Statistics inform us that about one-in-five will experience an episode of depression some time in our lives, but given the
reports of mental health problems among our youth, that statistic may increase in the not-too-distant future. For such a common condition, it is surprising the myths that still exist and the misinformation that is perpetuated. Clarification is required. When people have some degree of low Self Worth or unresolved anger, this may create an increased vulnerability to depression. This does not mean that they will inevitably get depression, but they may be vulnerable if they encounter chronic depressogenic life circumstances or acute traumatic events. Since a lot of people have some degree of low Self Worth or unresolved anger, particularly our youth, a lot of people are vulnerable, so it is appropriate to provide some real-life info on depression, particularly for parents.
Overview of depression - challenging the stigma
It isn’t all that long ago (probably as little as forty years ago) that anyone experiencing non-endogenous depression (see ‘Types of depression’ below) would be labelled as having a ‘nervous breakdown’ and could be ‘put away’ indefinitely in a ‘mental asylum’.They would quite likely be treated with electric shock treatment, the forerunner of today’s electroconvulsive therapy (ECT). It was a simple procedure to have a depressed family member such as a wife ‘put away’, requiring just a couple of signatures of family members. They were regarded as ‘crazy’ and as anyone who has experienced an episode of depression can attest, when you are depressed and are already afraid you are going crazy, and unsympathetic family or spouse tell you that you are crazy, it just confirms your own fears. Hence, the prognosis was not always very good for anyone who was unfortunate enough to be ‘put away’. Patients with a ‘nervous breakdown’ were mainly women, hence the view that women were weaker and more at risk of depression. Of course men had ‘nervous breakdowns’ – but their depression was hidden by alcoholism (ie, self medication). People who recovered from a ‘nervous breakdown’ (particularly if they had been put away in a mental asylum) lived with a dark cloud hanging over their head and the stigma remained for the rest of their lives. As a child, I recall hearing, in hushed tones, the comments referring to individuals who had at some stage in their life had a ‘nervous breakdown’ or had spent time in a ‘mental asylum’. These people seemed to be branded for life as being weak and mentally defective and were not expected to be capable of meeting the demands of life. (I realise now, that these ‘nervous breakdowns’ were actually non-endogenous depression. Depression sub-typing is explained, ahead).
Has anything really changed much? People with depression are not ‘put away’ anymore– but then, patients with schizophrenia are no longer committed to an asylum, either but are allowed to live in the community. They only spend time
in hospital during a psychotic episode or after they have committed a horrific murder - only the ‘criminally insane’ are ‘put away’ now. There is still undeservedly a stigma attached to depression, perhaps mainly due to the ongoing erroneous view that people who become depressed are weak and unable to cope with life. Or, people with depression are more likely to commit criminal acts, but are ‘not responsible’ for their actions.
First, let’s clear up some misconceptions. Contrary to this view, the reality is that being ‘weak’ is not a risk factor for depression and being ‘strong’ is not a protective factor. The issue of strength, or lack of, is completely irrelevant. ‘Strong’ people may sometimes be at increased risk because they ignore their own needs, put the needs of too many others first and take on too many responsibilities that are not theirs. They may stoically put up with untenable circumstances for too long. They may find themselves caught in the trap which they have created, due to old patterns of responsibility to and for others, and they feel ‘pessimistic’ that the situation will ever improve and ‘powerless’ to make the changes required to improve the situation or escape that trap.
Periodically, there are calls to increase awareness of depression and remove the stigma so depressed people will seek treatment rather than suffer in silence or be at risk of suicide. Ironically, contrary to this stated desire to reduce stigma, it is the media and spokespersons for mental health who actually perpetuate stigma by persisting in referring to depression as a ‘mental illness’ or a ‘mental disease’. Depression is neither. It is classified as an ‘affective (mood) disorder’. In addition, like having a criminal record, having a medical history that includes a diagnosed episode of depression (even if it is just non-endogenous depression) may brand a person as having a ‘mental illness’ resulting in being regarded as unsuitable in certain areas of employment. Ironically, individuals without a ‘history’ who are chosen for those employment positions may be at equal risk of having an episode of depression if confronted by adverse life circumstances. Added stigma is the use of depression or ‘mental illness’ as an excuse for high profile ‘celebrities’ engaging in anti-social behavior. It is also used as a defence for committing crimes such as fraud - as if depression is responsible for bad behaviour or losing their sense of ‘right and wrong’ or losing control over their behaviour. A person in the manic phase of bipolar disorder may engage in ‘out there’ behaviour and ignore the social norms, but a depressed person won’t be. Depressed cognitive function and lack of motivation when severely depressed may lead to some unwise decisions (in business, personal finances, relationships or driving a motor vehicle) due to un-thought-out decision making and slowed responses - but definitely not the kind of criminal decision making that involves motivation and sustained high-level cognitive functioning necessary for planning, secrecy and ongoing deception. The only people depressed individuals are likely to murder are themselves, ie, suicide. A mother with severe post natal depression who commits suicide and kills her children as well is not committing murder as such. She is acting on her mother instinct to not abandon her children and is taking them with her. (This does not include clearing the way for a new boyfriend or seeking revenge on the children’s other parent after a relationship breakup. Post natal depression cannot be used as an excuse for inflicting abuse or violence on her child).
And now, in the latest version of DSM 5 (the diagnostic bible), the ‘stigma’ list is to be extended to include ‘grief’. This is now to be re-classified as a ‘mental illness’ if the grieving individual does not recover within two weeks. Grief that is finished within two weeks would hardly qualify as grief. Most people would grieve longer than that for a pet. I think I would feel offended if my family had finished their grieving for me by two weeks! Grief is a normal, natural healing process in dealing with loss. Most commonly grief is thought of in regard to a death, but loss can also be for a marriage breakup or disastrous loss of a business or career. Previously, grief that lasted beyond twelve months was regarded as ‘abnormal’, although this does not make it a ‘mental illness’. What generally delays the normal grieving process is ‘complications’ such as unresolved emotional issues in regard to the deceased. Commonly, the person stuck in their grief may be experiencing guilt and regret for ‘conflicts that remain unresolved’, ‘not being there’ for the deceased, ‘not doing enough’, ‘not being present at the death’, ‘not spending enough time’, ‘not taking their illness seriously’, ‘not being more considerate, undestanding and compassionate’, ‘the last words were spoken in anger’, ‘I didn’t tell her I loved her enough and now it is too late’. In addition, if the death was due to suicide, grieving family may also experience anger and not being able to achieve closure due to so many unanswered questions. Before grieving can proceed normally, some form of psychotherapy may be required in order to resolve the 'complicating' emotional issues.
Does this mean that psychiatry expects grieving individuals to have the resilience to recover in two weeks or else they should just ‘toughen up, get over it and move on’ within two weeks anyhow? No – this new diagnostic classification serves to legitimise expansion of the pharmaceutical market. On the topic of resilience, how are people going to develop this resilience if they are not permitted to do so? Pathologising or medicalisation of ‘normal’ emotional or affective conditions has several negative consequences. First, the implication is that medication should be the ‘first line’ treatment - instead of a grief counsellor, they should have a prescription for an antidepressant. Second, an unfortunate consequence of medicalisation of ‘normal’ conditions is that psychotropic medication prevents the grieving or depressed person from experiencing normal
emotions and working their way through the normal and natural healing process that will contribute to the development of
resilience. Third, there is an inference that two weeks is sufficient time to grieve and not completing it and ‘moving on’ by then is a reflection of weakness. Fourth, the harmful impact of ‘stigma’. An important supplementary healing resource for grief is having emotional support from family and/or friends. However, since there is a stigma attached to ‘weakness’ and a stigma
attached to having a ‘mental illness’, people grieving beyond two weeks may be reluctant to reveal they are still grieving. They may deny they are still grieving and conceal it, so depriving themselves of the essential healing support network, plus ‘bottling up’ their grief can only delay and even further complicate, the healing process.
Stigma is caused by misunderstanding, misrepresentation, ignorance and a desire to separate or distance ourselves from what we fear or do not understand. Pathologising or medicalising what is ‘normal’ does nothing to empower ‘patients’ or facilitate understanding by society. Instead, it disempowers the ‘patient’ and prevents understanding which contributes to fear and distancing by society. However, the truth is that there is no ‘us’ and ‘them’ - given the right (or wrong) circumstances such as experiencing a major loss or a set of chronic or acute adverse life events, plus lack of support and ‘no light at the end of the tunnel’ and feeling powerless to change the situation - anyone can be vulnerable to experiencing grief or an episode of non-endogenous depression. This is ‘normal’ and ‘natural’, not to be feared and not to be regarded as a stigma.
Types of depression
There are two basic types of depression: Endogenous or biological depression, which includes ‘melancholia’, ‘bipolar‘ and ‘psychotic depression’, accounting for about ten percent of depression cases. The other ninety percent of cases are non-endogenous depression, which is regarded as psychological or psycho-social. This may be sub-typed as ‘reactive’ (to depressogenic life circumstances) or by personality type or cognitive style (which are regarded as being more predisposed to a reaction to depressogenic life circumstances).
Depression is considered to be hereditary, with ‘family history’ of depression being regarded as evidence. There may be a genetic predisposition to endogenous depression. However, what is more likely ‘inherited’ when there is family history of non-endogenous depression is role modelling of learned dysfunctional thinking and ineffective coping styles or a history of
unresolved emotional issues or adverse life circumstances - or a talent for getting into or creating messy relationships and life situations.
Although there is considered to be evidence of qualitatively different subtypes of depression, consensus on this view is lacking. The opposing view is that melancholia and non-endogenous depression are expressions of ‘severity’, on opposite ends on a continuum of the same condition. Melancholia is regarded as ‘severe depression’ and non-endogenous depression regarded as a ‘milder’ form. However, among those who support this ‘dimensional’ view, there is also an absence of consensus. Those who support a ‘biological’ or ‘medical’ model of depression regard all depression as ‘biological’, and accordingly, advocate physical treatments such as drugs and ECT. On the other hand, there are others who believe that melancholia and non-endogenous depression have their underlying causes in psychological and/or situational factors, so some form of psychological therapy is preferred. In support of this view, the first episode of melancholia is generally precipitated by life events and later episodes often triggered by life stressors.
Post natal Depression:
Is post natal depression endogenous or non-endogenous? Undoubtedly there is a role of neurotransmitters and perhaps hormonal changes interfere with this balance. However, my clinical experience is that there is generally some pre-existing psychological issue or emotional problem or unresolved childhood stuff that the woman has been coping with relatively successfully. With the birth, the combination of biochemical changes and challenges of changed life circumstances may overwhelm her normal coping mechanisms, precipitating an episode of depression.
Young fathers may also be at risk of post natal depression, particularly if they have a sensitive or anxious personality style and perceive their partner to not be coping very well with the new baby. With the focus generally being on the new mother, vulnerability of a new father may be overlooked. He is unlikely to speak up because he is supposed to be strong and
supportive for his partner. Male brains are hardwired to be the ‘problem solvers’ but if their partner has post natal depression, they cannot provide a solution that will resolve her depression, but that does not stop them feeling they are inadequate and failing her.
Theoretical perspectives on non-endogenous depression
Medical Model of Depression:
The view of a ‘medical model’ of depression (both endogenous and non-endogenous) is that depression is caused by lack of or
insufficient available neurotransmitters (such as serotonin) involved in mood regulation. This rationale is based on the effect of anti-depressant medication in alleviating depressed mood by a process of making the serotonin more available in nerve synapses in the brain.
However, this simplistic model fails to address the aetiology back far enough to ask the questions: What causes the deficit in available serotonin? For non-endogenous depression, what role do psychological factors play? Research has demonstrated that for depressed patients who improve after some form of psychotherapy - without intervention by anti-depressant medication - neurotransmitter function returns to normal (Antonuccio & DeNelsky, 1995). So, for non-endogenous depression, what causes the deficit in neurotransmitter function? Mainstream medicine acknowledges the impact depressogenic circumstances has in precipitating a depression episode and also acknowledges the impact stress has on neurotransmitters such as adrenaline and cortisone in the body. Hence, it isn’t all that much of a stretch to consider that severe or prolonged stress of depressogenic life circumstances can interfere with function of other neurotransmitters such as serotonin. Therefore, for satisfactory recovery, these life circumstances need to be addressed.
Oddly, when depressed patients recover without receiving treatment, the medical explanation is that the depressive episode ‘ran its course’ or went into ‘spontaneous remission’ which happened as if by magic - or dismissed as the patient having ‘not really been clinically depressed’ in the first place. Oddly again, although there is some recognition that low self esteem, negative thinking style and attitudes increase risk of depression and that depressogenic circumstances play a role in
precipitating non-endogenous depression, there is failure to acknowledge that changes in these factors occurring, even without medication, can lead to recovery. However, when ‘spontaneous remission’ occurs, one of the reasons is
that the depressogenic situation has resolved itself. Alternatively, the patient has taken control of their life by confronting and resolving the situation or had a ‘light bulb’ experience of awareness which has resulted in change in attitude and regaining a sense of empowerment (followed by making necessary life changes).
Personality and Cognitive models of Depression:
Negative cognitive style in interpreting events, while not seen as causal, is regarded as a ‘risk factor’, considered to increase vulnerability when stressful life events occur. While personality type (eg, anxious-worrier, hostile) and cognitive models of
depression are generally approached from different perspectives, any differences are merely in the labelling. Personality types reflect cognitive style in interpreting life events and coping styles, which can all generally be identified as having their origins in learning from childhood experiences and circumstances. For example, if during childhood, nothing much positive ever
happened but there were distressing or catastrophic circumstances in which the child felt powerless and unsupported, then it is hardly surprising if that child grew up to view life stressors with anxiety or hopelessness and has negative expectations.
Alternatively, these experiences may also foster development of resilience and inner strength, which may serve as protective factors against depression. Hence, having negative expectations or an anxious-worrier personality does not mean that an episode of depression during the lifetime is inevitable.
Personality is regarded as part temperament (genetic) and part childhood environment (learning) and it is likely that it is the learned component that is responsible for ‘vulnerability’ for depression - or getting into depressogenic circumstances. An illustrative example is ‘atypical depression’. This is associated with a personality characterised by ‘interpersonal rejection sensitivity’ which reflects early childhood experiences of emotional deprivation or maternal rejection (whether real or imagined).
Another view is that depression is a response to negative life events (Yapko, 2001). This view also accounts for non-endogenous depression that recurs. In the medical model, the view is that depression is a lifelong disorder which merely goes into remission after treatment, and recurrence is inherent in the nature of the condition. While this is true for biological
depression, it is not necessarily the case for psychological depression. In the ‘response’ account, it is the nature of life events that is recurrent (rather than depression itself). Hence, if a person has a depression response when negative events occur - and negative events are likely to recur - then depression will be recurrent. (All the more reason to target the vulnerability factors in therapy in order to reduce likelihood of the depression response).
'Outside the Square" #1: Psychological Pain Paradigm:
For a different ‘outside the box’ perspective, I think of depression as a ‘psychological pain’. This plays a role analogous to that of physical pain which is a warning that there is an injury or malfunction in the body that needs attending to (ie, diagnosis and treatment). Likewise, ‘psychological pain’ (depression) is a warning that there is some malfunction in the psyche, in attitudes, coping style or life situation that needs identifying and changing. According to this Triple P (Psychological Pain Paradigm) Model of non-endogenous depression, anti-depressant medication is equivalent to an analgaesic medication and while it eases the pain of depressive mood and enables the patient to continue functioning at work, it does not address the cause of the depression and will not bring about complete recovery.
When medical practitioners prescribe an antidepressant medication (psychological analgaesic), they also need to refer patients to a therapist to address the underlying psychological causal factors. To ignore the need for psychological treatment is
equivalent to simply just prescribing an analgaesic medication to a patient who presents with severe or chronic mystery pain - without carrying out a physical examination or diagnostic tests to identify the cause (eg, fracture, rupture, infection, cancer) and then treating the physical condition responsible for the pain. This would be regarded as medical negligence and if a doctor simply provided an analgaesic to a patient without further examination and tests – and the patient died from a ruptured appendix or a malignant tumour was inoperable by the time it was later identified - that doctor would be sued.
Yet, medical practitioners consistently engage in this kind of negligence when prescribing antidepressant medication for treating depression. Many rely on the psychological analgaesic they prescribe and ignore their patient’s need for therapy to address the underlying childhood factors that have created the vulnerability and the current psycho-social factors that have precipitated the current episode. If a doctor can be sued for failing to identify a medical condition that later results in
death of the patient, can a doctor be sued for ignoring or failing to identify a role of psycho-social factors and refer a depressed patient for psychotherapy - who later commits suicide?
Depression is really just a symptom (or a syndrome of symptoms) of the underlying psychological factors that are the real problem. If the psychological factors are not addressed in treatment, then even if medication alleviates the symptoms (ie, mood) sufficient to function at work, the patient has not really recovered and is at risk of future episodes. When the psychological factors are addressed successfully, then the patient is better equipped to cope with future stressful circumstances with reduced risk of recurrent depression.
However, in general, medication is the first line of treatment chosen by medical practitioners. This is in accordance with the 'medical model' of depression which has a treatment approach of ongoing ‘management’ of the symptoms, without expectations of a cure. Patients are referred on for psychotherapy as a ‘second line’ treatment only as a last resort when medication fails to achieve satisfactory results. Alternatively, patients may request a referral or those who prefer natural or alternative treatments will voluntarily seek out a therapist via the ‘yellow pages’ or ‘google’.
Hard-line advocates of antidepressant medication who believe exclusively in the ‘medical model’ of depression tend to be dismissive of the efficacy of psychotherapy. They claim that any benefits to the patient are simply a temporary ‘placebo’ effect and nothing more than the benefit from having a chat and a cup of tea with a supportive friend. Yet, due to the plasticity of
the brain, a skilled therapist, using an appropriate therapy on a co-operative client, can achieve real psychological change. Cozolino, in his book, “The neuroscience of psychotherapy” (2002) has provided evidence of new nerve pathways being created after successful psychotherapy.
'Outside the Square' #2: Child Ego States:
A ‘thinking-outside-the-square’ definition of depression: Child Ego States in the subconscious mind crying out in pain, crying out to be heard and comforted or adult ego states crying out ‘enough is enough’. Risk factors generally consist of issues associated with negative self beliefs and dysfunctional coping style that have been learned during childhood and/or unresolved emotional issues or trauma. These issues are represented by Child Ego States. The good news is that because of the plasticity of the brain, what has been learned is amenable to modification and what is unresolved can be resolved. Much of the dysfunctional learned material will relate to role modelling by parents and ALIAS needs being unmet, while unresolved emotional issues will mainly relate to ALIAS needs that have been unmet or violated. (Refer: "Self Esteem Parenting").
Some comments on depression
‘Absurdities’ of remission and recurrence:
Let’s examine this odd view that even non-endogenous depression is a lifelong mental disease, and when an episode
comes to an end, the depression is not regarded as being cured but merely in remission. Hence, any subsequent episodes are regarded as a recurrence of the original onset of depression. This recurrence is oddly used as evidence of the ongoing, lifelong nature of depression.
Why is this rationale not applied to colds and ‘flu? People generally have a ‘head cold’ and/or ‘flu several or many times during their life, some even as often as every year. Yet, there is no medical claim that when patients ‘recover’ from a cold or
a bout of ‘flu, they haven’t actually recovered, but merely gone into remission until the condition recurs - next time.
To illustrate the absurdity: Little Jason has his first nasty cold that has kept him in bed with a fever and runny nose. He has now ‘recovered’ and is up and running around again, the ‘picture of health’. The doctor does not say to the mother,
“Little Jason may appear to have ‘recovered’ from his cold, but he hasn’t actually. The medical reality is that the cold he was suffering from last week is a lifelong disease which has merely gone into remission for now until it recurs - because colds and
‘flu are recurrent by nature”.
It will probably be argued that different strains of ‘flu would challenge my facetious suggestion that colds and ‘flu would qualify as lifelong conditions when applying the same diagnostic criteria as is applied to depression. The answer to that challenge is that the precipitating events for each episode of depression are generally also different.
Who is at risk:
In spite of research that focuses on identifying who is most likely to experience at least one episode of depression during their life time, the fact is that, given the right (or wrong) circumstances (eg, feeling trapped, powerless, hopeless, experiencing major or multiple losses), anyone can experience non-endogenous depression. Anyone with unresolved emotional issues (from childhood or as an adult) such as emotional deprivation, anger, guilt, shame, grief (complicated by anger, resentment, guilt, regrets), abortions (associated grief, shame, guilt, anger, regret) has the potential to experience an episode of depression during their lifetime. Am I trying to scare everyone? No. I am merely illustrating that there is no ‘us’ and ‘them’.
Risk may be increased by dysfunctional coping styles (reflected in personality sub-types of depression and mainly learned from parental role models) and/or negative attitudes and low self esteem (reflecting unmet ALIAS needs during childhood) or taking on excessive responsibilities long term whilst ignoring one’s own needs. Risk is increased even more by ALIAS needs being violated during childhood which may have resulted in unresolved issues such as repressed anger and emotional pain of traumatic memories which are brought to the surface by later circumstances. Depending on severity of impaired capacity to live a happy and fulfilling life and other (ameliorating or exacerbating) factors in a person’s life, any of the conditions described in "Child Needs Unmet" have the potential (but not inevitability) to create vulnerability resulting in depression. While ‘risk’ does denote a vulnerability, it only represents a statistical probability, not an inevitability.
It is not necessarily a catastrophic event that precipitates the eventual episode of depression but often is the cumulative effects over time, gradually undermining the individual’s psychological coping resources. Then, a relatively
minor event may be the ‘last straw that breaks the camel’s back’. Conversely, depression can be triggered by a single catastrophic event if the individual has had a pretty smooth ride in life, with virtually no previous experience at
dealing with devastation or hardship to develop resilience. Coping can be regarded as a learned response, learning from observing parents dealing with the ups and downs of life plus learning from the ‘tests’ of personal experience. Hence, throughout childhood and adolescence, resilience can develop via a cumulative acquisition of coping resources and strategies that continues as an adult. If parents have protected their children from exposure to life’s knocks (in the erroneous belief
that this was in the best interests of the children), they have also denied their children the opportunities to develop resilience and learn how to cope. Then, when they may be confronted with one of life’s ‘knocks’ - and cannot be protected by the parents or anyone else - they are ill equipped to deal with it effectively and may be at risk of depression.
Role of dreams:
Australian research reveals that almost 16% of people have dreams that cause them to wake in fright, on a regular basis. An attempt has been made to attribute an adaptive function to these nightmares. One theory is that trauma-related dreams with ‘general’ themes (such as being chased) produce ‘threat stimulation’ which would give the person a ‘slight edge’ if they were to experience the same threat in real life. Another theory is that nightmares are used to extinguish childhood fears. (Is this just another example of cuckoo research conducted with tax payer funding?)
I doubt that either of these theories has any basis in fact. They are contradicted by the nightmare flashbacks experienced by victims of real life trauma. I don’t think any one has claimed that these nightmares play any role in
‘extinguishing the fear’ of the trauma - rather, they are an exacerbating feature of the ongoing trauma. I don’t think anyone who has ever had some form of traumatic experience has ever reported, “Hey, I’m fine, I coped with that traumatic event pretty well and I attribute that to having an ‘edge’ because I have been getting plenty of practice dreaming about this exact same traumatic event for ages prior to it actually happening”.
Using common sense (at no cost to tax payers), it is more likely that the function of these dreams is communication between the subconscious mind and the conscious mind, since during sleep is the time when the ability of the conscious
mind to block out the subconscious messages is shut down.
Just as there are numerous means of communication in the real world, the subconscious and higher conscious minds also have various means of communicating with the conscious mind. If they are in harmony, then communication is received
by the conscious mind as ‘intuition’. However, there may be inner conflicts when emotional or traumatic experiences are just buried deep in the subconscious mind instead of being faced and resolved. My personal and clinical experience is that
recurring nightmares with a common theme are the subconscious mind trying to bring these buried issues to conscious attention so they can be addressed and resolved. This would also apply to trauma-related nightmares with general themes. Rather than regard them as practice which will result in being better prepared for coping with traumatic events that might
occur, they more likely reflect a generalised anxiety and the dreamer would benefit from therapy to address this issue. Likewise for children. If their fear-based dreams are the result of real-life experiences, they need professional help to resolve these fears but if the fears just reflect anxiety or underlying insecurity, these issues also need to be addressed with the child.
There is also the possibility that a very small minority of such dreams can be pre-cognitive, warning of a future event that does actually take place, but its purpose would be to provide a warning so that steps can be taken to avoid (or prepare if the event were unavoidable) rather than practice to provide an ‘edge’ when it actually happened.
One difficulty with dreams as communication from the subconscious mind is that often they are in symbols that may not be readily interpreted, just like sending a coded message but the receiver doesn’t have the key to understanding the code. A common example is a ‘house’ representing the ‘self’, with different rooms representing aspects of self and condition of the house reflecting state of physical health or emotional issues. For example, under the house (basement or cellar) represents the subconscious mind, the kitchen where food is prepared represents nurturing, while a broken or blocked toilet represents inability to resolve and release emotional waste. Another difficulty for the subconscious mind communicating with dreams is that even if the dreamer can interpret the dream and acknowledge that some issue needs resolving – they can still ignore
the need to take action. After a period of repeated ignoring of the message in the recurring dream, the subconscious mind adopts the next line of communication, via the physical body. This results in psychosomatic symptoms (such as a skin rash), which cannot be ignored, but again, they are not easily interpreted except to use the catchall of ‘stress-related’.
What happens if the individual continues to ignore the dreams and the psychosomatic symptoms and fails to address the issues which have been buried in the subconscious mind? The next line of communication ultimately is likely to be
depression - a shutting down that can’t be ignored. However, the unresolved issues can still be ignored if the depressed individual chooses to just take medication to dull the pain and avoid addressing the ‘real’ problem. The implication is that given the high rates of mental health issues such as anxiety disorders and depression, recurring nightmares should not simply be ignored but the message in them should be heeded.
Why would the subconscious mind resort to communication with dream symbols and physical symptoms after intuition has failed? Language is a relatively new development in the evolution of the human brain while symbolism is much older. Jung has described universal archetypes in symbols. Louisa Hay (1984) has observed links between unresolved emotional issues and physical ailments and areas of the body where they occur.
As we come to rely more on speech and the written word, older systems of communication become redundant. They are not obsolete, but simply, we have ‘forgotten’ the key to decode them. Likewise, when archaeologists find the artefacts from ancient civilisations, they have difficulty in interpreting writing and symbols of a lost language. However, for recurring dreams, the good news is that they are a useful diagnostic tool for psychotherapists who choose to use them.
Medication is the first line of treatment and if a person is severely depressed and has to continue to function and hold down a job, then it is appropriate to take an antidepressant to help alleviate the depressed mood. For endogenous depressions,
medication will be necessary, and in severe cases, even electroconvulsive therapy (ECT) may be beneficial. However, for non-endogenous depression, I still regard medication as treating only the symptomatic psychological pain. To achieve real
improvement and reduce risk of recurrence requires some form of psychotherapy to address the real problems which are the underlying psychological risk factors and the specific factors that contributed to precipitation of the depression episode. I believe in the importance of focussing therapy on the origins of the vulnerability factorswhich may be dysfunctional beliefs or the learned component of personality, so that we are assisting clients to rebuild stronger, more secure psychological
foundations and foster resilience.
A ‘thinking-outside-the-square’ definition of depression: Child Ego States in the subconscious mind crying out in pain, crying out to be heard and comforted or adult ego states crying out ‘enough is enough’. Risk factors generally consist of issues associated with negative self beliefs and dysfunctional coping style that have been learned during childhood and/or
unresolved emotional issues or trauma. These issues are represented by Child Ego States. The good news is that because of the plasticity of the brain, what has been learned is amenable to modification and what is unresolved can be resolved.
Much of the dysfunctional learned material will relate to role modelling by parents and ALIAS needs being unmet, while unresolved emotional issues will mainly relate to ALIAS needs that have been unmet or violated.
While I have been discussing non-endogenous depression, psychological risk factors also have relevance for endogenous depression types. These patients are just as likely to have stressful life circumstances which may contribute to
triggering episodes of depression, mania or psychosis. They may also have learned dysfunctional coping styles and unresolved emotional issues that can exacerbate the episode. Hence, they may also benefit from psychotherapy. (Caution: Psychotherapy is recommended - and possible - only when the patient is not experiencing a manic or psychotic episode).
Conclusion: Depression is not all bad
"No pain - no gain"! Perhaps surprisingly, some people who have been through an episode of depression describe the experience in positive terms, expressing appreciation for what they gained from it. While the experience was one of suffering in their private hell, the outcome can be a sense of empowerment and personal and spiritual growth. They also find they have access to reserves of strength and resilience they hadn't realised they possessed. While in this place, alone, where no one else can come and share, it is a time for reflection, self examination and facing up to what needs changing. The individual experiences an attitudinal change, reassesses what is important in their life and feels empowered to take (or take back) control of their life. This also requires courage since often becoming empowered and making changes can be upsetting to those around who were quite happy with the old situation and may feel threatened by changes.
I do wonder if medication interferes with this process of self examination and growth? I say that pain can be the instigator of change. However, if there is a pill to dull the pain of depression so that an untenable or intolerable situation can be tolerated, it can then enable the depressed individual to ignore what needs to be faced, addressed and changed. The downside of reliance on medication as an easy option is that there is no motivation to change and instead there is a missed opportunity to grow.
Antonuccio, D. O., & DeNelsky, G.Y., “Psychotherapy versus medication for depression: challenging conventional wisdom”. Professional Psychology: Research and Practice 1995; 26(6): 574-585.
Cozolino, L., “The neuroscience of psychotherapy”, W.W. Norton & York (2002).
Watkins, John G., and Watkins, Helen H., “Ego States Theory and Therapy”, W. W. Norton and Company, New York
Yapko, M. D., “Treating depression with hypnosis”. Philadelphia, PA: Brunner-Routledge, (2001).