When depression is “treatment resistant,” perhaps it is resisting the wrong treatment.
I’m struck by how often depression is still treated mainly as a problem with the person’s thinking.
Interestingly, I found some guidance on this by contemplating what the Beck Depression Inventory-II is actually assessing.
Yes, it includes things like hopeless or pessimistic thinking, self-criticism, and thoughts organised around failure.
But these are often not just “thinking errors”.
They may also be thoughts trying to describe or make sense of deeper feeling states:
shame
defeat
grief
collapse
aloneness
emptiness
So, in that sense, our thinking is often not the primary problem.
It is often a description of what we are feeling further down, in our body and emotional life.
And beyond these cognitive descriptions, the inventory also covers a much wider state:
low mood
loss of pleasure
guilt
self-dislike
worthlessness
tearfulness
restlessness or agitation
loss of interest
indecisiveness
low energy
sleep disturbance
irritability
changes in appetite
difficulty concentrating
fatigue
Clearly, depression is much more than “problematic thoughts”.
The inventory itself points up that depression is often a somatic, emotional, motivational, and self-worth state, with cognitive features built into it.
That matters clinically.
Because if we are depleted in our body, cut off from pleasure, flooded with shame, low in vitality, and struggling to recover, then simply trying to correct our thinking may be nowhere near enough.
In my own outcomes data, 331 clients who began therapy in the clinical depression range averaged a BDI-II score of 26.6 at the start of therapy.
On average 9 sessions later, that had reduced to 10.6, below the cut-off for depression.
Effect size, ES(d) = 1.69, a large effect
p < .001
What interests me here is not only that people improved.
It is what may actually have helped them improve.
My experience is that much of the deeper work in depression is not only cognitive.
It often involves facilitating:
somatic safety
emotional processing
shame resilience
rebuilding self-worth
co-regulation
and helping a person’s body recover its capacity for vitality again
In the room, I am often listening not only for the thought patterns of depression, but for the deeper feelings that may have become too unbearable to remain fully felt and are being “depressed”.
So perhaps one of the reasons some depression is called “treatment resistant” is that it is resisting treatment aimed too narrowly at cognition, when the state itself is far wider, deeper, and more embodied than that.
Sometimes the problem is not that the person is resisting recovery.
It is that their depression is being treated at the wrong level.
The chart shows the average change in BDI-II scores across these 331 clients.
Depression may say a great deal through thought.
But it is rarely only a thinking problem.