Maybe you heard on National Public Radio last weekend that the number of medical diagnostic codes is about to be increased from 18,000 to more than 140,000 in America. These codes (called ICD-10) are used to describe just what medical condition your doctor uncovers during a visit to the hospital or her office.
As you can imagine, the new expanded set gets much more specific than the earlier one. What might before have been described broadly as a burn, for instance, can now be narrowed down using ICD-10 code V91.07XA, to a “Burn due to water skis on fire, initial encounter.” Physicians are well advised not to confuse this code with V91.07XD, “water skis on fire, subsequent encounter.” The folks at NPR had some serious fun with this one, naturally.
Listening to the story, I was reminded (again) that diagnostic codes and labels have a lot of uses beyond just describing what ails you. Insurance companies, researchers, the Centers for Disease Control and Prevention, hospital administrators — all these people and many more use them in their work. Consequently, all these groups have a hand in shaping them. Unfortunately, as diagnostic labels are stretched to satisfy more constituencies, they can become less efficient in helping the people most directly involved in their use — the health-care providers.
This is doubly true of the diagnostic labels and codes applied to mental health, where our clinical knowledge is less certain, and where questions of who is sick and who is well have political and moral implications as well. In fact, the more we know about the sources of chronic human unhappiness and emotional distress, the less clinically helpful our labels for it seems to be.
So it’s easy to forget that while a psychiatric label like “depression” can seem to convey important information about things such as its causes or treatment (the way a burn diagnosis might), the reality is slightly different. Depression (F32.9 in the language of ICD-10) is useful as an umbrella term that adequately describes the what of things, i.e., a patient’s symptoms. But it does little or nothing to reveal the why.
There are many theories about the causes of depression. It’s chemical. It’s the result of flawed thinking. It comes from bad habits, low self-esteem or poor coping skills. It’s inherited. It’s transmitted through the culture. Each of these ideas arose in conjunction with some new idea about a cure, whether it’s ways to correct your automatic thinking, change behavior, boost-self esteem or even actively strive to transform the culture.
What About Relationships?
Now, here’s an idea about depression that’s just recently gaining altitude: It’s social. People are depressed because they feel unloved, unwanted, disconnected, rejected and alone. They feel this way not because they lack social skills (depressed people can be very polished and popular), but because, down deep, they do not believe that anyone is really there for them.
What’s different about this idea of depression — based in attachment theory — is that the symptoms are maintained, not just by emotional or mental problems inside you, but by your moment-to-moment interactions with relationship partners and other important people in your life. Your mood fluctuates with your experience of being either connected or alone.
“The most basic tenet of attachment theory,” says researcher and couple therapy pioneer Susan Johnson of the Ottawa Family and Child Institute, “is that isolation—not just physical isolation but emotional isolation — is traumatizing for human beings. The brain actually codes it as danger.”
So, depression may be an evolutionary adaptation to help alert us or protect us when we are threatened by separation from important others. In the long-ago days when our psychological mechanisms evolved, separation from close family members might have been fatal. More specifically, depression might have helped our ancient ancestors focus on and solve the social problems facing them (depression, paradoxically, can focus and energize the brain), or to avoid family conflicts, or it might have been quite literally a “cry for help,” because depression shows up in behavior as a kind of helplessness that can elicit sympathy and support. Thinking about depression in social terms has led Johnson and other clinicians to develop methods for attacking it directly through social means.
“He doesn’t have my back.” This is how Andrea described her relationship with Simon, with whom she had been living for four years. Andrea has the look of a fashion model, with short black hair, high cheekbones and rail thin frame. She always shows up for therapy in black. “We get along. And that’s enough for Simon. As long as he doesn’t have to go to bed alone. ... Simon hates to go to bed alone.”
Andrea is unknowingly describing her relationship with Simon in attachment terms. She sees their relationship as useful to him, but not deeply, emotionally important. She meets Simon’s attachment needs by being there for him when he needs her, but doubts that she can count on him in return. This unreciprocated attachment causes her pain, which is feeding into a conflict loop with Simon. “Last year when I was really depressed for a month, he kind of disappeared on me. He had a great excuse, because he was studying for the bar.” Andrea sat in silence for a moment before adding, “I don’t know what will happen when he passes the exam and doesn’t need me for support anymore.”
Historically, psychologists looking at Andrea’s situation might say her relationship problems are the result of her depression. But a still-small group of clinical researchers, including Johnson, are beginning to suspect the opposite — that her depression is the result of the chronically poor state of her attachments, beginning in childhood.
Because her mother was unemployed, poor and stressed out during the years of Andrea’s early development — from age 6 months to 18 months — Andrea developed a “working model” of how important people in her life would respond to her needs and her cries of distress. They wouldn’t be there for her. This was what she experienced from her mother, and what she learned to expect from the world. As a result, Andrea enters into each new romantic relationship hoping to be rescued from her loneliness by a caring adult, but in her profound anxiety and doubt about her own lovability, she smothers the budding relationship with demands and complaints, until her prophecy of abandonment is self-fulfilled. She then sinks even deeper into depression.
Johnson describes this ebb and flow of a troubled connection as the “dance” partners do as they try to stay attached to each other, while at the same time protecting themselves from old feelings of inadequacy and rejection. In Andrea’s case, this dance took the form of seeking more and more affirmation, while becoming less and less secure in Simon’s love. Eventually, she began to suspect Simon of infidelity, and even followed him secretly to his law school study group. Simon, when his turn came to describe the relationship, complained that he was “never enough.” No matter what he did to reassure her, Andrea never acknowledged his efforts. By the time the couple came to therapy, Simon was becoming depressed himself.
While not all depression follows this self-defeating pattern, researchers such as Wayne Denton of Florida State University are seriously investigating the use of couple therapy as a treatment for depression. Denton, who directs the Marriage and Family Therapy program at Florida State, conducted studies last year comparing the effects of anti-depression medication alone vs. medication and couple therapy. Along with Denton’s earlier work in this area, the study confirms that couples therapy can, under the right circumstances, be at least as powerful as medication in alleviating the devastating symptoms of depression.
To conduct his research, Denton used a particular protocol for couple work designed by Johnson to address the attachment deficits so often found in depressed people. Johnson calls her therapy “Emotionally Focused” because it encourages couples to explore together the unconscious, internal “working models” of relationship that cause them so much pain.
The fundamental notion of this kind of work is that human happiness comes largely through our interdependent relationships with significant others. When we are secure in these attachments — when we know that someone is really there for me — we become resilient against the discouraging but inevitable slings and arrows of life. “We conceptualize depression as a response to attachment distress based on a perceived loss of connection to, abandonment by or rejection by another who is of attachment significance,” Denton writes.
While this doesn’t negate other ways of defining depression, it runs intuitively counter to the description contained in the diagnostic codes, which portray depression as an individual disorder.
Why It Matters
Because most of us don’t think about our mood as a barometer of our relationships, we don’t really notice how often depression and emotional disconnection travel together. But it surprises me how often, late in the therapy process, one partner will say to me something like, “I didn’t realize just how freaked out I was about losing her.” Reconnecting emotionally can have a powerful and lasting anti-depressant effect. And, according to Denton’s initial findings at least, these effects can persist long after treatment ends, which appeared not to be true for antidepressant medications administered without couple therapy.
The idea of redefining depression as primarily a relational problem has a long way to go before it gains mainstream acceptance. Not only are our medical institutions like health insurance not set up for it, but our cultural commitment to the idea of each person as an island of emotional autonomy — for better or worse — stands pretty firmly against it.
Clients who come in for family or couple therapy don’t do so to take care of their chronic personal unhappiness. They come to reduce the conflict or otherwise fix their relationships. But the lift in the partners’ individual mood that therapists routinely see when couple therapy is successful can be dramatic.
News from neuroscience is confirming that any relationship, but especially a primary relationship, can be activated as a resource against the stresses of pain and fear. And the application of therapeutic techniques for couples — like Johnson’s — based in attachment theory are demonstrating their effectiveness against a host of other emotional problems, including addiction and PTSD. Not only that, but clients like Andrea and Simon, as they explore together the deeper emotional currents of their attachment, often find that problems in other areas of life are less difficult to resolve, or at least less fearful and paralyzing.
My point is this: Whether or not the diagnostic deities who give us water skis on fire ever define depression as a relationship problem, your relationship has the power to lighten the load of chronic worry, helplessness and hopelessness they call depression.
— Russell Collins, Psy.D., is a Santa Barbara psychotherapist and divorce mediator. Click here for more information.