The Upside of Depression and the Downside of Medication

Are there advantages to being depressed? Something good about something we think of as so bad? A recent New York Times Magazine article by Jonah Lehrer makes just that case: Depression’s Upside.

The essence of the argument is that some episodes of depression allow for and encourage a kind of analytic rumination that is productive. Put another way, the tendency in depression to focus on a problem, mulling it over to the exclusion of other thoughts, permits the sad person to find a solution to his difficulty and change his life in a positive way.

The counter-argument, however, is that the ruminative process is both painful and unproductive — that it often creates a kind of self-flagellating preoccupation with one’s trouble rather than a process that leads to something good; that unhappiness and focusing on pain and its concomitants simply feed on themselves to no helpful end.

In my clinical experience, therapy with people who are depressed over loss or injury often breaks down into two phases. The first of these is a grieving process, where the person expresses and processes (or sometimes purges) the feelings of anger, sadness, emptiness, desolation, and hopelessness that come with the loss of something of value — a love, a job, high social status, a capability, a fortune, etc.

The second phase involves learning from one’s painful experience about how to live differently, make different decisions, associate with different people, become more assertive, overcome fear; value things differently in life such as money, material things, status, accomplishment, friendship, and love.

Naturally, neither of these two phases is absolutely discrete — they blend into each other and overlap each other. As a practical example, someone who has had a series of bad relationships will typically need to grieve the unhappy end of the most recent one and, in the process, learn how he happened to choose a person or persons who made him so miserable; then changing whatever needs to be changed internally and externally so that different and more satisfying choices occur in the future.

People who are like the hypothetical individual just cited usually come into therapy in emotional pain and seek relief of that pain as promptly as possible. This desire is entirely reasonable — who wouldn’t want this? Some of them request medication, which is often the fastest way to “feel better.”

But many are leery of psychotropic drugs and see them as artificial, hoping that therapy will produce a more lasting fix without dependency upon a foreign substance. Indeed, while a good therapist will strongly encourage the use of medication for someone who is seriously depressed, i.e. suicidal, unable to work, sleeping away the day away (or almost unable to sleep); that same therapist will also know that medication sometimes serves to “de-motivate” the patient, giving him or her a relatively quick solution that allows that person to tolerate an intolerable situation. In the New York Times Magazine article mentioned above, Dr. Andy Thomson describes this problem eloquently:

I remember one patient who came in and said she needed to reduce her dosage. I asked her if the antidepressants were working, and she said something I’ll never forget. ‘Yes, they’re working great. I feel so much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.’

Clearly, this woman was aware that she needed to be in some amount of discomfort in her relationship with her husband in order to be motivated to get out of it. The drug made her feel better, but, it also reduced her incentive to change herself and her life. It was, in effect, a kind of band-aid, rather than a real cure. It anesthetized her and, in so doing, robbed her of something that was essential for new learning and behavior change to occur.

Unfortunately, most people who come to therapy are neither as courageous or insightful as the woman just described. Once they feel significantly better, whether due to therapy or medication, it is common for them to be less interested in continuing treatment. They have recovered from the event that precipitated their entry into therapy, but they might not yet have learned enough to avoid making the same mistakes that contributed to the problem in the first place.

Such a person can reason that the cost of therapy (both financially and in terms of time, effort, and the difficulty that comes with changing one self) is now greater than emotional pain from which they might still be suffering. Put another way, at this point, doing therapy “causes” more difficulty and pain than not doing therapy, just the reverse of what seemed true when they started the treatment process.

At this stage, those who continue in therapy have something that an old mentor of mine, Truman Esau, used to call “therapeutic integrity.” What he saw in some of his patients was an almost heroic desire to make themselves better regardless of how much the actual process of doing so was difficult, uncomfortable, or painful.

These patients didn’t shy away from problematic truths about themselves or others. They worked hard to stretch and challenge themselves, knowing that it was crucial to improve. They didn’t simply want a quick fix. Like the woman in Dr. Thomson’s example, they recognized that some pain was essential to being motivated. They knew that there was no such thing as “a free lunch,” and were willing to do whatever it took to repair and better their lives.

If you are in therapy now, it will be important for you to be sensitive to this shift from the often intense distress that brought you into therapy, to the point when the therapy itself might seem distressful. This can mean that the therapist is not skillful or that he is pushing you too much, but it just might also signal that some of the most difficult life changes you need to make are still ahead of you, even if the cost of making those changes seems greater than when you started treatment.

If you leave therapy because it is hard and unpleasant work, the problems you have won’t care. They will simply continue to reside in you, work on you, and trip you up. It is not enough to get over your last disappointment or unhappiness, but to change yourself enough to avoid future problems.

Few things that are worthwhile come to us for free.

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The above image titled Depression is the work of Hendrike, sourced from Wikimedia Commons.