Depression or Anxiety? Often it is Both
Many people suffer from what are called co-morbid conditions. That means that there are at least two different conditions and that an individual may suffer from both of them at the same time. This is often true of the disorders called depression and anxiety. Generally, one condition masks the other. The individual presents with identifiable symptoms of depression. The depression gets treated or naturally improves, and what comes to the surface is anxiety. Or, conversely, the individual is treated for the different manifestations of anxiety and they improve, then the individual begins to present with depression.
Both of these conditions are believed to be caused by physiological issues and emotional/stress-related issues. Depending on whom you engage regarding the origin of depressive states, you will hear that depression is caused by a neurotransmitter imbalance and is purely a biochemical issue. You will hear that anxiety is caused by adrenal issues and is primarily biochemical in nature. Both of these presume that finding the correct medical intervention will alleviate the problem and restore the balance to the individual.
My clinical experience with people suffering from depression is that anti-depressants alone are not enough to “fix” the problem. Many people need and take anti-depressants but do not feel more energized, more up-lifted, or more hopeful. At best, they report feeling less despair, but not “elevated.” An argument is made that anti-depressants are not mood elevators, rather they are drugs which attempt to restore the bodies natural neurotransmitter functions. This is the presumptive cause of depression for those who focus on the “biological” issues. There are side effects to these anti-depressants, one of which is loss of libido. Many who take these drugs over an extended period will report that they no longer “think” about sex or they report that when they are engaged in sexual activity suddenly, without warning, everything just goes away. It is like a chemical switch is turned off, and so is the client. As you can imagine, this leads to very stressful relationship issues when it is not understood by the individual or their partner!
People suffering from anxiety conditions often report being “hypervigilant” or having a high “startle” reaction. They sometimes report that they are constantly in a state of dread because they are “waiting” for something bad to happen, waiting for the other shoe to drop. Often, anxiety sufferers will know that if they are going to experience a situation with enhanced emotional potential, they will feel their bodies “run wild.” Their heartbeat increases, they break out in a sweat, their chest hurts, they have the sense that they are going to choke, they fear a heart attack, they don’t think clearly, etc… There are drugs that they can take which will reduce these effects, or help avoid them by putting both a “floor” and a “ceiling” over the physiological “arousal” potential of the body. These are like beta-blockers which prohibit the heart from going into overdrive. They are situational in nature and one takes them in anticipation or in response to an “arousal” state.
The medicines help. They help control the range of the body’s responses. They often have side effects and/or are addictive. Questions arise regarding the cost-benefit ratio for taking these medicines. Sometimes people resist taking these meds, (especially men) because they are “un-manly” or indications of weakness. Sometimes they resist taking them because of the sexual side effects. Sometimes they resist because taking them does not really “fix” anything.
I believe in taking medicines when they are needed and are helpful. I encourage my clients to go to their doctor and discuss the situation with them. I often have an opportunity to discuss with the doctor the situation of the client as I understand it. Some doctors, in my experience, welcome this additional contribution of information. Some doctors see no need to look at outside information. That being said, I believe that medicine is seldom enough. There have to be behavioral interventions and behavior changes to make progress. These are most likely to come from therapy.
Working in therapy sessions with clients who are clinically depressed is a very difficult thing to do. I see more progress with people suffering from anxiety attacks. They tend to be more responsive and have more immediate relief and I am more aware of their success in overcoming it. But many clients with whom I deal do suffer from varying degrees of depression. Some of them have lives which are minimally functional and they believe they have limited options. These clients are, at best, surviving and waiting for time to pass and things to change. They feel victimized by life’s circumstances and they are hopeless to change. I remember in particular, a woman I worked with for years. She was severely depressed and went through suicidal cycles regularly. She felt powerless to change her life and cycled from quiet impotent rage to helpless cries of despair and self-pity. She would get a little better, begin to make some behavioral changes in her life, i.e. go back to school, get a dog, join a social network, go on a diet, etc., then it would just all dissolve and she would sink back into despair and have suicidal thoughts. It was very difficult to work with her week after week, month after month. I often felt that I was the only one bringing energy to the session. I would feel depleted after she left because it felt like my battery drained in order to recharge her battery. It seemed like every week we had the same conversation.
There were elemental places in her life where she was abused and victimized. She had survived much. I had so much respect for her and for her survival from the traumas of childhood and adult losses. She was a tower of strength and intelligence. Yet she could not see or experience herself as the strong, capable woman I saw and knew. She saw herself with a jaundiced eye of critical self-hatred. She was convinced it was her fault that these things happened to her. If she had been a more worthy daughter, friend, worker, then good things would happen and she would be successful, beautiful, slim, and happy. She did not deserve any of these things because she was fatally flawed. She would get angry with me when I encouraged or praised her. She hated me and called me a “paid” friend because I expected her to pay her bill and only worked with her because it was my job. She wanted me to love her for herself, not for the money she paid me. She wanted me to respect and care for her even though she was not able to do this herself.
These clients are so very challenging for a therapist. It is such an uphill battle. It is exhausting because you have to stay alert, focused, encouraged, and encouraging, against constant resistance of negative energy and refusal to hope or engage. I had to keep reminding myself that I could go home at the end of the day. I had a life filled with color and excitement. I felt good about myself. My hour with her would end honorably when I had done my best during that session. She lived in her skin and in her life every minute of every day and could not get away from her feelings by leaving my office. Keeping this in mind helped me find the energy and maintain the desire to work with and encourage her. I continued to respect her and care about the pain with which she lived, but to this day, I do not know if I made a difference in her life. I don’t know if I offered insight, help, or any positive benefit from all my investment of caring and energy. But like every other therapist, I remain committed to the belief that it does matter. All I can give is my dedication, my attention, and my caring. I do not know, nor do I expect to know, the ripples that occur in the lives of those with whom I work. It is not my lot to see the effects of the work with these individuals. I must be satisfied with my own sense of having done the best I could every single day. I believe it matters, that it is worthwhile and that it helps. It is an article of faith and professionalism. Otherwise, I would not do this job, it is just too damn hard.
If you are a therapist, you will understand. If you are training to be a therapist, you will learn. You must go to work every day with the energy, focus, and commitment to do your job in a caring, professional way. You cannot afford to ride the waves of energy that come off of your clients. Your energy must come from within you. Their success or failure is not yours, it is theirs. Your job is to do your job which is to live your life and work ethically and professionally, constantly trying to accurately and empathically attend to experiencing the client honestly. You reflect back to them your observations and encourage them to see themselves honestly. But each client has to walk their own walk, and so do you.