Four Types of Depression

[Note:  this article still needs minor revisions]
I see patterning suggesting at least four types of depression, each with significantly different implications for treatment. The first three will likely sound at least somewhat familiar to most psychotherapists, while the fourth likely will be an unfamiliar conceptualization to many. For this reason, I spend much more time on the fourth. One point worth noting at the outset is that only two of the types of depression are conceptualized as truly dysfunctional, while the other two are conceptualized as conditions in the service of broader healing, and therefore functional. Psychotherapy has an important role in both dysfunctional and functional types, but the assessment of depressive symptoms as dysfunctional or functional has important implications for what constitutes appropriate treatment. As I elaborate my conceptualizations and treatments for all four, the reader will notice that a variety of theoretical orientations are represented in these conceptualizations. This is because I see different systems (for lack of a better term) involved in different depressions, and as a result the depressions are responsive to different approaches.

Fallow Seasons or Developmental Depression 
One type of depression I have often encountered with clients is what I call fallow seasons depression. Farmers let a field lie fallow (unplanted and seemingly inactive) during times when the field needs to replenish soil nutrients. The fallow times allow farm land to remain fertile over the long term, when otherwise it might become too depleted for crops to grow. I believe some lower level depression periods are natural and even necessary components of our development. These periods seem to occur when we have depleted ourselves or when a life path is no longer serving us. As such, these times serve a similar function as fallow fields.

Most people in the midst of a fallow season will describe low energy, low motivation, procrastination, and a sad or blue feeling—often sufficient for a dysthymia (pervasive depressive disorder) diagnosis, but even more commonly, sufficient to lead a person to seek psychotherapy. Our mainstream U.S. culture seems to give the message that we should always be in a good mood and always energetic, with plans and goals we are actively seeking to fulfill. But this idea does not match my experience with people. On the contrary, I find that most if not all people go through these fallow seasons from time to time, and such periods are not pathological. I believe these are necessary times, when we are internally regrouping and redirecting energy and effort towards what will serve our growth. With no cultural pressure to hurry, or to keep an upbeat, energized state, and instead left to natural processes, we soon enter into a more active growth period.

However, just because fallow seasons are normal does not mean they are not distressing; and just because we would naturally eventually get where we need to be does not mean that psychotherapy is unhelpful. On the contrary, psychotherapy can offer influence and assistance that can significantly improve the process, duration, and outcome of a fallow season depression.

Fallow Seasons/Developmental Depression: Implications for Psychotherapy

Self-Care. One commonality among treatments for all the four types of depression I cover here relates to self-care. Psychoeducation on what constitutes good self-care is a key contribution a psychotherapist can offer the client in a fallow season depression. I believe mainstream U.S. American culture is pretty misguided about what constitutes good self-care, so I will elaborate here. Most of the information I provide here on good self-care does not come from a high level of expertise—my granny would have recommended much the same. But without this information and the client’s agreement to engage in plenty good enough self-care, developmental tasks and daily coping during a developmental (or any other) depression are far more difficult to accomplish. However, I did consult other health care professionals over the years, to validate the information.

Physicians and others whom I have consulted variously recommended self-care instruction addressing energy-relevant aspects of sleep, nutrition, and exercise. No matter what challenges we might be facing, good self-care in these areas will set us up to be more effective. Regarding sleep, health practitioners have advised that we sleep at the same time every night, even if we can’t get the 8-9 hours we should. The restorative functions of sleep apparently improve as we become more consistent in our sleep cycles. (*refs)  Regarding nutrition, the notion of “eating for energy” seems helpful to clients. “Eating for energy” focuses on foods that will sustain blood sugar at adequate levels throughout the day. Most important in “eating for energy” is eating a breakfast that includes fruit (for quick energy), quality complex carbohydrates (such as whole-grain toast or oatmeal--which will break down into blood sugar over several hours), protein (such as peanut butter, eggs, cheese, meat--which will break down throughout the day), and a small portion of fat (usually present already in the protein source--which will break down even more slowly than the protein). Another common recommendation is to eat several mini-meals throughout the day to keep blood sugar stable. (See, for example, www.todaysdietitian.com/newarchives/040609p20.shtml). Regarding exercise, extensive research shows that regular exercise improves energy and decreases depression (and anxiety) symptoms. Mayo Clinic, for example, recommends: “Doing 30 minutes or more of exercise a day, for three to five days a week can significantly improve depression symptoms. But smaller amounts of activity — as little as 10 to 15 minutes at a time — can make a difference. It may take less time exercising to improve your mood when you do more vigorous activities such as running or bicycling.” (www.mayoclinic.com/health/depression-and-exercise/MH00043/NSECTIONGROUP=2). 

Psychological literature suggests that maintaining at least some social, creative, and spiritual activities is important because, for many people, these activities give back more energy than they take and often counteract depression contributors like loneliness and isolation. (ref***)

It is not uncommon for me to see clients’ symptoms so dramatically reduced when they make significant changes in self-care, that the client no longer feels the need for psychotherapy. When I assess that a client has major self-care deficits, and the depressive symptoms are not severe, my treatment interventions begin with psychoeducation and behavior change interventions, even though my primary theoretical orientation is psychodynamic.

Normalization. Another important element in addressing developmental depression is to help the client understand how normal and temporary the experience is. Knowing that most people go through a time like this in their lives and that it turns out just fine or even better is very relieving for many clients. I like to further emphasize that it is not only normal, but necessary and beneficial. I like to help clients envision this fallow season as a cue to engage in self-examination that will then guide changes in course, to improve their lives in important ways. Fallow seasons are not a dysfunction but rather a sign of healthy growth. Important seeds are germinating. When clients understand this, they stop fighting against the process and direct their attention to useful efforts. When they understand how normal these times are, shame can be removed or significantly reduced as well, leaving more energy and hope for redirection and taking on developmental challenges. Our job is not simply to get the client feeling better, but to decode the message about what important, valuable aspect of the person’s life needs attention and self-compassionate effort.

Road Maps. In helping a client consider what important aspects of his or her life might be calling for attention, we begin developing a road map for the next stage of a person’s life. I believe that a road map changes the whole picture. Being lost in a city, forest, desert or ocean with no map is a pretty unpleasant experience for most people. But the exact same circumstances can be transformed to excitement and adventure with the simple addition of a map. The same transformation happens with a road map for psychological development processes.

When we have some energy (self-care), when we understand what is happening (normalizing) and have some idea of the choices for where we can go (road map), we become more empowered and motivated. Helping clients develop a conscious vision for their lives turns this “depression” into a challenging but potentially exciting new journey.

Common examples of fallow seasons include entering new stages of development, life challenges that we did not fully take into account, accepting dashed hopes, and others. For example, one woman could be a prototype for the “new stage of development” category and the treatment indicated: She came to me with low energy, poor ability to enjoy time with friends and family, feeling she had nothing to look forward to, and then guilt feelings for wasting her life and her time and for a lack of gratitude for the positive things in her life. She believed she had nothing to complain about, as she had an upper middle class standard of living, and she knew her family loved her. But she just was not happy and judged herself harshly for that. I suggested that her symptoms were telling us that something important was missing or off-track or she wouldn’t be feeling this way; that we could trust her feelings to be coming from a healthy part of her. As we explored what this missing or off-track aspect might be, or what she associated with it, she had no immediate insight. When I asked her to let herself be aware of what she wants when she is feeling this way, she said she didn’t know what to do with herself anymore. Her use of the word “anymore” suggested a change, so I asked when was the last time she knew what to do with herself. She commented on how her days used to be filled with taking care of her children and volunteering in various ways in her community.   But now her kids were grown and the volunteer work had “become meaningless, just a bunch of women trying to feel important when they aren’t.” This statement and the harsh feeling behind it had the hallmarks of the core issue—she didn’t feel important. Now I knew we needed to consider what might make her life important.  (Note, wanting to feel important is a healthy longing, not dysfunctional; berating oneself for perceived unimportance is the dysfunctional part). In the end, she concluded that while being a mother is inherently important and therefore easy to reassure oneself with, she felt motherhood had actually masked or soothed a much deeper longing to live a spiritually important life. She recalled as a young woman that she had considered becoming a minister but had put that aside, as she felt it would be incompatible with having a family. Once she was more conscious of her healthy longings, she could begin to develop ideas about what would constitute a spiritually important life. I didn’t need to do much in this stage at all—she was the expert on what would be spiritually important to her. I merely needed to be vigilant to denial, judgment or other forces that might get in the way of her full conscious awareness. She decided she needed to get to know herself spiritually again and began journaling every day, with attention to her longings. She began to talk to her family and friends about her journey and found them to be interested and supportive. Just the act of embarking on this journey lifted her depressive symptoms. Her development had been in a transitional stage; seeds needed to germinate before they could be acted upon. Her low energy and down time were, I believe, necessary to the process as well as important cues to where her attention was needed next. Such depression is not pathological but does benefit from our expertise as psychotherapists in understanding what is happening and helping to navigate the new terrain.

Another example of the developmental type of depression is a man who came for therapy because he felt like he was dragging himself through his days and his performance at work was faltering.  This in turn made him irritable which was beginning to affect his family relationships. He didn’t understand what was wrong. He had worked hard to get where he was career-wise and had a coveted position in a well-respected company. He was happy in his marriage. Basically he had arrived where he thought he wanted to be. But then he started having a “dragged down” feeling.  He had been certain it was physical and had gone to his physician. When the physician didn’t find anything wrong, he referred him for psychotherapy. As the client told more, it became apparent that the only area of his life where he was “dragging” was with his work life. Because it was sounding like a fallow season depression, I asked him about depletion or unexpected challenges in his work life. He commented that about a year prior he had moved from working on projects himself, to managing others who worked on projects. There were many things he liked about this—he got to be involved in a wider variety of projects and had a lot of influence over the vision for the projects. But there were many things he didn’t like as well. He complained that he had never been trained to deal with people, and the many ways they get in each other’s way. He felt completely green at helping creative people navigate conflicts. His own style was to be very politely persistent; but he had someone working in his area whose style was very vocal and intense and it wore him out. He respected the person’s work but felt drained just being in the same room. We discussed this as a new challenge he hadn’t expected. We identified some of the skills he might need to develop in order to fulfill this part of his job well. We discussed the choice he had: to step out of a management role or learn new skills to do it well. Once he had a road map, he could make the choices. He was blocked a bit by the belief that he should want the management position and that he would be judged negatively if he returned to the prior role. But, once he had the awareness that his symptoms were telling him something important, he could attend to the cues, could see where his distress was centered and begin to problem-solve. Nothing about his situation was pathological, and learning to understand the cues helped this stage become useful to him.

Personal Accountability

As evidenced in the above two people and many others, I have found that another common block to resolving normal developmental tasks, which can then result in depressive symptoms, is poor skills in what I call Personal Accountability. I believe skills in Personal Accountability are generally poor because our US American culture operates on a dominance paradigm which values blame and shame over true accountability.  Accountability in this model is defined quite literally as “the ability to account for oneself”, with no blaming or shaming involved. When we have the ability to know and articulate our own internal experience, many things are possible that are otherwise out of reach. Personal development is healthy when guided by our own longings because longings (as opposed to mere wishes or wants) are always healthy. It follows that awareness of healthy longings would improve effectiveness in life and thus be antithetical to a number of symptoms of depression. As we can see from the stories of the man and woman in the above examples, a critical part of the therapeutic process was to help these clients become aware of their deep longings. Being aware of longings turns out to be something a surprising few are truly good at doing. For this reason, I sometimes will include Accountability skills training as part of my treatment.

To facilitate development of better Accountability skills, I explain that longings are our best guide to making life choices; that sometimes we have multiple longings; and sometimes those longings are in conflict with each other. For these reasons, we need to become as conscious as possible about our longings in order to sort out our best available choices and take effective action to build the life that serves us best. I explain that Accountability involves three sub-skills: self-focus, self-awareness and self-expression.

Self-focus sounds so simple that therapists, who are generally very good at this, often overlook it as an area for work. Self-focus is merely focusing on our internal experience, so it seems like an inborn ability. While virtually everyone is capable of doing it, many things can get in the way of this ability developing to the degree needed for navigating life well. Cultural norms and shaming experiences are two common forces that interfere with developing self-focus skills. As just one of many examples of the dominance paradigm, in multiple subcultures in the U.S., “boy culture” includes socialization that being male means not having tender feelings and not letting others see what matters.  Boys who show tender or deep feelings are often targeted by others, with shame, abuse and messages of inferiority. Thus, I believe that many boys are socialized to numb self-focus in order to banish tenderness and compassion from consciousness—it can be difficult to hide tenderness if it is felt. Others are trained by their lives to be numb or blind to their own experience in other ways. With some clients, then, therapy requires re-teaching the ability to attend to one’s inner experience.  Gendlin’s book Focusing elaborates this skill in great depth, so I refer you to that book and will not cover self-focus further here.

Once we have the ability to attend to our own experience, thorough self-awareness is the next skill for Accountability. I offer a “map” of internal experience as an aid for developing self-awareness, depicted in Figure 1, which I call the Personal Awareness Path.* (reference Couples Communication and my additions in footnote). To summarize it, our experience begins with sensory experiences—we see, hear, taste, smell, and feel experience first. Then we interpret those sensory experiences; we put meaning to them. Our prior beliefs, expectations, biases, and experiences all impact the meaning we assign to a new experience. We might be firm or tentative in the meaning we assign. Next, the thoughts we have or meanings we assign give rise to emotions. For example, if I think that I have been lied to, I will likely feel hurt and angry. If I think that someone I care for has left me, I will likely feel sad and maybe hurt and angry depending on why I think they left. Next, from the emotions arise wants and longings. I define “want” as a more surface wish and “longing” as deeper. If I am angry, I might want revenge, but the deeper longings when we are angry are usually to stand up for ourselves, to be protected/safe, for the person to stop the hurtful behavior, and to be understood/validated. Surface wants are not always healthy or effective but deeper longings are. The ability to be aware of our deeper longings is key to true empowerment. Next, from wants and longings arise intentions, defined as a pooling of energy and resources towards a particular outcome. Out of our intentions arise our actions. Conscious awareness of intentions allows us to push them in alignment with our values and priorities, which is also empowering. Actions can be clumsy or skillful, but tying them to conscious intentions nearly always adds to effectiveness. The ability to gain conscious awareness, particularly to the point of identifying our longings and intentions, provides new empowerment that combats the helplessness of developmental and other depressions. When difficulties involve interpersonal situations, the skill of Accountable Self-Expression, defined as communication of our Personal Awareness Path, provides the means to navigate through creative resolution of conflicts, appropriate self-advocacy and many other goals.

*Insert Figure 1: Personal Awareness Path (Sensory->Thoughts->Emotions->Longings->Intentions->Actions->Effects)

Identifying Blocks to Self-Awareness

Not uncommonly, self-awareness deficits in developmental depressions and other types are not due to Personal Accountability skills issues per se, but rather to psychological defenses against consciousness. Psychodynamic orientations teach us that when experiences/circumstances/conditions are psychologically overwhelming in some way, we humans have the capacity to block the overwhelming pieces from consciousness. We tend to continue these defenses far beyond the period when they are truly useful or necessary. In a sense, once a defense mechanism has been used and resulted in significant enough reduction in distress, we become more likely to use the defense when just a hint of overwhelm is looming. Even though our current situation might be resolved without too much challenge, we humans often avoid taking on the challenge and instead defend against awareness of the distress. Depending on the psychological and personal costs to using the defense, we may develop highly entrenched habits in defending and never be consciously aware we are doing so. Defending against distress instead of actively resolving the challenge is one type of dysfunction that can get in the way of recovering from depressions of several types.

For this reason, even with developmental depressions, treatment sometimes needs to take a psychodynamic approach of noticing the defensive patterns, helping the client become aware enough to combat the defensive pattern, allowing more distress into consciousness which then can be used in the service of making more empowered choices. Just as we need to know when our skin is too hot to make the good choice not to place our hand on a hot stove, clients need to understand that their distress provides useful cues, of which they cannot afford to stay unaware. Clients must become assured that letting in the distress will lead to something positive, and encouraged to override the too-quick defense.  Often, insight about the current situations that trigger use of defenses is not enough; we sometimes have to help the client resolve older experiences and the old overwhelm, before the client can stop using the defense so readily. It is as if the client has an old wound that is tender and even when a new experience is not all that difficult, if it bumps up against the old wound (if it is enough of a reminder of the old experience), the client will feel compelled to defend against the new experience as though it is as wounding as the old experience. If I have ever had a broken foot, I might be extra sensitive and protective in crowded situations, even if my foot now would not be terribly hurt were someone to accidentally step on it. This unneeded protectiveness might be limiting my life in important ways. Becoming fully aware of both the prior need for this protectiveness along with the current safety to take more risks would open up more possibilities in my current life, without shaming or blaming myself for being “overly sensitive” in this situation and without any denial of the prior hurt. This combined compassionate awareness of a prior hurt with work to heal it, along with awareness of present day safety, strengths and resources helps the client let go of no longer needed defensive patterns that can block personal awareness and effectiveness.

Grieving

Grieving is often a part of the therapy for developmental depressions, whether due to leaving behind phases of life that were enjoyable or comfortable, or resolving old traumatic or overwhelming circumstances that led to habits that block our new development. To many clients, grieving seems the exact opposite of what will improve their depression. Why would I want to take on more painful feelings when I am already feeling down? This question often must be addressed directly in therapy. Healthy self-advocacy warrants such a question and we should be accountable for why grieving work will lead to the outcomes the client wants. When we give them the road map for this process and where it leads, they know why it is worth doing.

In many situations, I find I must explain what grief really is. I blame our mainstream U.S. culture again for misunderstandings about grief. With U.S. culture’s messages that we should always be upbeat, many people do not understand that grief is not a weakening process but a strengthening process. It is transformative even. Grief is not “wallowing” or “whining”, as many have been taught. Grief is the full feeling and acceptance of a loss or a legitimately helpless circumstance. Grief is also paradoxical. The process of mourning a death for example, provides the capacity to more fully integrate the relationship with the person into our ongoing sense of our lives—in a sense, grieving the loss allows us to “keep” the person more. The process of fully accepting that a path we chose no longer works for us opens up room in our lives for a path that will work even better. The process of full painful acknowledgement of traumatic, helpless experiences makes us bigger inside in ways that leave us more resilient and powerful than we were. Without the grieving process, we are left with a lower level pain, but one that will not resolve and will block growth. Grief does not damage us unless we block its full processing.

I often use the metaphors of training for a marathon or building up muscle to encourage a client to accept grieving. If you try to run a marathon with no training, you likely won’t succeed and could even overwhelm your body enough to create serious health problems. But if you run a quarter mile today, a half mile in a few days, and gradually build up, you will not only run the marathon but have abilities you never had before, that will be with you long term. If you pick up 3 lbs. today, 5 lbs. next week and so on, someday you will be able to pick up a huge amount of weight, which will not only achieve that goal but leave you with strength for other goals you might never have thought possible to achieve. If you never get running or never pick up the weight, you remain as easily winded and weak as you are in your most run down moments. Grief is the same—if you block it you are stuck with it, if you take it into consciousness and feel it, you become stronger than you ever were. The concept of “strength” being equivalent to stoicism is completely backwards. We become emotionally and psychologically strong by letting in feelings and fully integrating the loss experiences, not by pushing them out of consciousness.

In summary, developmental depressions are not pathological but do improve with psychotherapy that includes self-care training, normalizing, providing a road map, self-accountability, and addressing various blocks to self-awareness. All of this in turn leads to better awareness of the developmental task and the true choices available to achieve the development needed.

Bipolar Depression Very different from developmental depressions are depressive episodes arising from Bipolar Disorder. Although it is important to remember that people with Bipolar Disorder also have fallow seasons, to treat their depressive symptoms as merely cues to next developmental tasks would be a disservice. We have ample evidence that Bipolar Disorder is in part a physiological dysfunction, likely highly genetically-based (*example refs). As such, medication to help stabilize the functioning of the neurophysiological system is essential for many if not most people with Bipolar Disorder. But psychotherapy has a pretty important role to play as well.

Self-Care. In my experience working with people who have Bipolar Disorder, all the self-care strategies mentioned previously become absolutely essential. Though the person is biologically prone to destabilize and that is not within the person’s control, minimizing the stresses on the neurophysiological system is within the client’s control. The self-care strategies described previously seem to help tremendously, though are even more difficult to maintain for the person with Bipolar Disorder due to the nature of the disorder. When manic, sufficient sleep and nutrition is a huge challenge; when depressed, sufficient exercise, nutrition and social time are a huge challenge. For these reasons, I strongly emphasize building very sturdy habits in these areas as a primary goal with clients who have Bipolar Disorder. Some people with Bipolar II Disorder who are able to maintain very sturdy self-care habits can function well without medication.

A number of other issues that are responsive to psychotherapy intervention arise when clients are dealing with bipolar depressions as well.

Grief about the Bipolar Disorder. Many people with Bipolar Disorder struggle to come to terms with having a disorder for which there is no cure; for which medication will likely always be needed; and which, for many, requires a significant lifestyle change. Being different than others and having to make so many accommodations to the disorder are hard circumstances to accept. Many also struggle with giving up the “highs” in order to stabilize enough to diminish the “lows” to manageable levels. They strongly identify with the person they feel they are when in a hypomanic or manic phase and feel they are inferior or not at their best when in more stable ranges. Sometimes they are more productive, more creative, more socially adept, for a short time while manic--before they become psychologically disorganized and depressed. So we can understand the wish to find some magic to be in the “high” phases without the depression. But that magic doesn’t exist and this is a huge disappointment for some. Many people with Bipolar Disorder, in my experience, also need to grieve the damage to their relationships that arises from their behavior during the severe manic and depressive episodes. For example, one client I remember was very harsh when hypomanic, even becoming violent with loved ones when fully manic, only to be very dependent on their goodwill when depressed. As she improved, she faced crippling guilt and self-loathing about her behavior while hypomanic or manic. She needed interventions to repair her self-compassion and ultimately grieve the pain and helplessness of these time periods, while also directing energy to rebuilding her empowerment to do her best to prevent recurrences of the aggressive behavior and the episodes themselves. Helping clients accept and process the real losses inherent in this disorder while also embracing choices and empowerment that is within reach is the balance I seek in psychotherapy for these issues.

Substance Abuse. Unfortunately many people with Bipolar Disorder also have substance abuse problems. For some, alcohol or other substances relieve the agitation of the mania. Whether they consciously use to manage the symptoms or not, substance use is getting reinforced because of this relief. Others abuse substances due to impaired judgment, increased high-stimulation social activity and increased risk-taking that can be part of the manic phase. Some also abuse substances during their depressive episodes.  For example, a number of clients over the years have acknowledged amphetamine use during depressive episodes to try to recreate a hypomanic state and stave off depressive symptoms (though it never works for more than a short time). There are probably a number of other triggers for substance abuse. When we don’t like what it feels like to be us, we humans try to change our state of mind through many substances and activities, some more healthy than others. If we can help our clients consciously identify the deeper motivation or function of the substance—how does it work for them in the moment?—then we can help them achieve that purpose in a more healthy way. If they are drinking to calm agitation, I let them know it is normal and healthy that they want to calm the agitation but the alcohol too often has other effects that create problems in their lives. Helping identify and effectively use other strategies to manage their state of being can be very significant new empowerment. For example, taking prescribed medications that specifically target the symptoms and have fewer physical side effects and rarely any negative social effects is far preferable to the destruction of alcohol abuse while manic. Self-care strategies also often make a significant enough impact on stable functioning to make it easier to reduce substance abuse.

In summary, the primary goals for the psychotherapist working to help a client with Bipolar Disorder are to develop sturdy self-care habits; to accept, grieve and identify positive choices regarding living with the disorder; to cope with the reality of the suffering that comes with this disorder; and to address substance abuse problems. Almost always, the client will need medication to be part of the treatment plan.

 “Scorched Earth” or Traumatic Depressions A third type of depression I frequently have seen over the years is what I call “scorched earth” or traumatic depression. These are times when we feel done in by life events, when our hearts and souls feel scorched and perhaps even partially destroyed following very difficult, overwhelming or traumatic events. During these times, our weak spots, helplessness, or lack of effectiveness have been highlighted to a very disturbing degree. Such events might include death of a very close loved one, traumatic violence, natural disasters, and others. Unlike fallow season depressions which are likely necessary to our development, and unlike bipolar depression which is primarily due to neurophysiological malfunctioning, scorched earth depression symptoms arise from psychological damage and from the psyche working on healing in the aftermath of quite damaging events. Though individuals may differ in specific depressive symptoms, the symptoms are mostly attributable to the nature of the event and not to the specific make-up of an individual. Many if not most people would end up with similar depressive symptoms after the experiences these folks have had. People in scorched earth depressions can experience very painful sadness, dismay, and powerlessness in addition to the low energy, low motivation, and bleak perspective of “depression.”

Although the depressive symptoms of a scorched earth depression tend to interfere greatly with usual daily functioning, these symptoms are not pathological per se. The symptoms are representative of a natural healing process and generally progress toward better rather than worse functioning, even with no intervention. During scorched earth depressions, we are conserving energy and working on inward healing processes. External output needs to be minimal to allow healing, just as it does with serious physical injury or illness. While relief from some of the worst of these symptoms through temporary use of medication is appropriate in some cases, for the most part I believe treatment providers should take the depressive symptoms as a huge signal that the person needs a break from daily obligations. If they have trouble getting out of bed in the morning, they might benefit much more from rest than medication, for example. If they have trouble being around others because it is difficult to participate in the lighter exchanges that are typical of most social interactions, they will likely benefit more from time and support to grieve than from medication.

Stage-specific interventions.  People seem to go through three major stages of recovery from traumatic events (*refs): crisis, adjustment, and recovery. Our therapy interventions should be gauged by the needs of the psyche in each stage of recovery. During the crisis phase, the primary need is safety and equilibrium. For example, in the early crisis phase, we would only encourage exploration of the event if the person needed to tell of the experience to put some order to it and not feel so alone. This would serve equilibrium and safety needs. But we would not probe for the client to tell more than he/she is naturally inclined to, which would tend to upset equilibrium. We would provide compassionate active listening but we would not probe for further emotional processing or even further description of the incident. During the adjustment phase, the overwhelmed individual needs to reclaim as much control and functioning in her or his life as possible. The traumatic event upset the sense of power, competence, effectiveness, and connectedness to help. The adjustment phase is a time of deeper stabilization, and grounding in what power the client does have in life. During the adjustment phase, the client is rebuilding or at least testing how strong she or he is in these areas. Some therapists are tempted to call this a stage of denial and work to “break through,” because the damage is not being addressed. I believe that is a significant therapeutic error at this phase. I believe the Adjustment Phase is a natural and necessary phase of getting regrounded, of pooling internal and external resources needed for the final healing process to be less difficult. Then in the final phase, when the client is safe enough, stable enough, and has enough to bring to the process, the fuller integrative healing can occur. Now it is appropriate and therapeutic to address the damage done and this will nearly always include remembering the event, at least all the unprocessed hurtful elements. But when done within the context of good-enough safety, grounding, and resources to support the healing, this phase leads to phenomenally higher levels of functioning. People get “bigger inside” through the process of trauma recovery, just as through grieving. Although we would never choose such a difficult path to growth, if a traumatic experience has occurred, we might as well help the client gain the full measure of growth in the aftermath. Knowing where the integration process leads will help a great deal in maintaining the client’s motivation for moving through the pain. Much as a physical therapist helps a patient distinguish between “injury pain” and “healing pain”, psychotherapists must help the traumatically depressed client to protect himself/herself from painful damaging experiences while approaching painful healing experiences.

Regarding the depressive symptoms in particular, I intervene differently at each phase of recovery from a traumatic depression. During the crisis phase, I find the distress and “down” aspects usually to be related to the blow to the client’s prior sense of goodness, of predictability, and of personal power. Scorched earth events challenge the whole foundation on which we base our choices in life. Even if we knew things like this could happen to people, we rarely truly expected them to happen to us. Who could live that way? So when such things do happen to us, we are not easily able to respond effectively and rarely have any experience to help us predict how bad it will be. Our normal ways of being in the world become disorganized. In this phase, I work very hard with clients to provide predictability for what life might look like for them in the next several months. I provide a lot of psychoeducation and reassurance, I explore their prior experiences that will give them wisdom to draw on and that also remind them they have gotten through tough things in the past. Beginning to see that life as they knew it is not entirely over, and dealing with it is not entirely beyond them, brings hope. Hope in turn brings energy and motivation. I also work on keeping their attention open to the range of experience in their current life. Most have a tendency to become vigilant to the negative or dangerous experiences in life and fail to notice the equally positive experiences. Keeping hope alive for the possibility of a less distressing, even fulfilling, life is a primary goal at this phase, serving to counteract the depressive pull in terms of thoughts and beliefs. Regarding sad or angry feelings or the wish to sleep a lot or avoid social interactions—I encourage clients to accept these as normal and give themselves compassionate time to heal. I encourage them to seek support from those who won’t ask them to pretend they aren’t hurting and/or can remind them of the positive aspects of their lives without denying the traumatic experience.

I generally start to see some return of energy and a wish to reconnect to their “old life” somewhere from two weeks to two months after the event, but this is gradual. I keep an eye out for hints that this is beginning and help the client notice them, pointing out she/he is on track in recovery and encouraging conscious decisions about priorities regarding what to reclaim first, attending to pace. Rarely does a client wish to talk about the devastating events in this phase, except to express anger or frustration at the challenges they are facing in their current life. My interventions at this point are primarily cheerleading—helping to recognize progress and maintain motivation for more work, encouraging the client to take on more and more of normal functioning while attending to energy and capacity for this work. This phase can last anywhere from a few months to many years, but typically in my experience, clients are ready for integrative recovery work sometime between 6 months and 2 years after the event.

When they are safe enough, stable enough, grounded enough, people start to notice the areas in their lives where their wounds are still impacting them in ways they don’t like. Sometimes they have noticed they aren’t functioning as they wish, but haven’t connected it to the traumatic experience. Many clients have a resurgence of what might be called depressive symptoms—feeling bad about themselves, others or life in general; having reduced energy for the challenges life presents; less hope for longings to be met, and others. In this phase, my interventions emphasize pulling the salient unprocessed aspects of the difficult experience into full consciousness and facilitating full experiencing of the meanings, emotions and longings associated with the event. I provide psychoeducation about what will be gained from the conscious processing vs. numbing of the impact of the event—the light at the end of the tunnel so to speak. This is a tremendously transformative time, often intensely emotional, often involving building new perspectives and views on people, relationships, good and evil, etc.

What I hardly ever do at this phase is suggest medication. I only suggest medication if the client’s natural containment capacity is being overwhelmed. This can happen if the client came to this phase by a retriggering event rather than by natural readiness. It can also happen with clients who already had difficulty managing affect before the traumatic event. But for all other clients, medication could interfere with the goal of this phase: to accept the experience into consciousness and understand its impact, develop meanings and build a new life approach that takes this experience into account without giving it more weight than is warranted. In my experience, medication often interferes with or slows down this process tremendously, again with the exception of those who have significant difficulty managing affect anyway or who were triggered into this phase by a new difficult event.

A couple of aspects of therapy with traumatic depressions warrant emphasizing. The first is that recovery is a built-in process that will usually progress eventually, with or without a psychotherapist involved but will progress better with a qualified psychotherapist. This is very similar to the physician’s role in treating, for example, a broken bone. The bone will heal well or badly on its own. The physician’s role is not to make the healing happen but to create the conditions under which the healing will happen best to restore the fullest functioning possible. In trauma recovery treatment, we do not need to make the healing process happen, we need to facilitate an existing process to progress more smoothly. On the other hand, humans have tremendous capacity to block many psychological processes, including healing processes, particularly when we mislabel them as a threat in some way. Because of this, treatment in the final phase of recovery from traumatic depression is very much about removing blocks to the natural process. I don’t have to know what a client needs next, I only need to notice where the client numbs out, avoids, skips over, minimizes or otherwise seems to be trying not to fully know--then help them know, and know safely. The second aspect is that it helps me and the client to remember that she or he has already psychologically survived the event. The remaining work is not survival but integration. Because the client has already survived and carried around this terrible experience, we know that he or she already has the strength needed for integrating the experience, provided a safe and stable enough life situation currently. I can say this with confidence to a client because the strength it takes to go through the integration process, in my experience of this work, is actually less than the strength needed to carry it all around while defending against it, keeping it outside of consciousness. Psychological defenses take energy and strength. Though many will fear they can’t handle it, they already have handled it in a manner harder to sustain than recovery processes are. The recovery process will sometimes include more emotional pain intensity than defensive coping has, but those intense times will abate, and the processing of the event liberates energy and even liberates aspects of the self that are being kept numb. I can think of no exceptions to this among the clients with whom I worked who were integrating traumatic experiences--which gives me a great deal of confidence in the process. I can then pass along this trust and confidence in the process to my clients.

One other challenge in treating scorched earth depression is the impact on us as therapists. Sometimes what has happened to our clients shocks our world view because it is outside our previous understanding of people and the world. In these cases, a miniature version of integrative recovery for ourselves is needed, too. As compassionate beings, we are also challenged by the pain of watching someone else in tremendous psychological or emotional distress. We cannot numb ourselves and remain effective, so this work requires us to develop greater capacity to hold intense experience in consciousness and to remain sufficiently connected to the client during such times, while also maintaining good access to our clinical expertise and skill. We will benefit personally from being stretched in this way but it is difficult nonetheless.

Shutdown Depressions The final type of depression is what I call Shutdown depressions. I find it to be the most common type and yet the least understood by therapists, as well as people in general. Unlike the others, this type of depression seems directly connected to the distinctly human version of the Threat Response. Other than the self-care strategies which are indicated for all the depressions, treatment implications are quite different for Shutdown depressions than for the other types. With developmental and traumatic depressions, we would help the client move into the depression, to understand the cues or to process unresolved damage. In contrast, with Shutdown depressions, we must help the client extract themselves from a mistriggered process. This will likely be the least familiar conceptualization for most readers, so I will elaborate much more in the following sections. Due to space limitations, in some cases the material is simplified more than I would like, but in its essence is accurate enough to my knowledge.

Entire books have been written on aspects of the Threat Response (see for example, Biology of Aggression by ***), but I will do my best to lay out the core pieces for our purposes here. One basic premise is the idea of the triune brain (see for example, *****): that is, the human brain has three major components that represent significant evolutionary developments. The most basic functions are managed by what some call the reptilian brain—the brain stem primarily. The fight, flight or fright (fight, run or freeze) responses to threats are like a program run via this part of the brain. We share this response to threats with animals all the way down the phylogenetic tree to the reptiles. For reptiles, the response is triggered by such events as physical threat and challenges for food. Once triggered, the Threat Response behaviors themselves are quite similar whether reptile, mammal or human: heart rate increases, breathing moves to the chest muscles and rate increases, blood flows less to internal organs and more to large muscles, etc. People describe constriction of thinking too—a kind of tunnel vision focus on the threat stimulus, to the exclusion of other information. The only possible outcomes of this reptilian brain Threat Response are to freeze, run or fight--or (most typically) some combination of the three.

However, there is another branch to this Threat Response program that isn’t usually talked about. Peter Levine’s writings (such as Waking the Tiger) offered my first insight into this other branch, though he describes it differently than I do here. Levine wondered why prey animals such as deer seemed to recover so well from even daily life threatening events, while we humans seemed so vulnerable to post-traumatic stress symptoms. I participated in a training workshop with Levine’s group in which they showed a film illustrating the Threat Response in a deer being pursued by a cougar. They had filmed this pursuit in order to study the deer’s recovery process. In the film, the deer first freezes, then runs, then seems to consider fighting with its hooves, but the cougar is winning the battle. At the moment when it seems inevitable that the cougar will be digging its teeth and claws into the deer, the deer collapses. Apparently, the researchers chase away the cougar and continue to film the response. The deer is still on the ground, but is not unconscious. However, you can see that, in dramatic contrast to its state just moments before in the pursuit, the deer’s eyes are glazed over (but open), the deer’s breathing is barely visible, and its muscles appear completely flaccid. After several minutes of no further danger, its eyes appear to clear and it looks around without moving its head. Satisfied that the cougar is not nearby, its ears then begin to rotate. Hearing no further cause for alarm, the deer now goes through an interesting process of recovering from this state. First, we see it take three or four very big sighing breaths. As it takes these breaths, its muscles appear to tremble significantly. Then it jumps to its feet and goes bounding about for a few minutes. I took this to be a discharge of pooled energy. Then the deer returned to calm grazing. The collapse appeared to be a shutting down process. The capacity to collapse and shutdown like this, then “reset” when not killed, must have aided species survival—perhaps when a creature isn’t killed, survival after an attack is easier if shutdown has occurred. At any rate, shutdown and recovery from shutdown appears to look pretty much the same, throughout all the species with a Threat Response. The process after the shutdown phase appears to be a neurological reset with three parts—reorientation to threat absence, belly breathing, and large muscle energy discharge. We humans have these threat response, shutdown and reset “programs” as well.

However, the other parts of the human brain—the mammalian brain and the neocortex—can create serious problems with mistriggering of the reptilian Threat Response program and blocking of the reset program processes. The mammalian brain becomes involved in most of our human interpersonal processes—particularly those involved in reproduction and in being part of a “pack”. Our mammalian and reptilian brains interact in that the mammalian brain recognizes additional “threats”, which then (mis)trigger the reptilian fight/flight/fright responses. Whereas reptilian threats are very much threats to individual survival, mammalian threats might be thought of as threats to genetic survival: mate jealousy, protection of young, status in the group, protection of our own group against physical threats by another group, territorial protection of food sources. Not only can we see fighting, running, freezing in these situations with mammals, but we also see the shutdown response when fighting, running and freezing aren’t “working.” Mammals “give up” when they perceive they can’t win a particular battle.  With especially higher mammals such as primates, we also see the emergence of a new response to threats, which is variously called “tend and befriend” (refs?), “social--**”(refs) in other literature. I call it placating. Placating might have originated as a response to a distressed infant. Particularly female primates, when faced with aggression, sometimes will attempt to soothe the aggressor rather than fight, run, or freeze. We humans exhibit the reptilian brain threat response to these same triggers (mate jealousy, protection of young, status threats, us/them threats) and also show the mammalian placating response to threats.

It gets even more complicated, and unfortunately even more dysfunctional, when the neocortex is involved. With a neocortex, we humans are capable of abstract reasoning, symbolic thinking, imagination, perception of future and past, and many other great feats that give us advantage in evolutionary survival. However, these same processes produce new sources of “threat”, which in turn mistrigger the reptilian and mammalian threat response programs. The neocortex brings with it the possibility of fearing the future, fearing the imagined, fearing images of things that aren’t there, fearing our possible low worth, fearing being afraid even! The possibilities for imagining fearful circumstances are endless for creatures with an advanced neocortex. If the fear experienced while imagining circumstances is sufficient, it will trigger fight, run and freeze responses. But we cannot fight the future into submission, we cannot run from the effects of the past, we cannot prevent any imagined outcome by freezing. We also can’t placate the forces of life. Sadly, though, we try—because we are wired to do so! We may feel gratified by trying to engage neocortical threats in reptilian threat response ways, but it isn’t effective. The sad reality is that our fancy brains set us up to be mistriggered into a program that not only doesn’t actually create the outcomes we want but usually makes things worse. And if we keep doing things that don’t work, we start to perceive that we are “losing the fight”, and now the shutdown response might be triggered. We numb out, we disengage from problem-solving, we disengage even from actions in other areas in our lives where we were effective! Now we are in a self-perpetuating cycle—the more we feel ineffective, the more we shut down, which means we lose further motivation and energy for maintaining or improving, which leads us to feel more ineffective, so we shut down more, and so forth. To make matters worse, with our neocortexes that often respond to signs of things as the real deal, we humans are very easily conditioned to perceive the hint of a threat as the harbinger of a full-on threat, to perceive the hint of ineffectiveness as an indicator of full-on failure, to perceive the hint of rejection as just the first step to being a full-on outcast. We are prone to over-respond to stimuli or events that are indicators of high threat-value events. This over-responding makes us especially prone to triggering the reptilian defensive threat responses or the mammalian placating response, none of which lead to effective functioning in reality.

The condition of being easily triggered--and for such a wide variety of situations--might not be a bad thing if the reptilian threat response behaviors of fighting, running, and freezing, or the mammalian placating behaviors were useful to us. But these behaviors are actually never the best response that a skilled, problem-solving neocortex could come up with. Even when faced with a physical survival threat, most of us could come up with better responses than fighting, running or freezing. If, like the deer, we were pursued by the cougar, the reptilian responses would not be useful to us. With less dangerous teeth and claws than the cougar and likely less physical strength, fighting would leave us on the losing end. With less speed and agility than the cougar, running would also leave us on the losing end. Besides cats love to chase. Freezing would just put us in a stalemate unless the cougar lost interest. Experts advise us to make ourselves bigger by putting our arms up, and gradually back away, while also leaving the cougar an exit route. You need a neocortex that is not in a threat response program to remember that when you need it most!

Even bigger problems in functioning arise from repeated mistriggering of ineffectual threat responses. First, repeated mistriggering will lead to varying degrees of Shutdown. Just as the deer collapsed and numbed out when the battle with the cougar seemed lost, we humans enter varying degrees of a similar state when our ineffective responses to threat make no improvements on our situation. Second, as creatures with conditioned learning processes, we are prone to very easily enter a Shutdown state because Shutdown diminishes immediate distress. For example, a child raised with domineering parents who use shame and physical punishment to discipline is rendered helpless time and again. Particularly if the child’s natural defensive responses (fighting, running, freezing) are further punished, that child likely will become conditioned to enter Shutdown at the slightest sign of dominance. Even when the other person would not in reality be able to enforce dominance, the child (and later the adult) is likely to respond in the way that reduced distress in the past—with Shutdown processes.  This conditioning can be extremely resistant to extinction because it is so effective in reducing active distress in the moment. Although it is completely ineffective in resolving interpersonal difficulties in nearly every other situation, the immediate relief from distress blinds him or her to that awareness. The conditioning to easily enter a Shutdown state can become a lifelong pattern, occurring completely outside of consciousness.

The Shutdown state itself, when chronic, looks a lot like dysthymia and when more acute can get severe enough to qualify as a Major Depressive episode. While in Shutdown, we are highly compromised in our ability to address difficulties or to build a fulfilling life, which contributes to depressive symptoms. When depression is arising from Shutdown processes, the treatment must include building skills for recognizing and pulling out of the threat response “programs”. The skills needed to do this are several, but none of them are terribly difficult to master sufficiently. First, the therapy can target the process of how life events are identified as threats and use cognitive techniques to change labeling from “threats” to “tricky situations” or “disappointing situations.” This approach is only appropriate when there truly are no major threats to safety in the client’s current situation. In my experience, with most depressed clients of this type, very rarely is their distress due to true survival threats. (Those with true survival threats usually have different symptoms.) This treatment component corresponds to the classic cognitive therapy approach to depression, but it is only one component.

A second target in treatment of Shutdown depression is the skills needed for self-assessment and self-management of the reptilian brain or sympathetic nervous system Threat Response itself. I have almost never met a client who had already been made aware of and learned to manage the sympathetic Threat Response, so this becomes a significant focus for many. I start with psychoeducation about the built-in Threat Response and use specific examples from the client’s own description of symptoms, experiences, frustrations to illustrate how it applies in this situation. I usually tell the story of the deer, including the active defense and shutdown phases, as well as what the deer does after the cougar leaves. I then invite the client to identify body cues that might signal that he or she is entering the active threat response—such as increased heart rate or pounding in the heart, tension in the shoulder and arm muscles or leg muscles, clenching the jaw, pit in the stomach, and others. I assign the client to work outside of session on identifying ever-earlier cues as well, because the earlier we are aware we are entering the Threat Response program, the earlier we can intentionally pull out of it. I remind the client of the story of the deer’s recovery process after the cougar left—orienting, big sighing breaths, and big muscle exercise. The comparable skills I teach to imitate the deer’s neurological reset are Sensory Grounding and Belly Breathing in the moment, with (non-aggressive) large muscle exercise when possible. Sensory Grounding is merely turning the focus to detailed sensory stimuli present in the current moment: noticing the specific color of the walls, the feel of the air on skin, the sound of the heating/air conditioning, the feel of the fabric on skin, etc. Shutdown is a process of tuning out or dissociating to varying degrees and purposeful efforts to notice sensory stimuli effectively blocks shutdown for many clients. Belly Breathing is even more essential in my experience though. (Some have called this diaphragmatic breathing but I prefer the simpler term for use with clients.) Without the Belly Breathing, people seem to continue to fight against active defense or shutdown responses; effective Belly Breathing appears to shift the nervous system from sympathetic to parasympathetic. I invite clients to consider how common it is for us to give a big sigh when a particular stress has passed and offer this as an example that this is a natural process and we can get the same result more quickly when we do this on purpose, which will open us up for more effective responses. For people who are new to Belly Breathing I teach the following process: “Place one hand in the center of your upper chest and the other over the belly right about where the rib cage comes together (solar plexus area). Now let out all the air in your lungs and begin to breathe for 6 counts; in-2-3-4-5-6 now hold-2-3-4-5-6 now out-2-3-4-5-6 and in-2-3-4-5-6, hold-2-3-4-5-6 and out-2-3-4-5-6. Now keep going and try to push out the hand on your belly while keeping your hand on your chest pretty still. And now let’s start again, let all your breath out and breathe in-2-3-4-5-6 and hold-2 –keep going but notice what is happening in your body—pay attention to your large muscles especially. For me, right about on the hold-2, I start to feel a warmth in my shoulders—other people might feel a shift in their legs, their face, their back; just take note of any changes you feel in your muscles and as you breathe all the way out notice the further change in muscles. As you continue, you also might notice a change in the quality of your thinking—some people describe feeling more alert but relaxed. Okay, let’s stop for now and tell me what you noticed about yourself while you were doing this.” Sometimes, I notice that the client is still “chest-breathing”—the chest is rising rather that the belly extending and I will intervene or have a second training to work on getting the extension of the diaphragm. In my experience with myself and in working with clients on this, the neurological reset we want does not occur without a significant stretch of the diaphragm. The “hold” portion of the breathing exercise helps achieve that stretch without hyperventilating.

When a client can notice her own body signals of entering the defensive or shutdown processes of the Threat Response, and then initiate effective sensory grounding and belly breathing, she is basically reconditioning herself to respond to certain stimuli with a new physiological response, which in this case will also bring opportunities for different actions to address the “threat”.

Following the retraining of the mind not to mislabel situations as “threatening” when they are not, and teaching the skill to pull out of the Threat Response program, some clients can then engage their already good problem-solving and other skills to make effective choices to build the life they want for themselves. Other clients, especially those who came to states of Shutdown through repeated traumatic experiences or chronic domination, will need further treatment components to provide re-empowerment. These clients will often need help to fix what I call “power dysfunctions” through developing what I call True Power.

Developing True Power includes a paradigm shift away from the reptilian brain’s formulations of power as “survival of the fittest”, away from battles of domination, and towards higher human functions. Re-empowerment and the repair of power dysfunctions requires skills in three areas, which I broadly categorize as Personal Respect, Personal Accountability and Personal Responsibility. In the True Power paradigm, Personal Respect is defined simply as the ability to maintain value for oneself and others at all times. Personal Accountability is defined as simply “ability to account for one’s experiences and choices.” And Personal Responsibility is defined as the ability to respond effectively in the services of one’s own values and intentions.  

Self-management of the Threat Response program is one skill in the Personal Responsibility category. Other Responsibility skills commonly needed include good communication skills, affect management, interpersonal boundary-setting, creative conflict resolution and more. Full elaboration of these Responsibility skills would take more space than possible in this paper; but hopefully many of these are already familiar enough to the reader. 

Personal Respect includes attention, valuing, nonharm and nurture--skills imparting four levels of increasing Respect. The Latin root of the word “respect” means “to look again.” The mere act of paying good attention to something imparts value. The next level of valuing is more like a standard or moral belief—if we hold that all people are worthwhile (including ourselves), we will make more effective choices. A commitment to nonharm is a further anchoring in a path away from the behaviors of the Threat Response. If we hold that even when someone appears to be a threat to us, we will maintain attention, value and a commitment to nonharm, then we will be able to access more effective choices than the Threat Response would lead to. When we can invest our resources and energy for the growth and development of ourselves and others, this is the highest form of Respect and also imparts the most true power to engage in actions that help build the life we want.

I have mentioned this idea of building the life we want as a goal of empowerment, which in turn is the “fix” for some of the symptoms of Shutdown depression. It follows that a critical aspect is that we need to know what we want. This is surprisingly difficult for many people. Surprising until we learn how their life experiences trained them not to know, that is. Authors such as Alice Miller (Drama of the Gifted Child, Thou Shalt Not be Aware and others), make a case that normative child-rearing practices often encourage just such “not knowing.” Though there is much to say about this and other reasons clients might have difficulty knowing themselves and what they want, I will have to forego that discussion in the interest of saving space. Whether we know all the reasons or not, though, we can teach skills that at least to some extent will help override the old training not to know.

I reviewed Personal Accountability in a previous section, identifying three skills that each lead to deeper levels of Accountability which in turn imparts increasing capacity for effective action. The first level is simply the act of self-focus. Gendlin’s book Focusing is one of the earliest elaborations of this skill. Much of the mindfulness literature of the past decade also addresses this skill. Self-focus even at its most basic level, counters the Threat Response because in the Threat Response there is a natural pull to hyperfocus on the threat, not the self. If a cougar is crouched nearby and watching me, I will be very focused on its every detail, from the tension in its muscles, to the intensity of its stare. What I won’t be very aware of in that moment is how glad I am that cougars are not extinct. I won’t be aware of my higher values and intentions regarding cougars. Unless I have become very good at managing my Threat Response, my thoughts will be solely focused on how to “win” by fighting, running or freezing. I will be willing to hurt and even kill the cougar if I am not self-focused enough. But I likely won’t win in terms of my safety or my higher values if I remain in the threat-focused mode inherent to the Threat Response. If I am able to self-focus, I will then be able to access my neocortex strengths and remember that fighting, running or freezing are actually very ineffective ways of dealing with large cat threats. I don’t have the strength, agility, teeth or jaws to match the cougar in a fight. Cats love to chase and given they are likely to be faster than me, running won’t keep me safe. Freezing might save a few moments but we are still at the mercy of the cat and not in control. If I am able to self-focus, belly breathe and get out of the Threat Response, I will remember and be able to access my knowledge that the best way to deal with a big cat is to display as big as I can (stand tall, even raising arms) and back away slowly while also giving the cat an exit route. (ref?) Similarly, with human interactions, self-focus will pull us away from ineffective threat response behavior and allow us to access our higher level knowledge and skills. But self-focus also provides the foundation for self-awareness, which is the guidance needed to even know what skills are called for.

Self-awareness is an easy concept in general. We focus our attention on ourselves and we inherently gain an increased level of self-awareness. However, because the human mind is capable of many defenses against full awareness, purposeful focus on specific aspects of our experience becomes important. Such purposeful focus counteracts the “not knowing” forces of Shutdown. The Personal Awareness Path depicted in Figure 1 provides a map for the important aspects of our experience.

Beyond self-awareness, True Power requires the skill of self-expression—which is the articulation of our self-awareness. It might not be obvious at first, but this ability to account for our experience and especially our longings and intentions is very critical to True Power. We have to be able to name our self-awareness to use it effectively to guide action. The more refined and accurate our ability to articulate self-awareness, the more refined and effective our actions in the service of longings will be. The more we are able to serve healthy longings, the more satisfied and meaningful our lives will be.  Effectiveness, satisfaction, meaningfulness are all antithetical to depression.

Although it might seem obvious, it bears stating outright that effective treatment must include the therapist maintaining her or his own Respect, Accountability and Responsibility practices within the relationship with the client. This will help the therapist avoid responding from a Threat Response stance to even clients who engage in aggressive or passive-aggressive styles; this will help the therapist avoid dominating or engaging in privilege-based interactions which disempower the client; and it will help the therapist teach Respect, Accountability and Responsibility by modeling. For some clients (though not all), the healthy relationship with the therapist also seems to have a corrective or reparative effect—almost as though the client comes to believe that he or she must be worthy because the therapist has treated him/her so.

For some, especially those who experienced chronic trauma and domination, treating a Shutdown depression will also require full-blown trauma recovery treatment. I often integrate empowerment-oriented treatment components with trauma recovery. It isn’t enough to simply heal the trauma when normal development of self-respect, self-awareness, and self-advocacy abilities were also thwarted. We also need to spur the development of these. It also isn’t enough to train in these skills if the reason they weren’t developed in the first place is because they were repeatedly traumatized. In many cases, both treatment elements need to be addressed simultaneously.



[i] In all clinical examples, I have blended several client’s details and clinical dynamics, to preserve confidentiality while also presenting a realistic clinical picture.