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Dispatching Depression

Dispatching Depression

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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.