Blog

In my earlier blogs I stated that there are many different causes, or pathways, that lead to depression. The goal of this brief commentary is to focus on the role anger and aggression play in keeping the depressed mental state alive. The emphasis will be on a few different  ways that anger and aggression directly impact one’s mood.

What Causes Depression? Relationship Dissatisfaction

Depression can sometimes be triggered by a traumatic event such as the death of a loved one, a break-up or divorce or any abrupt and unanticipated changed circumstance. However, the emotional reality is not the pain of feeling alone and abandoned because the individual does not actually accept the loss. Unlike many people who suffer a devastating loss, the fact that something is over, or has permanently changed, is not mourned. Instead, the feeling (which may or may not be conscious) is that someone took something away from me, and therefore they, or someone, has to pay.

Having someone to attack, for one thing or another, is all that seems to matter.  If there was a good and satisfying relationship the constant stimulation from the blaming and attacking would eventually melt away. This good relationship, or pleasure in life, is a problem because it would allow one to slow down. If one slows down, they may begin to feel sorrow, pain or loss. A healthy and good relationship poses a real threat, and therefore must be avoided at all costs. If there is a good relationship this model I am describing would begin to break down.

One way to ensure relationship dissatisfaction is to let those who are closest to you know that you are suffering. It is not enough, however, to just let them know you are in pain, you must remind them constantly and continuously.  More importantly, it needs to be made clear that there is nothing they can say, no advice they can give, or support they can offer that can ameliorate the suffering. The goal, which is not consciously intended, is to upset or frustrate the other person in an attempt to make them feel responsible for your suffering.

Anger and its Link to an Empty Feeling

Another way to punish someone is to be critical, devalue, and diminish them. This can play out internally (in one’s mind) or one may behave overtly aggressive. When you criticize and devalue a loved one, or in many situations anything of value, such as a compliment, a promotion, or a piece of advice, the important people around you begin to lose their status and value. In fact, everything, the compliments, advice, promotion, etc. all begin to lose their value. These devaluations and attacks have very serious consequences on one’s self-esteem. For instance, if you devalue your job, or partner, your own self-representation as someone connected to a devalued job/other can leave you feeling like a failure and in turn this increases the depression.

When one attacks and devalues in this aggressive way, and denigrates anything of value, this ensures the destruction of any possibility for love and connection. If this vicious cycle of attack, denigration, judgement, and criticism is not broken you can be left with an inner world devoid of meaningful, valued, and loving emotions. It is not uncommon, in fact, that I hear many depressed patients complain of an incredibly painful and visceral feeling that something is missing, there is a void of some sort, they tell me, as they point to the empty space they feel in their chest or upper stomach.

A Basic Example:

In order to protect the identity and anonymity of my patients I will not talk about any one patient experience. The following example describes a composite of several patient’s issues.

Let’s say, for instance, a male patient of mine experiences a loss or defeat of some kind. Over the preceding months, and sometimes years in a prior psychotherapy treatment, he can’t seem to put this to rest. One may hear from this person that he is all alone, nobody is there for him, and he expresses this misery in many different ways as he becomes sullen, pouty, and withdrawn.  Even though he is withdrawn and depressed, appearing to not want to engage, this person may actually not want to suffer alone and would love it if someone, preferably the person who he feels hurt him, would suffer alongside of him. If he is suffering, someone should be suffering too. The thought and intent are not conscious, but just below the surface he is saying to me, in his suffering, nobody can help me, why doesn’t someone make me feel better, what is wrong with you, or you are useless to me.

There are many different meanings and reasons one becomes depressed and goes on the attack, that is why talking to someone who is highly trained and has extensive experience working with these complicated inner dynamics is incredibly important to the healing process.

What is Causing my Depression – A Few More Dynamics

There is so much more that can be said about this prototypical patient, such as his unique way of feeling loved and not alone when he creates a fight, how he needs to fight in this way because it recreates an aspect of his childhood experience of an emotionally unavailable caregiver, and how the fight and suffering defends against the greater pain of loss.  Space constraints will not allow us to go into each of these dynamics, but we can see how getting angry and critical prevents and distracts him from dealing with and thinking about that which was initially lost (and all of what it means to him that something is lost forever). These things get complicated BUT lasting change is possible when one can, over time, work through and put to rest each of these dynamics.

Wrapping it Up

In my work with depressed patients the main goal is to help them begin to examine and think about what they are feeling.  The fact that one is depressed indicates that while they know something is wrong, they are not yet able to deal with the feelings that are causing the depression. In other words, rather than deal with the feelings and solve the problem, for instance, some depressed patients will get angry and critical. It is far more complicated and requires more technical tact when the anger comes out indirectly in the form of pouting, whining, and complaining about how most things in life are of little value. With this in mind, the first treatment step is “containment,” which means I have to help this kind of patient express his anger more directly. Once expressed, containing and detoxifying the anger has very valuable consequences. Containment does not mean sitting around passively listening to all of the complaints. This act of containment, an active way of working with these patients, is so important that it will require its own separate article, which will be coming soon.

If you or someone you know suffers with this kind of angry depression it is important to keep in mind that the depression, anger, and criticisms may be just the manifest level of the problem. More genuine and true feelings that are too overwhelming and therefore difficult to see and process are pushed away with anger and judgements. Treatment, that will have a lasting impact, allows one to get to these more complicated and painful idiosyncratic feelings. If you have any questions about this commentary or if you or someone you know suffers with this kind of angry depression, feel free to reach out.

Narcissistic deflation as a pathway to Depression

It is important to discern what is driving the depression. There are many different pathways that cause depression, which are not mutually exclusive, and a thorough assessment with careful attention to one’s history will help guide an effective treatment approach.

A few thoughts on 1 pathway:
From what I have seen in my practice a ‘narcissistic crisis’ in depression is oftentimes quietly and unconsciously at work, behind the scenes, but powerfully playing a significant role in the depression. When there is disappointment, frustration, or some kind of let down, the grandiose image one has of oneself collapses, and depression may be a response.

In general, a narcissistic deflation is a state of psychic helplessness. For some, there is a pre-existing narcissistic vulnerability that leaves them incredibly vulnerable to what I would call the slights and disappointments of everyday life. These slights and everyday losses are incredibly painful, difficult to manage, and lead to feelings of intense helplessness and/or “rage” (soon I will post some thoughts on the role anger and rage play in causing depression). A simple example of this is when a couple is out socializing and she, for one reason or another, draws attention to herself. If there is NOT a pre-existing narcissistic vulnerability he can feel happy, or even proud of his partner and the attention she is receiving. However, when there is this kind of vulnerability, the only thing he can say to himself is something akin to, what is wrong with me, why is the attention not on me, why am I not admired, special, or loved.  These thoughts, as one can imagine, may leave him feeling defeated and depressed.

Depression is often linked to particular experiences of narcissistic injury and may yield to interpretation or repair of that injury.  How to repair the injury needs to be flushed out further, but we can see that the depressed individual’s method of repair, such as withdrawing from life to protect the self from further injury, on some level has positive adaptive roots. However, this mode of repair does not ameliorate but instead prolongs the suffering and depression. Therefore, we need to examine more effective ways to repair the damage.  I will do that in a later post!

If you or someone you know is struggling to manage their emotions it may be helpful to contact and talk with a qualified mental health professional.  If you have any questions about this commentary or if you would like to set up a consultation to talk about your emotional state feel free to reach out.

The goal of this brief commentary is to provide you with a better understanding of what drives depression. I wanted to put this out there now because the relationship between the coronavirus that causes COVID-19 and depression has been well documented and rates of depression have been on the rise. I would like to address just one etiological factor, loss, and the role it plays in driving up depressive symptomology.

While there are many factors that contribute to depression it seems that Covid restrictions that promote social distancing have quite a significant impact on one’s mental state. Particularly vulnerable are those who for one reason or another did not already have many existing close, intimate, enriching relations and due to the Covid restrictions, are not comfortable, or at least now have a good reason, to not develop new relationships. 

What Causes Depression and why the Heck is it Affecting ME! 

What makes someone who becomes depressed different from those who do not? This is a very complicated question with many answers. Again, for now, I will focus only on loss, and to be completely transparent, my perspective on this matter is biased by my psychodynamic training. From this perspective, one’s early upbringing plays a critical role in shaping one’s personality and who they are today. The very early relationship with significant caregivers influences how you cope with loss and isolation today. Loss can range from a death of a loved one; loss of close contact with friends or colleagues; financial insecurity; isolation from others, or loss of a sense of oneself. When things go well in early develop the loving caregiver is there to help a developing child tolerate natural and necessary losses of everyday life. At this early age loss can entail something as simple as darting away from the comfort of your caregiver (around age 2 to 3) or functioning more independently when dressing, feeding and later making one’s own decisions independent of the primary caregiver.

Emotional independence is a function of successfully mastering all the little separations and loss’ and internalizing (taking into oneself) the smiling comforting soothing capacities of the caregiver who supports each of these acts of independence. This leaves one with a stable sense of self and without this the self remains fragile and vulnerable to all subsequence losses.

If the developing child experiences a hostile or rejecting caregiver who was not sufficiently sensitive to these early separations this disrupts the capacity to take in and internalize the soothing, comforting functions that are so necessary to pull on in times of separation and loss. Alternatively, imagine a caregiver who for his or her own reasons cannot allow the child to develop a sense of independence and needs to always manage that child’s life (yes, this is what we call the ‘helicopter parent’) with excessive devotion. This too will interfere with the child’s capacity to internalize that comforting and soothing smile leaving one with a unstable sense of self.

The Unstable Sense of Self and its Relationship to Depression:

In my practice I have successfully treated many patients who came to me after having suffered with depression for many years, at times even decades. The depression, from my perspective, is not the problem, it is the outcome of the problem. As I mentioned earlier, there are many different reasons one can become depressed but at times, what I have discovered, is that repeated reactions to loss and separation often go unrecognized. These deeper feelings are hard to recognize because they are hidden away or made to disappear. In other words, compensatory actions are taken, and these actions require immediate attention but also distract from the underlying problem. There may be, for instance, a compensatory use of drugs, vaping, video gaming, over-eating, over-sleeping, withdrawal from life, etc. I have noticed that younger adults seem to be suffering more, as evidenced by increased substance use, increased engagement with mind numbing activities such as social media and video gaming, social isolation, dreams of idyllic relations, or many self-destructive behaviors that need constant attention, such as hypochondriacal symptoms – rashes, upset stomach, back aches, etc.  I will say more about this in a later commentary but all of these ‘symptoms’ are designed to not think and experience painful feeling around loss. 

Depression vs Ordinary Sadness, Disappointment, and Grief:

Why, you may be wondering, in the face of loss, doesn’t everyone become depressed. Many people have the inner resources, the inner comforting image of a caregiver, for instance, that allows them to experience disappointment, grief, and mourning, but this is not depression. This type of person has some capacity to regulate their emotions as they conjure up that image of the soothing, caring, loving figure. There is much more to be said about this, but for now I can provide a simple example. In order to protect the identity and anonymity of my patients I will not talk about any one experience or patient. The following example describes a composite of several patient issues.

Example:

Over the course of treatment Ms. A would experience frequent and severe depressive episodes. Despite her telling me that nothing had changed or caused her depressed state close exploration revealed that just recently her department at work had a going away party for an esteemed colleague of hers. She did not attend the party, claiming she was busy with work, and never did get the chance to say goodbye. As this was discussed we came to see that this fellow was indeed quite important to her and played a significant role in her professional development. I helped Ms. A give voice to that which she was not aware and was too hard to acknowledge; this colleague was important to her, and she would miss him. Over subsequence sessions further work was done around deeper emotions and she gained insight and increased awareness into an empty place in her life, a hole, she described, that she felt in her chest and stomach. Being able to work through the pain, by putting her thoughts and feelings into words, experiencing the loss was now possible.  I was able to help Ms. A maintain empathic contact with the separation and loss. I did not feel anxious or rushed to make her pain go away quickly and she therefore was able to withstand the discomfort as we worked together through painful feelings, emotions, and subsequently older memories dating back to earlier traumatic loss’ when she was a child. 

What was offered to Ms. A, and all my patients, is the talk therapy. When one can talk through and process thoughts and feelings, they can get better control over them. This puts the patient, instead of the un-thought emotions, in control.  For a deeper look at ‘un-thought’ emotions please refer to my blog post on “…How we Don’t Think.”  

Wrap Up:

In this brief commentary I have attempted to demonstrate one factor, loss, that plays a role in depression. Early relationships with important caregivers influence how one experiences loss and separation today. If you or someone you know is struggling to manage their depression it may be helpful to contact and talk with a qualified mental health professional.  If you have any questions about this commentary or if you would like to set up a consultation to talk about your emotional state feel free to reach out. 

PROVIDENCE, R.I. [Brown University] — Depression among U.S. adults persisted, and worsened, during the first year of the COVID-19 pandemic, found a new study by public health researchers at Brown University and Boston University.

Published in the journal the Lancet Regional Health – Americas, the study found that 32.8% of U.S. adults experienced elevated depressive symptoms in 2021, compared to 27.8% of adults in the early months of the pandemic in 2020, and 8.5% before the pandemic.

“Rates of depression did not decrease over time, nor did they stay the same — surprisingly, they went up,” said lead author Catherine Ettman, a doctoral candidate at Brown’s School of Public Health and chief of staff and director of strategic initiatives in the Office of the Dean at Boston University’s School of Public Health.

The most significant predictors of depressive symptoms during the pandemic were low

ResearchTrusted Source shows that people experienced increases in depressive and anxiety symptoms during February and March of 2020, at the start of the pandemic.

• Lockdowns and quarantines were associated with a 31%Trusted Source increase in new depressive symptoms, a 21%Trusted Source increase in new anxiety symptoms, and a 13%Trusted Source increase in fearful spells.

In an earlier commentary I spoke about the important and often times unrecognized role loss plays in depression. I detailed and began to discuss why some of us suffer from depression while others have a capacity to better tolerate everyday feelings of disappointment and sadness. I mentioned that the symptoms typically associated with depression are designed to not think and/or experience painful feeling around loss. Not thinking is second factor that operates behind the depressive scene so it is important to understand the role it plays.

I would now like to say a little more about thinking, and how many people wrongly believe they have a capacity to think, and ‘analyze’ their problems. Many people have ‘thoughts,’ but thoughts are not thinking. Thoughts, more often than not, are persecutory in nature, obsessive, and leave one stuck and depressed. Thoughts are often critical, or judgmental, of oneself of others, and this only leads to further problems and provides no genuine relief.

Transformation of Thoughts to Thinking: Couples Therapy

In order to protect the identity and anonymity of my patients I will not talk about any one couple’s experience. The following example of a couple in psychotherapy treatment describes a composite of many couple’s issues.

A couple comes into session appearing defeated, hopeless, and depressed. Initially they can’t talk about that which put them in this state but can only use generalizations, accusations, and express an overwhelming sense that things are hopeless. Close exploration reveals that she made a simple request, such as he clean such and such a thing in the apartment, prepare a meal, or drive her to a certain venue. He agreed to this request, but when it came time to perform the act, he got busy with work, confused about what was asked of him, or just outright forgot that he made this commitment. Her initial response was one of rage, she went on the attack and accused him of being lazy and stupid.  He felt badly, and could see how she would think this of him, and in fact admitted that often times he forgets and gets confused when she asks him to do things.

As I helped them look at this example more closely, I had in mind my psychodynamic perspective, admittedly my own bias in listening to the material. If we are to come to a more meaningful understanding of what happened in these situations, and for this understanding to have any value, it must unite with prior experiences that are scattered and forgotten. The goal is to introduce order where the appearance of disorder reigns. I want to help this couple discover, much like I do with my individual patients who come to me in distress, a new fact in their story, a fact unknown, but one that will be sure to unite past and present.

Her Contribution:

As we talk about the incident it slowly becomes clear that the he is perceived as someone who is supposed to be there for her, who is supposed to soothe, comfort, mirror and take care of her when she has a need.  This, as I discussed in my first commentary, is quite common when someone lacks that inner maternal smile. When that internalized image of the comforting caregiver is missing there is a fragile sense of self, I explained. Since one’s inner self is fragile and does not have the resources to manage emotions IF she, in this example, can control his behavior she can also control the flow of sustenance and love. She will accuse him, and call him names (judgmental thoughts) in an attempt to self-justify her behavior BUT she will not THINK about her problems as arising from within.  This is what I call not-thinking. It is only when I can help her begin to think that she can locate and begin to talk about the problem as an intense feeling of having been abandoned. However, the abandonment is not just coming from him, any longer, it gets linked up with earlier more traumatic losses that have not yet been processed because of her inability to think.  

Once she recognizes that she cannot control him, completely, the wish and hope for love and nurturance is again lost. The inability to think negates the necessity of confronting these issues and weakens the capacity to mourn the loss (of him/her primary caregiver not being there for her). As these kinds of incidents get discussed, and a capacity for thinking grows strong, one can begin to see and articulate long forgotten wishes that someone should have and should be there for her.  The past is in the present and the present is a replay of the past! 

His Contribution:

Much more will need to be said about his contribution to this ongoing struggle in a later commentary but in short, the question for him to ‘think’ about is, how is it he ‘forgot’ or got too busy to fulfill her request. How did he suddenly get too tired, or busy with work? These are the questions I would help him begin to think about, especially since there is systematic repetition in the way he does not fulfill a need of hers. Why does he initially agree to go along with the request to only later frustrate her wish and need for him to be there for her, I would help him consider. We can slowly begin to see, as he started engaging his mind in the thinking process, that he too has an image in mind. His is one of a relationship between a scolding, controlling other (again, we needed to look back at his own history with his significant caregiver) and an incompetent, weak, impotent and depressed self.

Wrapping it Up:

The work of thinking is accomplished, in part, by a trained professional who can function, and provide for the patient, an apparatus for thinking. I help this couple, through my own capacity to think with them, begin to think about their own intolerable emotional experiences.

In this brief commentary I tried to share some of my thoughts on another factor that leads to and intensifies depression. My focus was on the incapacity to think and I tried to demonstrate how this inner limitation has interpersonal consequences. My goal is to transform unprocessed and undigested emotional thoughts into thinking. If you or someone you know is struggling to manage their emotions it may be helpful to contact and talk with a qualified mental health professional.  If you have any questions about this commentary or if you would like to set up a consultation to talk about your emotional state feel free to reach out.