Four faces of depression

Four faces of depression
MARGARET WEHRENBERG
Although a common diagnosis, depression remains one of the most challenging presenting
problems to assess and treat accurately. A broad, poorly defined diagnostic category,
depression embraces a range of symptoms; cognitive and physical lethargy, mental rumination,
loss of concentration, chronic negativity and pessimism, feelings of worthlessness and personal
inadequacy, and unassuageable sadness. At the same time, symptoms of depression such
as hopelessness, rumination, and negative mood interfere with usual therapeutic interventions.
MARGARET WEHRENBERG argues that therapy needs to nudge clients into action quickly,
help them take charge of their cognitive habits, instill hope, and reduce negative mood. She
identifies four basic clusters of depressive symptoms, each reflecting a different underlying
cause — neurobiological, traumatic, situational, and attachment-related. A brief description
of how to begin treatment with each cluster is illustrated by clinical vignettes. WEHRENBERG
describes a therapy of small steps with a focus on subtle shifts in behaviour patterns and daily
attitudes that, with time, can create profound change in clients who staunchly resist interventions
that seem too threatening. Therapists who recognise the crucial differences among the many
demoralising varieties of depression, and who have the patience to work in this careful way, will
discover that being slow and steady is an all-too-often underrated therapeutic virtue.
A
lthough psychotherapists see
more clients with depression
than perhaps any other diagnosis, it
remains one of the most challenging
presenting problems to assess and treat
accurately. Part of the problem is that
‘depression’ is a broad, poorly defined
diagnostic category, embracing a
daunting range of symptoms, including
cognitive and physical lethargy, mental
rumination, loss of concentration,
chronic negativity and pessimism,
feelings of worthlessness and personal
inadequacy, and unassuageable sadness.
Furthermore, the very symptoms of
depression — hopelessness, rumination,
and negative mood — all interfere with
the usual therapeutic interventions.
To get beyond or around the powerful
drag of inertia in depression, therapy
needs to nudge clients into action
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quickly, help them take charge of
their cognitive habits, instill hope, and
reduce negative mood.
Rather than seeing depression as
some kind of monolith, I have found
it useful to see depressive symptoms
as falling into four basic clusters,
each reflecting a different underlying
cause — neurobiological, traumatic,
situational, and attachment-related. By
immediately addressing the attitudes
and distinctive vulnerabilities that lie
at the core of each cluster, treatment
can begin to bring about a shift in
brain function that makes longer term
work easier. In what follows I offer
a brief description of how to begin
treatment with each cluster with a
particular emphasis on how to enhance
the likelihood of initial engagement.
Endogenous depression
People who complain of low
cognitive energy — “I just can’t think
about that now”, or “I just can’t decide
what I should do”, or “I just sit and look
at the work” — persistent negative
mood, irritability, and limited pleasure
or interest in daily life are most likely
suffering from endogenous depression,
a condition assumed to be biologically
and probably genetically based. These
clients tend also to be passive and hard
to motivate — their attitude toward
therapy can be summed up as “What’s
the use?” Despite the neurochemical
factors implicated in their depression,
you can still nudge these clients into a
more active, positive state of mind by
engaging their power to make small
decisions that will briefly override their
PSYCHOTHERAPY IN AUSTRALIA • VOL 18 NO 4 • AUGUST 2012
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low energy. By deliberately shifting
away from their negativity and acting
consciously in opposition to it, they
can begin to make changes in their
lives to provide just enough positive
reinforcement to boost them a little
way out of their trough of despondency.
Angel
Angel had suffered from depression
most of her life and had to exert
tremendous energy just to get through
the day doing the minimal amount
of housework and taking care of her
child. She also berated herself for
being so unpleasant and bad-tempered
to people. “Kindness is a fatality of
depression!”, Angel exclaimed, telling
me how mean she had been to her
mother last week. She had been short
and critical, and still felt both irritable
and guilty about her behaviour.
In my initial work with her, I asked
Angel to recall any act or thought of
kindness, no matter how small, that
she had given to her mother. She was
able to come up with some examples
easily, then followed immediately with,
“But that doesn’t count!” When I asked
“Why not?”, she replied, “Because the bad
moments are so many, why should I count
good ones? I am just not a good person”.
Angel was trapped in the habitual
pattern of thinking, common to people
with this kind of depression, that bad
moments deserve more attention than
good.
I explained to Angel that given
the way neural networks process
information, her mind frequently
became like a runaway train of
pessimism, tapping into an ever
growing network of negative
thoughts — different versions of ‘all
things wrong’. Forcing her mind into
a different network — ‘at least some
things right’ — would require cognitive
commitment. In short, Angel needed
to train her brain to identify and
rehearse positives.
One of my favourite ways to practice
the positive is to get into the habit of
giving ‘The Virginia Report’. My friend
Virginia has had much to be depressed
about — losing an adult child to cancer,
seeing her family break down from the
consequences of grief, twice having
cancer herself, and suffering severe,
debilitating side effects from treatment.
Yet you will never encounter Virginia
without hearing her tell you about
an experience she just had that was
absolutely ‘the best!’ She just had the
best sandwich she ever ate, the most
fun she ever had, she laughed harder
than ever before. In ‘The Virginia
Report’, everything today is better than
anything that came before.
and hopefulness into daily life. Angel
felt awkward using superlatives while
telling me about a restaurant meal, so
we jokingly exaggerated. The rigatoni
was “sooooo tender” and the meat “sooooo
succulent” and the gravy “sooooo intensely
garlicky”, she “never had any meal as
amazingly fabulous as that meal!” After
…‘depression’ is a broad, poorly defined
diagnostic category, embracing a
daunting range of symptoms…
Asking Angel to give ‘The Virginia
Report’ about her prior week forced her
to say something out loud about what
was positive. She was not unconscious
of good things — she simply believed
they did not count, so I wanted to
enhance the sense of importance of
each positive. She agreed to make a
daily record of at least one good action
or experience. Then, therapy helped her
practice expressing it as ‘the best’ to
inject a note of eagerness, enthusiasm,
the laughter, she admitted she felt
great but quickly added, “Of course, the
dinner was not really as good as I just
said”. In that moment she saw how
she continually robbed herself of fun.
She described the meal again and
noted the pleasure derived from her
positive attitude. She was able to see
that describing her dinner as ‘the best
ever’ reinforced an attitude of upward
comparison she could use whenever
thinking about her experiences.
Illustration: © Savina Hopkins, www.savinahopkins.com
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Charlene
Charlene presented a different kind
of lethargy typical to endogenous
depression. Sitting slumped in her
chair, she told me she had mail piled
up unopened from the last two weeks,
groceries purchased two days ago still
bagged and sitting on the kitchen
table, and unwashed laundry heaped on
the floor. The clutter of old newspapers,
dirty dishes, toys, and ‘stuff’ covering
every surface of the family room made
it nearly impossible for her two kids
to find a seat. Since contemplating
the task of cleaning all this up was
overwhelming to her, I asked if she
could clean for just three minutes.
had both the kitchen and family
room tidy in the space of one week of
commercials. By the following week,
she had even got her son to pick up
after himself, and for the first time in
months the floors were clear enough to
vacuum.
Because summoning up the energy
to move forward is so difficult for
people with endogenous depression,
they need goals that are intrinsically
satisfying and meaningful. Therapists
can help clients to notice what is
satisfying, because that is what is
overlooked in depression. I asked
Charlene to list every single activity
in the course of a day, and then follow
Extended attention to what feels good is, in
itself, a powerful anti-depressant and stirs a
motivation to have more of that pleasure.
She agreed that she could do that,
but asked, “What is the point?” Things
would still be in an unholy mess.
I knew she needed to mobilise
and one way was to ‘prime the energy
pump’ by doing the work in small,
manageable bits — returning one phone
call, answering one email, paying one
bill, and then rewarding herself for the
effort. Like many low energy clients,
Charlene came home from work, and
immediately turned on the TV — what
she called her ‘reward” for getting
through another day on the job. I
suggested she use ‘commercial breaks’
to literally ‘break’ up her pattern of
comatose sitting. She should get up
and do some tidying just during the
commercials, and then sit down to her
show again — an immediate reward for
about three minutes of effort.
She doubted this would work, but
agreed to give it a try. I helped her
make a list of discrete, circumscribed
tasks that needed doing — empty the
dishwasher, fold laundry, put away
food, throw out junk mail, etc. She was
to pick one item from the list and do
it during commercials until that one
task was done. Then, she could begin
a second task to do during commercial
breaks. When she returned to therapy
the next week, she was amazed and
feeling quite a bit more hopeful. She
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up with a forced choice question
about each: “Was that pleasurable or
unpleasurable?” I would not accept
the answer, “I can’t tell because I am too
depressed”. I insisted she pick one or the
other. I accepted a grumbled, “Okay,
pleasurable. But not much!” as long she
landed on one side of pleasure or the
other!
Next, I asked Charlene to make a
list of only the pleasurable activities,
and then use the list to find natural
motivations to enhance them. I asked
her about each item, “How can you make
the good moments even better?” This
is not so hard — if taking a morning
shower is pleasurable, can it be even
more pleasurable if you make it two
minutes longer, or play music in the
bathroom, or add some fancy shower
gel? This same technique can apply to
meeting a friend for coffee (make sure
to order a specialty coffee you enjoy),
taking a short walk (notice the colour
of the sky or the neighbour’s flower
garden, or remind yourself how many
calories you burned), talking to the
kids after school (review in your mind
your child’s smile after the chat is
over), and so on.
With these clients, the next step
is to put the ‘more-pleasure’ plan into
effect, to do something that increases
the pleasure, which is surprisingly easy
if the enhancements are small steps to
increase enjoyment of what they are
already doing. Extended attention to
what feels good is, in itself, a powerful
anti-depressant and stirs a motivation
to have more of that pleasure. When
applied skilfully, this incremental
approach enables clients to spend more
time having pleasurable moments and,
more importantly, paying attention to
them leads to a powerful shift in mood
and activity level.
Post-traumatic depression
Post-traumatic stress is another
source of depression that can
manifest itself in sudden feelings of
intense helplessness, often set off by
emotional or environmental events,
that the client may not even recognise
as triggers. Trauma victims can
experience disproportionately powerful
mental and physical states from even
seemingly minor stressful experiences,
especially when they somehow evoke
a version of the helplessness and sense
of danger they felt during the initial
trauma. They also have a hard time
believing anybody can help them, far
less that they will ever be able to help
themselves.
Mike
Mike was the kind of client often
referred to as ‘high functioning’, but
it was clear from our first session that
he did not think treatment would do
him much good. He was a member
of a small engineering company that
relied on his specialty to round out
their team. He wasn’t happy at work,
but said, “I know I am stuck at this job for
life”. At fifty years old he saw himself
as “too old for anyone to allow him to
change jobs”. And he was sure that his
colleagues would try to get rid of him
if he did not show more optimism
for their new business plan. In fact,
he had only come to see me because
they complained so much about his
negativity and indecisiveness that
he worried he might be fired. To my
first remark that he did not seem to
hope for much, he rolled his eyes and
wondered aloud why he should hope
for anything. “No offense”, he said, “ but
every time I have hoped that things would
change, they got worse”.
For Mike, the sensation of hope
immediately evoked memories of
loss, disappointment and pain.
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He had been abused verbally and
physically throughout childhood
and told the abuse was his fault. No
academic or athletic achievement
won parental praise, and no amount
of good behaviour gave a reprieve
from the abuse. For him, hope was
a trickster — positive feelings of
hope were entangled in very negative
expectations. He became tearful when
he said he hoped he could have more in
life — more peace, more love, and more
feelings of being good enough — but
he expected it would never happen.
He was afraid even to try therapy
because he had no hope that it would
work. It would only result in more
disappointment and pain.
I realised that in order to help him
install a sense of hope, it had to be
manageably modest in scale so that it
did not trigger memories of loss and
fear. Consequently, we made a plan for
him to focus on small hopes — hopes
for a good dinner with his kids, or a
pleasant afternoon at work without
worrying about next week’s meetings.
I asked him just to note whether these
small hopes actually were realised so
he could do a reality check to see what
happened when he allowed himself to
hope for small, everyday things like
looking forward to seeing his children.
To his surprise, he discovered that
allowing himself small hopes actually
contributed to their realization. True,
hoping for a good life was just too
much hope for now, but it no longer
scared him to hope for a nice evening,
or enough quiet time to get a report
written — bringing those small hopes
to conscious awareness made him less
fearful of ‘hope’ itself.
Since both going into the past and
thinking about the future, took Mike
into very negative, miserable territory
and evoked worry and negative
expectations, I introduced the concept
of mindfulness as a way to help keep
Mike keep calm and anchored in
the present. He practiced watching
his breath and eating an orange with
complete attention to the sense of the
peel in his fingers, the fragrance of the
burst fruit, the texture of one segment,
the taste as he chewed slowly. He
caught on immediately and found that
he could remind himself numerous
times every day that, “this day, at this
moment, all is well”. While Mike is
still not ready to hope for big changes,
these moment-to-moment exercises in
mindfulness have made him feel less
afraid of hoping and trying — because
getting what he wants might not be an
entirely hopeless endeavour, after all.
I also addressed his chronic sense of
helplessness by asking him to become
aware of how often he described
negative aspects of his life with the
coda, “I can’t do anything about that”. No
matter the topic, from controlling his
anger to reviving his children’s desire
to spend time with him, he essentially
shrugged verbally, indicating his
unrecognised feelings of helplessness.
We know from neurobiological
research that language, coming from
the left prefrontal cortex, modulates
emotion by exerting control over
the limbic system. So, helping Mike
to change his language — making
it less about his inability to do
anything, and more about his personal
agency — could actually reduce his
feelings of helplessness. First, I pointed
out the times he said “I can’t” until he
himself became aware of how often
he used this phrase. Then, I suggested
he substitute “I won’t” for “I can’t” and
notice how the change made him feel.
He found that while saying “can’t”
made him feel helpless, “won’t” in effect
was the language of rational choice and
activated his neo-cortex. It wasn’t even
necessary for him to say that it was in
his power to change a situation because
simply saying, “I won’t” reminded him
that he was, in this moment, simply not
choosing to try to change it.
Situational depression
Situation-induced depressions
may result from serious personal
losses (job, spouse, death of a loved
one), work burnout, or exhaustion
from long-term care of a sick family
member. In addition to causing
sadness, discouragement, or a sense
of meaninglessness, these stressful
situations can also engender
physical lethargy and emotional
isolation, which tend to be selfreinforcing — exhaustion and isolation
just engenders more exhaustion and
isolation. Furthermore, this kind of
depressed client does not just need
to change an attitude, but also the
situation by doing something about it.
Paul
Paul was sent on a year-long job
assignment to the other side of the
country. Since his wife didn’t want
to be uprooted — she preferred being
close to her two adult children and
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several grandkids — he went by
himself. Lonely and away from his
normal routines, he worked very long
hours to fill the void — often 10 to 14
hours a day. When he finally returned
home to his former job, his old world
had changed. He had been replaced
on his bowling team; he had dropped
out of his men’s club and didn’t rejoin;
begin doing it again. For example,
he re-instituted a previously enjoyed
lunchtime basketball game with
work friends; the camaraderie and
the exercise both began to raise his
energy. Paul slept better for having
some exercise and even lost a few extra
pounds, which had made him feel even
more sluggish.
…a focus on subtle shifts in behaviour
patterns and daily attitudes can, with
time, create profound change in clients
who staunchly resist interventions that
seem too bold and threatening.
his very young grandchildren hardly
remembered him, while his wife had
become more deeply involved in their
lives, and was busy much of the time
with her other activities — gardening,
book clubs and women’s golf league.
Feeling even more lonely and empty,
he filled his hours with work, which
at least gave him some sense of being
useful, if not important. Instead of
being happy to get back into things,
his exhaustion and detachment left
him irritable with everyone and
disinterested in social activities, so he
stayed at work for long hours and grew
aloof even with his wife and children.
Finally, his wife suggested they
separate and this prompted Paul to
seek therapy. He felt deeply alone,
exhausted, and discouraged. In a classic
case of burnout like Paul’s, working
becomes a substitute for feelings and
relationships. The adrenalin rush of
non-stop activity or meeting deadlines
creates the sensation of having feelings,
temporarily obscuring an otherwise
painful awareness of underlying
emptiness and isolation.
Clients suffering burnout tend
to complain about their intense
responsibilities and the ensuing stress,
but they don’t see the depression
lurking beneath the surface. Paul
needed first to cool down his burnout,
by taking straightforward, practical
steps to restore his overall health — eat
better, exercise more, improve his
sleep habits. He needed to remember
what he used to like doing for fun and
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During his year away, Paul had
developed no social life and spent his
evenings watching TV alone until
bedtime. It was a habit he kept up
when he returned home, so his family
finally stopped talking with him.
He only seemed to interact when he
was with his grandchildren — which
wasn’t often because he was too
emotionally depleted and apathetic
to initiate social contact with them.
Such self-reinforcing isolation is not
unusual — depressed people show
limited interest in others, who lose
interest in response.
To end isolation, Paul agreed that
instead of waiting for his kids to
become interested in him, he would
act as if he were interested in them. He
thought he could get enough energy
to call and invite them to come over
once a week and a couple of weekends
a month. Because his mental lethargy
made it hard for him to think of
things in the moment, we planned
specifically what he would invite them
to do, e.g., walk to the park or play
a new video game — they should be
activities he couldn’t readily excuse
himself from doing. Isolated people
often find it takes less energy to stay
isolated than make efforts to connect
with other people, even though the
latter makes them feel better. Because
Paul was genuinely devoted to his
grandkids, he felt more responsibility
to try harder for their sake. Interacting
with his grandchildren gave Paul more
opportunity to talk with his adult
children about their mutual interest in
the kids — beginning a reverse cycle of
self-reinforcing meaningful contact.
Attachment or abuseinduced depressions
Depression that stems from
attachment problems often manifests
as a default attitude of negative
expectations about the world and an
inability to soothe oneself in adversity,
leading to a deep sense of vulnerability
that often results in a plunge into
despair, even in the face of minor
upsets. A child who is left uncomforted
repeatedly by adults when distressed
first becomes frantic, then resigned and
hopeless, and ultimately shuts down
emotionally. A child suffering from
this kind of chronic neglect or even
more severe attachment failure (e.g.,
physical and emotional abuse) becomes
an adult who tends to feel generally
hopeless, with low expectations of self
and others, and susceptible to sudden
plunges into psychological despair.
These clients exhibit dramatic shifts of
mood, and can descend quickly from
relative equanimity to abject misery as
if ‘falling off a cliff’.
Shawna
Shawna had a history of neglectful
parenting. Her father was absent and
her mother was depressed. Neither
offered her much warmth as a toddler
or protected her later from bullying
and abuse from a neighbour. As
an adult, her mental default mode
was set on “ life is deeply unfair and
much more unfair to me than to others”.
My therapeutic goal was to help
her to balance her chronic sense of
disappointment and victimisation with
more positive experiences of other
people.
To refocus her attention and reset
her automatic default position of
hopelessness to a more neutral ‘wait
and see’ attitude, I gave her several
assignments. One was to ‘say five
positives’ every day — find five good
things about the character or behaviour
of others, and then tell them. Besides
being an antidote to the assumption
that everyone else is unfair and
mean, this exercise sets up a positive
feedback loop: others, in response,
are more likely to live up to your
positive remarks than down to your
PSYCHOTHERAPY IN AUSTRALIA • VOL 18 NO 4 • AUGUST 2012
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low expectations. Over several months,
Shawna did begin to see some good
in the world, and feel slightly more
trusting that people might not always
disappoint her.
Shawna also had a tendency to
catastrophise even the smallest setback.
A friend canceling weekend plans, or
her boss telling her they had to discuss
a problem were sure signs that the
friend intended to dump her, and the
boss to fire her. Unable to tolerate such
intense dread, she would tranquilise
herself by spending the weekend
compulsively eating or drinking
too much, or losing a lot of money
gambling. It is virtually impossible for
clients like Shawna to prevent such
impulsive reactions when they are so
primed to succumb to hopelessness.
The ability to ‘put on the brakes’
before emotionally crashing requires
a cognitive recognition of what is
happening and the capacity to forestall
it through conscious self-comforting
techniques. Having never been
comforted as a child, Shawna simply
did not know how to comfort herself.
Such clients need to learn conscious
ways to put on the brakes when their
moods begin to slip until that process
eventually becomes an automatic
reaction. Without support, clients
like Shawna cannot even get to this
point. If, however, consistent support
from someone else is available, they
can learn fairly quickly to call for help
before going over the edge into despair.
Together, Shawna and I set a plan to
call a lifeline. When on the verge of an
emotional nose-dive, she agreed to call
either me or a good friend.
With Shawna’s permission, I talked
to her best friend and we agreed that
instead of just offering sympathy, she
would refocus Shawna’s attention to
the possible positive interpretations of
any situation that seemed desperate
to her. If her boss told her they had
to discuss a problem, the friend could
say, “Your boss may want to brainstorm
about the problem rather than blame you
for it”. We also wrote ‘lifeline notes’ she
could read when no one was available
to talk. One, for example, reminded
Shawna to identify three potential
positive outcomes to a situation before
assuming the worst would happen. This
helped put the brakes on her tendency
to get carried away by assuming the
worst.
As time went on, Shawna became
more able to avert the plunge to
despair. A notable turning point was
when a colleague from work told
her she did not want to join her for
their regular Friday lunchtime walks
anymore, that she wanted to keep her
time ‘flexible’ so she could join other
friends at times. Instead of falling into
despair, Shawna got mad at what she
felt was a betrayal. ‘Mad’ was not ideal,
but it was better than depressed and
full of self blame! Indeed, her anger
actually seemed to lift her depression
and allowed her some energy to decide
what to do about taking care of herself
at lunchtime without her friend along.
With that step to anger instead of
despair, we saw Shawna turn a corner
towards self-care instead of despair.
What I have described is not
a therapy of dramatic moves, but
of small steps — a kind of microtherapy — a focus on subtle shifts in
behaviour patterns and daily attitudes
that can, with time, create profound
change in clients who staunchly resist
interventions that seem too bold and
threatening. This carefully calibrated
kind of therapy is, of course, always
grounded in the therapist’s attunement
with the clients’ model of the world
and an appreciation of the initial
limits on just how far they will allow
themselves to be influenced. Those who
recognise the crucial differences among
the many demoralising varieties of
depression too often lumped together,
and who have the patience to work in
this careful way, will discover that, as
in the fable of the tortoise and the hare,
being slow and steady is an all-toooften underrated therapeutic virtue.
AUTHOR NOTES
MARGARET WEHRENBERG, Psy.D. is a psychologist in private practice and specialises in the
treatment of anxiety and depression. She is the author of ‘The 10 Best Ever Depression Management
Techniques’ and three books on anxiety, ‘The Anxious Brain’, ‘The 10 Best-Ever Anxiety Management
Techniques’, and the recent, ‘The 10 Best-Ever Anxiety Management Techniques Workbook’. She is a
frequent contributor to the award-winning Psychotherapy Networker magazine and is an internationally
recognised speaker on these topics. She will offer professional training in Australia with PsychOz
Publications in November 2012.
For more information visit www.margaretwehrenberg.com.
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