Depression Therapy

The concept of treatment-resistant depression cuts two ways. On the one hand, it conveys the struggle that many individuals have getting help even after great effort and trying multiple treatments, including different modalities of psychotherapy and medication. At the same time, it’s a word that can imply stigma, blaming the patient rather than inviting mental health counselors to consider that perhaps despite their good efforts and hard work, they have fallen short. 

While there are countless ways that depression might not get better despite significant effort, we do see several patterns. One is that symptom management, while effective for many, isn’t enough for individuals with certain kinds of severe histories of trauma or intensive depression symptoms. Instead, the difficult labor of identifying the historical roots of depression is often key. In some instances, we discover that the depression isn’t getting better because something else is masking itself as depression, such as shame, self-esteem issues, early childhood deprivation, and a variety of kinds of unacknowledged trauma. 

Most importantly, if you are not getting better, it’s not your fault and doesn’t mean your situation is hopeless. It means you need a good therapist who is willing to get creative to discover a treatment plan tailored to you.

Typically, this kind of depression is called dysthymia, though the mood disorder label is less important than acknowledging that what is happening is real, distressing, and can be helped. In some ways, dysthymia is easier to miss and harder to treat, exactly because it comes and goes. There can be a tendency both in the individual and the providers from whom they’re seeking treatment to underappreciate just how distressing it is. We take this experience seriously.

By being too focused on the diagnostic question, we can miss the more crucial issue here, namely that you are experiencing distress and need help. While it may or may not be useful to understand this as depression, you may nonetheless need help. Depression or persistent feelings of sadness might be an understandable, reasonable, or even healthy response to a difficult situation. Whether depression or not, it may benefit from therapy.

Grief is traditionally conceived of as working through a loss. It can be useful in therapy to conceptualize grief more broadly. Grief is a form of working through, a kind of acceptance of something as painful and difficult. One way to understand depression is as a kind of stuckness in grief, in which the body’s ordinary capacity to work through something difficult is stuck.  

The language of trauma has been scrutinized in the last several years as it has infused itself into popular culture. At Tribeca Therapy, we don’t deny the reality of trauma, which is all too real. We are also concerned that its overapplication risks muddying the waters. What’s most important is to understand that forms of struggling that are often conceived of as fundamentally biological always have significant psychological, social, and cultural components. Even when someone has a biological disposition toward a particular kind of affective struggle, they need and deserve space to make meaning with the cultural and social aspects of their struggle. Depression very often isn’t simply biological, but comes from somewhere—a formative experience that we may decide together is best called trauma or something else.

Clinically, the distinction between a depressive episode associated with a bipolar process and major depressive disorder is not incredibly important. It’s most relevant in the context of understanding medication and, therefore, critical to discuss with a psychiatrist if you’re taking psychiatric medications. In terms of the therapy itself, the complexity of how depression expresses itself for each individual is what matters in how we help.

While we don’t prescribe antidepressants (only a medical doctor can do so), we often discuss individuals’ complicated feelings about them in treatment. Evidence on their effectiveness is mixed. A small number of individuals experience dramatic improvement with the right antidepressant. Many experience merely mild effects. Others, however, receive little or no relief. They also come with serious side effects that are often not talked about enough. We work with many people who choose not to consider antidepressants and support that path for their well-being. We also work with others to therapeutically support going off medication with additional guidance from their medical doctor.

There are dozens of antidepressants. It can take time to get the dosage correct, and it’s not uncommon to need to try a few before finding one that works for your wellness. That said, for many, antidepressants just aren’t that helpful, even after trying various combinations. Of course, there are other medical options, but many understandably find them to be too severe for their comfort. A medical doctor can offer expertise on how these medications may act for you; our expertise is in looking at how skilled, depth-oriented talk therapy can provide relief from severe and persistent depression symptoms.

There is a good deal of talk about CBT as the right treatment for depression. For the first twenty years of this century, it was seemingly a settled issue, and nearly every mental health professional recommended CBT for depression symptoms. Increasingly, CBT is receiving more scrutiny with a recognition that while it can be helpful for many people, especially in the short term, the idea that it is the “gold standard” is far from accurate and isn’t upheld by empirical research.

We believe the traditional dichotomy between CBT and psychodynamic therapy is silly. CBT is a relatively straightforward set of practical skills that help people use interventions with their thinking and behavior to feel better. Many of these skills are unquestionably helpful. We are fluent in these skills and offer them freely. At the same time, we believe that a process of understanding and self-exploration is ultimately better suited to help people create deep and lasting change for depression.

Absolutely not. The story that still predominates about depression is that it’s a “brain disorder” or a “chemical imbalance.” This is simply false. Many people who come to therapy for depression have been in pain for their whole lives. Longstanding depression is a terribly difficult way to live. For these individuals, they need a highly skilled therapist who is willing to work both in the realm of the practical (CBT), as well as take on the work of understanding where these feelings originate.