My approach to working with depression
Watch to learn how I work with depression. Prefer to read? Click here
Psychotherapy for depression, in person and via telehealth, based in Dupont Circle. Click the Free Consultation button to schedule with Dr. Levine.
My Approach to Depression
The roots of my approach are both personal and professional
Depression is a particular area of interest for me, both in my clinical work and in my research. My doctoral dissertation focused on depression—it was an integrative literature review that worked to bring together different perspectives on the causes of depression, both clinical perspectives and some really fascinating and underrepresented perspectives from evolutionary psychology. My approach to treating depression in therapy draws on a combination of that research, my clinical experience, and my own personal experience with loss, grief, melancholy, and reflections on my ongoing attempts to navigate the human condition.
Before anything else, comes an understanding of the experience of depression
The first thing I think about when treating depression is working to really understand and appreciate the depth of pain that depression can bring, and to really accompany the people I work with in their suffering. I'm not rushing to fix the problem the minute you enter my office, as this rarely works and is rarely what anybody actually needs, unless the situation is truly dire and there is risk involved. Except in those cases of high risk and acuity, my priority at the very beginning of treatment is to really try to step into your shoes and do my best to understand what it's like to experience this kind of psychological pain for you. Once I understand that as best I can, we move toward seeing how we might come to some kind of resolution.
Depression takes many forms, so there is no one-size-fits-all treatment.
The second thing I'm always thinking about is that depression is an incredibly broad term. Sometimes it's brought on by a very specific event or antecedent: a loss or disappointment, financial difficulties, relationship problems, a crisis of faith or values. Other times, depression can present as a kind of amorphous, ambiguous thing that seems to have existed ambiently for years without being focused on or caused by any one thing in particular that can be easily identified or articulated. And, of course, there are all sorts of presentations in between those two poles. Because of this, there is no single way to understand or treat depression, because every person is unique. If there was one way to understand and treat depression, I wouldn’t have needed to write a 370-page dissertation outlining every possible way to conceptualize it! To that end, my treatment approaches are as bespoke as the many ways depression can show up for my patients.
Treating depression requires both insight and action.
While it is true that there is no one-size-fits-all approach to treating depression, what I can say is that all of these approaches adhere to the overarching principle of balancing insight and action. While some form of action alongside more exploratory “insight-oriented” work is necessary for any concern in therapy, it is especially true for depression. The reason for this is that depression, from an evolutionary perspective, can be understood as a kind of “shut down” response, or the opposite of action.¹˒² It is a “depression” (as in, suppression) of one’s motivation and engagement with the world. Indeed, one of the most effective and well-researched treatments for depression is called Behavioral Activation (BA), which aims to counteract this shut down response through simple behavioral change.³ BA is remarkably simple. It does not directly address depressive thoughts or feelings. Rather, it is the simple act of systematically and gradually scheduling specific types of activities into each day which get a person out of bed, off the couch, and reengaged with their life. It moves a person from being in a shut down response—from being inactive—to being “behaviorally activated.” It turns out that when you do this, your mood improves in a pretty significant way, because you are doing the opposite of what the depression response pulls you towards: the urge to shut down, conserve energy, and disengage from the pursuit of goals. Acting in opposition to what the emotional state of depression “wants” you to do is a powerful way of modulating the emotional state itself. This is an important example of when thoughts and feelings—including depressive thoughts and feelings—can be changed indirectly through the change of behavior.
Therefore, while in my view the treatment of depression requires more than just this kind of behavioral change, including working directly with thoughts and feelings, treatment approaches which fail to include concrete action steps often fall short because they do not adequately address what I understand to be the fundamental nature of depression from an evolutionary perspective.
In addition to action, insight is still invaluable for the treatment of depression. Often times, it is necessary for guiding the kind of action that will ultimately resolve depression. For example, it may help a person choose more life-affirming and value-aligned activities to engage in or goals to pursue, or enrich relationships and reduce feelings of alienation and loneliness. Other times, insight can in itself, independent from action, help to resolve depressive episodes. For example, through the resolution of internal conflict, clarification of values, increased acceptance of formerly disavowed parts of oneself, or self-understanding that allows for increased self-compassion and reduced self-criticism. There may also be factors underlying your depression that operate outside of your awareness, and bringing increased awareness to these issues can in itself be relieving and reduce suffering.
Therefore, when working with depression, I am always striving to balance action-oriented, structured approaches (e.g. cognitive behavioral therapy), with more insight-focused and exploratory approaches (e.g. psychodynamic therapy).
1. Henriques, G. (2000). Depression: Disease or behavioral shutdown mechanism? Journal of Science and Health Policy, 1, 152–165.
2. Nesse, R. M. (2000). Is depression an adaptation? Archives of General Psychiatry, 57(1), 14–20. https://doi.org/10.1001/archpsyc.57.1.14
3. Ciharova, M., Furukawa, T. A., Efthimiou, O., Karyotaki, E., Miguel, C., Noma, H., Cipriani, A., Riper, H., & Cuijpers, P. (2021). Cognitive restructuring, behavioral activation and cognitive-behavioral therapy in the treatment of adult depression: A network meta-analysis. Journal of Consulting and Clinical Psychology, 89(6), 563–574. https://doi.org/10.1037/ccp0000654