(This is revised from an earlier post.)

Amy: As part of my family therapy practice,  I often  work with  women who consider themselves depressed. Often these women see this as a purely personal struggle, believing they have a “chemical imbalance”. They often feel burdened and alone, and responsible and/or guilty for their depression.

Unknown-1In fact, depression is rarely a simple personal affair. Most often, the roots of depression can be found in that person’s intimate relationship sphere, where important parts of our happiness/unhappiness live. The tricky thing is that often women may not think of their depression as being related to their self-expression: Our medicalized psychotherapy culture has too often reduced questions of depression to genetics, or other seemingly “scientific”, static explanations. This can create a huge missed opportunity to explore what our depression may be trying to tell us—about our lives, and our relationships.

Here’s a clinical case from my office that illustrates what I’m talking about.

The first call came from Jake, a fifty-something architect, who wanted to bring his family to see me for a consultation. His primary concern revolved around the troubled relationship between him and his twenty-six year old daughter Brittany.

A Snapshot of the Therapy:

The father, Jake, was clearly the overt powerhouse in the family. He presented himself, as his wife Paula characterized him, as “the kind of guy who knows right from wrong”. A strong autocratic streak, he prided himself on maintaining order and decorum, though he did this in a rather subtle and sophisticated way. His daughter’s recent decision to apply to  Divinity School drove him mad. He thought this represented her “impulsive streak.”. Though Jake clearly cared about his daughter, he specialized in trying to poke holes in Brittany’s way of operating in the world.

Brittany, a bright, thoughtful, intuitive young woman, spent a lot of her family life in ongoing verbal battles with her father. Her decision to attend Divinity School actually seemed like a perfect fit for this humanistic, spiritual young woman. Brittany both wanted her Dad’s approval and had launched a one-woman crusade to free her father from his rather destructive rigidities.

images-6The mother, Paula came across as incredibly cautious, speaking like she was stepping between land mines, afraid to set one off. The first session I encouraged her participation, and was impressed by her intelligent, though reluctant, observations.  I encouraged Paula, expressed my appreciation for her and conveyed that I thought she was, perhaps, the smartest one in the room. I also suspected that Brittany was worried about her mother’s emotional withdrawal and was perhaps doing some of her work. Perhaps Brittany was trying to show her mom how to fight with her husband?  I guessed that Paula had given up trying to penetrate her husband’s rigidities, and Brittany stepped in to save the day.

After a couple of rather stormy sessions, when Brittany and her father showed me how they went at it, Paula, the mother, suggested a meeting for just herself and her husband. I wasn’t sure what prompted her request, but it seemed like a good idea. At first the conversation felt stilted. Paula and Jake were clearly not used to talking about their own intimate patterns.They were more comfortable talking about their kids.

I observed that Paula seemed empowered by of our previous sessions and perhaps felt safer to challenge her husband and his righteous ways. She looked different, slightly younger and more alive than when I first met her. Jake initially expressed skepticism  of my way of working, particularly since I didn’t keep to the script. I indicated in every way possible that, with all due respect, I thought he was full of hot air, and that his self-confidence could use a little tweaking. At this session, however, his skepticism gave way to a new kind of engagement in our sessions. I suspected that he might have felt some grudging respect for me: I was clearly not a pushover.  Now, to Jake’s credit, he appeared almost eager to talk about his way of operating. He and Paula shared a code about his “tunnel vision”, a phrase I apparently had used in a previous meeting.

As we talked, I expressed curiosity about Paula’s reticence in expressing herself. I asked her, “When did you lose your voice?” After pausing a moment, she said, “I know exactly when”. Her husband’s eyebrows went to the ceiling. Paula then told her story in vivid detail, as though it were yesterday. The incident, some eight years ago, had to do with a typical, though more heated conflict over something innocuous thing Brittany  had done that offended Jake’s sense of order. When Paula tried to stop her husband’s inflamed response, he shut her down– hard. At that point, Paula decided that she couldn’t change her husband. And her “depression”, which she had previously alluded to, got worse.

images-6In an earlier session, Paula described how she had been on anti-depressant medication for the past fifteen years. When I tried to elicit a story around her depression, she acted like this was the first time anyone had asked about the meaning of her depression. This was not part of the script, and she seemed intrigued by the idea that depression is an expression of an interpersonal story. We explored her family background, which was characterized by her parent’s turbulent marriage and subsequent separation when Paula was a teenager. Lots of parental fighting and her mother’s suffering over the marriage made a huge imprint on Paula. I think she (unconsciously) decided she wanted a peaceful home, no matter what.

As we explored this couple’s relationship, I was heartened that Paula and Jake appeared to enjoy–if that’s the right word–our conversation about Paula’s loss of voice. I noted that Paula seemed to be taking a bit more risks with her husband, not tip-toeing around him as much. Her voice became bolder. Their relationship looked like it had a strong foundation; they seemed ready, almost eager, to open up some of these closed channels. Though painful at times, Paula seemed to be letting go of an invisible blockage, and Jake didn’t back away; in fact, he seemed to enjoy this “new” wife. Some of these long-held patterns began to give way.

At our next session, Jake was called in for a last-minute work meeting, so Brittany and her mom came in by themselves. Shortly into our session, Paula began to talk about her depression, and said she had been thinking about trying to wean herself from her long-term use of anti-depressant medication. She said she was feeling much better and wanted to see if she could do without it. Brittany began talking about her own history of depression which she thought of as a “spiritual illness.” I encouraged this conversation.

I was glad that Paula began to think of her problems as dynamic–a mood state that has context and meaning, that can change, that can grow. I said I liked Brittany’s characterization of  depression as a spiritual problem. I said that for me, our intimate relationships are powerful mood-regulators. Our sense of ourselves is strongly influenced by the (semi-invisible) relationship patterns we inhabit. I don’t think I put it so clinically, but these ideas felt affirming for these two bright people.

images-7I gave Paula the name of a family doctor colleague who could address her medication request. Paula smiled as she said, “You know, before we came to see you I was feeling very depressed. I thought I needed some other medication and I called my psychiatrist to see if he could prescribe something else for me. He had a waiting list and couldn’t see me for a month. And now look what’s happened!” Brittany laughed; “Sometimes waiting lists are a good thing!”

I was struck that Paula and Brittany  had never had these kind of conversations with a professional before. The only way they knew to think about depression is that it’s something you “have”, not a mood that is part of a larger, relational picture. Paula lacked ownership when it came to how she felt. Depression was something like weather–we don’t have any responsibility for it, we just have to find a way to deal with it.

For this family, I understood Paula’s “depression” as a reflection of her experience of disempowerment. Paula was self-aware enough to realize that her rather chaotic upbringing made her husband’s “certainty” attractive. She wanted some relief from instability, not anticipating the downside to her husband’s ultra confidence in his positions. An amateur when it came to conflict, Paula, a dedicated peace-seeker, took the escape route when it came to trying to change her husband. But, of course, in the long run, escape never really works.

This case may seem exceptional, a rare example of long-standing depression responding to relationship therapy. In fact, I’ve had repeated experiences like this in the office. This case is actually typical in the sense that these intelligent, educated people saw themselves as discreet individuals, with individual problems. They had names for their individual problems which, until now, had individual solutions. But this framework didn’t do much for them in terms of pain relief. Only when they began to connect their personal distress to their relationships to each other did the family patterns begin to be transformed. This acted as an anti-depressant for the whole family. And the side-effects were good.

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