The Psychotherapeutic Treatment of Anxiety and Depression
By Richard Sussman, LCSW
Depression and anxiety are two problems that afflict a considerable segment of the population. Although these conditions can be treated medically with drugs or, alternatively, many other methods (diet, exercise, biofeedback, meditation, etc.), complete healing does not result from treating the symptoms alone. Any approach that only seeks to eliminate symptoms precludes the possibility of recognizing and learning their deeper meaning and significance for our lives and our future growth.
Although depression appears in different guises, from chronic low-grade forms to acute debilitating ones, it is almost always a reaction to a deep sense of loss or defeat. This sense of loss can occur for any number of reasons: death of a loved one, ending a significant relationship, loss of a career, or financial ruin. In many cases, there may simply be a pervasive sense of loss or emptiness ever since childhood. The effects of any of these losses shatter one’s identity, resulting in a deep sense of insecurity or instability.
What is particular to the depressed person is that he blames himself for the loss. A normal response to such loss is sadness or anger. Depression occurs when an individual interprets that normal emotional response as indicative of something inherently wrong with himself, such as “I am weak” or “I am inadequate.” This sense of shame and self-blame prevents him from experiencing the normal and somewhat painful, but quite manageable emotions of anger, sadness or fear. What is left in their place is depression, with its accompanying moods of helplessness and despair.
There is a significant difference between anxiety and depression. If depression is a response to a loss that has already occurred, the anxiety is a fearful response to a loss or failure that is anticipated in any risky or uncertain future context. For example: “I am going for a job interview tomorrow; I imagine I’m going to do poorly. I’m never going to be a success.”
Interestingly, with both anxiety and depression, it is not the actual event that causes the acute suffering—in anxiety’s case the event hasn’t even happened yet. Rather, it is what we tell ourselves—our thoughts and beliefs about these events— that causes our distress. These thoughts are called “stories.” Stories are mental fabrications in the form of judgments, interpretations or assumptions about our experience. We believe that they are accurate descriptions or representations of reality, when in fact they are only subjective opinion or conjecture. “I did poorly on my exam.” “I’ll never succeed.” “I’m just a failure.” These are examples of depressive story lines. It does not inevitably follow that doing poorly on one test necessitates continual poor performance or that a pejorative designation of being a “failure” is necessarily true.
“I just know I will do poorly on the test tomorrow”. “I never do well on tests.” This is an example of an anxious story. The person can’t know what will happen in the future; if he or she has adequately prepared for the test it is more than likely that the results will be positive.
Depressive stories of blame and judgment prevent the simple experiencing of disappointment or loss. Instead of experiencing those feelings and ultimately moving forward, one is filled with self-recrimination and hopelessness. Anxious stories of dreaded outcomes prevent opening to and accepting the uncomfortable feelings of uncertainty in the face of the unknown. Instead, one finds a specious sense of security in a seemingly predictable result (“I will fail”, etc.), even though it is painful and imaginary.
In the treatment of anxiety and depression it is necessary to separate the stories from the events and emotions and to realize that the stories are fabrications rather than factual. This dissolves the toxic overlay of intense negativity and permits the experience of the normal emotional response to loss. Once these emotions can be fully felt, there is room to resolve or transform them. Depression opens up to sadness, which may ultimately turn into a peaceful acceptance. Or perhaps it will change into anger, which can become a powerful sense of strength and resoluteness. Similarly, anxiety can become an exciting anticipation of the challenge of the unknown.
In both instances, it is crucial to remember that the reality is never the story. This is the ultimate work of therapy, which goes beyond the medical approach: it offers a kind of healing and transformation that doesn’t just treat symptoms, but addresses the person as a whole.