Shades of depression in the cave

Shades of depression in the cave
Contents
Introduction    1
Cave Entry    2
Loss of meaning    2
Treatment    2
Social Element    3
Treatment    4
What then keeps us in the cave?    5
Learned helplessness    5
Punishment    5
Cognitive\Behavioural maintaining factors    5
Social element    5
Finally Time    6
Treatment    7
Summary    8
References    8

Introduction
In evolutionary terms, depressive symptoms can be seen a defensive reaction.  Paul Gilbert sees  depression as a return to the cave when overwhelmed to recuperate before returning back to the fray.  This seems to agree with clients who talk of their depressive symptoms of not wanting to socialise for fear of being judged as boring or uninteresting, or not wanting to do things as they wouldn’t enjoy them or it would go wrong. They seem to be talking about protecting themselves from criticism, displeasure, emptiness and failure by withdrawal.  In short if I don’t do and don’t engage it won’t go anymore wrong, I won’t be criticised and I won’t be hurt even more. 
Therefore there are two aspects of depressive symptoms, what gets you into the cave and what keeps you there.
Cave Entry
Loss of meaning
Dorothy Rowe thought that the entry to the cave is due to a loss of meaning in your life, a gap between how your life is and how it should be and blaming yourself for this .  The possible reasons for this gap seem varied:
1.    How my life is and how it should be, therefore I haven’t achieved
a.    Because how I’ve been treated (anger)
b.    Because I’m not good enough (depression)
2.    I have no knowledge of how my life should be its just not like this as its empty
a.    I did know but then I lost a life defining aspect (specific loss)
b.    Over the years what my life should be has made less and less sense (gradual loss)
3.    I can never have my life as it should be as I am in a social\cultural group that is  mistreated
Treatment
It would seem then these three different aspects might call for different treatment approaches.
How my life is and how it should be, therefore I haven’t achieved
This seems to have two parts.
Firstly understanding the sense of how my life should be, opens up conditions of worth questions and also introjections. For conditions of worth the questions could be asked about the connection of achievement and love. For introjection then there would be the questions of where did this “how my life should be” come from and does it suit me now.
Secondly is the conclusion of why there is a gap, i.e. because I’m not good enough.  This sounds the outcome of blame based criticism which asks the question of where being critical was learnt which may lead back to critical people in the client’s life. Then to how it is perpetuated which may show the internalisation of this original experience, to result in self-criticism.
Whilst there are different treatment approaches to self-criticism. It would seem understanding both the “traumatic” origins of self -criticism followed and a functional analysis of self or other criticism, to notice the effects, would be a good place to start. This could then be followed by a compassionate approach to self when things go wrong or encouragement is needed. If self-criticism pops up then a mindful\attention switching approach to something more valuable, in an ACT related way, would also support the compassionate approach.
I have no knowledge of how my life should be its just not like this as its empty
This is in two parts either due to a specific or cumulative loss of meaning.
Firstly with a specific loss you would be doing bereavement work with a view to integrating and accepting the loss both of the specific thing and the beliefs about how the world should be and then rebuild your life on the basis of this new foundation.
Secondly with the cumulative loss bereavement work would be harder as you have a cumulative bereavement but no obvious thing to grieve for. Here I guess there might be a move to look at all the times when there was a decline, what was the meaningful thing that was lost, to make sense and to grieve for that. 
For both of these there is a need to reconstruct/reconnect with value, although possibly harder with the cumulative decline as there isn’t an obvious loss. There seems a few options here. Firstly to enable access to existing meaning through working with any of the blocks to that meaning, i.e. fear of failure, criticism etc., as people might know what might give them meaning but be blocked from engaging with it. Alternatively there could be a case of reconnecting to what has been important in the past but now lost. Finally you may need to create\discover meaning, which can be done in the same way that we did when we were kids, by trying, by following what others do and by doing what you are told to.
I can never have my life as it should be as I am in a social\cultural group that is mistreated
This seems a tough one in psychotherapy as it enters both the social and political realm, the abused child, and a person in an abused group. Safeguarding would be the first port of call, and risk management. Once the high level work has taken place, and the level of risk has reduced then the work here would be around firstly normalising and depersonalising, facilitating if there are any legal routes to pursue, and then finally noticing if there are treatment opportunities in terms of the reaction to abuse, even if you can’t stop that abuse, you can minimise it. Then in terms of cave entry, the how life should be gets modified to how the context of my life currently is.
Social Element
One aspect that is part of all the above ideas about cave entry is people and it merits talking about separately. There are a cast of people that help get people into caves and this can be due to how they act or how the client perceives them acting, or how they imagine they think.
To get cave entry then people need to be seen as not understanding you, or critical, or higher achievers than you, or more interesting, or treating you badly. You need to see yourself as not popular in the eyes of others, or others as not valuing you or your work. You can’t take the compassion of others or you wouldn’t get into the cave, you certainly don’t want to identify with others as similar to you, your depression needs to be because of your perceived dysfunctional characteristic. You need to suffer it alone although you can make it worse by thinking of how other people have it worse than you and yet they still manage.
There is a highly isolated aspect to depressive symptoms, there is a highly isolating aspect about them. In some ways inside the cave there is something of the social outcast, the hermit, again this is a self-outcast, apart from the person who is abused by group or context.
So to understand entry to the cave, what were the roles and changing roles of the others significant to this entry, they may be known people, film stars or anonymous friends on Facebook. They define the life that should be, that persecute me through what they believe, who taught me self-criticism by criticising me, who bullied me to plant the seeds of I’m useless.
Treatment
As we get to meet this cast, then we get the chance to get to know them better, as this happens so we can open up different thoughts:
Is their life as good as it seems and would it suit you?
What do you make of people that bullied and criticised you, does their behaviour say anything about them?
There is a good chance that the person with depressed symptoms has some of this casts voices and attitudes as their thoughts\beliefs and values. So as we get to know them better, we effectively get to know some of the cognitive mechanisms that takes the person into the cave.
In some ways the “cognitive restructuring” is more about getting to know about the specific people who made for the cave entry and then also other people. In understanding the cast then we enrichen their behaviour, if their behaviour was critical then there were reasons for this, and not all of them were about you. If their life seemed to be envied, then as we understand more about it, we hear more about their suffering.
 
What then keeps us in the cave?
I will mention three main ideas here, learned helplessness, punishment and cognitive/behavioural factors.
Learned helplessness
Seligman tells us of learned helplessness, i.e. pessimism towards our self-efficacy, through interpretation of misfortune in terms of the continuums of personalisation, pervasiveness and permanence . So if you interpret misfortune because it was your fault, you always mess up and always will, then this leads to learned helplessness. So you stay in the cave as you have no belief in your ability to either define or live the life you want so you seek damage limitation. 
This in some ways helps us to understand the difference between the reactions of unhappiness and depressive symptoms to unpleasant events. The former has hope, and will accept comfort and give themselves it where the latter does not.
Punishment
Rowe would also add that if you have learnt to believe yourself as bad,  either as a result of taking the blame as a child, or the outcome of continued criticism\self-criticism, then “You review the stupidities and failures of your life and punish yourself for crimes known and unknown” (Rowe, 2003, p. 6). Again you stay in the cave as both prisoner and gaoler.
Cognitive\Behavioural maintaining factors
The following seem to perpetuate low mood, and keep you in the cave:
1.    Low value activity: creates low mood and continues depressive thoughts about self, world and others.
2.    Self-criticism: telling yourself how you are no good/incapable.
3.    Comparisons telling yourself you’re no good in comparison with others
4.    Rumination: The replaying of all the bad things in your life, both lowers mood and reinforces depressive thoughts about self, world and other
5.    Self-care: reducing self-care leaves you to experiencing yourself as of low value in society and having low abilities.
6.    The inability to accept compassion (this would confirm low status) or give it to one self (kindness would condone your position)
7.    An inability to make meaning out of our depressive symptoms: the future is hopeless as you can’t imagine the ending of this story and the next chapter.

Social element
Again with the elements above there contains a social element.

There is a cast of people that keep people in the cave, be they real or imaginary. These are the people who would criticise, whose lives are better, who don’t understand you and say the right thing.
So in the work to forge an escape there is an aspect of re-engaging with people, to reduce the sense of isolation and that its only you that suffers, to get the validation of your worth as a person because people want to take the time with you, to challenge the ideas of both the levels of unpleasantness that people will be to you and how awful it would be if they are.  Likewise as much as you reconnect with people, repopulate your life so there is a virtuous circle of feeling better about yourself due to the validation, a reduction in isolation, which is a form of torture used throughout history, and a opening to both the meaningful activities you can do with or for others. Again as this happens we get to either challenge the beliefs we have about other people:

The interesting other who I must stay away from as I will bore them.
The critical other who will laugh at me as I struggle to do things I used to excel at.
The other who is better than me, whose life is what my life should be.
No-one understands my suffering
They don’t suffer like I do

There is also a relationship to yourself that keeps you in the cave
I must criticise myself to motivate myself
I must ruminate to learn
I shouldn’t care for myself
I must not be compassionate to myself
The effect of this is there is hostility outside the cave from people, and inside the cave there elf-hostility, an “it’s good for me hostility”, almost boarding school hostility if I can call it that.

Finally Time
One last thing to mention before I say goodbye is to mention time, which is rarely mentioned. In the cave time is heavy, slow and painful. This is sometimes worth noticing both as a depressive symptom and also something that can be engaged with, as non-cave activities, or shall we say escape route have a different cadence, a different way times feel that can help guide the cave dweller back home.


Treatment
In some way the bed rock of coming out of the cave is self-care, self-compassion and making meaning.  I guess without some looking after yourself and care towards yourself everything else becomes much harder. So in some ways this might be the place to start.
The entwined nature of life however would also point out that self-care is reduced because of low self-valuation which is maintained by rumination, self-criticism, comparisons and low value activity. So I guess here is to find an “in”. Somewhere you can make a difference, and in some way as you reduce the low value creating activity or inactivity, then to increase self-care and compassion would seem to be the way to go as this could create more momentum for tackling the next cave staying aspect.
Meaning seems also key: to make sense, to make meaningful how you got into the cave and therefore the meaning of being in and getting out of the cave would also seem important. It places cave dwelling as part of a narrative that shows how the main character, gets his second chance, overcomes his adversities, learns and builds on his prior mistakes to a phoenix return.  As soon as you can make sense of cave dwelling and escaping, it offers you a method to get out, and you can orient yourself with this narrative.
So after we provide some foundations then we need to tackle the different shades of cave dwelling:
If learned helplessness seems powerful a good anti dote to this would be shaped behavioural activation as you want to enhance self-efficacy.
If there are core beliefs around about being bad\useless etc. compassion work would seem a soothing balm.
If self-criticism is high then to understand its purpose, generally to do with learning and motivation and then to see its effects and seemingly then the encouraging aspect of compassion seems helpful.
If rumination is high then to understand its purpose and effects seems critical, again to notice the secondary benefits that the rumination might be an attempt to hold onto a view of the world that I had good parents or it’s a just world etc. Attention switching\mindfulness to more valued activity seems helpful in this space.
If comparisons are high then you can work with them in the same way as self-criticism as they are part of this in that you compare with yourself to result in a critical attitude to yourself.
The social element of staying in the cave seems about using some of the techniques to cave entry back with the client. So as often peoples self-relation is a lot harsher than their other relations, you can use comparison to ask would you say that to a friend.  In the face of self-criticism or rumination learnt from a significant other you can invoke a compassionate other be it as an individual or composite of individuals and ask how they would react to you. You can also bring in the imaginary person, if you had a child and something went wrong, would you encourage them to criticise themselves and ruminate. So in some ways this is a cognitive restructuring but the method is through relations. It uses the same mechanisms, comparisons, imagination and memory but just with different people, people that you love or loved you. In some ways it seems less of a cognitive curiosity rather a meeting old friend and maybe even new ones.

Summary
Entry to the cave happens like this:
1.    Feel distress in life
2.    Consider the reason for this that I’m not living or don’t know the good life
3.    Consider others better than me\punitive and uncaring
4.    Go to the cave to minimise damage, no mistakes, nothing goes wrong, no criticism, no failure as I’m not trying and that’s the reason I’m depressed.
And you stay in the case like this
1.    Through learned helplessness consider I can’t find out how to get\live the good life
2.    Use the depressive cognitive\behavioural maintaining factors mentioned above

Whilst it seems significant to address the cave entry ticket to both ensure early release and prevent relapse, the maintaining factors whilst related to the entry ticket are significant and without treatment of these escape is unlikely. Of course the division isn’t as clean as this and the maintainers will also be seen in the cave entry and vice versa, but logical clarity here seems helpful.

Of course I guess one obvious answer to all of this not mentioned above, it to make a really swish cave, all bear skin, plasma, wine and grapes and wait for everyone else to come to yours, but then that is another story….bye now.

References
Gilbert, Paul. The Compassionate Mind (Compassion Focused Therapy) (p. 40). Little, Brown Book Group. Kindle Edition.
Rowe, Dorothy. Depression: The Way Out of Your Prison (pp. 18-19). Taylor and Francis. Kindle Edition
Seligman, Martin E.P.. Learned Optimism: How to Change Your Mind and Your Life (p. 58). Knopf Doubleday Publishing Group. Kindle Edition