The interpersonal structure of depression

Abstract

This paper addresses the manner in which alterations of interpersonal experience are (a) central to most of those predicaments labelled as ‘depression’, and (b) inextricable from other, seemingly distinct depression-symptoms. I sketch an approach inspired by the phenomenological tradition of philosophy, which emphasizes how depression-experiences involve profound changes in one’s sense of possibility. In so doing, I show how anticipated and actual interactions with other people shape and re-shape experience of the wider world by imbuing it with certain distinctive types of possibility. It follows from this that a shift in how one anticipates, experiences, and relates to other people in general also amounts to a shift in the types of possibility offered by the world. My discussion is concerned primarily with the structure of depression-experiences, rather than with causes or treatment. However, I conclude by tentatively addressing some implications for the latter.

Keywords:

• depression
• existential feeling
• interpersonal connection
• isolation
• phenomenology
• possibility
• self-regulation

1. Introduction

Changes in the structure of interpersonal experience are central to most of those predicaments labelled as ‘depression’. Furthermore, various other ‘depression symptoms’ cannot be adequately conceived of in isolation from the interpersonal. However, one can be forgiven for thinking otherwise. Consider, for instance, the diagnostic criteria for ‘major depressive disorder’ in DSM-5. It is stated that five (or more) of nine symptoms must be present, including at least one of two core symptoms (depressed mood and loss of interest) and others from a list of seven (weight and or appetite changes; sleep disturbance; activity changes; fatigue; worthlessness and/or guilt; lack of concentration; thoughts of death or suicide). Interpersonal relations are not explicitly mentioned at all (American Psychiatric Association, 2013, pp. 160, 161). Granted, persistent feelings of worthlessness and guilt do at least point towards a wider change in how one relates to others. However, its nature is not addressed and, in any case, the presence of such feelings is not essential to the diagnosis. We are thus left with the impression that any disturbances in the interpersonal realm are effects of depression symptoms: social relations are impaired because the person is depressed. This is illustrative of a wider tendency to think of depression, and psychiatric illness more generally, as a disorder of the individual.¹

In contrast, first-person accounts of depression consistently convey the centrality of interpersonal experience. Consider the following excerpt, from a depression memoir by Tracy Thompson:

I wanted a connection I couldn’t have; I did not understand or value the ones I did have. It was a story I saw time and time again in the ward. ‘Only connect!’ E. M. Forster had written, but we hadn’t, or couldn’t, or never had. There was the doctor, lost in his personal torment, or Heather, grasping for superficial symbols of connectedness, or Luisa, looking for it through sex. It seemed to me the basic definition of any mental illness, this persistent, painful inability to simply be with someone else: It might be lifelong. Or it might descend like a sudden catastrophe, this blankness between ourselves and the rest of the world. The blankness might not even be obvious to others. But on our side of that severed connection, it was hell, a life lived behind glass. The only difference between mild depression and severe schizophrenia was the amount of sound and air that seeped in. (Thompson, 1995, pp. 199, 200)²

That is my focus here: an inability to be with other people in a certain way. We might be sceptical about the reliability of certain sources of testimony, such as depression memoirs and we should certainly be wary of cursory remarks about the differences between depression and schizophrenia. Nevertheless, what Thompson writes is, in my opinion, broadly right. Other depression memoirs similarly emphasize this inability to ‘connect’. For example, Sally Brampton (2008, p. 1) writes, ‘If we connect with even one other human being who truly understands, we take one step out of the illness. Life is about connection. There is nothing else. Depression is the opposite; it is an illness defined by alienation’. Furthermore, the theme of painful disconnection from others is not specific to published memoirs; it is just as prominent in almost every detailed first-person account of depression, regardless of source. In what follows, I will illustrate my various points by quoting from responses to a questionnaire study that I conducted with colleagues in 2011. (Unless otherwise indicated, testimonies quoted here were acquired via this study. Most of the respondents whom I quote from had diagnoses of major depression. In other instances, the experiences described are equally consistent with that diagnosis. For full details of the study, see Ratcliffe, 2015). There remains the concern that over-reliance on one source of testimony has its limitations and presents a number of interpretive challenges. However, the kinds of descriptions offered by respondents are consistent with first-person accounts more generally, as is their emphasis on the interpersonal.

I will not speculate as to the causes of depression, even though many people do attribute their depression to sequences of unpleasant circumstances involving other people, often dating back to childhood. Instead, my emphasis is on the relevant phenomenology: on what the experience of social isolation actually consists of and how it relates to other, seemingly distinct aspects of depression. It is easy enough to illustrate that interpersonal experience is central to depression, regardless of what diagnostic manuals and the like might suggest. But there remains the temptation to construe it as an isolable symptom amongst others. What I want to show here is exactly how the interpersonal is integrated into a wider experience of depression (or, to put it more accurately, how it is integrated into wider experiences of the kind(s) that are often associated with the label ‘depression’ and, more specifically, ‘major depression’). My approach draws on the phenomenological tradition of philosophy, which I think is especially well-placed to clarify the nature of the relevant experiences, given its distinctive emphasis on how we find ourselves situated in a ‘world’. With this emphasis, I will suggest, we can come to see exactly how the interpersonal fits in.

It is debatable whether and to what extent the kinds of approaches advocated by phenomenological philosophers are compatible with one or another conception of psychoanalysis and with wider therapeutic practice. I will not try to tackle this set of issues here. However, I should at least stress that the account of depression and interpersonal experience laid out in what follows does not require the acceptance of any particular phenomenological method and is potentially compatible with a broadly psychoanalytic perspective. My aim here is to provide a framework for conceptualizing certain commonplace ‘symptoms’, one that has the potential to inform a wide range of therapeutic approaches. Furthermore, a phenomenological approach that emphasizes interpersonal dynamics, rather than just ‘subjective experience’, is especially well placed to enter into dialogue with psychoanalysis. In this respect, my phenomenological analysis is consistent with certain recent attempts to integrate phenomenological and psychodynamic perspectives (Stolorow, 2013; Throop, 2012).

2. Possibilities

A common theme in first-person accounts of depression is that other people do not understand one’s predicament, cannot understand it, or do not even try to understand it. Accompanying this is the acknowledgement that depression, or some aspect of it, is extremely difficult or even impossible to describe:

I think the feeling of being paralyzed by the depression is hard to explain, as it’s hard to explain it to myself.

The disconnection I feel is the most difficult to convey. It’s very difficult to explain to others who have never felt it, that the world looks distorted and imposing and alien, and that I don’t have a place in it. It’s like being in a bubble with no sound or colour, and a complete lack of familiarity in everything, even in places I know well, like my home. Even people seem very alien.

Being unable to convey one’s predicament to others and feeling that nobody ‘gets it’ are not simply consequences of being depressed. They are integral to a more general feeling of social alienation that is itself central to many depression-experiences. But why do people find these experiences so difficult to articulate? Granted, it could be that depression impairs the required cognitive abilities. However, those who have recovered from depression often state that it remains difficult or impossible to describe. Although the difficulty may well be attributable to a range of factors, a prominent and consistent theme is that depression involves the profound, all-enveloping transformation of a ‘world’ that was previously taken for granted, of something that people seldom reflect upon or even acknowledge in other circumstances:

You know that you have lost life itself. You’ve lost a habitable earth. You’ve lost the invitation to live that the universe extends to us at every moment. You’ve lost something that people don’t even know is. That’s why it’s so hard to explain. (Quoted by Hornstein, 2009, p. 213)

Most of all I was terribly alone, lost, in a harsh and far-away place, a horrible terrain reserved for me alone. There was nowhere to go, nothing to see, no panorama. Though this landscape surrounded me, vast and amorphous, I couldn’t escape the awful confines of my leaden body and downcast eye. (Shaw, 1997, p. 40)

The phenomenological tradition is a valuable resource for understanding, given this alteration of ‘world’. How we find ourselves rooted in a world and how world-experience differs qualitatively from any attitude adopted towards something within a world are consistent themes in phenomenology. Whenever I perceive p, remember q, think about r, believe that s, or imagine t, I already find myself situated in a world, in a realm where it is possible to take up attitudes of these and other types. Because the relevant aspect of experience is so pervasive and deep-rooted, it is something that we seldom explicitly acknowledge. What is thus needed is a perspectival shift, whereby ‘world’ ceases to operate as a pre-reflective background to our thoughts (including our thoughts about the nature of human experience) and instead becomes an object of inquiry. Here is how Edmund Husserl puts it, in one of his later writings:

Waking life is always a directedness toward this or that, being directed toward it as an end or as means, as relevant or irrelevant, toward the interesting or the indifferent, toward the private or public, toward what is daily required or intrusively new. All this lies within the world-horizon; but special motives are required when one who is gripped in this world-life reorients himself and somehow comes to make the world itself thematic, to take up a lasting interest in it. (1954/1970, p. 281)

My suggestion is that the ‘world’ that is altered in depression corresponds roughly to the experiential ‘world’ that phenomenology seeks to investigate. Hence, we can draw on insights from phenomenology in order to characterize something that is otherwise elusive. To do so, we first require a more specific account of what this ‘world’ actually consists of. Importantly, it is quite unlike any experience of or thought about something within the world. The world is not taken to be the case in the same manner as an object of perception or belief. Its acceptance is instead a precondition for attitudes of ‘believing’, ‘perceiving’, and so forth. In order to take something to be the case, not the case, or possibly the case, one must already be situated in a realm where some things are and others are not. So one does not discover this world as an object of experience or thought. Rather, one finds oneself practically, habitually, affectively immersed in it.

The nature of this ‘immersion’ can be described more specifically. Another consistent theme in the phenomenological tradition is the way experience incorporates possibility and, more specifically, anticipation. All experience is said to be permeated by possibilities of various kinds. For instance, when I look at a cup, it appears as something that I could see from another angle, reach out and touch, or drink from. Some experienced possibilities are perceptual in nature: ‘I could reach out and touch it’; ‘by moving this way, I could see the other side of it’. However, others relate to goal-directed activities and involve various types of significance or mattering. My computer, desk, chair and pile of notes are experienced as mattering in an integrated way, insofar as they all relate to my current project of writing an academic paper. The long list of emails in my inbox, in contrast, is experienced as an obstruction to other pursuits that I am preoccupied with, even as a potential threat to my well-being. Many experienced possibilities consist, more specifically, in immediate anticipation, in a sense of what is coming next and how it matters. Anticipation of this kind is not separate from our experience of the actual. Rather, the actual is imbued with salient possibilities. Take the case of watching a glass fall from a table towards a hard floor. The prospect of its shattering and making a certain noise is there, now, as it falls.

Importantly, our anticipation of unfolding events is not atomistic in structure. Anticipatory experience has what we might call an overarching style, a cohesive way in which one’s situation as a whole is experienced as unfolding. The sense of being situated in the world is to be identified with this style:

The natural world is the horizon of all horizons, and the style of all styles, which ensures my experiences have a given, not a willed, unity beneath all of the ruptures of my personal and historical life; the counterpart of the natural world is the given, general, and pre-personal existence in me of my sensory functions, which is where we discovered the definition of the body. (Merleau-Ponty, 1945/2012, p. 345)

As this quotation suggests, it can be added that a style of perceptual and practical unfolding is inseparable from diffuse sets of felt bodily dispositions. It is through the feeling body that we experience the significant possibilities offered by our surroundings (Ratcliffe, 2008, 2015, 2017a). To make things clearer, consider more localized feelings of practical confidence. For instance, suppose one is giving a well-prepared lecture to a group of interested students, while feeling unusually refreshed and healthy. One’s experience of the situation as a whole is characterized by the confident, unproblematic anticipation and fulfilment of various significant possibilities. Of course, what one anticipates can be quite indeterminate in nature. Even so, experience unfolds in line with what is anticipated; it does not conflict with it. When surprises and disruptions occur, they do so against the backdrop of this broader pattern of confident engagement with one’s surroundings; they are localized anomalies. Such experiences also involve a diffuse feeling of ease or confidence, something that is not localized in a particular part of one’s body.

The next step is to maintain that our more general sense of being rooted in a world similarly consists in a diffuse sense of practical confidence (something that I take both Husserl and Merleau-Ponty to be saying, albeit in different ways). Experience has an anticipation-fulfilment structure, which operates as an all-enveloping backdrop to more specific situational engagements, experiences and thoughts (Ratcliffe, 2015, 2017a). And the crucial point is that this structure is susceptible to change. Elsewhere, I have referred to its variants as existential feelings (Ratcliffe, 2005, 2008, 2015). Emotions and moods might be thought of as intentional states with more or less specific contents, such as feeling happy about p, angry about q, scared of r, or in a bad mood about s. That being the case, existential feelings are distinct from both. It is only in the context of a given existential feeling that intentional attitudes of one or another type are possible. For instance, one can only experience something as frightening in a world that incorporates the possibility of threat, of anticipating something as significant in that kind of way. Pronounced changes in existential feeling thus involve shifts in the kinds of possibilities offered by the experienced world. The ‘world’ of depression can be characterized in terms of such shifts. There is a distinction to be drawn between tokens and types of experienced possibility. The following description of how things appear upon hearing that a friend will not show up for dinner is an example of the former:

What I was seeing then was not a green bottle, with a white label, with a lead capsule, and things like that. What I was really seeing was something like the disappointment about the fact that my friend would not come or about the loneliness of my evening. (Van den Berg, 1972, pp. 34, 35)

Here, a particular situation is experienced in the guise of disappointment, insofar as certain specific interpersonal possibilities present themselves as unfulfillable. Nevertheless, one retains a sense that possibilities of that type remain and can be actualized in other situations. The loneliness is contingent and temporary; other such evenings are still possible. In contrast, people with depression diagnoses often experience the world as bereft of the relevant types of possibilities. It is not just this evening that appears in the guise of loneliness; the world offers nothing else. To find oneself in a different world is to inhabit a different possibility space. This, more than anything else, is what people struggle to articulate. It should be added that labels such as ‘major depression’ accommodate a range of different kinds of experiences. These include various different changes in a person’s sense of the possible, along with other predicaments that do not involve such profound phenomenological disturbances. In most instances, though, ‘major depression’ does involve some kind of shift in the types of possibility that are integral to the experienced world. Such shifts are also describable in terms of an altered sense of ‘self’; a unitary change in ‘how one finds oneself in a world’ encompasses both self-experience and world-experience (Ratcliffe, 2015, 2017a).

3. Incarceration

Many first-person accounts of depression state that, while depressed, one firmly believes that recovery is not merely unlikely but impossible, that the world of depression presents itself as inescapable, eternal. This should not be construed in terms of a specific belief with a circumscribed content. It expresses something much more pervasive: a loss of certain kinds of possibility from the world. The relevant experience comes in many subtly different forms. However, for current purposes, it will suffice to characterize it in an abstract, simplified way. Take the general possibility of ‘things changing for the better’. Even when a particular situation seems hopeless, we usually retain the sense that something in our lives could change for the better, the sense that this type of possibility remains. But now consider a world from which the possibility of things changing for the better is altogether absent: nothing is experienced as offering that possibility and one cannot even imagine a scenario where it might. More usually, a sense that things could change for the better is integral to the experience of one’s current situation as contingent – a sense that it could change in ways that matter. Drained of the prospect of positive change, the world can offer up only more of the same or something worse. Hence, one’s situation is experienced as inescapable, something that is often conveyed in terms of being imprisoned, entombed, trapped, encased in some immovable substance, or stuck behind a sheet of impenetrable glass.

The relevant experience is temporal in structure, more so than spatial. One cannot ‘get out’ because the required types of temporal transition are no longer amongst the world’s possibilities. The same experience could be described with a number of different emphases. It is a change in how one experiences time: there is no future, or one’s predicament seems somehow timeless. It is also a change in how one experiences one’s body: no longer drawn in by worldly possibilities, the body is sluggish, cumbersome and conspicuous. And it is a loss of hope: one can no longer summon attitudes of the type ‘hope’. Interestingly, people not only offer descriptions that are consistent with this emphasis on possibility. Some also explicitly refer to possibilities and their absence. Here are some representative examples:

You can’t see far into the future so you can’t see aspirations or dreams. Everything I ever wanted to do with my life before seemed impossible now. I also would think that I would never get out, that I’d be depressed forever.

… when depressed I see life as pointless and sometimes cruel. I cannot see any possibilities for change or improvement.

The world seems pointless because when I am depressed I can’t see the world in a positive way. All I see is a place full of suffering which I often feel I would be better off escaping from … I can’t think positively.

When I’m depressed life never seems worth living … I think that my life will never change and that I will always be depressed. Thinking about the future makes my depression even worse because I can’t bear to think of being depressed my whole life. I forget what my life is like when I’m not depressed and feel that my life and future is pointless.

My entire focus is on the negative. I cannot see a positive future. I often find myself thinking I could be anywhere in the world right now, doing anything and I would still be desperately miserable.

The world holds no possibilities for me when I’m depressed. Every avenue I consider exploring seems shut off.

While certain types of possibility are gone from experience, others may be amplified. For instance, without significant possibilities for meaningful action, one might instead experience everything in the guise of threat: ‘There are lots of threats in the world and they all seem to be about to happen, or be very likely they will happen. Loved ones are in danger’. There are many variants but, in all these cases, what we have is a unitary change in the overall form of experience rather than a cluster of separable ‘symptoms’. And, having acknowledged this, we can begin to see how the interpersonal fits in.

4. Connection

My central claim is that the loss of contingency from the world, the sense of one’s predicament as inescapable, is identical to the feeling of estrangement from other people. So you cannot have one without the other. In brief, the anticipation of certain types of relations with other people imbues the world with a distinctive degree and kind of openness and uncertainty – what we might call a sense of there being self-transformative possibilities. Where such possibilities remain, one cannot experience one’s current predicament as inescapable or one’s current perspective as exhaustive. And, where they are lost, the world cannot but be drained of a certain kind of contingency. Although the relevant loss is not exhaustive of depression-experiences, it is what we find emphasized again and again in first-person accounts.

It is important to distinguish two things: (a) a sense of connection that we sometimes experience during interaction with other people; (b) the anticipation of interactions involving that sense of connection. First of all, I will suggest that (a) essentially involves a change in one’s experience of possibilities, something that can be subtle and mundane or exceptional and profound. Second, (b) includes a sense of the potential for this, and thus a sense of one’s current perspective as incomplete, open to possibilities that cannot be fully specified in advance.

Various philosophers have noted -in one or another way- how, when we interact with another person, the two parties inevitably affect one another in a certain, distinctively personal manner (something that can be especially salient in the context of psychotherapy). This does not demand conscious attention and is not something one can willfully avoid. We are inevitably permeable to one another’s influence. Through an interplay of expression, tone and gesture, we solicit various affective responses, and these responses are inseparable from how the wider world is experienced. The Danish philosopher, Knud Løgstrup, describes this as follows:

By our very attitude to one another we help to shape one another’s world. By our attitude to the other person we help to determine the scope and hue of his or her world; we make it large or small, bright or drab, rich or dull, threatening or secure. We help to shape his or her world not by theories and views but by our very attitude toward him or her. (1956/1997, p. 18)

Interpersonal processes thus alter the possibilities offered by our surroundings – both immediate and the longer term possibilities. At one extreme are experiences resembling what Sartre calls shame, where one loses one’s possibilities in the face of another: ‘I grasp the Other’s look at the very centre of my act as the solidification and alienation of my own possibilities’ (Sartre, 1943/1989, p. 263). However, there are many other ways in which people affect one another, and the point to note is that all interpersonal encounters exert at least some degree and some kind of influence, however subtle and trivial it might be in a given case. The relevant experience is especially pronounced and also has a certain, distinctive character in those cases where there is sustained, patterned interaction between two or more parties, involving feelings of mutual connection. Fuchs and De Jaegher (2009) refer to an experience of ‘mutual incorporation’, where the two parties form a coupled system; the interaction between them structures both their understanding of each other and also how they experience their shared surroundings. Complementing this, Fuchs (2013) describes a kind of ‘bodily resonance’ that shapes interpersonal interaction, fostering a sense of connection in ways that shape wider experience and thought.

Such phenomenological claims are complemented by other sources of evidence, including various empirical scientific studies. A substantial body of evidence indicates that actual and anticipated interactions with others, and even the mere presence of others, influence the perceptual and practical salience of one’s surroundings in a pre-reflective fashion (e.g. Bayliss, Frischen, Fenske, & Tipper, 2007; Becchio, Bertone, & Castiello, 2008; Sebanz, Bekkering, & Knoblich, 2006; Sebanz & Knoblich, 2009). Others have proposed that certain regulatory processes are not internal to the human organism but interpersonally distributed. Bereavement and other circumstances can thus involve the ‘withdrawal of specific sensorimotor regulators’, something that may impact dramatically on how a person experiences and interacts with her surroundings (Hofer, 1984, p. 188). Also of relevance is a substantial and fast-growing body of literature on emotion regulation (e.g. Gross, 1999, 2001, 2014). Regardless of how we might think of ‘emotion’, it at least seems safe to say that emotions are involved in experiences of significance and salience (and, by implication, experiences of possibility). It can be added that, even in adulthood, emotion-regulation is not a wholly internalized process. We interact with the social environment in a range of ways that serve to regulate our emotions (Colombetti & Krueger, 2015; Krueger, 2018). In particular, interactions with other people play a key role (Diamond & Aspinwall, 2003; Gross, 2014). They can nurture or fail to nurture feelings of connection, which are themselves prerequisites for other kinds of emotional change that shape one’s relationship with the surrounding environment (Ratcliffe, 2017a).

All of this is consistent with a variety of mundane, everyday experiences. An example I often find myself using in conference presentations is that of two different scenarios that can unfold when you take a visiting speaker out for dinner after a talk. In scenario A, the two of you ‘hit it off’ straightaway and the conversation glides effortlessly from one topic to the next. As you walk home afterwards, your world seems enriched – it offers all sorts of possibilities, some more determinate than others, that you had not anticipated before the encounter and perhaps could not have anticipated without it. In contrast, in scenario B, the whole evening is characterized by mutual awkwardness – there is no flow of word, gesture, or expression; points are not followed up or developed; and, after a while, everything seems effortful, difficult. The same restaurant now appears small, suffocating, drained of possibility. And, as one heads home, everything seems somehow depleted, diminished.

Interactions with other people can thus shape and re-shape, in various ways, the wider possibilities offered by our surroundings. Importantly, these include self-transformative possibilities of a kind that cannot be anticipated in a determinate way. Turning to (b), it can be added that, in anticipating interaction with others, what we anticipate includes the potential for such relations (which is not to suggest that we ordinarily conceptualize or articulate it as such). What we anticipate from the interpersonal is distinctive in kind; it is essentially indeterminate, to some degree unpredictable. (This is not to make the strong claim that only other people can ever offer certain types of possibility. Rather, the proposal is that there is a qualitative difference between the kinds of possibility ordinarily offered by other people and those ordinarily offered by inanimate entities and non-human organisms.) It is partly for this reason that we frequently seek consolation from trusted others when bad things happen. Interaction with them can involve re-construing the significance of relevant events, in ways that often cannot be accomplished alone and are not merely a matter of obtaining concrete opinions, advice, or practical support. Other people thus imbue the world with a distinctive degree and kind of openness and spontaneity, a sense that this is not all there is, that the possible is not exhausted by those concrete alternatives that I am currently able to entertain. This is something that our experience of the world more usually takes for granted, but it is notably absent in many cases of ‘depression’. This absence is central to the relevant experiences.

Granted, loss of possibility in depression can extend beyond what is implied by a loss of interpersonal connection. Arguably, one does not have to be capable of anticipating interpersonal connection in order to anticipate enjoying an ice cream. A loss of anticipated pleasure can thus be further-reaching. Nevertheless, many other aspects of depression-experience are implied by loss of connection: a loss of possibilities from the world more generally (including all of those anticipated pleasures that do implicate interpersonal connection in some way); a sluggishness associated with practical disengagement from the world; a change in the sense of time, involving a loss of openness from the future; loss of a hopeful attitude towards the future. Conversely, without this disconnection, the world could not incorporate the profound loss of possibility, hope, and an open future that many people with depression diagnoses describe.

5. Disconnection

First-person accounts of ‘depression’ are in many respects quite varied. This should come as no surprise – the kinds of criteria employed to diagnose depression, along with more specific categories of depression, are cursory and permissive. Hence, they are highly unlikely to identify a single, unitary phenomenon. Nevertheless, a consistent theme in almost all accounts is the intimate connection between loss of possibilities from the world and an absence of interpersonal connection. Although many accounts refer to an impenetrable barrier between self and others, the experience is seldom just that of being cut off, unable to make contact. Along with this, other people often continue to present certain other possibilities, such as threat, disapproval, condemnation, or humiliation. In all cases, though, what is diminished or altogether lacking is a sense of the potential for a certain type of interpersonal connection:

I feel less connected to people around me – completely alone even in a crowd … They seem more distant and collectively living their lives around me, as if I am not an active participant in my life.

I assume my family dislikes me and that everyone is looking at me and thinking what a terrible person I am. I begin to feel as if my friends aren’t real and secretly they see what I see in myself which is horrible.

I would sometimes describe it as though I was wearing tinted glasses when I was feeling depressed. My best friends and family could appear to be enemies, I would fear them sometimes, that they would hurt me, that they no longer liked me. Or, I would, when trying to drag myself out of those feelings make them appear vulnerable, that it was in fact me that could hurt them, and that I needed to protect them from my thoughts and actions, I would then distance myself, which would make it even harder to feel better.

There is often an emphasis on one’s own inadequacy, worthlessness, or failed moral character, coupled with either the threat of other people discovering it or its being on display for all to see. Alongside this, one may dread, fear, or be suspicious of other people in general. In many cases, there is also anger towards others. Sometimes, there is alternation between blaming oneself and blaming others. Indeed, self-denigration often seems to translate effortlessly into criticism of others: I am a burden / they won’t tolerate me; I am worthless / they don’t value me; I am alone / they have abandoned me; I can’t achieve anything / I’m not supported. For example, ‘often I feel angry with family and friends but that changes almost immediately to self-loathing that I could think that way about loved ones’. This is reminiscent of Freud’s famous discussion in Mourning and Melancholia (1917/2005), at least insofar as Freud proposes that self-denigration can amount to a veiled criticism of others (Ratcliffe, 2015)

Interpersonal experience in depression often involves a further tension. It is not simply that interpersonal possibilities are absent from experience. More often, the felt absence of these possibilities is itself a salient aspect of the experience. And, in many cases, one does continue to anticipate certain forms of interpersonal connection. However, in seeking them out, one is confronted with a world where there is no prospect of actualizing them, comparable to needing a drink in a desert. There is thus a conflict between seeking to engage with and to retreat from the social world: ‘I feel lonely if I withdraw but it feels hard to be around people’.

Distinctions should therefore be drawn between various ways of being estranged from self-transformative interpersonal possibilities. Someone might no longer seek interpersonal connection, continue to seek it but experience its consistent disappointment, anticipate disappointment but seek out connection regardless, or continue to need connection but find the interpersonal world too terrifying to venture out into. The latter is consistent with something else that is often mentioned, a pervasive loss of more usually habitual, pre-reflective ‘trust’ in other people: ‘I close away from the outside world, I get a feeling of being scared to go out in case I see someone I know. I don’t trust the world around me when I am depressed’. When especially pronounced, this may also be described in terms of ‘paranoia’:

I am incredibly negative and paranoid – I can’t walk around a shop without feeling that everyone is staring at me. I am convinced that everyone hates me. I feel isolated and that no one understands me. I feel as though I have no friends and I am bad at my job. I feel like I’m wasting my doctor’s time.

When I was depressed, I also became much more paranoid. I assumed that if a friend didn’t text me back after a few minutes, they hated me. Tiny off-hand comments would make me believe even my own mother hated me. I always assumed that the root of this hatred was my awful personality. I thought that the other people in the building I lived in (even those I didn’t know) were making fun of me behind my back. It sounds ludicrous now, but that’s how I genuinely felt at the time.

Lack of ‘trust’, in such cases, is not a localized attitude towards however many people. It is an all-enveloping shift in what one anticipates from others, who no longer seem predictable or dependable. This is closely associated with a wider sense of the world as turbulent, unstructured and uncertain. If you cannot depend on other people, then you cannot depend on social norms, items of equipment maintained by others, information they provide, and so forth. Erosion of trust can also extend to the efficacy of one’s own actions, to one’s bodily functions; to the reliability of one’s thoughts and feelings; and to the integrity of one’s sense of self. It is here that we start to see a blurring of the boundaries between experiences typical of ‘depression’ (of one or another kind), ‘post-traumatic stress disorder’, ‘schizophrenia’ and other diagnoses. All can be fuelled by much the same form of social alienation, involving the erosion of a primitive, non-localized, habitual form of trust or confidence (Ratcliffe, 2017a).³

6. Implications

What I have said implies that the establishment of interpersonal connection is not incidental to the treatment of depression but unavoidably integral to it, and indeed central (see also Ratcliffe, forthcoming). Establishing and nurturing a sense of connection that someone experiences as absent implies the transition from the frozen world of depression to a world that is imbued with meaningful contingency.⁴ Hence a pressing issue to address is that of how to distinguish between different forms of estrangement, which may be amenable to different kinds of responses. Consider a case where the prospect of self-transformative interpersonal connection is altogether absent from experience, where the person cannot even imagine such a scenario unfolding. We cannot rule out the possibility that this aspect of experience is veridical, that he really is impervious to certain interpersonal processes. On the other hand, the relevant experience might turn out to be less robust. Regardless of how compelling the sense of certainty may be at a given time, it could be something that waxes and wanes, perhaps depending on situational factors. To put it in terms of (a) the experience of interpersonal connection and (b) the anticipation of this experience, it is possible for (b) to be wholly absent, even though something remains of the capacity for (a). Indeed, it is quite conceivable for someone to experience something as utterly impossible and then to accomplish it with ease, when somehow coaxed into an appropriate course of action. Hence, one issue to explore is that of when and how certain kinds of interpersonal process might facilitate (a) in the absence of (b), in ways that can also assist in re-instilling a sense of (b).

Another relevant consideration is the level of first-person insight that is present. The need to understand what is happening is often a prominent theme in first-person accounts. In the absence of various kinds of significant possibility from the world, a type of curiosity, even an urge to make sense of one’s predicament, sometimes remains. People often emphasize the lengths that they have gone to in pursuit of understanding:

Ever since I realized I probably had depression (long before I was diagnosed), I did all I could to understand it.

I have read a countless research on the internet and own a couple of books about CBT and anxiety/depression. I talk to my GP, university mentor, and counsellor. I have also spoken to many mental health professionals.

Furthermore, such accounts often display a remarkable level of insight. For instance, they may acknowledge distinctions between feelings of certainty and propositional judgments, distinctions that elude some experts:

The other thing I really struggle to communicate is how my emotive and rational thoughts interact with one another. I can rationally think ‘I shouldn’t feel like I am worthless’ and still have an emotive thought ‘I am worthless’. Describing how those two things co-habit in the mind is deeply difficult, and I have no real words to describe how those things relate to one another. There is not a simple causal relationship between one emotion and one thought, the relationships are far, far more complicated than that, but I struggle to define clearly HOW those emotive/rational interactions go on.

Importantly, such insights into one’s condition can also feed into the project of self-regulation:

I’ve looked on a lot of websites, I’ve read books about depression, I’ve seen various doctors. I feel that my understanding of depression now is quite good. I wanted to familiarise myself with it as much as possible so that I could find a way out. Towards the end of my recovery, while I was at university, I did several projects on depression, because it was something I was interested in, and to find out more about it.

So an especially pressing question is that of whether, when, and how the intellectual acknowledgement that there are other possibilities can retain some hold over a person, despite an overwhelming feeling to the contrary. Having established that it is a ‘trick’, perhaps there is some prospect of overriding it:

We can then see that it is not necessarily REAL what we are experiencing but just another habitual, repetitive experience that has come back to draw us in again. The more time we CHOSE to invest in these experiences the worse we are going to feel. We can learn to recognise that these mental happenings will come back time and time again and that they rarely change their ugly tune at all! Get THIS and you are then in a position to say ‘hmmm, fuck that...you know today I’m going to give myself a break from that horror movie and clean my bedroom, or wash the car, or anything but that!’ There really is a mental training that HAS to go on for people who suffer with depression, and this responsibility is their own and ONLY their own because we are the only ones that can do it and we owe it to our wonderful selves and the lovely people around us to live a good and happy life.

Where there is some potential to erode a feeling of certainty and inescapability via a better understanding of its nature, this need not be a task undertaken by the solitary individual. As applies more generally, other people can assist in nurturing a sense of contingency that is currently lacking. A problem, however, is that the nature of the relevant experience, the loss of possibility and consequent sense of inescapability, is seldom appreciated by others. As noted earlier, first-person accounts often remark that it is both difficult to convey to others and difficult for them to understand:

The thing about believing that no one really likes me is difficult to convey with any real understanding. I’ve only recently really started to understand it myself, and I feel like when I do try to explain it to someone they either don’t really believe me (or the extent of my feelings) or they think that I’m trying to get them to reassure me that they really do like me (which is not really what I’m going for). Maybe people have trouble understanding it because they actually do like me and find it hard to believe that I don’t believe them.

If someone already feels utterly cut off from other people in general, she will be disposed towards experiencing them as indifferent, uncaring, or failing to understand. So it is arguable that the perceived lack of understanding is illusory and itself symptomatic of the depression. There is no doubt some truth to that. Even so, it is plausible to suppose that certain aspects of depression-experiences are indeed routinely misunderstood. And what I have referred to in terms of ‘world’ is the prime example. It is rarely explicitly acknowledged, something we tend to concern ourselves with only when it is shaken. Consequently, shifts in this aspect of experience are prone to being confused with something comparatively superficial:

Others have often misinterpreted my behaviour as sheer laziness and selfishness. It is extremely hard to explain to somebody who has never experienced depression exactly WHY you are so reluctant to get out of bed.

The worst was trying to convince people that the problems I had wouldn’t just go away if I really were using ‘positive thinking’. Basically people considered it to be my fault and that any time I didn’t like something or didn’t agree with someone else’s opinion I was just being negative which wasn’t the case. I am a very optimistic person who thinks the best of people by nature.

I wish there were centres for the depressed, open 24 h a day, somewhere to escape to without the risk of judgement!

Thus, a particular challenge one faces in engaging with someone’s experience of ‘depression’ is that of acknowledging the potential for profound phenomenological differences between the two parties, in a way that might be recognized as such by the other person. The point also applies to clinical empathy more generally (Ratcliffe, 2017b). Various authors have suggested that it involves not so much ‘experiencing what someone else experiences’ as being open to potentially profound differences between the two parties. In receipt of this acknowledgement, a person may, as Havens (1986, p. 24) puts it, ‘light up in recognition of your sudden presence in their lives’; they ‘feel found, and not in the sense of found out or criticized.’ Margulies (1989, p. 12) similarly emphasizes how empathy requires ‘the capacity to go against the grain of needing to know’. Likewise, the task involves not imposing the world of the non-depressed upon the world of the depressed, with all the misunderstandings that this would entail.

This kind of recognition can plausibly contribute towards the goal of making recovery a collaborative project. Once some initial sense of connection is achieved, further possibilities for collaborative self-regulation are opened up. For instance, other people can assist in the construction and revision of self-narratives, of a kind that might either sustain or re-shape certain forms of experience. Radden (2009, Chapter 10) distinguishes between ‘symptom-alienating’ and ‘symptom-integrating’ conceptions of depression, where the former sees depression as distinct from the self, while the latter takes it to be inseparable. Narratives of both kinds have potential regulatory roles to play, as does their revision. For instance, a self-integrating narrative along the lines that ‘I’m depressed because I’m a useless, horrible person who deserves it’ plausibly impedes self-regulation.

All of this is, I admit, somewhat speculative. And the points raised in this section require considerable further development, including some account of how they might relate to more specific therapeutic approaches. But what I have at least sought to show is how (a) the structure of many depression-experiences is essentially interpersonal; (b) the interpersonal is inextricable from the overall form of experience; and (c) a sense of certainty and inescapability, central to many depression-experiences, is to be understood in interpersonal, relational terms. To recover from depression is, amongst other things, to recover an openness to certain types of possibility, which are inseparable from the prospect of certain types of interpersonal relations.

Disclosure statement

No potential conflict of interest was reported by the author.

Acknowledgements

Thanks to Jeremy Clarke, Jessica Yakeley, and an anonymous referee for helpful feedback on an earlier version of this article.

Notes

1. The DSM characterization of major depression is problematic in various other respects as well. For instance, it has been argued that it fails to distinguish a range of importantly different predicaments (Ratcliffe, 2015), has undergone an unprincipled widening of scope (Horwitz & Wakefield, 2007), and tends to be mistakenly ‘reified’ (Kendler, 2016).

2. The reference to E. M. Forster relates to the novel Howard’s End, Chapter 22.

3. See also Fonagy and Allison (2014) for a complementary emphasis on this form of trust, and for a discussion of its role in social development.

4. Although I consider some of the implications for treatment, I do not address whether and how my account might contribute to the formulation of causal explanations. For complementary developmental approaches that emphasize interpersonal dynamics, see, for example, Fuchs (2013) and Varga and Krueger (2013). However, it should be added that the essentially interpersonal structure of depression-experiences does not imply principally interpersonal causes; the causal pathways are likely to be many, diverse, and often very complicated.