The collection of articles by the outstanding psychotherapist A. Langle is devoted to one of the most topical issues of practical psychology, psychotherapy and psychiatry – depression. At the heart of existential-analytical work with depressed people lies the phenomenological understanding of depression as a loss of experience of the value of life. The process of therapy includes a series of successive steps that lead to work with the deep roots of depression – with a violation of the fundamental relationship with life.
At the heart of existential-analytical work with depressed people lies the phenomenological understanding of depression as a loss of experience of the value of life. The process of therapy includes a series of successive steps that lead to work with the deep roots of depression – with a violation of the fundamental relationship with life.
In the process of treatment, patients must find new ground by recreating the ability to feel the fundamental value of life and the formation of a new attitude (mainly in the process of therapeutic relationships and experiencing sadness). This goal involves a number of preparatory and accompanying actions aimed at softening, “melting” the blocking structures of the psyche that have solidified in depressive suffering and opening the Person for the process of change.
Existential Understanding of Depression
From the point of view of existential analysis, depression is a mental disorder whose severity is determined by the degree of disruption of the experience of the value of life. Depression as a mental disorder has a more or less pronounced (primary or secondary) somatic part. In addition, it harms the personal dimension, influencing attitudes and attitudes towards both the external world and the internal, as well as the ability to make decisions, the spiritual experience of the world and of oneself. Thus, depression affects all dimensions of a person: physical, mental and personal.
Specific in a depressive disorder is that the correlation with the realities of the world and with itself (primarily with the body) as such remains virtually intact. The main disorder concerns a personal measurement. The ability to perceive the value of everything that previously filled the life of a person with joy and gave meaning to it is lost. What usually pleased a person, that he experienced as a pleasant, provocative interest, fades, loses the paint. This phenomenon is known in psychotherapy as “negative affizierbarkeit”. Its existential analogue is the depletion of “spiritual food” and the loss of the ability to experience values. It’s about the content that makes our life full, causing a sense of fulfillment. These contents make our relations attractive to us, creating a desire to preserve them as long as possible. Values have an animating, reinforcing and nutritional impact on both the Person and the human psyche in general. Through the experience of value, relationships are established with a deep structure of existence – with life itself. At its core, depression is a failure that a person has suffered in comprehending the value of life.
So, we can say that with depression, relations with the fundamental value of life, the ability to feel and experience it are violated.
Therapy of Depression
Existential-analytical therapy for depression should begin at all levels: at the level of relationships, on the cognitive, emotional, somatic, biographical and social levels, and this is being done today in many psychotherapeutic approaches. We are most interested in the existential nucleus.
A) In existential analysis in the treatment of depression, special attention is paid to therapeutic relationships. They must be imbued with a warm, understanding and accepting feeling. Active appeal to the patient and his trouble, empathic feeling is important because communication with the therapist represents a new contact with life, through which the patient can keep warm, and the frozen regulatory structures can “thaw”. Thus, next to the therapist, the patient acquires the opportunity to resume relationships with life. The therapist becomes like the representative of life itself, while, due to active treatment in the process of therapy, he is more likely to meet the patient than the real life in the situation of depressive retreat is capable of.
B) Address to the present and division of tasks. The depressed patient largely lives in the past. He has little actual relationship, which allows him to establish intimacy with life, all his relationships are mostly distant. To judge what life is, he can only observe others, and not on the basis of his own experience. Such a distance in relation to life disrupts its formation under specific conditions of daily life. The structure of the day, rest periods, sleep deserve special attention on the part of the therapist, since all these moments facilitate the unloading of patients. It is especially important to find out whether the patient is referring emotionally to what he is doing. Supporting the patient’s intentions to retain the ability to perform even small tasks gives him the opportunity to establish relationships with life.
C) Work on cognitive structures and misidentification. This step is not specific to existential analysis. We are talking about the disclosure and realization of “closed circles of thinking” – generalizations, generalizations of the type “always”, “never”, “all”, etc., leading to exhaustion.
D) Mobilization of personal resources and exercise in determining their position. Specific existential-analytical methods are used here, in particular, work with the central personal ability – to find and occupy one’s own position.
Self-distancing
- in relation to feelings (for example, “feelings are now frozen, but I will not allow this state to determine my behavior”);
- in relation to expectations (for example, expecting a feeling of indispensable joy from the fact that a person does something).
We are trying to develop with patients personal ways of dealing with negative feelings and such painful conditions as lack of joy. This is important, because under normal conditions, joy helps us, denoting the areas where we are closest to life. A depressed person who, when performing an activity, can not be more happy, will also perceive this fact as his own failure. As a result, there can be a gradual increase, an escalation of the negative: a person will begin to feel sad that he can not rejoice, he can not find joy for himself in anything. In therapy, one should take into account the possibility of such an injection of a negative. It is possible to alleviate the patient’s condition, if one draws his attention to the fact that during the period of “black and white cinema” (the metaphor of depression) the expectation that the feeling of joy will come to life, as soon as the conditions appear, is hardly justified. He should focus more on cognitive knowledge (the first fundamental motivation), on the intuitive sense of what is right and what is not (the third fundamental motivation), but not on the deficit feeling (the second fundamental motivation). Thus, the patient releases himself from the expectations of positive emotions and at the same time from the destructive feeling that he should rejoice, but he can not. The rupture of the vicious circle “Depression through depression” is an important element of depression therapy (work on the position).
Self-acceptance
Here it is a matter of seriously considering what you are doing, or being out of the case. It is important to establish that the action itself, too, has value, which, most likely, is more significant than it seems. Depressive patients tend to depreciate all their own (deeds, the results of their actions, dignities, etc.) or either perceive as the norm (“it should be so”), while they lose their openness to the value they really possess.
For example, if someone says that he likes to draw, but does not practice drawing, but constantly sits in front of the TV, then this may mean that watching TV for a person at this stage is more important than drawing, but he does not realize it himself. If the intrinsic value is determined for a person by the perfectionist ideas about himself as an artist, then this kind of pastime will inevitably lead to a fiasco (“I did not take place as an artist …”). In such cases, in the treatment of depression, it should be about promoting self-acceptance of the person and putting an end to attacks of daily self-depreciation. A depressed person believes that he is not engaged in important things, but is wasting his time on something insignificant: in fact, from the point of view of culture, it is more important to draw and do art, and what he is doing now does not cost anything at all. However, does not television represent a particular value for a depressed person? Perhaps, due to this source of information, he has a growing sense of closeness to real life, as a result of which the sense of loneliness loses its former acuteness? And is not this value existentially more significant than the universally recognized, but not capable of warming the soul?
If any value is a real reason for preferring a particular action, then a real evaluation will occur daily, which makes it preferable. Meanwhile, the occupation of a position in relation to this real assessment in a depressed person is usually absent or the evaluation does not correlate with the possible value that “wrong action” has, because rigid normative thinking does not allow anything like this. When a person openly admits the possible value of a rejected action, a reconciliation with oneself takes place, and the stress associated with devaluation goes away.
Personal position finding (Personale Positionsfindung – PP)
The purpose of this method is to translate the depressive “primary emotion” into an “integrated emotion”. This attempt is carried out using three steps, each of which is briefly described below by typical questions:
PP1 – position in relation to the outside world (“position outside”): What really happens? Is this really so? How do I know about this?
PP2 – position in relation to the inner world (“position inside”): If it is really so that I will lose? Could I have stood it at least once?
PP3 – position in relation to the positive: What is it for me in this situation? What for me personally is important, valuable in a broader life context?
E) Recycling the feeling that you have failed. It is necessary to find out the inability to do something and, starting from here, go through depressive feelings right up to the positive core, due to which the negative turns into a positive one: “Is there a strong side in what I consider to be weakness?” – “Is it really that I I consider incapacity, is that, or is there also an opportunity to Stand for Myself? “. Thanks to such work, an understanding of the intentions of behavior occurs and relationships with one’s own life are established.
For example, a patient with a depressive disorder comes to the reception. The reason for the visit was that she recently again found herself on something “incapable”. She accepted the invitation of her friends to sit over a cup of coffee, reached the house of one of them, where they decided to meet, was about to press the bell button, but at the last moment suddenly changed her mind and returned home. There she closed herself from everyone and indulged in depressive feelings and thoughts. She felt like she was not a capable loser. This feeling was further enhanced by the fact that she did not even call her friends to apologize.
“The inability to do something” we worked through using a phenomenological approach: what moved it when she decided to accept the invitation and go to her friend? For what reason did she not press the bell button? Why did not I call my friends when I got home? We sought to discover the hidden value of her actions. As a result of the search, it turned out that at the moment when she had to press the bell button, she was overwhelmed by the feeling that she could not meet her friends because she was depressed. She thought that would deprive them of joy if she came with such a mood. Now it became clear to her that she turned and left her for good reason – she wanted to protect her friends. In other words, she returned home because of her love for her close people. By understanding their own intentions, a sense of inability, failure, disappeared. And in relation to her depressive feelings she was now in a personal position. With her seemingly ridiculous act, she followed the values that were extremely important for her: to give her friends a friendly service, not to spoil the joy of meeting them, not to burden them with the burden of their problems. The patient left the session with a feeling of relief and in her own way moved. In the wilds of depressive feelings she was able to meet and accept herself.
F) Conversion of feelings of guilt and concretization of responsibility. Depressive feelings of guilt are determined, on the one hand, by a diffuse sense of responsibility in which to clarify the real content, the true responsibility or the actual guilt. On the other hand, it comes from an overestimation of value, which also requires a critical attitude and revision.
In addition, a depressed person is inclined to fill in “emptiness”, so he makes excessive demands on himself and thereby contributes to the emergence of frustration. No one can be responsible for the feelings of others, for example, whether the mother or father is happy or unhappy. However, a depressed person feels responsible and at the same time incapable of doing anything and guilty, thereby burdening and draining himself.
G) Work on relationships. Exercise in the receiving unit in relation to values. Motto: “Doing something good for yourself every day!”. Rejecting, devaluating attitude towards oneself and the associated loss of relations with one’s own life should be reviewed and revised. Thanks to the daily exercise, concrete, decisive actions, a new life-affirming experience is acquired.
To implement this program in practice, the patient is offered the following thesis: “Nothing can be good if it is not good for me, either.” At this stage, work is carried out with blockades of value, with a perception of value, with traumatizations or losses. Lack of vitality in endogenous depression requires a special approach to treatment, for which specific steps have been developed in the existential analysis. The ability to notice and prevent depletion is also important, so the patient learns to take preventive measures.
H) Deep therapy aimed at restoring the ability to experience a fundamental value, the process of experiencing sadness as the main condition for the therapy of depression. Preparatory work at the level of values precedes a deep level of existential-analytical therapy. At this level, working with the patient is to uncover and make tangible what led to the construction of a negative attitude toward life. It is divided into phases of anger, sadness and resource mobilization by further working out the attitudes and values of patients.
It is obvious that if a patient is asked about whether it is good that he is and how he feels about the question “Do you like to live?”, This will affect the painful aspects of his life. The deepest point of existential-analytic therapy of depressions is seen in laying the foundation for a new patient’s attitude toward life. At the same time, it is very important to help him realize that this new attitude follows from the source of personal life, which is born in the premonition and feeling of Being here.
We can assume that the goal is achieved if we come to “Yes” in relation to life – a position that is not taken on a rational, but on a deeply felt emotional basis. Such an acquisition of a personal position occurs after an understanding of the value of life, to which the patient can reopen. He gets access to it thanks to new installations and experience. And then on the basis of a new solution, he can rise above depressive feelings, for depression in our understanding is a loss of existential fundamental motivation and an active component of personal action. The most important thing is that painful experiences make one forget how important and necessary is the appeal to life and life values. To regain this ability is helped by experiencing sadness, and sometimes – anger. Thanks to these feelings, a person again begins to feel the power of life within him: a power of tears that brings relief, or a strengthening and defending force of aggression.
Therapy of Suicidality
Suicidality is a common phenomenon in depression. If one imagines that for a long time a person has to live under the unbearable burden of depression, losing strength, suffering from an inability to act, from feeling deficient, lacking something, from feeling guilty, having lost desire and joy of life, prospects and hope, then suicidal trends can be understood. From the existential-analytical point of view, we consider the desire to deprive ourselves of life as a symptom that corresponds to an internal attitude toward life. If you consider that a depressed person values his life, as if not worth it, as a burden to others, and therefore – as a source of insuperable guilt, then suicidal seems a logical consequence and even an honest expression of the experience. This negative assessment of one’s own life (in the existential analysis we call it “negative fundamental value”) leads not only to negative feelings, but also to a personal attitude that contains a solution against life. Therefore, suicidality in itself is not a disease, but a person’s decision taken in connection with a disease. The decision to realize what he thinks and feels, that is, to follow his psychic reality and his conviction. It is an act that appears to him to be truly moral within the framework of his relationship.
There are three grounds that can deter a depressed person from a self-destructive intention: a positive inner attitude toward life, fear and lack of power. The latter is especially characteristic for the middle of severe depressive phases. Therefore suicidality in the acute form is most often manifested at the beginning and at the end of the depressive phase, when the patient has enough strength to realize his intention. At the end of the phase, the risk is particularly high, because no one is waiting for suicide at this time – after all, the patient externally feels better: the negative feelings have largely receded, activity and enterprise have become more noticeable. And yet there is no basic – the reinforcement of the affirming attitude towards life. Retreat visible externally depressive feelings and lack of activity, but in the depths still remains and operates a gloomy, life rejecting life.
Let’s consider briefly the positive internal attitude towards life as the most powerful defense against suicide. It can stem from a deep belief in the value of life and rational knowledge that it is just a temporary shortage of neurotransmitters in the brain or in a mental state that corresponds to the loss of existential value and has not been personally developed, etc. Knowing the causes of a depressed state is important in order to maintain the conviction that life still has value. Persuasion is an attitude, a general solution to the fundamental value of life. Usually such a conviction is accompanied by memories of the former life, about the time when it had a positive value, which means that life has other sides that can not be seen at the moment.
Another form of inner positive attitude toward life is rooted in faith. This is an understanding of the value of life, which is based not only on a special subjective experience, but also on revelation, divine knowledge. And yet in this case the therapist should be careful: a belief that does not rest on its own experience and is not connected with memories of the positive value of life, can not always withstand the pressure and weight of depression.
Finally, the hidden form of a positive inner attitude is the rejection of suicide due to lack of courage. In this sense of “cowardice”, as patients call their setting in a typical self-deprecating and self-aggressive manner, phenomenology reveals uncertainty, doubt, hidden hope, an unrecognized impulse towards the fact that in the end life could be something good, or, that it is inherently inviolable. For such a definite and categorical solution, one often encounters the content of an experience whose meaning exceeds any logic and argumentation. It is important for therapists to see and take into account what is hidden behind such words, because then they can better help the patient in revealing his personality.
In suicide therapy, the following is important:
a) propose and work with the patient to understand the situation;
b) take from the patient a promise that he will not commit suicide;
c) if the patient refuses such a promise, it is mandatory to ensure a constant presence next to the patient of other people.
A) The therapist invites the patient to talk about his desire to commit suicide, his intentions or plans. Since here we can talk about concealed intentions, an empathic formulation is needed that will help the patient either to hear and accept the question, or to circumvent the intention concealed by him. For example: “I understand the situation in which you are now. You carry a huge load … And I admit that in such a situation the desire to live can disappear, up to the point that there is a thought … to put an end to life … Do you have such a feeling? “- Thus, the patient may feel understood and, if agreed, react with relief. Among other things, this understanding strengthens the relationship with the therapist.
If the patient does not experience similar impulses and feelings, then this request in any case will not cause harm. Some therapists are afraid that such a question will negatively affect the patient or even bring him closer to suicide. A person who does not have suicidal intentions, even if he is in a state of depression, can perceive this issue more likely as a challenge to his positive attitude towards the life situation and will respond with something like: “My situation is not so heavy!”
The one who is visited by suicidal thoughts will react differently. Either he will agree with relief, feeling that he is being understood, or for various reasons will try to hide his intentions. This may be a desire to avoid hospitalization and drug treatment; or the patient does not trust the therapist so much that he can talk to him on such a difficult subject, finally, he happens to be already determined and would not want someone to interfere with the execution of his plan. Then we should expect that the patient will indignantly reject this assumption.
How can we recognize the danger of dissimulation? To this end, V. Frankl already in the 1920s proposed a method that is widely used today. At that time, he headed the department where the suicidal patients were. On the eve of their discharge, he had to assess the risk that they could commit suicide. He developed a short survey technique, with which it was possible to estimate the danger of dissimulation with the necessary accuracy. The questions were indirectly centered around how the patient relates to the meaning. The author of the method relied on the following observation: if the patient sees the meaning in his life, this reduces the risk of suicide, if he does not see such a meaning, then nothing can keep him. Meaning – an important auxiliary tool (hilfsmittel), a resource that allows you to overcome suicidal.
The detection of latent suicide begins, as already noted, with the questioning of possible suicidal tendencies. If the patient intends to dissimulate, he will try to dispel the therapist’s doubts: “No, I have no such thoughts … It would never have occurred to me … Do not worry!”, Etc. With such an answer, the possible dissimulation will help uncover the question, at first glance, unexpected: “Why would you not do this? What gives you such confidence? “In the case of dissimulation, the patient usually surprises, begins to stutter:” No, rather no, I will not do it, do not worry, rest assured, I will not do it …! “Dissimulation is recognized on the basis of, that a person can not relate to the meaning and ask for a specific content. If the patient does not dissimulate, he calmly gives his arguments, for example, says: “I have a family … there is this or that task … I would not want to do this, knowing how my wife will suffer … out of fear before God … “, etc.
B) Patients with suicidal intentions are asked if they can promise that they will not do anything to themselves. It is not recommended to ask a general question: “Can you promise that you will not kill yourself?” Most people will not be able to give such a promise. The question should be more specific and designed for a certain time interval: “Can you promise me that this month (or this week) do you no harm yourself?” In severe cases, the question should be even narrower: “Can you promise me, that tomorrow we’ll see each other again? “
In acute and particularly acute cases, the only content that a promise can relate to is the relationship between the therapist and the patient, and not the possible act. “Can you promise me that in any case, contact me if your thoughts revolve around suicide? Can you promise that you will call me if you understand that you can not guarantee that you will not do anything with yourself? Promise me that in that case, you will most likely call, be it a night or a day before you decide on this act. ” It is necessary to consolidate this promise with a handshake, while openly looking into each other’s eyes. If the patient tries to avoid a handshake (or if it is not strong), if he avoids the look, then he should insist that the binding of the arrangement is normal. If the patient chooses to do this, then it can be guaranteed with a high probability that he will not break his promise. Such a promise has great weight, for it is hard to die with a broken promise!
C) If a promise is not obtained from the patient, then the situation should be regarded as critical, as an immanent suicide. In this case, you can not leave the patient alone. Recommended hospitalization. If this is not possible, then a social network should be established from credible individuals who are able to take responsibility and ensure that they are vigilant. It will be a fatal mistake to send the patient home without making sure that he is there to be provided with reliable supervision (while one can not rely solely on the patient’s assurances!).
Prevention of Depression
Let us consider a few more points concerning the prevention of depression and psycho-hygiene.
Savings and restoration of forces (care of forces). Prevention is to closely monitor the areas of depletion and be sensitive to areas where there is a loss of strength. This often happens where a person acts out of a sense of duty or exerts too much effort on something, for example, at work, while driving a car, even in the process of washing dishes late at night after a work day. Such stress factors should be realized, because they take a lot of energy, and often it leads to irritability, to the appearance of muscle tension (especially in the shoulder region and back). Proper organization of rest, attentive attitude to the duration of sleep, to breaks, to sports, the regime of the day, the planning of the week can prevent loss of strength and exhaustion. Rhythmicity and regularity make life easier. there is no need to make decisions. It is important to live according to your pace, for, as experience shows, there is a depletion share in any depression.
Medicines. To the care of the forces and, thus, to the area of the first fundamental condition of the fulfilled existence, the use of medicines also applies. Long-term use of antidepressants, as well as lithium, is a proven means of preventing depression.
Care of valuables. To preserve the joy of life and vitality, it is important to pay attention to what you like. The fundamental feeling – it’s good that you live, that you are in the world – should be preserved and, if possible, strengthened. For this, the experience that leads a person to relationships with values is important. This means the following:
- To look after pleasant experiences, knowing that where there is joy, there is life. It is not enough to know what would be useful, you must also experience it and do it.
- Enjoy the values of experience, give them time, turn to them.
- To look after the relationship.
- With things that are important to a person, treating as a value is a culture of life.
- To take care of the body, to move more, to go in for sports. Pay attention to good physical well-being. For the senses, the body is like a wax for a candle flame.
Appeal to life’s obstacles, to what takes a person’s life:
- Ask yourself questions about the cause of loading feelings (Belastende Gefühle) and discuss them with others.
Start to feel sad if there is no sadness.
- To turn to disappointments and losses, to accept a feeling connected with failure or failure. If there is no appeal to these vital obstacles, the soul holds on to what is denied by reason, and this inevitably leads to depression.
Careful use of time. Time is always a time of life. Thanks to careful use of time, people pay attention to the love of their own lives. Specifically, this means: if possible, do only what is important to you, and avoid wasting time on the secondary. For a depressed person, compliance with this rule is particularly significant. Do not set yourself apart again and again, do not give up yourself for others.
Special work on installations. A depressed person is prone to subordination, especially at the onset of depression. It is peculiar to him to adapt to “deserve” a valuable closeness, to submit to fate or authority. It is necessary to work on the fact that it is important to fight for oneself, to live their desires, needs, requests. It is necessary to critically examine and change the depressive “ideal” picture: it is by no means always good to be modest and “push” yourself. Working with desires: desires conceal the danger of latent passivity. A person is given to desires if he expects others to fulfill them. Because of fixation on desire to possess something that he does not have, a person experiences a scarce side of life much more strongly. The basic rule is: desires are good as long as the opportunity remains to abandon them. Work on the installation of self-esteem: to maintain or increase self-esteem, it is important to feel disrespect from others, do not tolerate disrespect. If it is, it is important to talk about it as prevention.
