To honor the memory of Robin Williams, who died tragically this week by suicide, I thought I would repost a blog piece I wrote about depression and add some comments. In response to the utter shock and horror of Mr. Williams’s death, there has been a more open discussion and examination of depression in the last few days in the media and over the internet. Some of that discussion has focused on a biological understanding of the condition, on what is referred to as an illness or disorder of the brain. And as one of my patients remarked, this focus helps to legitimize the condition and provide a response to those who, out of ignorance, respond to a depressed person with comments such as “snap out of it.” And in fact, as my patient pointed out, such responses can also be internal (even someone so intimately acquainted with the hopelessness and despair characteristic of depression can tell himself to “just snap out of it”).
Although the National Institute of Mental Health estimates that each year nearly 7% of US adults experience major (that is clinical) depression, there is a great deal of stigma and misunderstanding about it. And while discussion about the topic is so important, so too is a presentation of an accurate understanding about it. Like a human being and like the human mind, depression is a complicated phenomenon. While it certainly has a biochemical aspect to it related to neurotransmitters in the brain, it also has some very deep psychological and emotional dimensions. It is, in my opinion, a limited view to see it solely as a disease of the brain. The implication from such a characterization is that depression is caused by an insufficiency in neurotransmitters in the brain and that medication to increase those levels is all that is needed. It is not all that is need. It has been proven through controlled studies that the best treatment for depression is a combination of psychopharmacology and psychotherapy. And in some studies, particularly of milder forms of depression, psychotherapy of various modalities has been proven as effective treatment alone. We know that the mind and the body are linked; there are many factors, including psychological and emotional, that contribute to a person’s depression. Perhaps the most salient point I can make is that it does not in fact delegitimize the condition to acknowledge factors other than biological that contribute to it. It does not make it just something “in your head” (another derogatory and misguided statement that can be made to someone who is depressed). It is still a very disturbing and troubling illness, condition, or phenomenon (whatever your view is).
The following is a post that I wrote in response to a TV series hosted by Charlie Rose that aired some time last year. What I wrote was primarily a rebuttal of the notion, put forward by an eminent scientist on the panel, of depression as solely as biochemical disease. In the hopes of better understanding depression and refuting stigmas about it, I’d like to repost what I wrote. I offer these words in memory of Robin Williams, a man who touched me and so many others with his immense talent, his humor, and his humanity.
Keeping a Diverse View of the Mind: Some Thoughts on Charlie Rose Brain Series 2: Depression
It was with great interest that I watched the Charlie Rose show on the brain and depression. Mr. Rose has been doing a series of shows that highlight the latest neuroscience research on the brain. This show in particular focused on the clinical situation of depression. Mr. Rose’s panel of guests, comprised mostly of scientific researchers and academics, provided informed and useful information about depression in its unipolar (Major Depressive Disorder) and bipolar (Bipolar Affective Disorder) manifestations. They made clear that they were not addressing more ordinary experiences of sadness or “the blues.” The show is educational especially for someone minimally aware of depression (a blog entry from someone whose mother is experiencing depression speaks to this usefulness). One guest in particular, Andrew Solomon, the author of a well-researched as well as intimate memoir on depression, The Noonday Demon, spoke eloquently from his experience of depression. The guests talked about research on the brain that now reveals the areas that are implicated with depression.
The objection that I have with the show, however, is that it takes a unipolar view of what is a complex and multidimensional phenomenon. The panelists understand depression as a disease or, as the moderator, Eric Kandel says, a “disorder.” Their interest is the brain, and their focus is, therefore, on changes in brain chemistry and functioning that result in depression. The thesis behind this model is that something happens, particularly to the neurotransmitters, which impairs the functioning of the brain. They see depression similarly to other diseases with biological etiology, such as diabetes or Parkinson’s disease.
As a psychotherapist who has focused over the years in working with people suffering from depression and anxiety, I have learned that there are other important ways of understanding and working with depression. In my work, I take an eclectic view. While I do not dismiss the notion of depression as a disease, I also remain open to understanding it along more psychological and emotional dimensions.
Depression may be seen more as a symptom, an indicator of something else that is terribly wrong overall. Andrew Solomon says that he believes the opposite of depression is not happiness, but is vitality. I agree with him. From this point of view, depression signals some sort of problem in vitality, in the force that animates one’s life. The focus then in psychotherapy as I practice it is to understand what constricts or obstructs a person’s access to his or her vitality. These obstacles may be many things: specific traumas from the past that are unresolved and drain one’s energy; long-held negative beliefs about oneself and the world; maladaptive and persistent coping strategies for dealing with life’s challenges. The goal of therapy, in addition to understanding what has gone wrong, is to help stimulate a vital engagement in life.
Another view of depression focuses on it as a person’s unconscious attempts to cope. This may seem ironic, of course, given that the suffering associated with depression is often quite severe. Yet it may seem to a person that that suffering is the better of two evils. Clients of mine often speak of the depressed state as one of “numbness.” They see their depression not so much a byproduct of feelings (in that way it is different than say feeling sad); rather it is more the absence of feeling. That numbness is meant (unconsciously) as a coping strategy, a defense against not only painful feelings, but seemingly intolerable ones. The goals of psychotherapy are to provide a safe and trusting process for someone to reopen feeling sectors that have been shut down, to feel and thus work through the emotional issues that seem so intolerable and intractable. In this way, psychotherapy treatment helps the person create better defenses, ones that don’t impede emotional ways of responding to life.
The Charlie Rose show notes how the recorded human history of depression dates back quite a long time. In our modern era, we see a consideration of depression at the very inception of psychological treatment. At the turn of the last century, Freud wrote in his famous paper “Mourning and Melancholia” about the differences in grief (mourning) and depression (melancholia). As I have learned from my clients suffering from depression, there is often some sort of grief work yet to be done. Often some sort of loss or perhaps an experience of disappointment (which can be viewed as a loss of hope) needs to be processed. Psychotherapy provides a means in which, in the presence of another human being, to grieve. As is the case with the stages of grief, as one moves through the process of grieving, the depression resolves.
My approach when working with people with depression is to remain open to the various possibilities of viewing depression. It is not uncommon that my clients also work with physicians and take psychotropic medications as part of their treatment. My experience suggests what the panelists confirm: while medications alone cannot resolve depression nor the problems that contribute to the person’s experience of hopelessness and despair, they can assist in ameliorating some of the devastating and paralyzing effects and make it more possible to delve into psychotherapeutic work. With any given treatment, my focus is to understand that particular client, the meaning of his or her depression and therefore how to best address resolving it.
It seems axiomatic to me that in our modern world we are faced with holding seemingly contradictory facts. As science advances, and gives us views into the workings of the brain, it reveals much that was previously hidden and unknown. And it reveals how much remains unknown as well. (In fact a new book by Stuart Firestein called Ignorance argues that science is less about an accumulation of facts and more about embracing what we don’t know.) It seems beneficial to me to remain cognizant of this fact: while much is known, say about depression, much remains unknown and subject to inquiry both scientific and personal. Or perhaps I should put it another way: the more we know, the more we know about what we don’t know. Which leads us back almost a hundred years to the conclusion of Freud’s paper:
“As we already know, the interdependence of the complicated problems of the mind forces us to break off every enquiry before it is completed – till the outcome of some other enquiry can come to its assistance” [p. 258].
Perhaps we are wise to heed those words as we gather scientific knowledge about the workings of the human mind (not just the human brain). There is indeed an “interdependence of…complicated problems” and enquiring is never completed. Keeping a diverse, rather than singularly focused, viewpoint seems to me the best way to proceed.
Freud, S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 237-258.