Dear Therapist

Dear Therapist, I have been receiving psychodynamic counseling for the last 4 of my 41 years of life. I have found it a painful process but very helpful. I have also been taking citalopram for this period and still am. It takes a lot for me to share my feelings and experiences and that is why I have found therapy so uncomfortable.

Even though my confidence, development of my “self” and difficulty dealing with conflict have improved enormously I found myself struggling a little with a difficult situation at work.

Over the period of time October 2007 to February 2008 I became irritable (very out of character); my insomnia worsened considerably, I virtually stopped reading, walking etc (and still have) and found it extremely difficult to get myself to do anything. I am an extremely determined person and do not tolerate weakness in myself so was still able to function in my job and to a lesser extent in my private life.

From February till June the situation worsted considerably.

I found it nearly impossible to accomplish anything unless in a very structured environment. Even brushing my teeth seemed like a mammoth task. I was only managing to get to sleep at about 4 every morning. On the weekends I only managed to drag myself out of bed at about 3 in the afternoon – I wished I could just remain asleep. I would burst into tears at the drop of a hat – even at totally inappropriate times, at work. I had some experiences where I felt uncoordinated and as if I was looking at everything through a tunnel.

I started having suicidal thoughts (brief and no planning) and had one incident (the first ever) where I made a half hearted attempt to cut myself – I believe I would have inflicted more than a few scratches if I had had a blade.

I plucked up the courage and told my therapist of both the thoughts and the cutting incident. She asked if I had made suicide plans but other than that made no real comment.

As soon as I was out of the negative environment (end of June) the darkness started lifting quite quickly. I told my therapist that, in retrospect, I believed that I had been mildly depressed. She said that she thought that was a very strong claim, that depression is a serious mental illness and that feeling depressed is different to being depressed. I left it at that but it did not leave my mind. I was a little frustrated as was intending to check how my conversation about suicidal thoughts had been understood and instead had a discussion on depression terminology.

A few weeks later I did some research on line, looked up the difference between being and feeling depressed and did 5 different on line self tests (answering the questions as I had felt not how I was feeling at the time of doing the test). All came out that I may have been moderately to severely depressed.

I was not totally hopeless at the time as I had made plans to leave and thought that the situation would end. I was desperately trying to survive until I could leave. I did not loose all of my confidence. I have, however, been severely depressed more than once prior to this and believe that I am now able to recognise the feeling. It is not relevant but I probably should mention I suffered with bulimia for 25years but have now recovered. I have come to believe that my therapist never understood my history regarding the depression.

I printed off 2 of the tests and excerpts of the information I found and took them in and showed her. She once again said that being depressed is a very serious condition and then questioned if I thought being depressed made me more interesting. She warned me about pop psychology and said that one needs to take a person’s personality into account. I pointed out that I was not trying to put myself in a box but rather was trying to express the way I knew I had felt.

I looked up the DSM4 criteria and did some more research.

I know that I generally appear very composed. I used to be barely able to identify how I felt, let alone share it with others. I had thought that I was now expressing how I was feeling and was asking for help but think I may still not be doing it very effectively.

I do, however, wonder at the response I received to my telling her that I had had suicidal thoughts.

It has tapped into my feelings of not being understood. I also feel like I have been asking for attention and it has been denied and therefore feel a little foolish.

In your opinion is it impossible for someone with the symptoms I mentioned and who is still able to get through their work day, to be depressed?
Is it possible that some people cease to function at home and work at lower levels of depression than others experiencing higher levels? From what I understand, there are a lot of different states of mind that can accompany the depression. Is this correct?

I personally feel that, at some points in my life, I have been incapacitated by lower levels of depression than other times in which I have suffered a much more depressed state but have still managed to keep going by sheer determination. This I managed usually for the sake of others or out of intolerance of the weakness that I saw “giving up” representing.

As a matter of fact, and in retrospect, I do not see this as a helpful thing – it made the breakdown I had in 2004 much more severe than if I had not been so single minded and neglectful of my well being. I was more concerned about letting people down than of myself.

However, I must say that at my worst I was most definitely unable get out of bed.

The following may demonstrate this mindset: A few years ago I went to work with a severe gastric bug. I was vomiting into bags on the train on the way there and then in between clients throughout day. I value my health and well being so much more now and would not do this.

My sister’s boyfriend committed suicide about 15 years ago. It was a big shock to all as it appeared that there was nothing wrong with him. He was still going to work and socialising. Surely this indicates that it is possible that depression not always be 100% obvious?

My therapist is still bringing the conversation back to the difference between being depressed and feeling depressed.

The fact that I managed to start a business and started planning it around this time seems to be the reason that my therapist does not accept that I was depressed.

I was initially driven by fear as I had experienced two destructive work environments in a row and could not face a third. Eventually that fear was not enough to drive me on – I froze, was unable to make decisions and was only able to carry on planning after I left, had a break and had partially recovered. I was however still able to go to work and get through each day. I had to take 3days off towards the end but know I would not have been able to work if I had stayed longer.

My therapist says that she was probably reacting to me “labelling myself” and she does not believe in labels. I feel that by repeatedly bringing everything back to depression versus feeling depressed she is trying to put me in a box and is saying I don’t fit in it i.e. labelling me!

Unfortunately I do believe that I was depressed and therefore just feel that she does not understand what I have experienced. This is why I have persevered in my conversations about depression. Almost no time has been taken to discuss how I was actually feeling at the time. How can I carry on discussing my feelings with her if I feel she is has not been open to seeing my emotional life as I experience it?

I also feel that throughout 4 years of therapy, she has totally misunderstood my personality. The idea that I would exaggerate how I felt is so far away from something I would do that I find it very hurtful.

She has always been very gentle and supportive of me. She has encouraged me to confront her if I disagree with anything she says. I do struggle with confrontation and this situation is the first time I have done this which I know is positive but do not feel the rest of the situation is. I believe my fundamental problems are with trust, feeling understood and feeling heard and this experience has damaged that. The first time I have trusted someone with my vulnerability they have refused to accept it as real. Before I would have barely been able to admit to myself that I was not coping let alone tell anyone else.

I have spent hour upon hour upon hour researching depression but am still unable to come up with all the answers that I seek. I started off not being that interested in the ins and outs of depression. I was interested in how I communicated my distress and how I was understood. It has now become important for me to properly understand it. I really do not know how to get past this and regain trust in my therapist. Any information and advice would be welcome! Thank you. Larkin

Dear Larkin, thanks for the many details regarding your question. As I understand it you are asking primary about whether you have had depression now or in the past. You also want to know if there are varying degrees of depression and whether an individual could have it and still be relatively functional (i.e. attend work).

Based on the information you have provided it does seem that you have had depression. You may also have it now. You had a definite year in which you suffered severe depression symptoms. Throughout your life you struggled intermittently with depression, including having thoughts of suicide. You even attempted on one occasion to harm yourself. To me, this means that it’s certainly possible that you could be diagnosed as having depression.

Depression can exist on a continuum. That is, an individual can be depressed for a period of time and then feel better and have virtually no depression symptoms. Also, there are many people who are able to function day-to-day but would still qualify as having depression. Outwardly, these depressed individuals appear as though they are happy and well but many are not.

One aspect of your history that would be helpful to know more about is the time period between October 2007 and October 2008. You described experiencing a fairly severe depression. You later wrote in your letter that the “darkness had lifted” at the end of June. You did not detail a situation or event during this time that caused you so much distress. Was it because you were having difficulty at work as you vaguely mentioned? It would be interesting to know more about what caused you such difficulty during that “dark” year.

With regard to your therapist it’s unclear why she behaves the way she does. I don’t fully understand the difference she insists on making between being depressed and having depression or why she resists the diagnosis. I suppose it’s because she doesn’t like ‘labels” as you stated. Maybe she believes labels are harmful and stigmatizing. Without more details I can only speculate. My main concern about your interaction with her is the time you told her about your suicide ideation and attempt to harm you self and she had very little to say about it. As you said, you and she barely discussed the event. Perhaps there is a good reason why she chose to not focus your (half-hearted) suicide attempt but generally speaking, it’s an odd reaction from a therapist.

What’s most important about your therapeutic relationship is whether you are being helped by your counselor. From what you wrote in your letter it does not seem that you are being helped in a satisfactory way. She is kind and considerate but are you making true progress? Since I only have your version of therapeutic events its difficult for to me give you an objective opinion about whether you should stay with you current therapist. What might be helpful in this situation is to gain an outside, objective opinion. You can do this by meeting with another therapist to gain his or her opinion about the status of your therapeutic progress.

I would also suggest that you be honest with your therapist about what you’re feeling. Tell her that you feel she doesn’t adequately address your concerns. Tell her what you expressed so well in this letter. As you wrote, she encourages you to confront her when you disagree with her. You did it once and it was positive experience. I’d recommend that you do it again, especially if you are seriously considering ending the therapy. Part of the problem may be miscommunication or simply a lack of communication. You’ve had a relationship with her for four years that overall seemed positive. It may be that you’ve hit a lull in therapy or you’ve moving into an area that is extra challenging for you. You may be projecting that difficulty onto her. All of these situations are possible. Your challenge is to find the truth.

I hope this helps. Thanks for writing.