Mental Health, self-perception

Differentiating Depression: Affective and Cognitive Approaches

Something I’ve been thinking about lately:

About a week ago, I was speaking with a client about depression, exploring “the lies that depression tells us”. It’s a standard externalizing narrative framework clinicians use to help clients put a little emotional distance between themselves and whatever’s afflicting them; it’s an approach that works for a lot of different things. But I made a mental note in the back of my head that in my own mind, something had started to ring a little hollowly around that particular narrative construct (not for the client; the client ran with the externalization like it was tailored for them). It’s taken me most of the week to figure out what the mischord is. When we talk about depression and “the lies it tells us’, the implication is there’s something inside us that whispers or talks to us and fills us with narratives that are neither helpful nor healthy. This implies that depression functions as a cognitive process, operating in the part of the brain where language and thought processing occurs. When clients respond well to the idea that “depression lies” or tells us things about ourselves, we’re operating in the cognitive realm. We define the cognitive realm this way:

This domain includes content knowledge and the development of intellectual skills. This includes the recall or recognition of specific facts and concepts that serve developing intellectual abilities and skills. There are six major categories, starting from the simplest behavior (recalling facts) to the most complex (Evaluation)
http://serc.carleton.edu/introgeo/assessment/domains.html

I absolutely believe that this definition of depression as a cognitive dysfunction (with all its standard attendant physical byproducts and related chemical imbalance) rings true for a very great many sufferers.

It is most decidedly not, however, true for me. My depression doesn’t talk to me, and I’m increasingly certain it never has. And the more I work with other depression sufferers, the more convinced I am that there’s an entire constituency for whom there is no (or no signficant) cognitive aspect to the their depression at all. For example, my depression says nothing to me about my worth or value. It says nothing to me about my happiness or misery, nothing about the value of doing anything I would normally do, energy I would normally expend. I increasingly suspect that part of the reason why I failed to recognize depression in myself for what it is for as long as I have is precisely BECAUSE the entire internal “demon narrative” has been conspicuously absent. This suggests some forms of depression might operate predominantly, perhaps exclusively, in an affective state, manifesting physically and exclusively without the cognitive narrations::

The Affective domain includes feelings, values, appreciation, enthusiasms, motivations, and attitudes.
http://serc.carleton.edu/introgeo/assessment/domains.html

What I get is something like a gravity well; a thing I fall into in which the weight on my mind and body just increases until I have no tolerance, no strength to move past it. Emotionally I still feel happiness and joy, though muted; I still feel engagement. I’m still reasonably high-functioning, though compromised in scope and sustainability. It’s like something sits on my chest and weighs me down. It can be hard to breathe sometimes, it’s definitely nigh-unto-impossible to move. It’s easier to just stay still, or better yet, just sleep. There’s no judgment, no scripted storyline about what it means; I don’t know if it was always like that. I know I beat myself up fairly heavily the first spring I failed to get back to walking like I had been the previous fall, but that failure and self-recrimination narrative was as much disappointment over lost momentum and gear investment costs as it was anything else. All things considered, it was easy to let go of that cognitive process once I figured out what was going on.

My depression doesn’t talk to me, and I don’t talk to it. At the deepest points of the gravity well, it doesn’t whisper to me to kill myself, that the world would be better without me or that no-one would notice. I actually like my life; I have a mostly-healthy connection with my world and the place I have made for myself within it β€” not without challenges, but hey, I’m still human. At the deepest points, where people start to have urgent conversations about suicidal ideation, the sensation has been more what I imagine drowning swimmers eventually reach when they are too tired to keep struggling up past the weight of the water to the air, too tired to keep pushing their own waterlogged bodies to draw in breath, and they just… succumb. There’s the instinctive urge to breathe and stay alive, but eventually we can’t keep fighting against the weight and resistance of the surrounding elements. It seems to me that there’s not a lot of internal narrative in those moments, beyond “so tired” and “just let go”. I’m reasonably certain the only thing that pulled me through those times was the utterly unconscious, instinctive urge to keep breathing. In those moments it’s not so much that one consciously care much about living or dying; we can’t battle the weight any more, but autonomous bodily functions keep going. It occurs to me, this is likely where a big part of the mantra that has been a core operating principle for the last five years is rooted: “One day at a time, one breath at a time; one foot in front of the other.” Think no further ahead than the next breath; there isn’t enough energy to invest in speculating any further ahead than that.

A clinician friend in Boston this morning pointed me to the works of Edwin Shneidman, an American psychologist and author who wrote extensively on his work with the suicidal mind. Specifically, she was correlating my thoughts on depression as a predominantly non-cognitive, felt experience rather than a mental, narrative one, with Shneidman’s description of suicidality as a “psychache”, language that I suspect may resonate strongly with affective depression sufferers (even those nowhere near the point of suicidal ideation):

“As I near the end of my career in suicidology, I think I can now say what has been on my mind in as few as five words: Suicide is caused by psychache (sik-ak; two syllables). Psychache refers to the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind. It is intrinsically psychological – the pain of excessively felt shame, or guilt, or humiliation, or whatever. When it occurs, its reality is introspectively undeniable. Suicide occurs when the psychache is deemed by that person to be unbearable. This means that suicide also has to do with different individual thresholds for enduring psychological pain.”
(Shneidman, 1985, 1992a).

Looked at through this lens, we have the option now of language that supports exploring depression as a form of psychache, one with a scope of tolerance for enduring the affective or physiological experience, and how the client is able to function within the threshold of that experience. For clients who get frustrated by trying to use cognitive, narrative process to relate to their depressive experience, we can instead use bodywork language from the likes of Eugene Gendlin or Bessel van der Kolk (whose groundbreaking work on bodily retention of traumatic experiences is a go-to resource for many clinicians). This affective approach also opens up the options of a dialogue with clients around other physiological variables that can impact the physical and affective states. Western psychology sometimes skirts the edge of this holistic understanding when we press clients to consider their sleep/diet/exercise (any energy expenditure) habits in light of their depression, but often stops short of giving legitimacy to depression as potentially being a *wholly* affective state for some people. (The more I recognize this in myself, the easier it becomes to see this as an option for other depressive clients).

So now we can observe when the default cognitive “depression narrative” approach seems to sit badly with clients and others, and offer them this as an alternative to consider. Humans are narrators and interpreters and story-tellers by design, but I think sometimes the words actively get in the way of simply being *IN* an experience, especially if the experience itself is frightening in some way. If we can describe an experience–if we can safely box it up in words and interpreted meanings–then we feel we understand it. We feel we have a handle on it… we feel we have, in that handle, some measure of control, however slim. And therein we find comfort. We’ll invent entire mythologies simply because we experience fear when we don’t know why the sky flashes and rumbles at us.

Sometimes a cognitive, narrative *isn’t* the right approach. Sometimes it *doesn’t* encapsulate the experience. Sometimes it actually distances us from it. Recognizing the physical experience of my depression this week was a massive shift for me. There is no internal discussion or discourse, no whispered threats or seductive emanations. There is simply a force of gravity that is very localized; some days I function at Standard Earth Gravity, and sometimes I am flattened by Jovian Pressure so forceful it feels like it would be easier to stop breathing completely than expand my lungs against my crushing ribs one more time.

Even those words don’t capture the experience. Those are words and narrative elements that only fill in the blanks after the fact, for the most part, when I’m having to describe the experience to someone outside my own head. Most times, it never gets past the sensation of just stopping, letting my eyes close where I sit or lie, and letting sleep take me the rest of the way down into the pressurized deeps of that gravity well.

Now at least I have language to explore that with others as well. See? Even clinicians can learn new (and hopefully useful!) things.

Leave a Comment

Your email address will not be published. Required fields are marked *