Heightened guilt, the desire to take responsibility even for those circumstances that are beyond your control — all this can lead to the development of depression. Why is this happening and how is the treatment different in these cases?
The main thing to know about depression is that it has many faces. This diagnosis is made if the patient meets at least 5 out of 9 criteria (some of which are opposite to each other). And this means that the two «case histories» will be very different. It happens that a depressive episode happens to a person only once; and it happens that long-term (and sometimes lifelong) treatment is required — taking pills and psychotherapy.
Experts distinguish different types of depression, each of them has its own causes and prerequisites for occurrence. And everyone agrees that it is quite difficult to work with patients who believe that they themselves are to blame for everything and deserve it all.
Case study
Psychotherapist Mark Ruffalo recalls his 60-year-old patient, who suffered from depressive symptoms throughout her adult life. The last episode was provoked by the death of her beloved cat: she fell ill with leukemia and had to be euthanized. “It’s all my fault! the woman wailed. “You shouldn’t have vaccinated her – probably because of this.”
Previous episodes of depression were also caused by events in which the woman blamed herself. She generally believed that every failure in her life was a “punishment” for her, and she did not deserve help, including psychotherapeutic help. In English, there is even a separate name for this phenomenon — self-blaming depression, which can be rather clumsily translated into Russian as “self-blaming” depression.
Echoes of past losses
In psychoanalytic and psychodynamic theories, depression has historically been seen as a reaction to loss. Something happened in the patient’s life: he lost a loved one, a job, a position in society, an ideal or idea of himself — in a word, some key ingredient for a normal existence. And it caused depressive symptoms.
Depressed adults often grow up into children whose needs were initially met in full, and then abruptly ceased to be met. Such a radical change in the situation gives rise to a feeling of losing something important, and the child seeks to “correct” as soon as possible in order to regain his “lost paradise”: surely everything is because of him (her)!
But, no matter how hard the child tries, it is impossible to return the lost, and the first depressive feelings appear.
This pattern is often reinforced: a person believes that his behavior and lifestyle itself lead to losses. So, he allegedly deserves all this, and is not worthy of any help. Not surprisingly, these patients are difficult to work with and often require medication as soon as possible. However, one cannot do without psychotherapy — this is the only way to help a person change his attitude towards himself and his life.
What to do with it
So, it is very difficult to “convince” a person with this kind of depression — the psychotherapist is faced with powerful resistance. “I am not worthy of your help, how can you not understand this?! — as if screaming such a patient. “You just don’t know me well and don’t see what a terrible person I am.”
But if you do not support the client and do not give him hope — at least at the peak of the disease — then how else to help him or her? One way is to explore together what is going on in meaningful relationships, what exactly provokes the emergence or exacerbation of guilt and shame. These can be things that at first glance are completely harmless: for example, the partner’s phrases “you don’t feel well, leave the cleaning and go to bed” or “you took care of me / took care of me for so many years, now it’s my turn” can be perceived by the client as criticism and reproach, and thus exacerbate feelings of guilt.
It is even more important to help the patient realize that he is unconsciously replaying scenarios of the past, that all his current disappointments and losses leading to depression are “echoes” of earlier and more significant losses. Interpreting the meaning and symbolism of depressive symptoms is becoming more important than ever. Perhaps more important than in the treatment of any other form of depression.
The task of the therapist is to track the «downs» and «ups» in the client’s life, to help to realize what serves as triggers for the development of depression.
For example, symptoms may be exacerbated because the patient feels guilty about «falling into» depression too easily, or because he or she feels «undeservedly» better. And, of course, it is important for a person with depression to understand that it is important to work on the topic of childhood loss — otherwise the symptoms of depression will appear again and again.
Why is it necessary to know about all this? Because, perhaps, you are sure that no one is able to help you and that what is happening to you is a punishment for your sins. Or because one of your loved ones thinks so in depression, and from the inability to help him or her, you simply give up. The main thing to remember is that most cases of depression are treatable. Depression is the same pain, only mental. And, like any pain, it requires to be eliminated. As soon as possible.