How can it be that a seemingly depressed person, one who shows clinical symptoms, doesn’t respond to antidepressants or psychotherapy? Perhaps because the root of his anguish is something else.
Several years ago a patient named Brian was referred to me. He had suffered for years from an intractable depression for which he had been hospitalized. He had been through cognitive behavioral therapy, psychoanalytic psychotherapy, supportive therapy, and dialectical behavioral therapy. He had tried several medication “cocktails,” each with a litany of side effects that made them virtually intolerable. They had been ineffective anyway. The next step was electroshock therapy, which Brian did not want.
When he first came to see me, Brian was practically in a comatose state. He could barely bring himself to speak, and his voice, when I managed to get anything out of him, was meek. His body was rigid, his facial expression blank. He couldn’t look me in the eye. Yes, he seemed extremely depressed. But knowing he had been treated for depression for years without good results, I wondered about the diagnosis.
Even though we were together in my office, I was struck by a strong sense that Brian was elsewhere. I asked him what percentage of him was with me in the room.
“Maybe 25 percent,” he said.
“Where is the rest of you?” I asked.
“I don’t know,” he said, “but someplace where it is dark and I am alone.”
“Would you like me to help you get you a little more relaxed?” I asked.
He looked a bit surprised but said yes, so I grabbed a small cushion off my sofa and tossed it to him. He caught it and smiled.
“Toss it back,” I playfully commanded. And he did. His body loosened perceptibly and we talked some more. When I asked, after several minutes of tossing the cushion back and forth, what percentage of him was now with me, he responded with another smile. “I am all here now,” he said.
That’s how it went for several months: We played catch while we talked. Playing catch got him moving, relaxed him, established a connection between us—and was fun.
During our initial sessions, I developed a sense of what it was like to grow up in Brian’s home. Based on what he told me, I decided to treat him as a survivor of childhood neglect—a form of trauma. Even when two parents live under the same roof and provide the basics of care like food, shelter, and physical safety, as Brian’s parents had, the child can be neglected if the parents do not bond emotionally with him.
This I suspected was the case with Brian. He told me that his parents were both “preoccupied” with the heavy burdens of a family that “could barely make ends meet.” While his mother never called herself an alcoholic, she drank to excess, and his father was often emotionally checked out as well. Brian had few memories of being held, comforted, played with, or asked how we was doing.
Chronic Shame Affects Emotional Expression
One innate response to this type of environment is for the child to develop chronic shame. He interprets his distress, which is caused by his emotional aloneness, as a personal flaw. He blames himself for what he is feeling and concludes that there must be something wrong with him. This all happens unconsciously. For the child, shaming himself is less terrifying than accepting that his caregivers can’t be counted on for comfort or connection.
To understand Brian’s type of shame, it helps to know that there are basically two categories of emotions.
There are core emotions, like anger, joy, and sadness, which when experienced viscerally lead to a sense of relief and clarity (even if they are initially unpleasant). And there are inhibitory emotions, like shame, guilt, and anxiety, which serve to block you from experiencing core emotions.