety on your own, please reach out to a trusted professional like your family doctor or a counselor for help.