It is very common when I first encounter a client struggling with mental health issues that they report their problem is that they feel anxious or depressed. Here is a typical exchange:
Me: So, can you share with me what brings you in?
Client: Well, I have not been feeling good. I have these low moods that I can’t shake off. I want to stop feeling depressed.
Me: What is it that gets you feeling depressed?
Client: I don’t know. Nothing really. It just comes out of the blue. And I just wish I did not feel this way.
Then I begin to gather data about their lives, and almost always, the reason for depression (or anxiety) emerges. The most common narrative is something like the following (these elements would usually unfold over a half an hour to an hour of exploration—they are accelerated here for clarity and put in the context of a male college student):
Me: So, tell me a little bit about what is going on. What does your life look like here at college?
Client: I go to class, but I really am not that interested in what I am doing. But obviously I need a college degree if I am going to get a decent job. I have a few people who I hang out with, but they don’t really know what is going on with me, and I don’t feel like talking about it. Lately, since I feel bummed, I often just stay in my room.
Me: What about romantic relationships?
Client: I hooked up once last semester. But I don’t have any romantic relationships.
Me: Tell me about your relationship with your parents.
Client: It is fine, I guess. I talk with them some.
Me: Do they know about your moods?
Client: No. They care about my grades, but I don’t want to burden them with my moods.
Me: What was your relationship like them growing up?
Client: Fine, I guess. They divorced when I was 12. My mom left my dad and my brother and I moved in with her boyfriend, now my step-dad.
Me: How is your relationship with him?
Client: Not good. He is an asshole.
Me: Did that put a strain on your relationship with your mother?
Client: I don’t know. We never talked about it.
One of the things that folks are most confused about when it comes to anxiety and depression is the relationship between the feelings and the root nature of the problem. Our society confuses these things and way too often labels the feelings as the problem. Consider it this way. If you break your arm and then go into the emergency room, you don’t say, “I have pain-in-my-arm disorder”. The pain is the signal that there is the problem. Or if you are outside for a long time in the cold with no jacket, upon feeling very cold, you don’t say that you have "a coldness disorder". Or if you don’t eat for a long time and you feel famished, you don’t have a "hunger disorder". Feeling pain, cold, and hungry are signals that your basic needs for bodily integrity, warmth and food were not met. The feelings are not the problem, per se.
Negative feelings like depression and anxiety function the same way. Depression and anxiety are, for the large majority of cases, emotional signals that one’s psychological health is not ideal and that one’s psychosocial/relational needs are not being met. Indeed, the first place that I look when I see depression and anxiety is the need for relational value. As deeply relational beings, humans have needs for relational value in the following areas: 1) family; 2) peers/friendships; 3) romantic partners and 4) group/occupational/social identity. There is also the relationship they have with themselves and the extent to which they feel proud and accepting of themselves (or the reverse). In other words, it is crucial that we feel known and valued by our family, our friends and our lovers and that we have a way to be known and valued in terms of how we contribute to society. And it is crucial that we respect and have compassion for ourselves.
Now look back at the exchange above. One can see immediately that the client is low on all these domains. He feels alienated from his family; he lacks intimate friendships; he has had no romantic involvements; and he does not see a clear pathway that he can contribute to society in a way that feels valuable. And he has no idea about how to think about himself in a positive light.
Depression is a way the emotional system signals that things are not working and that one is not getting one’s relational needs met. If you are low on relational value in the key domains of family, friends, lovers, group and self, feeling depressed in this context is EXACTLY like feeling pain from a broken arm, feeling cold being outside in the cold, and feeling hungry after going 24 hours without food.
It is worth noting that, given the current structure of society, depression often serves not to help reboot the system and enlist social support, but instead contributes to the further isolation of the individual, which creates a nasty, vicious spiral of shutting down, doing less, feeling more isolated, turning against the self, and thus getting even more depressed. As such, depressive symptoms often do contribute to the problem, and folks do suffer from Negative Affect Syndromes, where extreme negative moods are definitely part of the problem.
BUT, everyone should be clear, first and foremost, that anxiety and depression are symptoms of psychosocial needs and threats. They should NOT be, first and foremost, considered alien feelings that need to be eliminated or fixed, any more than we would treat pain from a broken arm, coldness and hunger primarily with pills that takes away the feelings, as opposed to fixing the arm, getting warmer or feeding the hungry individual.
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