Understandably, people considering entering into a therapeutic relationship often ask about my approach.
Since my approach is designed in response to the person I’m working with, answering that question becomes kind of tricky.
If I answer it by listing theoretical influences— psychodynamic, narrative, humanistic, cognitive behavioral—a prospective patient can sometimes feel unseen and alienated.
If I answer it by saying “well it will emerge as we go,” they might feel like they’re being asked to take a leap of faith that isn’t fair to them.
And if I answer it by talking about the atmosphere—that it will be warm, curious, compassionate, consistent, etc.—they might feel like they’re getting vague tropes and Instagram-therapy cliches.
So below I’ve tried to put into words an example of my approach—here to a type of depression—for anyone who might find it useful.
Working with depression: an example
On the surface, therapy will feel like a warm, improvised conversation guided by the goal of your well-being.
Beneath the surface, something like what I describe below will be occurring.
In addition to its neurochemical manifestations, depression operates metaphorically like a colonizer—it places itself over you, uses your resources to perpetuate itself, and tries to pull a particularly sinister trick: making you believe that its messages of your inferiority are right, its presence is legitimate, and that there is no other option than to live beneath it. True to its name, it presses down on people, and many clients describe living with depression in phrases like feeling trapped, weighed down, or heavy. Anyone who’s lived with depression also knows how taxing it is—it doesn’t just smother, it also extracts from you. It saps your energy and occupies your cognitive space; it structures your perception and displaces positive images, memories, sensations, and vocabularies to a censored, marginal realm. It limits your range of activity, feeling, and mood. In its fullest manifestation, it convinces the depressive of its truth and validity. A person’s inferiority becomes felt as real. In this severest form, when depression’s insistence upon your worthlessness transforms into the feeling of fact, some paths emerge: escaping depression through rebelling against it; accepting depression and adjusting to its rhythms; living in a split-off denial of it; or exiting depression through suicide, the only domain of “agency” that depression leaves accessible to the imagination.
“‘Externalizing’ is an approach to therapy that encourages persons to objectify and, at times, to personify the problems that they experience as oppressive. In this process, the problem becomes a separate entity and thus external to the person or relationship that was ascribed as the problem.”
Michael White and David Epston, Narrative Means to Therapeutic Ends (p. 38, 1990)
How could therapy help in such a sticky and suffocating situation?
Depression transforms the territory of the psyche by placing upon it a design for the flow of feelings, the direction of thought, the experience of sensation, the objects of attention, and the daily patterns of behavior and activity. An important therapeutic process is helping a client see this design in its entirety, and since therapists have the perspectival privilege of being outside of your system, we’re not susceptible to its attempts to convince you that there is no outside. So in the beginning of working with someone experiencing depression, I tend to spend a while pointing out the patterns of the design as I see them emerge. Together, we became cartographers of depression’s presence in your life. This adds a kind of buffer between the client and the symptoms—like a second layer of gesso that gives you some distance, or as a crowbar that pries you away. Any metaphor of distancing, peeling off, and of gaining perspective works here, as the end goal of this stage is to figure out where depression ends and a life outside of depression begins. When this distancing successfully occurs, what was once felt as familiar becomes foreign, what was once believed as truth is shown to be depression’s ideology, and the self-negating thoughts that came cloaked in your own voice are revealed to have the cadence of the colonizer.
The depression will resist these efforts to see it for what it is; it’s depression’s mechanism for staying entrenched and alive. The resistance comes in many potential forms and combinations, and learning about your particular repertoire of defenses is a necessary part of the therapeutic process. This requires more interpersonal, in-the-moment relational work to identity them, as well as the construction of a biography that narrates their potential origins, functions, meanings, and limitations.
“Often the therapist feels as if he or she is talking to a ghost, and as if therapy, to be effective, will have to include an exorcism.”
Nancy McWilliams, Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed. (p. 240, 2011)
Depression’s resistance is a good sign because it’s evidence of depression shifting and responding to an external force, but it also typically comes in a concentrated dose of depression’s energy. It can be seen as a form of retaliation. Especially in early stages of therapy, its concentrated power can throw a person back into the depressive design, as though the escapee has been caught and apprehended. This stage of therapy is often characterized by us pulling you out of the design and keeping you in contact with other ways of being—only to have depression pull you back in, and then we pull you back out, and so on. Over time you accumulate more and more experience of life outside the design, along with more and more ability to imagine it. It may take a while, but over time life outside the design will become more familiar, more comfortable, with the hope of it eventually becoming pleasurable and desirable, more rewarding in itself. Sometimes I like to think of the goal of this stage of treatment as a reawakening to—or in some tragic cases experiencing for the first time—the possibility of pleasure, or delight, of life lived outside of depression’s design.
This delight is important because it becomes an answer to the resistant depressive question of “why?” Why try to change, when it’s so slow and hard? Why explore different ways of thinking, when there’s so much evidence to support my depressive perspective? Why maintain optimism when I just got punched yet again by depression? Why do the awkward, vulnerable work of stepping outside of the design just to stumble around in a new, unstructured albeit un-depressed way of being? Why do any of this?
There always has to be a motivator to counter depression’s influence. In the beginning, when someone is starting therapy for depression, the motivation is often to be “free from” something—free from the fear of suicide, free from the suffering of living a dulled and diminished life. These are beautiful motivators, because embedded in them are signs of life, and we use them so long as they’re relevant and effective. But eventually, once you get enough experience outside the depressive design, these motivators begin to feel a bit obsolete. If we never replaced them with new ones, we’d potentially stay stuck at the tug-of-war stage, pulled in and pulled out. Some depression-free days, some depressed days, on and on.
This is a risky stage, because tug-of-war is tiring, and so the “why do this?” question reasserts itself. Having planned for this moment, depression says something like “let’s stop fighting, you look tired…I’m sorry. Come home to me.” It offers you a deal, a kind of Pax Romana: submit to it and enjoy a bit of peace, and maybe even you’ll be allowed some good days now and then.
The desire to be “free from” depression is no longer sufficient at this stage, because depression is actively trying to seduce you back into itself. It cuts deals and offers compromises so that it can stick around. It gets really creative, and we have to have a more powerful counter-seduction, one that draws you in the other direction. At first we may find anger useful—anger at what depression’s done to you and how it pursues you—as anger can create distance between you and the “it” of depression. But the tension of this stage is unsustainable and limiting in itself. Anger might be an important transitional stage, but it’s too tense, too one-note, too risky and too unsustainable to be the end goal.
The end goal is delight. It’s not just “freedom from” depression, but is also “freedom to” create and enjoy a life of your own design, a life that has rewards within it. It’s this delight that will keep you going through the awkward early stages of dismantling or reappropriating the remnants of the depressive regime—the way it shaped your behaviors, your feelings, your thinking, your language, your sense of self, your imagination, and your relationships. This will take time, and an awakening to the delight of life outside of this design will keep us going.
Eventually, you’ll be far away enough from the depression design that its attempts at seduction look absurd. At this point, depression’s tricks are obvious and its viciousness repulsive. A period of mourning for time lost to the depressive regime often emerges—a difficult stage but again a good sign, as the sadness has within it a condemnation of the depressive worldview. It shows how far you’ve distanced yourself, because thanks to delight, you’ve developed a new aesthetic system—one that is no longer susceptible to depression’s suffocating “comforts,” and instead intuitively feels them to be repugnant. At this point, a potential for lasting change has emerged. Depression loses its magnetism and becomes a relic of your history. You have a new aesthetic system, forward-looking and rooted in your own worth and the delight of the delicious, which is drawn to new horizons. At such a stage, with depression in remission, therapy takes on a new direction, a new tone, and centers new questions. We go from “how do I escape?” to “now that I have, who am I and what do I want to do?”
This is an example of how I work—a multi-dimensional approach to a multi-dimensional problem. Starting with Narrative Therapy’s technique of “externalizing” a problem, depression is framed as operating on a person in multiple ways, which requires multiple techniques. When working with how depression has shaped your vocabulary and your way of explaining the world, we might continue with Narrative Therapy. When working on ways in which depression has corrupted your self-esteem, we might draw from Positive Psychology or Humanistic interventions. When trying to disrupt negative feedback loops between habits, thoughts, and feelings, we might be using Cognitive Behavioral Therapy frameworks. When building a compassionate explanation for your situation, looking at early influences that potentially put you on a depressive trajectory, and exploring unconscious elements that sustain the problem, we might be doing Psychodynamic Psychotherapy or using Family Systems concepts. When trying to jumpstart new behaviors, we might use Motivational Interviewing and Acceptance and Commitment Therapy. To cultivate a new sense of self worth, a new set of values, and a new future orientation, we might use Person-Centered Therapy or dive into Jungian mythopoesis. All of these are at our disposal, and we call upon them when needed.