Depression is a tricky customer. It seems as intrinsic a part of Western society as the flu. It is widely written and spoken about in the media and everyday life.  According to the Mental Health Foundation, in 2014, 19.7% of adults showed symptoms of anxiety or depression - a 1.5% increase from 2013. However, depression means different things to different people. It can mean a low mood that doesn’t impede normal functioning. A situation can be described as depressing. The Diagnostic and Statistical Manual (DSM) defines clinical depression, when leaving bed is impossible. Just as there are different experiences of feeling depressed, so there are different causes and different ways of dealing with it. Nevertheless, some symptoms which are common to depression are:

• Low mood
• Tiredness
• Insomnia
• Loss of appetite
• Feelings of hopelessness and helplessness
• Feelings of guilt
• Difficulty concentrating and deciding
• No longer enjoying activities which used to be pleasurable
• Low self-esteem

Unfortunately, it not possible to wrap the cause and cure of depression up into a neat little package. Nevertheless, there are certain common themes that are worthwhile to explore in therapy. Just as there are common depression symptoms, from my clinical experience depressed people share certain creative adjustments in common. ‘Creative adjustment’ is a Gestalt therapy term which means a way that an individual has adapted to cope with a particular situation in their early development, which may no longer serve them in the present. In the rest of this article I’m going to look at four common features: the critical voice, the relationship with anger, boundaries, and the fear of failure

The critical voice

This is the inner self-talk that most of us experience to varying degrees. It can be the voice that tells us we look too fat in what we’re wearing, that the person we’re talking to at a party doesn’t like us, that we could never write a novel, that we’re failing as a parent. These are critical statements that make us feel bad and lose energy. They never work to motivate us in a helpful way. Sometimes we have taken this critical voice on from a strict parent or authority figure. With a depressed client, the critical voice is particularly sadistic and punishing. When I invite depressed clients to vocalise the critical voice I get a sense of it wielding a huge amount of power. It seems to relish beating my client down like an inner tyrant running amok. It tells my client that they are useless, taking up unnecessary space on the earth, that the world would be better off if they didn’t exist, and so it goes on……It is constantly present, whether the individual is alone or in company when it judges how badly they are coming across to the other. People describe feeling exhausted by this vicious critical voice. Simply by gaining clearer awareness of its existence through therapy can already be a first step in regaining some power over it.

Relationship with Anger

What’s often missing in these intrapsychic dynamics described above is anger. Gestalt therapists sometimes invite the client to do “two-chair work”. This is a way to work with intrapsychic conflict. If there is a critical voice, then there is another part of the individual that is sick and tired of the critical voice. However, for some clients, the critical voice seems like the only part they are in touch with. In “two-chair” the client is invited to reply back to the critical voice. For someone who is not depressed they may reply to the critical voice with something like, “hey, leave me alone. Stop bullying me. What’s your problem? How dare you say that to me? I’m fine just as I am”. This would be a healthy response to a bully. However, some depressed clients do not experience any anger at all towards their critical voice, they just go along with it and agree.

As a therapist, this always interests me. One of the purposes and benefits of feeling angry is to protect oneself and to assert one’s boundaries.  I become curious if a client finds it difficult to own or express anger. I begin to wonder what happens to the anger they feel. After being angry is part of being human. However, those who view anger as something ‘bad’, ‘negative’ or ‘unhealthy’ tend to have a difficult relationship with it. In my experience, there is often a link between feeling depressed and having unhealthy beliefs around anger which prevent its expression. An unhealthy belief can be, “I can only be angry if it is justified’, or “if I get angry I will really hurt/lose the person love’. Often these beliefs go back to childhood. If one had a bullying parent, then one couldn’t get angry back for fear of retribution so we learn to swallow our anger. Another commonly held belief is that “there is no point getting angry, getting angry doesn’t get me anywhere”. As a child, this may well have been the case. I think of a baby crying in its cot to get attention. If the parents do not attend to it, eventually it will cry itself out and experience itself as powerless. I often see depressed clients who are the nicest and most compassionate souls when it comes to others but harshly angry towards themselves. I point out that all their angry feelings seem to be directed in only one way, towards themselves. If it didn’t feel safe enough to express anger at the person for whom it was meant, then because the underlying need in the anger has not been met it cannot dissipate. Instead, it boomerangs back onto ourselves.

The therapeutic work is then about developing compassion for that young part of us that felt angry because a need wasn’t’ met. It’s about understanding what the need was. It’s also about understanding what our needs are now. Often depressed clients find it difficult to get in touch with their needs as they are more used to suppressing them. In therapy, we work to develop support for the client to risk getting angry and asking for what they need without the fear of recrimination.

It can feel very scary to step into a different way of doing things and clients often needs lots of support and going slow. Support can include many things. As well as using Gestalt therapy principles and interventions, I also recommend other books that might help. A useful framework to understand more about why we may have difficulties with anger is schema therapy. 

. A book which clients have found useful is “Reinventing Your Life: The Breakthrough Program To End Negative Behaviour And Feel Great Again” by Jeffrey E Young.

In part two of this blog, tomorrow, I will discuss the remaining two common features of depression which are 1) boundaries, and 2) fear of failure.

If you have found this article useful then please share it with someone. If it has stimulated your interest in working with me then feel free to call me or text for an informal chat or to book an assessment session. I also look forward to reading any comments you have.

Warmest wishes,

Alexandra Stevens