Level V: Unconscious factors (chapter 15)

 When you read the case histories of many depressed people, it seems unlikely that the above methods will cure the enormous misery they suffer. This is especially true of cases with abusive childhoods as described by therapists cited in the section on shame or by Susan Forward in Toxic Parents or Arthur Janov in The New Primal Scream. They all contend that it takes years to overcome the feeling that you are unwanted, worthless, disgusting and so on. It is my experience that some depressed people are helped with the behavioral-cognitive-skills methods, particularly those struggling with losses and mild depression. But those who were miserable as children, always feeling alone and shame-filled, never liking themselves nor truly trusting others, and remain profoundly unhappy, they are difficult to treat. It doesn't seem likely that some simple advice, like "think positive," is going to cure them (but it might help).

 Although Freud would say, "I told you so 100 years ago," there have been several recent cases in which early childhood experiences of trauma and abuse have suddenly popped into consciousness. These insights are sometimes reported to be relieving--like a load is lifted. I believe some people do need to unload their emotional burdens, their "unfinished business." But, I don't believe every sad person was abused as a child. It is impossible, given our knowledge today, to know the true and original "cause" of a person's depression. I say this because the cause given for your depression depends on what therapist you see, i.e. most psychiatrists would say "chemical imbalance," Beck and Ellis would say "faulty thinking," Seligman would say "helplessness and pessimism," Bradshaw would say, "shame," etc. It is strange that each theorist only sees his kind of depression. We haven't put the elephant together yet.

 Certainly, some traits related to depression, especially to shame, go back to the first few years of life. Indeed, many depressing attitudes have a long history: feeling inferior, helplessness, pessimism, guilt, self-criticalness, perfectionism, hypersensitiveness, shyness, dependency, socially neediness, hostility, and being without systematic values to guide our lives. Naturally, theorists are prone to blame parents for the weaknesses starting in childhood. We should keep in mind however that just as the guilty, sad, self-critical, shame-filled person may have learned those things in childhood, the angry, degrading, neglectful parent developed his/her basic personality as a child too. You can't point the finger of blame at just one person; it's more complex than that.

 If you could learn to understand the development of any of the just mentioned factors or if you became more aware of how these feelings show themselves in subtle ways, you might be in a better position to reduce their impact on your life. Example: suppose you grew up feeling that you were slighted by your parents and concluded it was because you did not deserve to be dealt with fairly and as a worthy person. If you understood the origin and irrationality of this low self-concept, you might stop your self-put-downs, start seeing your strengths, and begin to tactfully demand your rights with others, i.e. stop responding with self-put downs like you did as a 10-year-old. Here are some "insight" methods:

 Read some insight-oriented psychological writings about depression, then self-explore and try to figure out your own dynamics. Assume the responsibility for getting insight into your life. Check your ideas out in a support group. You may have a thoughtful friend, if you are very lucky, with whom you can discuss the causes of your depression, but often you are on your own to "analyze" your psyche. I have already cited references in the specific areas of depression. General insight books include: Bass and Davis (1988), Miller (1983), Schaef (1989), and Forward (1989).

Warning: Some writers (especially Bass & Davis, 1988) declare that repressed childhood traumas, such as sexual abuse, are the probable cause of specific adult problems. It is true that abuse can be repressed (forgotten). And, since remembered abuse is sometimes (not always!) associated with adult problems, it is quite possible that repressed abuse could cause long-term problems. But no therapist or book can or should state that you probably have been abused just because you have certain symptoms (assuming you have no memories or other evidence of abuse). On the other hand, false memories of abuse are sometimes developed. When this happens, false accusations of childhood abuse can cause great distress to others (and might make the victim's depression worse). This is discussed in greater length in chapter 15.

 Unconsciously motivated interactions. Read in chapter 9 about "games people play" according to Transactional Analysis. These are unconsciously motivated interactions with others in which we may goof up and/or get put-down, thus confirming our childhood beliefs that we are inferior and undeserving. Once we know that we are designing our own failures (and for "sick" reasons stemming from early childhood), we can use our Adult intelligence to stop these self-defeating games.

 Anger and guilt. Depression is often associated with, maybe even concealed by, other emotions, especially anger and guilt. Research reveals that anger with the spouse is often the true source of depression. Therefore, the other emotions may have to be dealt with before the sadness shows itself clearly. Then the depression can be deconditioned, attacked cognitively, or understood through insight. Remember, our guilt may be unjustified (see section above) and our anger is likely to be suppressed (see next chapter). Flanigan (1996) writes about forgiving yourself. Often we are very angry about how we have been treated, but we have been taught that it isn't nice to be hostile (and besides it may actually be dangerous), so we don't talk about it. Venting might help. Determinism too.

 Shame. In some cases, for instance with shame, it may be necessary to uncover the original early childhood pain that made us feel inadequate. Then you can nurture the hurt, fragile inner child and build your self-esteem using more rational and mature methods. Several ways of reducing shame are described in the special section on shame above. Be sure to see John Bradshaw's books.

 Our inner child. Chopich and Paul (1993) describe how our "inner child" may be abandoned and shamed by our own "inner adult." When this happens the inner child feels very negative about itself, including feeling bad, shame, fearful, and in need of addictions to numb the hurts. Their treatment (it could be self-help) involves encouraging our adult part to attend to, accept, protect, and take care of our inner child. A healthy, protected inner child is very valuable to us; it is intuitive, creative, passionate, full of wonder, playful, energized, sensitive, wise, and fun. Basically, self-help of an insight nature for depression involves getting to know our true feelings, i.e. understanding and accepting ourself, including our inner child. Self-esteem results, in part, from our inner adult loving our inner child. Again, see the discussion of shame in the previous section.

Conclusion: Final words of advice

 Don't let your computer get overloaded looking at all these methods. Remember just reading will not make you happy; you must DO SOMETHING with the ideas you read! You must change how you act and think. Find two or three methods that seem practical to you and give them an earnest try! If your first attempts don't work, try something else until you feel less depressed.

 Don't assume that the psychological methods above will instantly change or overcome the ways you have been acting, feeling, or thinking for many years. You can't just plan one active, fun weekend and, then, expect the depression to lift forever. You can't try stopping depressing thoughts for two or three hours and, then, expect these upsetting ideas to stop forever. You can't just try for an hour to think of positive things about yourself and, then, expect to like everything about yourself ever after. It is a major undertaking to change yourself from a pessimist into an optimist. We are talking attending to details for weeks or months.

Note again: If your depression is serious or dangerous, get professional help immediately. Even if your depression is not serious but a support group and/or your self-help efforts are not helping, get individual therapy from two experienced professionals--a MD and a psychotherapist. If medication has not helped, see a psychotherapist. If several sessions of psychotherapy has not helped, get medication from a MD and consider getting another psychotherapist.

 I must repeat that antidepressive medication and PMS treatment are important sources of help. Scientists don't know exactly how the drugs work, but for some people antidepressants are a godsend. Strangely, many studies have shown that 30%-40% of depressed people improve when given a sugar pill for the depression, while about 50%-65% improve on an antidepressant. We don't know why placebos are so powerful with briefer and milder depressions. But for deep depression (including weight loss, early morning awakening, continuous sluggishness, total loss of interest and pleasure in life) antidepressants are often necessary and most of the time far more effective than a placebo (Brown, 1995).

 About half of all people evaluated by a psychiatrist for any problem are prescribed drugs! Over half of patients ordered to take drugs by psychiatrists are told to take anti-depressive medication! And, until the mid-1990s private psychiatrists, the most expensive kind, prescribed about 70% of all anti-depressive drugs, not Mental Health Centers or family physicians or other public clinics (this percentage changed as selected psychoactive drugs, such as Prozac, become highly advertised and popular). After 2004 when the FDA required a suicide warning label on anti-depressants sold to children, psychiatrists will probably be writing the majority of prescriptions for depression. As I mentioned, the benefits of drugs can be life-saving for some people, so psychiatrists like Kramer (1993) will strongly advocate Prozac for depression. Likewise, treatment for PMS helps many women avoid depression and tension.

 Many depressed patients feel certain that their prescriptions are very beneficial. Yet, everyone shouldn't assume that drugs will be an easy, cheap panacea for them. Drug companies spend $5 billion a year to promote drugs. Recent studies, however, using patient ratings and effective designs, have found that for many people antidepressive medication gave little relief from depression (Greenberg, Bornstein, Greenberg, & Fisher, 1992; Breggin and Breggin,1994, and Fisher and Greenberg, 1995). Even psychiatrists admit that perhaps 30% of severely depressed patients are not "cured" by antidepressants. Nevertheless, the point is: millions of other people have gained relief by using prescribed drugs even though less than 20% of depressions have identifiable medical causes. Drugs should not be avoided, but the truth is that many people won't use drugs, and when they do, the drop out and relapse rates are higher with drugs than with psychotherapy. Effective drugs (which include placebos) should be used cautiously in conjunction with psychological methods (treatment and self-help).

A Special Caution: Many physicians prescribe antidepressants, especially Prozac, without recommending psychotherapy.

 It has been common to prescribe Prozac (over 1 million prescriptions per month, mostly by non-psychiatrists in the last 10 years). Because of the hype and few side effects, Prozac was considered a miracle cure for many things: eating disorders, obsessions, compulsions, shyness, unassertiveness, poor thinking, low productivity, weak personality, low zest, lack of confidence, lack of poise, etc. None of these "treatments" have been proven. Be careful when you take drugs. Prozac may be helpful with depression but its help with these other problems is questionable.

 The effects of Prozac are enhanced by its popularity, i.e. a powerful placebo effect. In addition, Prozac seems to act as a stimulant, something like a mild amphetamine of the 1960's. These two factors lead many depressed patients to be convinced that their Prozac prescriptions are very beneficial, say the Breggins (1994). However, when drugs become a well advertised fad (like Valium a decade ago and Prozac recently), we "medicalize" our problems, i.e. we see our feelings as caused by uncontrollable biochemical factors permitting us to deny our history, our conflicts, losses, and stresses, and our morals or personal failings. Feeling better becomes the doctor's responsibility; we don't have to try to help ourselves.

 Don't overlook the effectiveness of psychological treatment. Several extensive investigations conclude that psychological treatment, such as improving social skills, increasing pleasant activities, and correcting maladaptive negative thoughts, yields better long-term outcomes than drugs (Antonuccio, Danton, & DeNelsky, 1994). Both cognitive-behavioral and psychodynamic-interpersonal therapies work with depression (Gallagher-Thompson & Steffen, 1994; Shapiro, et al., 1994). So, don't think that psychology is just a cheap, second-rate source of help for depression; objective research says psychotherapy is the best treatment you can find but, like drugs, psychotherapy doesn't work for everybody.

 Psychological methods aren't just for reducing depression; there is evidence that psychoeducational sessions can prevent depression. Gillham, Reivich, Jaycox & Seligman (1995) gave 5th and 6th graders 12 sessions covering some of the cognitive and social problem-solving skills mentioned above. Among those getting training, only about half as many (compared to an untreated control group) got depressed during a two year follow-up.

 Don't forget there are many sources of self-help with depression, especially books. Some are excellent, especially both of Burns's books (1980, 1989) which give detailed instructions for a cognitive psychology approach to reducing depression. Recently, a rare evaluation of a self-help book showed that Feeling Good reduced depression (Jamison & Scogin, 1995). Mental health workers also recommend Burns highly (Santrock, Minnett & Campbell, 1994). Research says cognitive methods are the best we have today. Also, among the better books for general psychological self-help with depression are: Carlson (1994), Lewinsohn, et al. (1986), Preston (1989), and Ellis (1988). One of the more extensive packages for depression and manic depression involves two books and a video tape by Mary Ellen Copeland (1993, 1994).

 A man (Emery, 1988) and a woman (Braiker, 1988) have written cognitive therapy books for depressed women. A psychiatrist has addressed dysthymia, i.e. long lasting but moderate depression (Hirschfeld, 1991). Herskowitz (1988) gives advice to parents with a depressed child. Hipp (1996) writes for the teenager suffering through a loss--a death, a divorce and so on. For genetic factors in depression, see Arterburn (1993). Gold (1986) and Klein & Wender (1988) do a good job describing drug treatment before Prozac; Kramer (1993) tells you about Prozac but oversells it.

 For coping with death, loneliness, perfectionism, low self-esteem, lack of hope and motivation, and boredom, see the sections above. For low self-esteem, see chapter 14.

 For more information write for: Depression: Awareness, Recognition, Treatment, National Institute of Mental Health, Rockville, MD 20857 or phone 800-421-4211. The National Depressive and Manic Depressive Association, Box 3395, Merchandise Mart, Chicago, IL 60654 also provides information (phone: 800-826-3632). There is a Clearinghouse for Depression on the internet at The Clearinghouse cites many references, including Mindstreet TM's Cognitive Therapy (8 hours of computer assisted psychotherapy) and Lewinsohn et al (1986) book which is available on line. For older persons, booklets (D14220 & D14862) are available from AARP Fullfillment (EE0713), P.O. Box 22796, Long Beach, CA 90801-5796. Also, a film is available ($29.95) from Impact Resources, Murrieta, CA 92564-1169 or 1-800-333-6475. For depression oriented self-help groups, write Depressives Anonymous, 329 East 62nd St., New York, NY 10021 or phone 212-689-2600.

 There are many Web sites about depression, check a search engine. There are several large Websites that offer reviews of many good books and articles: John Grohol’s Psych Central Depression/, Psych Central Depression Articles, Psych Central Depression Books, and Psych Central Seasonal Affective Disorder. Other good sites are: Mental Help Net-Depression, Mental Help Net-Bipolar, and Mental Health Recovery-Depression,.

 Special mention should be made about Postpartum Depression. Any woman who gets pregnant, has or loses a baby, or has weaned a baby recently can get this disorder. The risk is significantly higher, however, if the mother has been depressed and been treated before getting pregnant. The symptoms differ from person to person, some get sad and cry, some get tired and fatigued; some get very emotional and so on. The same person’s mood may rapidly change, for example being sad early in the morning and feeling they just can’t handle the situation by themselves today, by 10:00 they may be feeling OK, and then in an hour feel very angry with the husband or very tired and wanting to sleep. It is important to talk to your doctor about any kinds of feelings. It may not be clear what is causing these changes (probably hormones in part) but many women benefit from talking to other mothers in a support group and finding out that it isn’t unusual for a young woman have the similar reactions. It is treatable.

 Kleiman (1994) has written a helpful book for women having postpartum depression or other emotional reactions. There are also very good Websites: Postpartum Depression, Postpartum Support International, and Depression Central Postpartum.

 I'll end this long chapter with a description of ideal treatment. It is expensive unless you have good health insurance. It is certainly extensive and hard work. One of the more highly recommended (particularly by insight therapists) self-help books for depression is by a psychologist, Richard O’Connor (Undoing Depression, 1999). In essence his book recommends getting an insight therapist and then supplementing that therapy with careful self-observations that help the depressed person understand how and why they are different and depressed. In conjunction with the insight therapist, the patient can observe how he or she sees the world; how he or she doubts that he/she can ever change and meet their own standards; how he/she feels towards and interacts with others; how he/she sees more criticism and hostility directed toward him/her than others do; how he/she is puzzled by human emotions, and so on. These are not easy feelings to uncover and they tap into both the scarier feelings and the stronger needs of a depressed person.

 Depressed people are often needy, steadily seeking some accomplishments to make them feel good. They may be strongly dependent on others for encouragement and support. Self psychology theory, founded by Heinz Kohut (1971), called such a supportive relationship a “self-object.” The depressed person especially needs others to feel positive about him/her. As a child, the depressed person needed to idealize his/her parents and, in turn, have them offer ample support and affection, otherwise he/she feels alone and vulnerable. The young child wants to feel clearly and openly loved, powerful and adored. If this doesn’t happen with the parents, the child and later the adult constantly look to others for affirmation.

 According to Kohut and O’Connor, depression is a result of suppression or loss or denial of the parts of the self that contain deep hurts. A depressed person uses several defense mechanisms that help us hide the painful childhood memories and feelings. O’Connor calls these defenses the “skills of depression.” The problem is: the pain, hidden by the defenses to protect us, continues to cause the misery of depression but the repression keeps us from being aware of the sources of our depression. And just as Freud said, insight therapists believe these suppressed, hurtful feelings, like being unloved as a child, have to be uncovered, re-possessed, looked at again and worked through as an adult to overcome the pains of childhood. With defense mechanisms at work, the depressed person would probably make use of various other symptoms produced by the defenses, such as denial, excuses, distortions of reality, and focus on other problems to hide the real hurts and fears. Since the defenses hide our needs for love and security, we devise other indirect ways of asking for care and concern, e.g. complaining about feeling tired, having aches and pains, or complaining about other people, arguing, and getting in trouble or just plain withdrawing.

 O’Connor makes the point that depressed people do depression very well—the defenses against past hurts get rid of the upsetting memories. So, he says what needs to be done is to undo depression…to undo the defenses and deal with the pain instead of denying it so we can learn to experience all the emotions life brings—pain and hurt as well as joy and excitement. Undoing depression requires new skills. Most depressives feel guilt and a sense of failure. They are often perfectionists. They feel responsible for bad happenings. Their self-esteem is probably low. Feeling unlovable they may be lonely. It is natural to try to put bad feelings out of mind. Changing this tendency requires new viewpoints and a different way of thinking.

 Getting better—in therapy or by oneself—involves past hurts and one’s own guilt. For example, you may have felt intense anger towards someone and the defenses have helped you put that episode behind you, but the guilt about the anger may still be there in full force. The anger and the guilt need to be dug up and understood in terms of why you did what you did and in light of the current situation. Keeping a daily mood journal may help you uncover underlying feelings, assess the appropriateness of your emotions, see the history and causes of your irrational emotions, understand the role of your defense mechanisms in prolonging your depression, etc. Antidepressants may reduce the depressed person’s sad feelings but they can still lack confidence, be shy, lack social skills, feel guilt and shame, avoid hard tasks, be faced with an unhappy marriage or work situation. New skills taught by a therapist or learned through self-help education are needed. There is never—well, rarely—a single cause for depression; the person him/herself and the therapist have to look for hurtful childhood experiences, upsetting current situations, and genetic-family traits.

 The needed skills aren’t just uncovering childhood hurts and anger. Learning ways to express one’s feelings is very important and counter to the depressive’s tendency to suppress feeling. Not having feelings is an unhealthy condition. Writing feelings in a journal may teach you how to better express feelings to yourself and with others. Learn to use several social/communication skills in chapter 13 that deal with handling emotions. If you are uptight, learn to relax. However, O’Connor makes a good point when he says some of “the skills we develop with depression in a vain effort to save ourselves pain—emotional over-control, isolation, putting others first, being over-responsible—prevent our recovery.” So one has to look for traits and habits that stand in the way of tactfully expressing one’s feelings and then develop ways to experience and share feelings.

 Since so much depression occurs unconsciously, it is reasonable to seek professional help with this problem. This doesn’t mean you are hopeless without an insight oriented therapist. What I hope I have made clear is that mastering self-help techniques can increase the efficacy of psychotherapy and improve the eventual outcome.

 Good luck on your journey.


 References cited in this chapter are listed in the Bibliography (see link on the book title page). Please note that references are on pages according to the first letter of the senior author's last name (see alphabetical links at the bottom of the main Bibliography page).

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