The Disconnection of Depression: How to Restore Attachment Using Cognitive Interventions

• Blended Truths: A Cognitive Intervention
• Divide By Two: A Behavioral Intervention
• The Five G’s: An Affective Intervention

“Despair is an ultimate or ‘boundary-line’ situation. One cannot go beyond it.” – Paul Tillich

“I don’t want to be a burden,” she told me. It’s a phrase that I’d heard many times, and it often came from my aging or depressed clients. Her words came from a selfless place. She didn’t want to hurt others with her pain. She didn’t notice that withholding her suffering meant she was introducing disconnection within her relationships. Or maybe she did. As she pulled away from the people in her life, her silent march towards death’s absolute disconnection had begun. It was an incremental, self-inflicted dying.

In the last entry, I shared how clients can experience the moral dimension of suicide. It’s important for me to notice when my clients feel like a burden, because suicide can appear like a strategy to protect others from themselves. In this context, I wanted to explore what my clients have taught me about how to avoid this trap, and how they were able to eventually reconnect to those they desired to protect.  

Blended Truths: A Cognitive Intervention

When my clients have talked with me about being a burden, they usually point to a mountain of supporting evidence. They tell me they’re no longer able to work, that their spouse is earning the only income, and the kids are visibly confused. To make matters worse, they aren’t helping around the house. They tried to vacuum, but “the chord got tangled.” Then they tried to cook dinner, but they became “overwhelmed by the existential absurdity of shredding carrots.” So, back to bed they go. In their absence, their loved ones are suddenly forced to do it all, and they’re sure it’s their fault.

When clients present this way, I try to help by asking them to reconsider this belief. At first glance, the conviction that they’re a burden appears to have some merit. The people in their life are struggling to compensate for the consequences of their depression. That’s usually true. But one of the hidden mechanisms found within depressed thinking is the presence of blended truths.

Blended truths are thoughts that contain some amount of truth, but they also contain some amount of falsehood. Facts and fiction co-mingle. The problem with these blended truths is because they hold some amount of merit, they initially seem persuasive. Unable to argue with the apparent validities, clients are simultaneously baited into swallowing their inconspicuous falsehoods. The good goes down with the bad. Blended truths operate like a worm-hidden hook — or an Almond Joy.

But it’s true that their loved ones are affected by their depression. That’s the first part of the blended truth that’s factual. This is an unavoidable part of being a social animal, and it’s the cost of admission when we’re meaningfully connected to each other. But I’ve noticed that my clients believe something more than this. If they simply believed their loved ones were having trouble, this would create feelings of worry, but it wouldn’t create feelings of guilt. So where does the guilt come from? It comes from the second part of the blended truth. It comes from the belief that it’s their fault. This is the hidden falsehood within the blended truth. It’s the sharp hook. Or the chalky almond. This is where I try to help clients address their sense of burdenhood, and if I’m having a good day, it might sound something like this:   

Therapist: You mentioned feeling like a burden, can you tell me more about that?

Client: Well, everyone is working to pick up my slack. My wife is exhausted. She’s working and doing the parenting while I watch reruns and avoid phone calls. I hate what I’m doing, but I can’t seem to get myself right.

Therapist: You hate that your family is affected by the depression. I mean, how could you not? It sounds like everybody is really struggling. I’m sorry to hear things have been so difficult.  

My first step to untangle a blended truth is to validate the part that’s true. In the past I tried to reassure my clients that their loved ones couldn’t be struggling too badly. That was a mistake. It was a mistake because my clients knew I didn’t know their loved one’s experience, and when I feigned that I could, this made me less credible. My false consolations had led to lost credibility, and my lost credibility led to damaged rapport. What was intended to be a supportive sentiment, ended in a damaged therapeutic relationship. But despite the punishing grind and slothful speed that is my learning curve, I eventually learned that if I could acknowledge the part of my client’s blended truth that was true, I could earn credibility and tighten our rapport. Then with the relationship standing on firmer ground, I could initiate the second step of addressing these blended truths. I could invalidate the part that’s false:

Client: Yeah, so that’s what I mean by being a burden.

Therapist: I gotcha. Would you mind if I picked a friendly fight?

Client: Go for it.

Therapist: So, I don’t doubt that your family is struggling. That sounds undeniable. You make a difference in your family, and so your absence is going to be felt by them. But I’m not sure considering yourself a burden is completely fair.

Client: Well, it’s my fault that they’re struggling and so that’s what I mean by being a burden.

Therapist: Hm, that’s hard. Would you mind if I keep pushing?

Client: Fine.

Therapist: I think worrying about your family makes sense because it sounds like they’re having a hard time. There’s no getting around that. But the second part of what you’re saying — that it’s your fault – this sounds to me like it could be depression talking. So, with the risk of sounding obtuse, let me ask you directly. Are you choosing to be depressed?

Client: What? No, I’m not.

Therapist: Of course not. If you were choosing to be depressed, you could simply choose not to be. But that’s not exactly the nature of what we’re dealing with, is it?   

There are a couple things I try to make happen in these moments. The first is I ask to pick a friendly fight. If I can characterize the impending disagreement as friendly, I can emphasize that challenging my client will occur between the cushions of our existing rapport. If I can get their permission to proceed, I can then introduce the idea that part of their thinking might be depression-inspired (“this sounds to me like it could be the depression talking”). This invites the client to depersonalize their thinking about being at fault, and if they can separate their authentic thoughts from the depressed ones, this can make challenging their depressed thinking more realistic. In whatever form it takes, “Is this really you, or is this the depression?” is a question I can’t do without.

This second step of invalidating what’s false is concluded by plainly asking the client if they’re choosing to be depressed. This is a ridiculous question. It’s like asking, “How many inches is the temperature outside?” But the ridiculousness is the point. This makes the implicit falsehood within the blended truth explicit, and it invites the client to sign on depression’s dotted line. When the falsehood within the blended truth is no longer hidden, my clients have a better chance to avoid digesting it.  

Divide By Two: A Behavioral Intervention

Untangling blended truths is one way to explore the mental dimensions of the depression, but in some cases, I’ve found that the cognitive strategies don’t work. Sometimes my clients are overcome by their despair, and they lose any interest in thinking abstractly. In these cases, I think it’s better to start with the behavioral interventions.

I’ve found it can be useful to begin by identifying the behavior that’s connected to the client’s belief that they’re a burden. I’ll call this burden-behavior. Burden-behavior seems to present similarly across differing cases. Clients withdraw from their life in order to protect their loved ones from themselves. They hide out in bedrooms, run the fans on high, and bundle themselves in blankets. The judgmental Netflix algorithm keeps prompting them, “Are you still watching?” (What does it take to get some unconditional-positive-regard algorithms around here?)  

But as each day passes, life becomes more difficult to reenter. When these determined clients make the choice to re-enter their lives, they quickly run into problems. They plan to go for a walk, but the front door appears miles away. They schedule time to meet with friends, but they immediately find reasons to cancel. As quickly as plans are made, they’re unmade, and their return to isolation occurs. Reentering life feels more like mountain climbing, and each attempt upward is followed by a slide back to the bottom.

In these situations, I try to show my clients that their plans are divisible. When they determine their plans are too difficult, instead of returning to the bedroom, they can learn to divide their plans. My aim is to interrupt the status quo of complete inactivity and to encourage them to find the outer rim of what they can handle. Then eventually, they can widen the circumference of their experience. To provide a sense of how this can work, and to show how much division can be done, here’s an example of how Divide by Two can sound: 

Client: So, I tried to go for a walk around the neighborhood, but honestly my body just felt incredibly heavy, and I stayed home.

Therapist: That’s sound really uncomfortable. What did you do, instead?

Client: I just stayed in bed. I’ve been watching reruns of Cupcake Wars.

Therapist: Cupcake Wars? Yeesh. Things are worse than I thought.

Client: Tell me about it.

Therapist: On a serious note, it’s really difficult to feel cemented the way you do. Would you be open to a suggestion that might not apply?

Client: Sure.

Therapist: In these situations, I often suggest dividing by two. Here’s what I mean. If you plan to take a walk, but it becomes too difficult — divide by two — try going to the mailbox. This way you won’t find yourself trapped behind your bedroom door, beating yourself up for the plans you didn’t implement.

Client: This is going to sound pathetic, but the mailbox feels pretty far away, too.

Therapist: I bet it does. I’m glad you said that. The useful thing about this technique is that it’s flexible. You can always divide by two again. If the mailbox is too far away, determine if you can make it to the living room. If that’s too far, divide by two again, discover if you can make it to the nearest bathroom.

Client: If the bathroom is too far?

Therapist: It might be. Depression can be that way sometimes. But the trick is to do more division. Determine if you can put your feet next to your bed. If that’s too much, you guessed it — divide by two — practice a progressive muscle relaxation exercise while in bed. Too much? Start thinking about what it might be like to practice progressive muscle relaxation. The idea is to divide your plans until you find the outer range of what you can handle. Anyway, I’m sorry for preaching. Tell me about where this might not fit your situation.   

With this behavioral intervention, I can invite my client to consider how to reenter their life after forfeiting their plans, and this can prevent them from sliding back to the base of the mountain. Instead of returning to complete inactivity, they can ask themselves what half-measures they can handle, and this can boomerang them back to the outer edge of engagement in their life.

The Five G’s: An Affective Intervention

Exploring the cognitive and behavioral parts of my client’s experience of being a burden is important, but so is discussing their emotional experience. This means exploring the emotion of guilt. Guilt has always carried a negative connotation for me. It makes me think about childhood religious guilt or being prompted to donate to sick puppies at the grocery store register. No thanks. Those puppies had it coming. I’m too familiar with the internal wincing that’s created by guilt. It’s an emotion that pinches the heart.  

But my clients have taught me how to help them with their guilt. And in order to explore guilt’s excesses, I had to learn about its purposes. There’s a version of guilt that’s deeply important to wellbeing, and once I understood this, guilt’s surpluses became clear. What I learned is that guilt is an emotion that requires training. It’s an unbroken colt teeming with raw force. Nature doesn’t provide guilt with a safe level of calibration.

Without the right technique, it’s dangerous to the rider. This is the reason my perspective on guilt had previously been negative. I experienced guilt’s force, and it led to injury. The only colt that I had ever known had bucked me to the ground, and from the dirt I cussed and condemned it. I didn’t know it needed to be trained. I didn’t understand that before guilt could teach me anything, it needed to be taught by me. More on this in a moment.

I also used to think that guilt was an emotion that was only relevant to my past behavior. When I behaved in ways that were misaligned with my values, my guilt pain came after. Then I’d get stuck there. I’ve since come to understand that this fixation with the past is characteristic of untrained guilt. It can lead to injury. But when guilt is well-trained, it’s not only an emotion related to past regret, but it protects me from future regret, too.  

The purpose of guilt isn’t to create suffering for the mistakes I made yesterday, but to prevent more suffering in my tomorrows. This guilt might take a moment to evaluate my mistakes in the past, but its additional purpose is to create fulfillment in the future. It seems that when guilt is well-trained, it’s equal parts retrospective and prospective.

This also seemed true with my clients. When my clients held unbroken eye contact with their past, they lost the ability to move forward. Focusing on their mistakes this way could lead to self-hatred, and this self-hatred would foment the conviction that others must be protected from themselves. When the retrospective was dominant and the prospective was absent, these clients would become convinced they were a force for harm in the world. But in order to join them in these difficult moments, I will try to introduce the 5 G’s. With it bit of luck, it can sound something like this:  

Client: I don’t know, I’m just the worst.

Therapist: That seems harsh, and only one of us has that opinion of you, but what brings that forward?

Client: Same stuff. I just feel awful that I can’t get back to work. I tried to contact HR to figure out the process, but I started crying while I was drafting the email. My wife deserves better.

Therapist: It sounds like there’s a lot of guilt going on in there.

Client: Yeah, and I deserve it.

Therapist: Can we explore this guilt a little more? I have a few ideas.

Clients: That’s fine.

Therapist: I don’t believe guilt is harmful in every case, but in this one, I’m not so sure. Can I share a strategy to help you determine whether your guilt is useful or not?

Client: Go for it.

Therapist: So, I think we can assess guilt by using the 5 G’s. This stands for Good Guilt Gives Good Guidance. Yes, the alliteration is excessive but here’s what it means. When guilt teaches us something about how to succeed in the future, then I think it can be helpful. But when guilt doesn’t provide guidance, or if the guidance that it provides isn’t particularly wise, then the guilt is working in service to the depression. It creates an emotional environment where the depression can make itself more comfortable. But tell me what I might be overlooking.

Client: Well, I hate myself for being stuck, but my guilt is also telling me to go back to work. How is that not good guidance?

Therapist: Right. I think you’re close to identifying what your guilt is saying, but I think you might be missing two words. Tell me where this doesn’t fit, but is it possible your guilt is telling you to return to work right now?

Client: Okay, right.

Therapist: I’m wondering if you think that’s good guidance. What do you imagine would happen if you returned to work after lunch today?

Client: It would be a nightmare.

Therapist: We can probably agree it wouldn’t go so well. So, how might we update this guidance to make it more useful to you?

Client: I don’t know. Maybe I should tell myself to return to work eventually? But that doesn’t feel urgent enough.

Therapist: Hm. I can see how that might feel too open-ended. Can I submit a rough draft for your editing?

Client: Go for it.

Therapist: What about something like, “Do everything that’s possible to feel better today, because this will get me back to work as quickly as possible.” But take out your red pen, where should we make edits?”   

This framework can help me to extract the wisdom within my client’s guilt. If I can ask them to evaluate their guilt along the lines of its guidance, this can nudge them away from looking backward and towards looking ahead. The client can travel towards their feeling of guilt, but for the purpose of returning with a new direction. This can bring the retrospective to the prospective, the colt to its bridle, and the feeling of guilt to its belated resolution. Once it’s well-trained, their guilt is a guide. 

***

Working with clients who consider themselves a burden has been rewarding work. These clients have taught me that when they unravel their Blended Truths, Divide-by-Two, and implement the 5 G’s, they can release themselves from this conviction. Once their sense of being a burden is broken apart, disconnection from others can be incrementally reduced, and attachment to those they wanted to protect can occur once again.

[Editor’s Note: In the next and final installment in this five-part series, the author will address the challenges of balancing empathy and burnout]