amatyultare (![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
amatyultare) wrote2019-01-03 06:05 pm
amatyultare) wrote2019-01-03 06:05 pm
Entry tags:
depression on more than one axis: notes towards a conceptual framework
I wrote this in mid-2017 and I'm still quite happy with it.
I’ve been thinking through versions of this essay for a while. After a couple of recent conversations on the topic, I figured the time had come to actually write the thing, just in case others might find it helpful.
Disclaimer: I am not a health professional or expert of any kind, and particularly not an expert in mental health. This is a personal theory based mostly on my personal experiences. If you are suffering from depression or any mental illness, I REALLY recommend talking to a trustworthy medical or mental health professional.
Here is what I have realized over the past few years. Clinical depression happens on two distinct axes. One is, broadly speaking, biological; the other is cognitive. Separating the two in my mind has helped to address the symptoms of each more effectively. I hope it may do the same for you, gentle reader.
The Biological Axis
Zach Handlen wrote a really good essay on mental illness back in 2014. The essay is technically about bipolar disorder, not unipolar depression, but many of his points are specifically about his experiences with depression and rang true to me. A particular favorite is his attempt to explain the sheer banality of depression:
Depression is one of the most unglamorous forms of suffering imaginable. I once drafted an entire essay around the search for a good metaphor for depression. Almost every comparison I made seemed insufficiently descriptive of its awfulness, while simultaneously being far too dramatic. Depression is an all-encompassing, yet completely boring and shitty, experience. It’s not grief or misery. It’s not a dark cloud or a black dog following one about. It’s not exciting or wistful or photogenic. It’s senseless.
The metaphor I’ve settled on is this: depression is a mental version of nausea. It’s not pain, exactly, but it’s a clearly physical wrongness which is deeply unpleasant and unsettling. The worse it gets, the more it absorbs your energy and attention. Some people have constant low-level illness, i.e. dysthymia, which sucks in its own constant, grinding way. Others suffer from major depressive disorder and will have intermittent periods when they suffer severely. I’ve read accounts of people who experience such deep depression that they literally cannot get out bed. Their energy is entirely devoted to handing/processing this intense wrongness they are experiencing. Still others experience depression as one half of bipolar mood swings.
So yeah. Imagine having the worst nausea you’ve ever experienced. Does it seem the slightest bit romantic or glamorous? Nope! Does it seem incredibly shitty? Sure does! Now imagine having to live your daily life, go to work or school, pay your bills, care for your pets, keep your living space clean, maintain your relationships with friends and family, while constantly feeling that nausea. For months, sometimes years (or in the case of dysthymia, basically forever). Congrats, you have now started to understand depression.
This kind of mental-nausea-esque, biological-based depression isn’t caused by negative thinking. It’s never going to be fixed by mindfulness or gratitude exercises (though these tools might help a sufferer live with the symptoms of depression, in the same way that chronic-pain sufferers sometimes find meditation techniques helpful). “Biological” depression is treated through medication and behavior modification that impacts one’s physical state (e.g. exercise, getting more sleep, changing one’s diet).
So what’s the deal with “talk therapy”, psychology, Cognitive Behavior Therapy, and the like? Are they worthless? Absolutely not! They’re just designed to treat a different axis of depression.
The Cognitive Axis
Ten Lies Depression Tells You, published in 2013 by Anne Thériault, is one of the most succinct descriptions of how I’ve felt and thought during depression that I’ve ever read. I tear up every time I read it from sheer recognition. I mean, not to get too personal, but #4 is almost verbatim something I started telling myself around the age of eight (!!!).
And here’s the thing: contrary what I’ve been arguing for the last several paragraphs, this essay does reflect a lot of the drama that often is attributed to depression. “I’m the worst person ever! If something goes wrong, no matter what it is, I must be to blame for it somehow!”
Contrast to, say, Allie Brosh’s wonderful comic Depression Part Two. Allie’s base, biological description of her experience still resonates. But the way she thinks and feels about her depression is strikingly different. She basically sees it as a long interval of being really confused by what’s going on. She’s suffering, and she knows it, but she has no explanation for why.
What's up with this discrepancy?
The pieces fell into place for me when I starting reading David Richo’s excellent book How to Be an Adult. (This is not an #adulting book in the sense of instructions to get your oil changed and vacuum underneath your couch. Rather, it’s a book about how to achieve psychological maturity.) Richo points out that the negative beliefs and stories we tell ourselves are often a control mechanism. They comprise a strategy we use to try to manage, contain, and channel negative emotions.
At the time I started the book, I had been struggling immensely with the idea that I should Stop Having Low Self-Esteem. I was extremely resistant because, well. How do you stop feeling the way you feel? “I feel bad, and when I tell myself to stop, I feel bad about feeling bad.” Getting out of that loop felt impossible, a paradoxical directive.
Richo made me realize that I was feeling…depression, full stop. The negative stories - “I’m not good enough”, “No one likes me”, “It’s all my fault” - were secondary mental structures that I had created as an attempt to make sense of this overwhelming experience of depression. They were channels I’d built to contain and route the floodwaters of emotion. (Mostly gouged out, I suspect, from the most vulnerable veins of the human psyche - fear of inadequacy, terror of not belonging - hence why so many people’s cognitive depression presents along similar lines.)
(See The Dirty Normal’s How to Feel Your Feelings and Another Thing About Feelings for more on this and the concept of “meta-emotions”. Heck, throw Emotion Coaching on that list as well.)
Of course, simply recognizing the dichotomy between feeling and belief isn’t enough to eliminate these negative stories. But it has helped me to use tools like cognitive behavior therapy MUCH more effectively to address those negative beliefs.
Cognitive depression, in other words, isn’t simply a symptom or manifestation of biological depression. It is a belief system and set of mental structures. These structures are created in reaction to biological depression (or, I suspect, mental suffering in general), but thereafter exist independently from it.
Addressing Each Axis
Does this model really matter? To the extent that they can be, both the biological and cognitive aspects of depression should be addressed in treatment. That’s why “medication + therapy” is such a common prescription.
On the other hand, understanding depression as moving along multiple axes has helped me get very clear about what each form of treatment will do. For example, medical interventions or even the straight-up cessation of a depressive episode won’t automatically change what I’m thinking. Those conscious stories exist separately from the biological state of depression. They are triggered by, but not caused and certainly not synonymous with, “depression” in its base state. Even at my best, I sometimes revert to unhealthy “stories” to cope with everyday stresses. Which makes sense, given how engrained these stories are after years and years of using them!
On the flip side, changing my thinking will not stop depression. I can learn to stop telling myself negative stories. I can build up new, healthier mental models. But that work will not check or mitigate one iota of my brain’s physical illness. When that biological depression comes back, the absolute best I can hope for is to recognize it and allow it to run its course with little or no maladaptive storytelling.
This all sounds grim, but honestly it’s really helpful. When I start telling myself that “I feel awful, I’m not good at anything”, the cognitive/biological framework has helped me pull back. I can see now that “I’m not good at anything” is an interpretation of my feelings, not the feeling itself. That makes it possible for me to challenge the interpretation without negating or denying my feeling. And contrawise, when I’m feeling depressed, I am much better at stopping my scramble to find some kind of reason (i.e. way to blame myself) for it. I am able to acknowledge that I’m feeling bad because depression means feeling bad sometimes, and I can ride it out with as much equanimity as possible.
It’s not perfect. But it’s a start.
(Does this model resonate with other people with depression? I’m honestly really curious and would love to hear your thoughts.)
I’ve been thinking through versions of this essay for a while. After a couple of recent conversations on the topic, I figured the time had come to actually write the thing, just in case others might find it helpful.
Disclaimer: I am not a health professional or expert of any kind, and particularly not an expert in mental health. This is a personal theory based mostly on my personal experiences. If you are suffering from depression or any mental illness, I REALLY recommend talking to a trustworthy medical or mental health professional.
Here is what I have realized over the past few years. Clinical depression happens on two distinct axes. One is, broadly speaking, biological; the other is cognitive. Separating the two in my mind has helped to address the symptoms of each more effectively. I hope it may do the same for you, gentle reader.
The Biological Axis
Zach Handlen wrote a really good essay on mental illness back in 2014. The essay is technically about bipolar disorder, not unipolar depression, but many of his points are specifically about his experiences with depression and rang true to me. A particular favorite is his attempt to explain the sheer banality of depression:
I’ve never been sure I should write a post about depression.There’s something so fundamentally uninteresting about the condition that any attempt I make to describe it falls short. I can throw words out all morning, and still not capture the idiot simplicity of the experience.
Depression is one of the most unglamorous forms of suffering imaginable. I once drafted an entire essay around the search for a good metaphor for depression. Almost every comparison I made seemed insufficiently descriptive of its awfulness, while simultaneously being far too dramatic. Depression is an all-encompassing, yet completely boring and shitty, experience. It’s not grief or misery. It’s not a dark cloud or a black dog following one about. It’s not exciting or wistful or photogenic. It’s senseless.
The metaphor I’ve settled on is this: depression is a mental version of nausea. It’s not pain, exactly, but it’s a clearly physical wrongness which is deeply unpleasant and unsettling. The worse it gets, the more it absorbs your energy and attention. Some people have constant low-level illness, i.e. dysthymia, which sucks in its own constant, grinding way. Others suffer from major depressive disorder and will have intermittent periods when they suffer severely. I’ve read accounts of people who experience such deep depression that they literally cannot get out bed. Their energy is entirely devoted to handing/processing this intense wrongness they are experiencing. Still others experience depression as one half of bipolar mood swings.
So yeah. Imagine having the worst nausea you’ve ever experienced. Does it seem the slightest bit romantic or glamorous? Nope! Does it seem incredibly shitty? Sure does! Now imagine having to live your daily life, go to work or school, pay your bills, care for your pets, keep your living space clean, maintain your relationships with friends and family, while constantly feeling that nausea. For months, sometimes years (or in the case of dysthymia, basically forever). Congrats, you have now started to understand depression.
This kind of mental-nausea-esque, biological-based depression isn’t caused by negative thinking. It’s never going to be fixed by mindfulness or gratitude exercises (though these tools might help a sufferer live with the symptoms of depression, in the same way that chronic-pain sufferers sometimes find meditation techniques helpful). “Biological” depression is treated through medication and behavior modification that impacts one’s physical state (e.g. exercise, getting more sleep, changing one’s diet).
So what’s the deal with “talk therapy”, psychology, Cognitive Behavior Therapy, and the like? Are they worthless? Absolutely not! They’re just designed to treat a different axis of depression.
The Cognitive Axis
Ten Lies Depression Tells You, published in 2013 by Anne Thériault, is one of the most succinct descriptions of how I’ve felt and thought during depression that I’ve ever read. I tear up every time I read it from sheer recognition. I mean, not to get too personal, but #4 is almost verbatim something I started telling myself around the age of eight (!!!).
And here’s the thing: contrary what I’ve been arguing for the last several paragraphs, this essay does reflect a lot of the drama that often is attributed to depression. “I’m the worst person ever! If something goes wrong, no matter what it is, I must be to blame for it somehow!”
Contrast to, say, Allie Brosh’s wonderful comic Depression Part Two. Allie’s base, biological description of her experience still resonates. But the way she thinks and feels about her depression is strikingly different. She basically sees it as a long interval of being really confused by what’s going on. She’s suffering, and she knows it, but she has no explanation for why.
What's up with this discrepancy?
The pieces fell into place for me when I starting reading David Richo’s excellent book How to Be an Adult. (This is not an #adulting book in the sense of instructions to get your oil changed and vacuum underneath your couch. Rather, it’s a book about how to achieve psychological maturity.) Richo points out that the negative beliefs and stories we tell ourselves are often a control mechanism. They comprise a strategy we use to try to manage, contain, and channel negative emotions.
At the time I started the book, I had been struggling immensely with the idea that I should Stop Having Low Self-Esteem. I was extremely resistant because, well. How do you stop feeling the way you feel? “I feel bad, and when I tell myself to stop, I feel bad about feeling bad.” Getting out of that loop felt impossible, a paradoxical directive.
Richo made me realize that I was feeling…depression, full stop. The negative stories - “I’m not good enough”, “No one likes me”, “It’s all my fault” - were secondary mental structures that I had created as an attempt to make sense of this overwhelming experience of depression. They were channels I’d built to contain and route the floodwaters of emotion. (Mostly gouged out, I suspect, from the most vulnerable veins of the human psyche - fear of inadequacy, terror of not belonging - hence why so many people’s cognitive depression presents along similar lines.)
(See The Dirty Normal’s How to Feel Your Feelings and Another Thing About Feelings for more on this and the concept of “meta-emotions”. Heck, throw Emotion Coaching on that list as well.)
Of course, simply recognizing the dichotomy between feeling and belief isn’t enough to eliminate these negative stories. But it has helped me to use tools like cognitive behavior therapy MUCH more effectively to address those negative beliefs.
Cognitive depression, in other words, isn’t simply a symptom or manifestation of biological depression. It is a belief system and set of mental structures. These structures are created in reaction to biological depression (or, I suspect, mental suffering in general), but thereafter exist independently from it.
Addressing Each Axis
Does this model really matter? To the extent that they can be, both the biological and cognitive aspects of depression should be addressed in treatment. That’s why “medication + therapy” is such a common prescription.
On the other hand, understanding depression as moving along multiple axes has helped me get very clear about what each form of treatment will do. For example, medical interventions or even the straight-up cessation of a depressive episode won’t automatically change what I’m thinking. Those conscious stories exist separately from the biological state of depression. They are triggered by, but not caused and certainly not synonymous with, “depression” in its base state. Even at my best, I sometimes revert to unhealthy “stories” to cope with everyday stresses. Which makes sense, given how engrained these stories are after years and years of using them!
On the flip side, changing my thinking will not stop depression. I can learn to stop telling myself negative stories. I can build up new, healthier mental models. But that work will not check or mitigate one iota of my brain’s physical illness. When that biological depression comes back, the absolute best I can hope for is to recognize it and allow it to run its course with little or no maladaptive storytelling.
This all sounds grim, but honestly it’s really helpful. When I start telling myself that “I feel awful, I’m not good at anything”, the cognitive/biological framework has helped me pull back. I can see now that “I’m not good at anything” is an interpretation of my feelings, not the feeling itself. That makes it possible for me to challenge the interpretation without negating or denying my feeling. And contrawise, when I’m feeling depressed, I am much better at stopping my scramble to find some kind of reason (i.e. way to blame myself) for it. I am able to acknowledge that I’m feeling bad because depression means feeling bad sometimes, and I can ride it out with as much equanimity as possible.
It’s not perfect. But it’s a start.
(Does this model resonate with other people with depression? I’m honestly really curious and would love to hear your thoughts.)