Voicelessness: Depression

At 3:00 a.m., millions of emotional alarm clocks go off all over the world, waking people in a panic:

"What's the point? Do I really matter to anyone? Do I have a place in other people's lives? Who knows me? Who cares? Why do I feel so unimportant?"

And even worse:

"I despise myself. I am truly worthless. I have been a burden to everyone. I hurt people. I don't deserve to live."

Some get back to sleep after an hour or two of tossing and turning. Others start their day at this early hour filled with dread. Showering, dressing, preparing breakfast (if they're able to eat at all) take monumental effort. "Keep going" they tell themselves, trying to complete simple activities that most never think twice about. Finally, in an act of incredible courage, they push themselves out the door and start off to work, struggling against emotional headwinds that make every step an exercise of will.

The prevalence of depression in the United States is alarming. According to Nemeroff (1998) (from The Neurobiology of Depression ), "5 to 12 percent of men and 10 to 20 percent of women in the U.S. will suffer from a major depressive episode at some time in their life (and) roughly half of these individuals will become depressed more than once." And these statistics do no include incidences of the less severe but lingering depression known as dysthymia.

What causes depression? Is it a biological disorder caused by neurotransmitter or hormonal imbalances? The logical consequence of faulty or pessimistic thinking? Or the inevitable outcome of childhood trauma? A whole book could be devoted to this topic, and the answer would still not be clear. The problem is that the three explanations are interrelated, and, perhaps none, alone, are completely adequate. Consider the following:

• Nemeroff reports that early emotional trauma has important and lasting neurobiological effects (at least in other species).
• Perceived inability to manage current threats affects neurotransmitter functioning (see Albert Bandura's (1995) book: Self Efficacy: The Exercise of Control [W.H. Freeman, New York]).
• Pessimistic thinking although "faulty" when applied to current situations, may not have been "faulty" during childhood, within the context of a dysfunctional family.
• Studies of identical twins separated at birth suggest that genetics play a role in depression, but don't tell the whole story.
• One child from a dysfunctional family may experience severe depression, while another remains untouched.

If this seems challenging or confusing, it is. In the depression flow chart, the arrows point in almost all directions.

Still the suffering remains. While I have no answer to the big question of causality (although I suspect all three "explanations" play a role in many depressions), there is one observation that I would like to pass along from my years of treating depression. That is: many chronically depressed clients I have worked with have had a childhood marked by the absence of voice, or what I call "voicelessness."

What is "voice?" It is the sense of agency that makes us confident that we will be heard, and that we will impact our environment. Exceptional parents grant a child a voice equal to theirs the day that child is born. And they respect that voice as much as they respect their own. How does a parent provide this gift? By following three "rules":

1. Assume that what your child has to say about the world is just as important as what you have to say.
2. Assume that you can learn as much from them as they can from you.
3. Enter their world through play, activities, discussions: don't require them to enter yours in order to make contact."

(See "Giving Your Child Voice" for more. You may want to consider your own personal history to see whether your parents followed these "rules".)

What happens when a child's feelings, thoughts, wishes, and interests are never heard? He or she feels worthless, non-existent, and incapable of having an effect on the world. A child without voice has no license to live. These feelings don't go away as a child get older, instead they go underground, replaced by eating disorders, acting out, painful shyness, or sometimes over-responsibility (a child acting like an adult).

Nor do the feelings go away when a child reaches adulthood. Maintaining a sense of self and agency is necessary for our emotional well being. But for adults who grew up voiceless, this sense is very fragile. Without "voice" people are prone to feeling hopeless and helpless. Often, the voiceless have no "place" of their own; instead they struggle to anchor themselves in other people's worlds. Unconsciously, many try to use relationships to address old wounds and repair their "self." Some try to inflate themselves like blowfish in order to feel secure and consequential (see Voicelessness: Narcissism). Others search endlessly for powerful partners who will validate their existence (see Why Do Some People Choose One Bad Relationship After Another?) or twist themselves like a pretzel in order to fit into another person's world (see Little Voices). At times these (and other) unconscious strategies succeed, but the satisfaction is rarely lasting. In everyone's life, situations occur that threaten our sense of agency (facing death is a prime example). But the "voiceless" have no ground floor, nothing or no one to catch them--the thought: "yes, but I am a good and valuable person" provides no safety net. An event usually occurs (a loss, betrayal, rejection, etc.) which re-opens the childhood wound and sends them tumbling into a bottomless pit.

Aloneness contributes to the problem. Because the emotional injury is well concealed, people do not understand. "You have family/friends, a good job," they say. "People care about you. You have no reason to feel this way." But the depressed person has good reason even if they can't verbalize it or see it themselves: a history of childhood "voicelessness."

If depression is, in part, a "voice disorder" then psychotherapy should help. And, in fact, it does (see, for example, The Effectiveness of Psychotherapy--The Consumer Reports Study by Martin E. P. Seligman). For some, correcting the faulty/pessimistic thoughts (e.g. I am a worthless person; I have no control over my life) is enough. Cognitive behavior therapy efficiently serves this purpose. Others find it important to understand the historical reasons for the absence of "voice" and the roots of their helplessness. They want to know why they struggle, and to understand how their voicelessness has affected their relationships. And, of course, they want to re-find their missing "voice." This is the realm of psychotherapy. The work of therapy does not occur in five sessions as the insurance companies would like consumers to believe. A client's voice emerges slowly in the context of a relationship with a caring therapist, often with the analgesic aid of medication. The therapist's job is to explain self-destructive thinking in the context of personal history, find the client's true voice, nurture it, and help it grow so that it can withstand the challenges of life. Once developed and applied to relationships and work, voice can be a powerful and lasting anti-depressant.

About the author: Dr. Grossman is a clinical psychologist and author of the Voicelessness and Emotional Survival web site.

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