TIFT #105: Empathizing with Depression

Seeking accurate empathy is a good way to create the conditions for change. That is the theme of the Five Key Questions approach to teaching core psychotherapy skills. What it means in practice is putting oneself (and the client’s observing self) in the shoes of the limbic problem solver or inner self, the part who so often seems firmly in charge. In depression, that’s not so easy. How can we understand our client’s powerful wishes to withdraw from life?

The inner self is working hard to isolate, to think badly of the self, to punish the self, and would rather spend the day in bed, or even cease to exist. In this post, I want to differentiate between purposely destructive symptoms, the ones that make sense as anger turned inward, and those that have more to do with a general shutting down. The backdrop for both is early failure in fulfillment of basic emotional needs. I’ll talk about anger later, but for now, I want to consider the profound deflation that is part of depression. In brief, the idea is that the inner mind shuts down because it is unwilling to commit already depleted resources to a losing cause.

The brain as organ of prediction

Thinking of mind as the brain’s information processing function and turning to computational neuroscience, the concept that sheds some new light is how the mind is focused on prediction. In practice, it puts more energy into predicting the future than looking at the past, and when it is concerned with the past, it is to prepare for the future. This makes perfect sense from the point of view of evolution, favoring survival and procreation. The past is done, but what the mind really values is improving the odds for the future.

In recent essays, I have been trying to flesh out the logic that leads to entrenched maladaptive patterns (EMPs), in general. Today, the focus is on depression. Homing in on the factors that are weighed in the lead up to a protective response, one in particular is relevant to depression. To recap, the three factors are:  1.) Is the threat serious enough to require a response? 2.) What is the best strategy for dealing with it, and 3.) do I have the resources and strength to succeed. The last one is where the mind calculates the probability of success, given the resources available.

Getting into the depressed person’s inner mind

If conscious feelings have a metaphorical relationship with unconscious ones, then it is relevant to use conscious thought as a likely window on the nonconscious problem solver. Let’s consider, then, how we feel when we have invested a lot in a project that has failed. Naturally we think twice about trying the same approach again. In a similar way, the depressed mind is reeling from an experience of failure or loss. When circumstances are such that no one is to blame, what remains to do is to manage the resources still available. We are programmed to avoid wasting energy in general and that includes the energy to invest in something likely to fail. The reluctance becomes even greater when past failures have depleted what we have left. From that point of view, it makes sense that depressed people resist socializing and other emotionally risky activities. To do so would be evaluated as foolhardy and dangerous. The more significant the loss, the deeper the reluctance to try again.

Why depressed people resist hope

From this point of view, the resistance we so often experience in working with depressed people makes sense. We promote the idea of re-engaging with life, but the depressed person’s inner sense of reality objects. Why should they believe us or even their own positive past experiences when they have experienced painful failure and are still reacting to the loss. As suggested above, there is a kind of multiplier factor, too. Taking a risk when we are feeling flush isn’t so serious. But taking risks when we are on our last drop of emotional energy has much more serious consequences. Depressed people act as if they need to be highly conservative about what they have left, responding reluctantly to any assurances of reward. “No, thanks, I’ll feel better staying in bed.”

In confirmation, a substantial body of research using money shows that the more a person is depressed, the less likely they are to make risky decisions on expenses or investments.

Panksepp’s SEEKING system

In parallel with this thinking, the late Jaak Panksepp wrote about the motivational apparatus in our limbic system. In brief, the SEEKING system can attach itself to any goal. If the goal is too hard, meaning the likelihood of reward compared to investment is poor, then the system powers down, essentially giving up. The accompanying emotion is depression. But when the goal seems attainable, the system is energized and drives our efforts. It works like the carrot and the donkey. If the carrot is too far away, the donkey won’t move. It has to be temptingly close. When our human SEEKING system has its goal in sight, we feel pleasure and are energized. Panksepp’s work explains much of the neurophysiology of this motivational system, while the idea of a limbic odds-maker describes how specific circumstances can activate or deactivate the nonconscious, limbic SEEKING system.

Emotional energy

The concept of “emotional energy” seems intuitively right, yet what might it be made of? My guess is that what feels like energy actually represents the current state of the SEEKING system. When it is powered up, we feel like we have great stores of emotional energy, while powered down, it leaves us feeling exhausted and depleted. Thus, emotional energy is quite likely not a real form of energy but rather a measure of the state of our SEEKING system, a gauge of readiness to undertake new investments in life. Subjectively, when we don’t have emotional energy, we feel like we have used up something finite and will need to hunker down before we might be ready to re-engage.

A twist of time

One quirk of limbic thinking is that time, like negation, simply doesn’t compute. That’s how I understand clients’ frequently repeated assertions that their hopelessness is forever and will never be relieved. This firm belief effectively blocks many of the positive things we might say. Fortunately, it does not stop our actions from speaking the limbic language.

Adding Anger to the picture

So far, we have looked at failures where no one is seen as responsible. Often, though, that is not the case. When the inner mind evaluates that someone is at “fault,” the natural emotional response is anger. Just a note here, that children assign blame in their own ways, not always the way adults do. They may blame the more competent parent who didn’t provide protection, even though the other one was the main source of trouble. Slightly older children may also hold themselves responsible for providing protection for a sibling or shielding an overloaded parent from their own needs. Any blame can become a source of anger and a reason for punishment.

When anger is expressed openly and processed appropriately, consequences may not be lasting. On the other hand, as we so often observe, when the one to be blamed won’t or can’t accept responsibility, the anger has only a few paths to follow. The most adaptive response for adults, acceptance, is generally not available to children because accepting existentially threatening conditions is (accurately) experienced as equivalent to death. Instead, a child can wait and hope there will be a chance to change the “no” to a “yes.” Another strategy is to hold onto a wish for rescue and hope that someone will come along to provide what has been missing. Staying angry is problematic when the object of the anger is someone on whom a child depends. That is why the final choice is so frequently turning the anger against the self.

Implications for therapy

Help with the angry part of depression consists in working with the client to find the true inner source of anger and, when that is activated, bearing witness to those authentic emotions until they heal. Therapy for the deflated and unbelieving component is quite different.

Much of contemporary treatment is focused on somehow getting the depressed person to re-engage with life. Doing so creates a message of hope to disconfirm the limbic protector’s pessimism, but that means acting in a way that is perceived internally as risky. And, that’s exactly what depressed people are trying to avoid. There are a variety of tricks and techniques to talk people into engaging, which may work to some extent. They are easy to find elsewhere but here I want to talk about what goes on behind the scenes. The view through the eyes of the inner self is that the deck is stacked and additional investment is more likely to lead to bankruptcy than success. Psychoeducation showing the client the desirability of engaging with life doesn’t seem very attractive to the inner self.

Once again, this is a time when we need to pay attention to the language of the limbic system, where deeds and authenticity count much more than adult logic. More likely to make a difference is making sure the client experiences real and persistent support from valued others. Creating a supportive environment happily willing to invest caring is a form of disconfirming information expressed in language the limbic system is more able to understand. Persistence is key, because the inner self sees its stuckness as permanent and irresolvable, so it is biased against believing in the “positive” actions we might propose.

In today’s world, one action often taken is to provide antidepressant medication. Let’s think how the inner self sees that. In our culture, medication has gained a great deal of credibility, deserved or not. To convey that credibility, advertisements on TV are designed specifically to speak to the limbic system. SSRI drugs do suppress emotions, including negative ones, but research shows that as little as 20% of their effect is due to the drug, and the rest is “placebo effect.” It is likely in this case that a significant part of the placebo effect arises from the therapist’s concern and willingness to support powerful steps to help. If that is part of the action of medication, then other demonstrations of concern and willingness can also contribute to the effectiveness of treatment and to recovery.

The risks are real

It also goes without saying, that we want our depressed person to take seemingly risky actions only when the odds of success are high. Setting our client up for possible failure can lead to disaster. Another real risk is when caregivers can’t sustain whatever they have allowed the client to expect. “Running out of gas” is likely to subject the client to yet another painful disappointment. It is critical to assess our own and others’ ability to fulfill the expectations that may have been encouraged or implied.

The bottom line

What this really means is that when we make use of the range of techniques for getting the client to invest in life, we need to be aware of how it looks through the eyes of the inner self. That is how we get to accurate empathy and the realization that we are tempting our client with the promise of value for their investment at a time when the inner self is in a state of serious skepticism. We need to be careful about what we are promoting and authentic in our commitment to understanding. The more we are real and energetic in doing so, and the more we can enlist others in the same persistent support, the more likely we are to succeed in showing the inner self that new risks can be worthwhile. When those risks pay off, they begin to disconfirm the inner protector’s understandable pessimism.

Jeffery Smith MD

Photo credit: Gadiel Lazcano, Unsplash