Of all the words or phrases that have passed from psychology down into everyday speech – narcissism, co-dependent, introvert/extrovert, unconscious, trauma – none come with quite the confusing force of depression. Over two blogs I want to reflect on this malady, this shadow that hangs over some of us – and as far as we can compare past to present and one country to another – always has done, and everywhere at the same time, crossing cultures and tongues. Over recent decades the subject of depression, from both medical and autobiographical perspectives, has blossomed, if you tolerate the black humour.
Another element of depression that makes for much confusion is its proximity to other states of being, or better, non-being: primarily here I'm thinking of exhaustion or life-weariness which in itself is closely related to what Freud and others have called the death instinct; and then there are those older (pseudo?) scientific attempts to map what we call depression - melancholia and neurasthenia. And last but not least those broadest of all existential-emotive terms - despair, gloom, 'the blues', sadness, ennui. Helpful or not, depression has become the umbrella term under which all these linguistic siblings live. See related blog for more.
A personal note. I've lived with my own species of depression for most of my adult life. I can best experience it like this. Somewhere deep inside of me there is an opening, and in it a plug which keeps in all the attachments and meanings that make life the fulfilling and endlessly surprising experience that it is - most of the time. But depression weaves a silent hand inside and pulls the stopper out. At this all the meaning and purpose in me drains out in and instant and seeps away. This mundane image of pulling a plug in a bath captures the awfulness and the ordinariness of it so very well. Once the plug is out I am empty, obviously, and can then fall into dissociation and disconnection: to stare into space, or at a radiator, or at the sky, for an hour or two is no bother at all. There is an edge of self-distain in this for me, and a death wish at times: I don't regret what has been but have no interest in having a future. I know for others self-distain can easily morph into self-hatred and worse. I recognise too the isolating nature of depression expressed by literary and cultural critic Jonathan Dollimore: 'It sounds callous, but the experience isn't one of callousness; you may want to care still, but you just can't. Something has been severed. It is one of the darkest things about depression, the way it totally isolates you from the people you love.' (Desire: A Memoir, p. 154) And not surprisingly therefore living with and/or recovering from depression is assisted when we have love and support around us - if we are fortunate to have such in our lives. But loving and living with a depressive is not easy.
Trying to pin the word down – and words are all we have to make sense of what we feel and struggle with – is itself a near-impossibility because it seems to mean many different things all at the same time. But we must try. Imperfect though they are for many reasons, diagnostic manuals - in the US the DSM-5, in the UK the ICD-10 - set the tone and a lot of the language for conversations about mental distress so let's start with the DSM-5's list of symptoms for depression. Note: in an effort to separate 'serious' depression from 'the blues', sadness, gloominess, etc. the DSM-5 speaks of MDD - Major Depressive Disorder. To 'qualify' for the label one has to be experiencing five (or more) of the following 'symptoms' during the same 2-week period. (I've highlighted in bold what I think takes us to the heart of felt experiences.)
Depressed most of the day, nearly every day as indicated by subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation)
Significant weight loss when not dieting or weight gain (e.g., change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day [this runs a whole list of mostly physical states - restlessness, fidgeting, self-hugging]
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
One of the most familiar elements in any discussion of depression is the endogenous v reactive split (endogenous means 'that which originates from within the organism'). To put it simply, is my depression the result of a chance 'chemical imbalance' or my not-yet-processed reaction to adverse life events, usually from one's childhood? The truth, as ever, is somewhere in the middle. With the former biological model - which dominated in the early part of the twentieth century, dipped in the 1930s and 1940s with the rise of Freudian psychoanalysis, and then returned with the rise of antidepressant psychoactive drugs from the 1950s onwards - the idea is we just have unlucky brains that are misfiring for some involuntary reason. The answer then is to push our brains back into 'normal' gear with an SSRI or other product of pharmacology (SSRIs are the latest if not necessarily the most effective form of antidepressant medications; most chart their arrival to the late 1980s with the arrival of Prozac (fluoxetine), the most (in)famous of the SSRIs). A go-to of this approach is genetic inheritance - depression runs though the generations. Whilst there is some evidence to suggest there is a causation dimension from genetics it remains murky and inconclusive. (See Sadowsky, Chapter 5, 'Just Chemical' for more on this area).
The chemical imbalance approach raises yet more fuzzy domains of categorisation and language. Is depression an illness or a sickness, and when does a sickness become that most oppressive of medicalised terms, a 'disorder'? What makes something arising from mental life an illness or disorder anyway? And what is the relationship between illness and disease? Reflecting this way tips us very soon into the vast subject of whether the concept of illness - based on what ails and affects the physical body - is a helpful metaphor at all for describing the mind and its creations - beliefs, feelings, meaning, identity. A recent book - People Not Pathology: Freeing therapy from the medical model (PCCS Books, 2023) - sets out in richly argued terms a position I hold to, namely this: 'Psychotherapy provides an alternative to, and respite from, medicalisation of a person's life and distress. It is often the only opportunity to explore experiences without them being medically diagnosed (or otherwise culturally judged), given the speed with which contemporary society diagnoses everything.' (p.10) But we cannot cut ourselves from the mainstream where science holds sway and gets to largely create the discourses of mental life that affect us all; everyone Googles and everyone therefore wraps themselves in language lifted straight from the biomedical model of mental distress. The age of self-diagnosis is truly with us, and all of that comes into the therapy room with every client.
Therefore, a psychological/social/interpersonal approach is much more interested in asking questions like: What have you been through? What have you witnessed? How helpless have you been? Obviously, there is no escape from nor any good reason to downplay the importance of our biology; every thought we have is the product of our neurochemistry after all; mind is nothing without the thick jelly substance we call the brain. But its where depression enters into the bio-psycho-social loop of being human that is the trickiest and therefore the most intelligent question to ask. As we will see below, a childhood of abuse and neglect - or even one subject to remote or unresponsive caregivers - can radically alter one's brain development and wider physical health (asthma and eczema for instance may well have deep connections to childhood neglect and unmanageable levels of stress. For more on this see the work of Gabor Mate, especially When the Body Says No: The Hidden Cost of Strength). Ultimately, as Jonathan Sadowsky rightly points out, 'depression is always a bodily experience' (The Empire of Depression: A New History, p. 16)
Early - and by early is often meant the nine months in utero and the 18 months following birth - trauma can come in many forms. The most obvious is abuse. There is world of complexity in understanding the toll abuse takes but to simplify: the infant or young child is left after repeated abuses in a parlous state of mind that is composed of at least three main feeling states. There is confusion - am I loved and wanted or not? - and fear - how much at risk am I here of dying? - and desperation - I think I fear you, mother or father, but I have no one else to care for me so I will continue to look up to you and seek for your love and approval, and who knows, maybe one day you'll be nice to me. To the confusion strand we can add self-reflexive hatred - I must indeed be the noxious thing I'm often said to be, unloveable and unworthy. I'm so bad and naughty that no parent could possibly love me. Nothing good can come from me. It's not too hard to see how such a troubled childhood might resurface as adult depression.
The originator of the oft-quoted phrase - 'depression is anger turned inwards' - was Karl Abraham, a contemporary of Freud's who worked out of Berlin in the 1920s. It is generally now used as a shorthand for many different but related psychoanalytical views of depression. The seed of his take on self-directed negativity wasn't born from active abuse per se but from parental avoidance and neglect due to loss and grief in the parent's world. One possible scenario: the eldest child dies, the mother can't get over her loss and number two child is overlooked, slowly abandoned by a grief-stuck mother. But the child can't tolerate their conflicted feelings that now arise - I love my sad mother and want to help her/ But I'm angry with my mother for not loving the child, me, that is still here and needs her! This tension erupts as depression later in life when the person meets just one too many new emotional setbacks or rejections - thereupon it can settle as a doomed and fixed self-concept - Perhaps I am unlovable or toxic after all, because this keeps happening. In short, depression arises through lack of love and attention rooted in early infancy. (A more general theory, but related to Abraham's, is that worked up by Melanie Klein. She has a great deal to say about the growth in humans away from what she calls the 'paranoid-schizoid' position to the 'depressive position' - for her the latter being a right place to get to, a place of adult human maturity where we see reality - and our impact on others and them on us - correctly. A place where we are able to blend and balance the need, aggression, love and guilt we all feel towards the people in our lives.)
This realm of continued parental mis-attunement rather than out-and-out trauma appears in the work of Donald Winnicott (see my blog on childhood for more about him). In short, for Winnicott, the trying-hard-though-far-from-perfect parent can leave the child alone with their chaotic feelings and instincts for too long; or they might name the child's emotions back to him or her incorrectly, or fails to name them at all, or generalises in a crude way (a classic here is: 'You are a naughty boy', rather than, 'You did a naughty thing'). The result is a sort of miseducation or a developmental gap in the child's ability to trust others and themselves that goes on to undermine many later relationships. Winnicott wrote with such perception on these childhood deficits because he had sad and withdrawn mother to contend with. In later life he wrote about a poem about her called 'The Tree'. This is a part of it:
Mother below is weeping
weeping
weeping
Thus I knew her
Once, stretched out on her lap
as now on dead tree
I learned to make her smile
to stem her tears
to undo her guilt
to cure her inward death
To enliven her was my living.
Mark Epstein comments: 'His mother's smiling face did not make itself spontaneously available to him - young Donald had to work for it. To Winnicott's way of thinking, this was a form of trauma ... The prematurely mobilized self is a life-saving adaptation that eventually squeezes out life.' (The Trauma of Everyday Life, Mark Epstein, p.210)
It may be more helpful, rather than endlessly chasing the mists of our last depressive episode, to define its opposite. As before, a key to the condition is in wordplay – to de-press, to hold down. What is the free release of life if depression is its suppression? Here I can only turn to that great English poet Blake for help – and for metaphors. Blake’s dense world of symbols and characters brings to life the ever-renewing impulse for joyous energy that most of us, even those who experience regular depressions, feel from time to time. The joy of nature, of touch, of sex, of food; the sound world, of music, of birdsong; the creative world of story and myth, of good TV. We 'normally' fall endlessly in love with this world of boundless Energy or God or the Life-Force or whichever term you prefer. What is so hopeful in the passage that follows are his teeming metaphors of re-birth and renewal after a period of psychic death or imprisonment.
The morning comes, the night decays, the watchmen leave their stations; The grave is burst, the spices shed, the linen wrappèd up; The bones of death, the cov'ring clay, the sinews shrunk and dry'd Reviving shake, inspiring move, breathing, awakening, Spring like redeemèd captives, when their bonds and bars are burst Let the slave grinding at the mill run out into the field, Let him look up into the heavens and laugh in the bright air; Let the enchainèd soul, shut up in darkness and in sighing, Whose face has never seen a smile in thirty weary years, Rise and look out; his chains are loose, his dungeon doors are open; And let his wife and children return from the oppressor's scourge. They look behind at every step, and believe it is a dream, Singing: "The Sun has left his blackness, and has found a fresher morning, And the fair Moon rejoices in the clear and cloudless night; For Empire is no more, and now the Lion and Wolf shall cease. (From Milton by William Blake.)
Dollimore is instructive again on this need to keep in touch with our restorative underground springs: 'One shouldn't need the ordeal of depression to know that staying alive is always about self-renewal, always about how we need to keep aware of the many insidious kinds of deadening that life in time habituates us to.' (Desire, A Memoir, p. 172) This ending might be seen as glib, a more pretentious and metaphorical version of 'snap out of it - count your blessings!' I have no simple view on depression, nor any simple remedy for it. I can only urge patience and hope and perhaps above all memory. For though we feel awful today tomorrow may be quite a different story. Indeed, we know it will be for we have been round this cycle numerous times before. To quote another Blake line, 'joy and woe are woven fine'. And if our troubles started with childhood archaic pain then our weave of the two will probably be finer than most.
I'll leave a final word on wrestling with depression - how we recover, how we make sense of it - to Andrew Solomon one of our best current interpreters of the malady:
'The opposite of depression is not happiness but vitality, and my life, as I write this, is vital, even when it’s sad ... This week, on a chilly night when I was overtired, I felt a momentary flash of hopelessness, and wondered, as I so often do, whether I was slipping, for a petrifying instant, a lightning-quick flash, I wanted a car to run me over, and I had to clench my teeth to stay on the sidewalk until the light turned green. Nevertheless, I cannot find it in me to regret entirely the course my life took.' https://andrewsolomon.com/articles/anatomy-of-melancholy/
Photo by Lucas Pezeta: https://www.pexels.com/photo/mysterious-spooky-lane-in-dark-forest-3772353/