The Triple Layer Cake

There is nothing like cake to get my attention. So maybe I have your attention, too.

This is the way I explain depression to my clients. It's like a triple layer cake.

Layer one is the original depression. Let's call it biological depression. Something has happened in the brain in response to stress. As a result, mild to moderate depression has set in. The person is having difficulty concentrating, less enthusiasm for doing things (anhedonia), and some fatigue. As a result, they aren't getting as much done. Their grades are going down in school. They are snapping at their children.

Now here is the kicker. Now they start to criticize themselves: "I am lazy." Or, they may think or say, "I am stupid." And so on. They are not able to deal with their decreased efficiency. They think that they "should" be totally in control of themselves, their symptoms, their behaviors, their lives, and if they are not, then they are defective. Now we have the second layer of the cake--being depressed about being depressed. This drives the person down deeper into depression--perhaps from being mildly to moderatly depressed all the way down to severely depressed.

Now for the third layer. The person stops doing the positive behaviors they used to do. They quit socializing. They quit doing their hobbies. They start developing the habit of thinking negatively. Old, good habits start to extinguish. New, bad habits are taking their place.

If the person is treated with an antidepressant, they may recover their appetite, their energy, their sex drive, etc. And this may well help layer two--their self blame, since they have less to blame themselves for.

However, the habits of negative thinking, avoidance, and withdrawal may remain even though many of their depressive symptoms are in remission. This is one of the tasks of psychotherapy--to make sure that the person fully returns back to their normal self.

Many of my clients find that this simple little model helps them understand how their depression became severe in the first place and also focuses them on what they need to be doing to recover. Namely, they need to quit blaming themselves for any remaining depression. They need to overcome their acquired habit of negative thinking (e.g., as in cognitive therapy), and they need to get back to their old positive habits of socializing and having pleasurable experiences.

The Therapeutic Alliance

In my testing and therapy, I am constantly struck by how much we don't know. How different is Bipolar II from Bipolar I? How different is Aspergers from Autism? Does depression permanently damage the brain, or are brain cells regenerated (as they are sometimes in the hippocampus)? And on and on. We know so much and so little. There is so much depression research appearing that a person could spend all of their time just reading it. But the big questions often elude us. And our patients must patiently suffer through our lack of awareness. It is as if we are always in the dark ages. Future generations will look back and marvel at how little we know, just as we look back and marvel at the treatments used in Freud's Vienna (and those were better than what was being used in the rest of the world!). It is my goal to use the best of current knowledge. What isn't known has to be imagined. We have to connect the dots and extrapolate in between for the benefit of our patients. And we have to learn from our patients. They teach us. The most exciting situation is when the partnership (AKA "therapeutic alliance") actually forms, and the patient and I go on a voyage of discovery together. We put together what we know, and something very important happens. It is an exciting experience.