And even worse:
"I despise myself. I am truly worthless. I have been a
burden to everyone. I hurt people. I don't deserve to live."
Some get back to sleep after an hour or two of tossing and turning. Others start
their day at this early hour filled with dread. Showering, dressing,
preparing breakfast (if they're able to eat at all) take monumental
effort. "Keep going" they tell themselves, trying to complete
simple activities that most never think twice about. Finally, in an act of
incredible courage, they push themselves out the door and start off to work,
struggling against emotional headwinds that make every step an exercise of
will.
The prevalence of depression in the United States is alarming. According to Nemeroff (1998) (from The Neurobiology of Depression ), "5 to 12 percent of men and 10 to 20 percent of women in the U.S. will suffer from a major depressive episode at some time in their life (and) roughly half of these individuals will become depressed more than once." And these statistics do no include incidences of the less severe but lingering depression known as dysthymia.
What causes depression? Is it a biological disorder caused by neurotransmitter or hormonal imbalances? The logical consequence of faulty or pessimistic thinking? Or the inevitable outcome of childhood trauma? A whole book could be devoted to this topic, and the answer would still not be clear. The problem is that the three explanations are interrelated, and, perhaps none, alone, are completely adequate. Consider the following:
| Nemeroff reports that early emotional trauma has important and lasting neurobiological effects (at least in other species). |
| Perceived inability to manage current threats affects neurotransmitter functioning (see Albert Bandura's (1995) book: Self Efficacy: The Exercise of Control [W.H. Freeman, New York]. |
| Pessimistic thinking although "faulty" when applied to current situations, may not have been "faulty" during childhood, within the context of a dysfunctional family. |
| Studies of identical twins separated at birth suggest that genetics play a role in depression, but don't tell the whole story. |
| One child from a dysfunctional family may experience severe depression, while another remains untouched. |
If this seems challenging or confusing, it is. In the depression flow chart, the arrows point in almost all directions.
Still the suffering remains. While I have no answer to the big question of causality (although I suspect all three "explanations" play a role in many depressions), there is one observation that I would like to pass along from my years of treating depression. That is: many chronically depressed clients I have worked with have had a childhood marked by the absence of voice, or what I call "voicelessness."
What is "voice?" It is the sense of agency that makes us confident that we will be heard, and that we will impact our environment. Exceptional parents grant a child a voice equal to theirs the day that child is born. And they respect that voice as much as they respect their own. How does a parent provide this gift? By following three "rules":
(See "Giving Your Child Voice" (link below) for more. You may want to consider your own personal history to see whether your parents followed these "rules".)
What happens when a child's feelings, thoughts, wishes, and interests are never heard? He or she feels worthless, non-existent, and incapable of having an effect on the world. A child without voice has no license to live. These feelings don't go away as a child get older, instead they go underground, replaced by eating disorders, acting out, painful shyness, or sometimes over-responsibility (a child acting like an adult).
Nor do the feelings go away when a child reaches adulthood. Maintaining
a sense of self and agency is necessary for our emotional well being. But for
adults who grew up voiceless, this sense is very fragile. Without "voice" people are prone to feeling hopeless and helpless.
Often,
the voiceless have no "place"
of their own; instead they
struggle to anchor themselves in other people's worlds. Unconsciously,
many try to use relationships to address old wounds and repair their "self." Some try to inflate themselves like
blowfish in order
to feel secure and consequential (see Voicelessness: Narcissism, below).
Others search endlessly for powerful partners who will validate their existence
(see Why Do Some People Choose One Bad Relationship After Another?) or
twist themselves like a pretzel in order to fit into another person's world (see Little
Voices). At times these (and other) unconscious strategies succeed, but the satisfaction is rarely lasting.
In everyone's life, situations occur that threaten our sense of agency (facing
death is a prime example). But the "voiceless" have no ground
floor, nothing or no one to catch them--the thought: "yes, but I am a
good and valuable person" provides no safety net. An
event usually occurs (a loss, betrayal, rejection, etc.) which re-opens the
childhood wound and sends them tumbling into a bottomless pit.
Aloneness contributes to the problem. Because the emotional injury is well
concealed, people do not understand. "You have family/friends, a good job," they say. "People care
about you. You have no reason to feel this way." But the depressed person has good
reason even if they can't verbalize it or see it themselves: a history of
childhood "voicelessness."
If depression is, in part, a "voice disorder" then psychotherapy should help. And, in fact, it does (see,
for example, The Effectiveness of
Psychotherapy--The Consumer Reports Study by Martin E. P. Seligman).
For some, correcting the faulty/pessimistic thoughts (e.g. I am a worthless
person; I have no control over my life) is enough. Cognitive behavior therapy efficiently serves
this purpose. Others find it important to understand the historical reasons for the absence of
"voice" and the roots of their helplessness. They want to know
why they struggle, and to understand how their voicelessness has
affected their relationships. And, of course, they want to
re-find their missing "voice." This is the realm of
psychotherapy. The work of therapy does not occur in five sessions as the insurance companies would like consumers
to believe. A client's voice emerges slowly in the context of a relationship with a
caring therapist, often with the analgesic aid of medication. The
therapist's job is to explain self-destructive thinking in the context of
personal history, find the
client's true voice, nurture it, and help it grow so that it can withstand the
challenges of life. Once
developed and applied to relationships and work, voice can be a powerful and
lasting anti-depressant.
