Treating the Black Hole of Depression
One of the difficulties of the therapist treating depression is that it hard to develop a lot of sympathy for depressed people. They don’t look like they are broken, they don’t have a visible disorder or handicap. They may appear slow and saddened, they may even move or speak in halting ways. They are in a funk and their processing is not up to par. Sometimes the therapist wants to shake them and say, “Snap out of it.” But, this is not helpful for them or for you.
Seriously depressed clients are depressing in their own right. If you had known them when they were not so depressed it can be very hard for you to deal with. You remember a more alert, involved client, one who has something going on in their lives. Maybe there were problems, but at least there was a level of engagement that allowed them to participate in the process. Clinically depressed clients do not really do that. If they talk at all, they just repeat the same old litany of emptiness and hopelessness. They see no way out or forward. They are stuck in more than pain. Often they are angry, sometimes very angry, but they deny it. They will tell you how much they understand why others in their lives behave the way they do, they will make excuses, they will rationalize but at the end of the day, they are still the helpless victims of fate.
As a therapist it is very hard to stay focused. Being in a room with a client who is severely depressed and unfocused is like being a piece of metal being sucked into an electromagnetic vortex. You are pulled against your will into a place where there is no light, no energy and no solid foundation to stand against. It is like trying to fight Jello. There is nothing firm to leverage against. It is hard to hang on to your own thoughts because it is hypnotic and causes you to lose your focus. No matter what you want to talk about or what parts of the case you want to review or hear about, there is no energy for the conversation. While you are trying to find an angle of attack or to discover the potentially open window, the depressed client is sitting there like an empty car sucking gasoline into its tank from the dispensing pump, which is YOU, the therapist! They drain your tank and then they leave with YOUR energy. Your energy is not enough to fill them, only to keep them creeping along until the next time that they come back for a refill.
Clinically we are taught to understand that depression is primarily a biological problem, where there are chemical imbalances in the neurotransmitters of the brain. There are medicines that can help with many types of depression, but nothing is guaranteed and nothing works for everyone. One of the problems encountered when working with severely depressed clients is that they are often treatment-resistant. They will not take their medicine. They often miss sessions, and when they do come, they don’t want to talk about anything. If you push them, they will just stare at you and sigh or they will get angry because you are abusing them just like everyone else does. Sometimes they will get angry because you are supposed to be the one who can fix them and you for some reason won’t do it. You are the problem. You are the one who is holding them back, but then they really did not expect anything else because that is what always happens to them….. and it really doesn’t matter all that much because they are thinking about just killing themselves anyway. There is no point in going on because nothing will get better and you can’t help them and pills don’t work and nobody gets it. They are alone, hopeless and angry. But the angry part does not present itself as energy. The energy of the angry part is absorbed in keeping them still and helping them find ways to sabotage whatever you have been discussing or asking them to do.
Therapists who do not have a good handle on working with these kinds of clients are doomed to a short career. You cannot give them your energy, you cannot allow them to take charge of your attention span or your direction. When you go into a session with them you must know how to make yourself stay focused and to resist the magnetic pull of their black hole. You have to stay on the outside looking in talking to whatever source of energy exists in them. You cannot just feel sorry for them and you cannot get angry with them because they do not get better. You have to wait for them and invite them, but you cannot feel sorry for them. You cannot give into the temptation to push your energy at them with your solutions. You cannot heal them, you cannot fix them. Many therapists find it useful to have clinical support group of their own. Not just for working with depressed clients, but generally it is recommended that you participate in such a group for balance and perspective and, finally, for support.
So if this is all true, why do anything? Why see them or sit with them or care about them? If you are a good person, you are compassionate and caring, then they wear you out very quickly unless you use the resources you were trained to use. You have to keep your perspective. Remember the power of the safe holding environment and the skill of accurate, empathic reflection. What you can do is stay in your own skin, stay alert, and give them empathic feedback about how you experience them. Share with them how it feels to be with them and ask if that resonates at all with what they know and experience. Do not give them false platitudes or hopes, tell them that you care about them (only if it is true) and that you will sit with them and feel with them what they are feeling. You will describe and label for them, you will try to reframe it and offer ways for them to try to fight back. BUT, you must know that they will resist, they will sabotage and you must remain hopeful that overtime, they will improve.
It is a difficult process. As a therapist, you are a fixer and a problem solver. You have energy and you are used to having people get stronger because they take a hit off of your energy and become happier and more focused. Clinically depressed clients do not react this way. It is a long and challenging road. It leads to a lot of burn-out among therapists. Remember: Do not to give into the seduction of “fixing” them or telling them what to do. You must have good boundaries. You must have endless patience, you must be able listen to them say the same things over and over. The only gift you can give them is the gift of your caring attention and your willingness to sit with them while they are in pain. It may not seem like enough, but it is. It is like waiting for the ice ages to melt but is helpful, and it is the most you can do. You must believe that if you do these things and use your skills the client will eventually improve. Very few of them really attempt suicide when they are seriously depressed. The danger of that comes when they start to improve. Their energy levels come back faster than their emotional and cognitive levels do, so they are more likely to act on their ideations of depression and death. You have to watch for these changes, they are subtle, but important. It is a narrow window of danger and once past it, they are for the most part better. They will get stronger and can make changes and improve. If it is truly a biochemical imbalance, the odds are that eventually they will cycle through it again. At least, for awhile they get better. If it is a situational imbalance, they will get better and stay better. While you care for and about them, you must not lose yourself in this process. Stay professional, stay focused, stay grounded and keep good boundaries and stay in some kind of professional support group.