Therapy for depression: A collective therapist conversation on the limits of words

We’ve been continuing our series of conversations, this one exploring the construction of depression: the ways those seeking therapy talk about their experiences, the many meanings of the word and the ways that depression is so often insufficient as a term to capture these experiences.

Matt: It's probably the case that therapy for depression is the single most common reason a prospective therapy patient reaches out to our NYC therapy practice.

As we so often talk about in our conversations together as therapists, there's no good way--no responsible way, really--to talk generically about the emotional experiences people bring to therapy. It's not sensible to say "depression is" this or "depression is" that. Everyone who seeks therapy for depression has his or her own experience of that depression and his or her own understanding of the word depression.

At times we've talked about our approach to therapy as involving deconstruction--a way of understanding language and the experiences it intends to make sense of by engaging in a sort of co-created sense-making with our therapy patients and with one another as fellow therapists who treat depression.

Depression is a notion particularly ripe for deconstruction for many reasons. Its meaning has been commodified by the process of psychiatric diagnosis in order to sell anti-depressants and psychotherapy (and herbs and acupuncture and chiropracty…). It's among those psychology words we’ve come to use in everyday language often without much curiosity about just what we mean when we use it. Everyone means something different by depression.

I'm wondering if we could deconstruct this idea/ word depression here, together. What is it? How do you talk about it with your patients? What are some ways you develop how this gets talked about with folks who seek therapy for depression in our NYC practice?

Rachael: Depression is too general of a word and there are many stigmas that come with it. It keeps us away from the person when they say "I feel depressed" or "they are depressed."  Depression is filled with assumptions about what an individual’s experience is like without getting to know the person.

In my practice I get more details about what someone means by depressed. What does that look like for him or her? Where did that term come from? Sometimes sad, blah, or even a facial expression may convey more than the word itself. At times they are more accurate in getting closer to someone's experience.

One way depression may look is being isolated in thought, from relationships, in feelings, and in activity. I want to be curious if someone experiences this isolation. I find when we talk about depression we are talking about pushing to the surface the suppressed feelings, experiences, and relational disconnection.  And then we bring the experience closer to the surface where we can talk about what we want to do with it and around it. By exploring cognitive, structural, and behavioral changes we can better understand the historical processes and relational processes that created it.

Heather: I find that everyone does use the word depression slightly differently and has a different relationship with it. There is even a spectrum of how useful people find it to use the word at all. On one end of the spectrum, some people seeking therapy find it helpful to come up with a definition and to say definitively "I suffer from depression"--it validates their experience and it diminishes anxiety. On the other end of the spectrum, some folks feel stigmatized and boxed in by the term and find it limiting so they prefer to not use the term at all.

Similarly to what Rachael wrote, anytime a person uses the word depression for the first time, I ask questions so I can learn more about what it means to them. I try to be careful not to make any assumptions, as it can be a descriptor for so many things. I get curious.

One of the things I find so compelling about people who identify as suffering from depression is that it never encompasses just the feeling state. Often I will find after getting to know someone a bit that there is a depressed lens through which a person sees the world and especially themselves. Again, when Rachael mentions the correlation between isolation and depression, if you are living your life wearing depression glasses it can be very dangerous. This is a way that a lot of people get stuck or "in their own way". Getting close to others is the only way to identify those glasses and begin to try on other glasses with a more neutral lens.

Matt: I've been thinking about this through my conversations in therapy over the course of the week. I'm struck by how little there is to do with the word itself. I'm not so sure that as therapists we treat depression, per se. Meaning, of course we work with people who are depressed, who find meaning in this word to describe an often very painful experience. Yes, CBT, which we all have some fluency with, can help bring some affective relief (help people feel better) but depression seems more like a rash than the disorder that is causing the rash (to use the medical construction). Reducing itching and swelling is meaningful--I very much want to help people feel better--but when we look deeper into the experiences that correlate with depression there is so much present: shame, isolation (as Rachael mentions), unresolved grief...

What difference does any of this make? Is it important to deconstruct how we talk with our patients who are looking for therapy for depression?

Karen: The word depression does seem to be weighted with a certain power. I think the word and the way it tends to be used almost takes the humanness out of the pain. My inclination is to try to get closer to that pain rather than push it away. It makes me want to get to know the person in there who is experiencing this. If I can make a connection with this person, build closeness it will help.

I always want to know how these feelings are being created: Are they in response to something in the past or something happening now?

I also have the sense that the word depression can be a way for patients to communicate to me that they are hopeless and even that they may be experiencing themselves as beyond help or undeserving of help. I often do work with patients around looking at the way their thoughts are depression-producing and this can be good place to start. I also want to know what are the conditions in this person’s life/environment that might be creating these feelings/ reactions. There is so much to understand in terms of how the conditions we live within may be creating sadness, pain and isolation. I do think deconstructing the word depression with patients is a meaningful activity because it is the process of creating meaning, seeing possibilities that can shift around what is producing depression. I am wanting for patients to relate to themselves as leaders/ choice makers, so if they use the label depression I want to be looking at how this locates them. Does it place them in a position to lead powerfully as an active creator or does it keep them stuck?

Heather: I am realizing in this discussion that the word itself, depression, is not so important, in a sense. We all have deep-rooted beliefs and values, some more conscious than others, that make up how we exist in the world. Depression is just a starting point and a short-hand to express something deeply complicated. If a new patient comes in and says, "I suffer from x,” x can represent anything. I want to intimately understand the person's experience, including what x is, because anything that makes up their internal landscape is important. Without that understanding, making assumptions about what x is can cause me to miss what truly is making up their deeper suffering.

Matt: Someone said to me that in her experience working with us, coming to understand herself not as "sick" (her word--we might say "non-diagnostically") made her better. Her comment felt so scripted for this dialogue we're having here. I nearly fell out of my chair. There's a movement of sorts to classify depression (and other so-called conditions) as real illness. The thinking is that by classifying these experiences in a manner similar to how we classify physical disorders that the result will be a sort of moral parity. I'm always torn about this. I respect the impulse--the desire that the experience of depression be taken seriously, seen as legitimate. It certainly has produced some positive results in improving access, with regard to parity in health insurance coverage, but I fear for what has been lost. Must it be the case that understanding these experiences medically is the cost of having them be taken seriously? Does it actually produce parity in understanding (in the sense of empathy)? I fear much is lost in the narrowing the lexicon available for us to understand the infinite complexity of human experience.

Kiran: I have been resistant to this conversation about depression and I am not sure why. Yesterday I was teaching a class and discussing case conceputalization with students. We were talking about how our clients may come in with a problem (and it may very well be a problem) and the acts of resistance that may completely go unnoticed because we live in a world that is problem focused, or pathologizing. Depression came up as an example. Someone may come in feeling depressed and this is the challenge: Can we see depression in more complex ways? Can the depression tell us something more? Can it add complexity to a person’s life story? Could the symptoms associated with depression be an act of resistance? For instance, someone who has a chaotic life with multiple challenges feels depressed; they are staying in, sleeping late, etc. Could the depression be helping them slow down? Could it be a sign that something else is off? In my work, I try really hard to get the person's meaning behind their depression, even the meanings that we might discover together.

Matt: Yes, yes! There are too few words! In some sense we've replaced the complicated, often slow process of creating conversations together with sorting out what word (depression) or phrase (generalized anxiety disorder) sums it all up. What we struggle to do here, in our NYC therapy practice, with our patients who are seeking therapy for depression or anything else is to get caught up in the semantics. We do belabor the point. We invite them to ramble on, in a sense. What matters less is which words we use (or perhaps whether there are words involved at all--we share so much with our bodies, our affect) but rather how we create emotional experiences together. Perhaps the question is less "What's wrong with this person?" and more "How can we create relational conversations that create understanding and help this person feel better?"