On the face of it, there seemed little to explain the misery Cleo* was exuding. Nevertheless, it was clearly all-consuming and terrible. Cleo had a lot going for her on the surface: she was attractive, young, successful in her career as a publicist, and in a stable relationship with a concerned partner. Yet she sat slumped in the chair across from me, tears streaming, palpably suffering.
I felt at a loss to make sense of her deeply depressed mood but knew better than to ask Cleo to explain it. She had already told me that it was inexplicable to her too – and this made it harder to bear, as she felt she had no legitimate “excuse” to be feeling how she did. “It’s like I have all the ingredients for happiness, but I can’t seem to bake the cake,” she lamented. “And then I feel useless.”
Cleo’s experience is not that unusual. While for some depression is catalysed by a specific set of circumstances – unemployment, a painful break-up, loneliness, financial stress – for others it is a cloud that descends, seemingly for no reason, and drains the world of colour. This is not to say that there really is no reason, but rather that the causes are less easily identifiable. Gradually unearthing these reasons and helping Cleo to process them would prove to be a big part of our work together. However, first I needed to empathise with her and validate her distress and let her know that she did not have to be alone with it.
By the time Cleo left that first session she was feeling some relief. We hadn’t figured out the source of her pain or found a solution for it, but the very act of talking about it in a supportive environment and feeling that I could connect with how she was feeling, was enough to provide some comfort. I encouraged her to do a little exercise if she could, as we know exercise acts as a natural antidepressant. I didn’t make any other suggestions as I didn’t want her to feel like a failure if she was unable to follow through on them.
Engaging her in a therapeutic relationship seemed more valuable at this point than providing her with a list of strategies, many of which she had no doubt tried already as friends and family had been giving her much so-called good advice. Depressed people usually know what they should be doing – but they lack the will or energy to do it.
Some of this advice had centred around antidepressant medication, and there is significant research demonstrating that a combination of medication and therapy provide a good outcome for many sufferers of depression. However, medication is not always a silver bullet, and the benefits must be weighed up against the potential side effects. I usually engage in a discussion about this with patients, but Cleo had signalled very early on that she was resistant to the idea of medication.
Cleo’s plight was on my mind as I was driving home from work that night, listening to the evening news. It occurred to me that many of us might describe ourselves as depressed by the current state of the world, with news stories dominated by climate catastrophes, war and disease. There is a collective sense of depression in the face of this; a heavier, wearier, darker social energy than the refractory anxiety we experienced at a communal level in the early days of the pandemic. But while many of us might use the term depression in response to this, we use it in the colloquial sense.
Colloquially the word has come to be synonymous with feeling down, disappointed, sad. But true depression in the clinical sense is much more than this. It involves a protracted period in which one feels persistently low in mood and largely disinterested in previously pleasurable activities. This is accompanied by feelings of hopelessness, emptiness, social withdrawal, difficulty concentrating and maintaining personal hygiene, sleep disturbances and, not uncommonly, suicidal thoughts. This was Cleo’s level of depression, and my heart went out to her.
As with most psychological difficulties, the full explanation for Cleo’s difficulties was complex. Her mother had a long history of depressed mood and Cleo might have inherited this vulnerability. In addition, she had a harsh internal critical voice, which constantly berated her for not being good enough. We connected this to her relationship with her father, who believed that criticism motivated children to achieve, and it had.
But achievement wasn’t the issue. For Cleo, it was a hollow achievement in which she never felt secure. Her internal pressure escalated in the context of winning her dream job, a job she loved but never felt confident that she deserved. And the social changes wrought by Covid hadn’t helped, as now she was mostly working from home and was unable to access support and feedback in the same way she might have if she was working alongside her team.
A constellation of these genetic, psychological and social factors provided the perfect breeding ground for Cleo’s depression. Added to this was an unconscious rage, which is not uncommon in depression, a rage Cleo felt towards her father but was too afraid to express. Instead, she channelled it into berating herself for her failures, including failing to be happy.
While it was a comfort to Cleo to make sense of her struggle, this didn’t instantly fix the problem. Slowly, she had to own her internal conflicts and her anger and to develop a more compassionate and supportive internal voice. External changes were also needed. Thus, Cleo began spending more days in the office with her colleagues. She also accessed more support from her partner and friends, as being in better contact with herself allowed her to share her vulnerabilities more easily.
There was no dramatic turning point for Cleo, but through this process of exploration, connection, support and re-engagement some of the colour that had drained from her world began to return, much to her and my delight.
• Crisis support services can be reached 24 hours a day: Lifeline 13 11 14; Suicide Call Back Service 1300 659 467; Kids Helpline 1800 55 1800; MensLine Australia 1300 78 99 78; Beyond Blue 1300 22 4636
*Cleo is a fictitious amalgam to exemplify many similar cases that we see. The therapist is a fictional amalgam of both authors
• Prof Gill Straker and Dr Jacqui Winship are co-authors of The Talking Cure. Gill also appears on the podcast Three Associating in which relational psychotherapists explore their blind spots
