The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines mental health, including depression, in terms of pathology or a deviation from normal that is reliably exhibited in observable behaviors. It describes genetics and risk factors, differences in gender, and considers cultural perspectives. Limitations of the DSM diagnostic criteria are acknowledged and recognize that human experience, or interaction between genetics and environment, cannot be captured completely. While the underlying neurobiology of depression has been the subject of focus in the medical field, interaction between the individual and their environment has been more the purview of infant research and the psychodynamic framework. In other words, the latter focuses on why the deviation from normal. This is important in understanding some of the benefits of medication and psychotherapy, where the strictly biological formulation robs the individual of any control over their symptoms. A purely pathological perspective diminishes the contribution of work approached in the context of a therapeutic relationship. Reframing pathology as possibly understandable self-preserving behaviors is an important de-stigmatizing perspective that also acknowledges the individual’s agency.
In exploring etiology and meaning in the devastating experience of recurring serious depression, there is a potential to reshape previously unexplored beliefs and assumptions. This includes learning what feelings more accurately represent, what they mean to the individual, a core feature missing in the experience of depression. Numbed, angry, irritable or sad, down, gloomy, blue, a lack of energy or joy, hopeless, helpless, lethargic, guilty, with a desire to disappear, melt away—all of these can be part of depression. Is this a mismatch in receptor neurotransmitter physiology? Or is it a reflection of the biology of an individual that learned in so many ways that their feelings are not important or even their own? It is an age-old question. If depression were predictably ameliorated with a medication and no other intervention, it would be simple.
A first indirect experience with depression was very early on reading a childhood story—the story of a quirky girl on a search for her father who disappeared under unclear circumstances at some unclear point in the past, leaving her mother behind, sad and disengaged. It was the story of a girl accustomed to entertaining herself with her imagination, making do with colorful threads and a view out her window. This was in fact the story of the disappearance of a parent to depression. The story was clever in centering the young girl’s central desire and sense of responsibility to fix everything for her sad mother and bring home the long-lost father. It of course was fantasy; rarely is there such a concrete success in fixing something so far out of the purview of a child.
Depression often grows out of childhood experiences. Raised by a parent who is depressed, angry, anxious, alcoholic, abusive, or neglectful, these children grow up learning a manipulation of their own emotions toward survival using the best logic of childhood, which is often long forgotten in the later world of adult responsibility. Additionally, instead of learning that this particular sensation in the brain or stomach is happiness, excitement, joy, or anticipation for something desirable, a child might not learn anything so reliable. Instead, messaging might depend on mother’s mood that day, anger toward the child, or state of inebriation. It might also depend on a need to appear admirable in every way as an extension of the parent instead of how the child authentically feels. That joy may suddenly be evaporated in the spark of a parent’s chronic sense of revulsion or rage and transmuted instead to shame. In addition to the chaos of unpredictability, the child’s perspective is developmentally egocentric. This creates a vulnerability to misappropriated responsibility for emotionally charged experiences. Mom is sad, mad, or confusing because I am bad. Like the little girl in the story, a child does their best to fix it, but unlike in the story, they often cannot.
Depression is a subjugation of feelings. It is a chronic, devastating evisceration of self—an emptiness, numbness, lethargy, moving through a sea of intolerable molasses, with depleting fake smiles and forced cheer. It is difficulty getting out of bed in the morning, with no sense of purpose or excitement, exhaustion before the day has started, defeated on repeat with no hope for change. It is an inability to enjoy the rest and regeneration of sleep and the pleasure of eating or company of friends. It is completing chores, getting by, and it is exhausting with no breaks. Depression can encompass a deep sense of self-hatred without really knowing why, an abandonment of self in an early enforced truce in a power-imbalanced authoritarian home. Sometimes it comes with feelings of guilt, failure, shame, and an inability to climb out of an unrelenting, intrusive sense that the world might be better off without such a creature as self around. Depression is a deeply held distorted belief about place in the world and an exhaustion that wants end. It is not hard to imagine how this might impact underlying neurobiology and how an antidepressant might help and support, even in the absence of understanding exactly how the medication works.
Feelings are an intrinsic part of our identity, and our treatment of feelings reflects our sense of self-understanding and worth. Our feelings reflect how we experience the world around us, how we show up in relationship, our sense of values and ethics. They are our goalposts, our delight, our love, our grief. Without them we are robbed of critical experiences, our own intuition, part of the pattern-seeking brain that contributes to a felt truth, and which sometimes deepens our experience of meaning. Diminishing how we feel, or having this diminished for us, demeans a core part of who we experience ourselves to be. On guided reflection, it is sometimes revealed to favor the originally learned patterns in abusive circumstances with a parent who has frequently not done their own work. This is a direct reflection of the mechanism of action of intergenerational trauma. It is an unfair trade, though, because much of this was configured before language and sense of self were present enough to consider the messaging. Part of working with depression as a psychotherapist, then, is helping someone reacquaint themselves with their feelings, with accuracy, and with a new understanding for the critical nature of this part of who one is—that part of self which is reflective of an inherent truth: That I matter. Sometimes therapy is enough, or medication is enough, and sometimes both are essential, where medication provides support and the ability to get up and out of bed to do the work of grieving the lost parent, among other things.
Maire Daugharty is an anesthesiologist who expanded her expertise by earning a master’s degree in clinical mental health counseling, merging her long-standing interest in mental health with her medical background. As a licensed professional counselor, licensed addiction counselor, and licensed marriage and family therapist, she brings a well-rounded perspective to her private practice, where she works with adult individuals and couples on a wide range of concerns. In addition to her counseling practice, she continues to work part-time as an anesthesiologist and has a deep understanding of the unique challenges faced by clinicians in today’s medical landscape. To learn more about her practice, visit Physician Vitality Services.
