Therapy for depression? More complicated than you may think
This article “It’s Not Always Depression” from the New York Times has me thinking about what any good therapist knows about therapy for depression: depression is but one mode of understanding an emotional experience that needs to be looked at through many modes of understanding. Ms. Mendel suggests from experience in her work providing therapy for depression that depression is at times a misunderstanding of some other malady.
The DSM-V understanding of depression in therapy
The DSM–the Diagnostic and Statistical Manual–is the big book for therapists who treat depression and other “mental illness.” It’s written by medical doctors (psychiatrists, with some input from neurologists) and psychologists, and accordingly follows the medical model of assessment: You look at symptoms, compare them against a set of norms, and issue a diagnosis from the book. Major Depression and Dysthymia are the two most relevant diagnoses when we’re talking about therapy for depression.
As with all medical diagnoses, there’s an emphasis on symptoms. But there’s a challenge here that most psychologists and therapists won’t tell you about depression: Diagnosis in mental health is almost always tautological, meaning, logically self referential. What that means, in ordinary language is best expressed in this (overly simplified) scene between a therapy patient and her NYC depression therapist:
Depressed Patient: “Hey, doc, I’ve been feeling pretty lousy much of the time, not sleeping like I should, not so interested in things that other people are interested. Do you think I have depression?”
Depression Therapist: “Yes, you have depression.”
Depressed Patient: “That’s a relief. What’s the definition of depression, anyway?”
Depression Therapist: “Feeling lousy much of the time, not sleeping well, and not being interested in the things you should be.”
In other words, the definition of depression is being depressed.
Depression is real
As I’ve said before, this critique of the way depression is typically related to in therapy isn’t intended to imply that depression isn’t real. It’s very real. I just don’t think a depression therapist has added all that much value by calling it depression.
It’s validating, sure, for a therapist to identify that the experience is real, but stopping there–thinking that a diagnosis of depression means you’ve uncovered something does a serious disservice to someone experiencing this sort of pain.
More than “something else”
Hilary Jacobs Hendel, the psychotherapist who wrote the New York Times article, speaks to the issue of depression diagnoses often missing the mark because there’s often some other malady better characterizes what’s happening, most notably in her New York Times’ article, shame. I’m thrilled she’s stepping out of the traditional DSM lexicon (shame isn’t an option the DSM gives depression therapists) and thrilled that she’s opened up a conversation about shame (in my opinion an under-discussed phenomenon in human suffering).
Effectively, though, she’s repeating the tautological problem that gets therapists into trouble with diagnosing depression and other emotional phenomena. The medical model remains, in Hendel’s formulation, intact: Interpret a set of symptoms, provide a name for those symptoms, offers those symptoms as the cause for an affective malady.
We’re considerably more complicated than that. Do we need to talk more in therapy about shame and it’s relationship to depression and sadness? Very much so. Do we need more words to offer our patients to understand their suffering? Terribly so, yes. But perhaps more than anything we need an entirely new conception of psychotherapy that breaks from the framework of diagnosis altogether.
Maybe it’s not the diagnosis that’s wrong but diagnosis itself that’s wrong, and leads us astray in our efforts at helping those who are in pain.