Depression Squared: No Choice?

One of the biggest things that makes it difficult for us to accept Depression as an illness like any other is the sense that those suffering are in some way making a choice to “give in” and suffer as they do. It is hard to look at someone in the depths of Depression and to understand why they might have chosen that state above all others. But there is equally a strong sense in which because we all get miserable from time to time, there is a feeling when encountering Depression that perhaps some of us choose to go down, rather than up.

Every professional I have encountered who works in the field would argue that Depression is not a state of choice. They may even go further to say it is not really a place where you can make meaningful choices, or even perhaps decisions.

But that isn’t quite true.

Because within Depression we are making choices all the time that affect outcomes: Whether to ask for help or not; whether to give in or to fight; what type of therapy to engage with; how to participate in it; what to share and what not to share.

Depressed, we tend to make objectively bad choices which come back to haunt us over again. We hide things away that can help us. We do not accept a hand stretched out to us. We choose to hate ourselves in place of allowing others to love us.

I find it difficult to accept the idea of no choice. In my mind that reduces us to victims of circumstances, or genetics, or some combination of both. It makes Depression continual, and more arbitrary. It means simply enduring day by day, waiting for torment to end of its own accord in a time frame all of its own.

I prefer to believe I have agency, even if it is misused. I believe that I decided to take that step off the diving board and spiraled down to immeasurable depths alone, not because I was pre-programmed to do that regardless of what life threw at me. And at least in theory that means that I can choose when things end, even if in the meantime I blame myself each day I wake up still depressed for continuing to choose the wrong direction.

Programmes that work with those who are Depressed — such as CBT (Cognitive Behavioural Therapy) and DBT (Dialectical Behaviour Therapy) — ignore the question of choice and emphasise the ability to focus on present realities. They set out to re-programme thinking patterns to adjust behaviours, assuming that it is possible to take a few steps away from thoughts to regard them objectively. These systems are brilliant and can allow those who master them to escape the roller coaster to control themselves and the way that they react to situations appropriately. But they require discipline, skill and insight to work — alongside a choice to commit to going down those particular pathways which it is not always easy to make.

Depression de-humanises. Thinking becomes difficult as thoughts spiral off into infinity, or else down cul de sacs. Choosing — even at a day-to-day level around what to wear or whether to shower — becomes momentous and extremely hard. The bigger choices — between what is bad and what is equally bad, or perhaps what is bad and what is marginally better — loom up like icebergs ready to shipwreck a somewhat wrecked sailboat that tilts at them. But to lose choice is to lose a means of escape.

With no element of choice, perhaps the physician becomes more of a magician, dispensing tricks with each treatment twist. The depressed patient can only respond.

But in normal life our choices are our identity, what makes us different from everyone around us. We are the accumulation of a series of choices to do certain things and not to do others. To lose choice is to become less than human.

Even if to have chosen all this is insane.