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Clinician's View of Depression & Self-Esteem

To link with glue depression and poor self-worth might create a misleading over-simplification. The illness is complex.

A sufferer of depression can emerge from that illness with low esteem while no longer being depressed. 

A person can have low self-esteem and not become depressed. 

Depression sufferers are seldom realistic, having a poor view of everything.

Any cynic can say something derisive about most events, but depressed people will see negative and believe bad about everything, including themselves.

A sufferer can become introspective even to the point of extreme somatic fixation and absolute despair. 

It is true that feelings of low self worth promote depression but no less true that depression adduces notions of poor self-image. Is this a 'chicken before the egg...' conundrum?

Take a look at this example. When a life partnership breaks apart, is manic behaviour and depression of the divorcing pair a consequence of loss and anger or is it a result of low self-esteem? I suggest we deal with the loss first. If one can remove guilt for the break-up and associated loss of 'what could have been', self-esteem is a lesser issue, right?

Maybe not. 

Degradation of self worth can be based on reality or a misconception.

A gentleman, a husband and father, becomes obese during his marriage and his self-esteem tanks as his automobile sags on its coil springs and none of his cloths fit, his wife flees the marriage and the kids won't be seen in public with him. I would write the referral to deal with the physiological crisis causing the self-worth degradation which in turn catalyzed the family break-up as the aggregate of events bred depression. Or did the depression come first? We might never know for sure.

Did obesity manifest from depression? Perhaps chronic low-grade depression over years led to the obesity. These are things we need to understand. But understand or not, the root cause of the acute self-worth issue is obesity with attached health risk, life quality, and lowered expectancy. A remedial plan for obesity with confidence needs to be set in motion while the therapeutic remedy staggers forward awaiting milestones of progress in the physiological health remedy.

A self worth crisis is never without cause whether real or perceived. Treat that cause as well as the depression. If the cause cannot be remedied as in the case with some illnesses (Multiple Sclerosis etc.) or physical dismemberment or disfiguring (i.e.: automobile accidents), then a blend of physical therapy, cognitive therapy and coping skill training with behavioural modification therapy might accompany the depression's pharmacological (if indicated) and therapeutic solution.

I am trying to illustrate to you that no absolute equation exists between self worth and depression.

Lacking social and life skills may also be at the root of a self-worth crisis and as in the previous example, the causatory issues need to be addressed and managed in conjunction with treating the depression.

It may be true that depressed people despair and wade through waves upon waves of low self-esteem, even to the point of acting out a suicide attempt, but in my view, anger causing depression is the root of intended suicide.

Anger is a powerful emotion. One needs to be very angry to truly intend self-inflicted death. That is the measure of extreme anger leading to depression.

Every person is unique. Each handles depression differently. 

Stress and depression are parts of life. 

We often refer to the challenges of life as stress. Stress therefore must be normal. 

Sometimes life heaps so many challenges upon us such that coping alone is too difficult. Caring and sharing families (and their shared communities) make light work of multiple heavy challenges. We help each other out by sharing the load. By caring. By loving. That's why it is important to build caring and sharing relationships and avoid tension and hostility. Family communication dynamics based on tension and hostility make dysfunctional the family and its members in more ways than the obvious. Not only does this environment breed depression but also it has lost its latent remedial processes.

Tension and hostility as the prevailing glue in human relationships cause dangerous forms of anger-driven depression. Tension and hostility breed depression. Tension, hostility, anger and depression can narrow the behavioural path toward violent outbursts including murder, suicide and other forms of criminality.

Functional families and communities have their problems too.

Think of life's big events as a figurative rocks in a knapsack on your back. Failures add a rock. Successes can remove a rock or make a heavier one become lighter. Too many heavy rocks can create a burdensome load inviting fatigue, anger and/or depression. When we are angry and depressed we might do things that add more rocks. Depression can become a self-feeding, downward spiral. The weight of depression can figuratively bring us to our knees.

On the other hand, a person having the compunction necessary to earn the goals they seek to achieve usually does just that. They have their failures but the successes, which they pay most attention to, pile up and their knapsack is light. Such people tend to either work their way out of depression or they play their way out. They always focus on the good and briefly seek lessons from their mistakes.

Sufferers are lethargic and loose their vim and vigour for life. They are slow to bounce back from a failure. They find it hard to work or play. Their depression lingers. 

When one's "knapsack" is laden with rocks, it is harder to feel good about self. Seek help. Find someone to co-manage the process of 'removing some rocks'. That helper could be a wise aunt, parent, sibling, teacher, minister, therapist or any other volunteer or professional caregiver. Removing rocks is done by articulating the name and meaning of each "rock" and reassigning its value or finding a solution when the rock represents an unsolved problem. Sometimes removing the rock is a process of changing the way we think, or of giving ourselves some permission to say, 'I am not responsible for that problem', or 'I am categorically unable to resolve it', therefore the rock can be offered to someone able to fix it or tossed out altogether. 

We can learn to worry about the things we have ability to change or fix and not worry about those things we can do nothing about. We can learn to make new policies for ourselves, to say that we are no longer offended or bothered by those menial events that previously represented a trial.

We can also learn about what matters most and what matters not at all. We can identify which of our expectations are dreams and which are goals. Dreams are fun and exciting. The rare time for dreaming is when we need a diversion. On the other hand, we always need our realistic goals in clear sight. Failure at achieving unrealistic goals is not worthy of any concern. We can't become an 'American Idol' if we can't hold a tune, so lets not confuse that dream with real goals. Young people worry about being 'accepted'. They fear rejection. Life is full of rejections so let's learn about criteria. Getting rejected by the local street gang is not such a bad thing. Getting rejected by a snobbish cliche of never-do-wells is not a bad thing. Rejection for membership in the Harvard Mensa club might just mean we set our sights too high. Let's try the local stamp-collectors and become a bigger fish in a smaller pond. Young people worry about their clothes being in fashion. Later in life they learn they were actually setting the fashion. Learning that earlier might ease some feelings. This is all about cognition. Cognitive therapy is available from a wide range of mentors and therapists. 

Defeating depression often is a matter of learning to think in somewhat different ways. Cognitive approaches to the things that bother us can be most helpful in coping with self-esteem problems. Better cognition and goal management are sometimes hard to learn for some people. Those people are vulnerable to lasting depression until they learn how to learn.
  • We all have our failures.
  • We all have our losses.
  • We all have depression. 
  • Some folks cope well. Others do not.

Sometimes we go with those 'rainy days'. We chill a little. We feel a little sorry for ourselves. We might pamper ourselves a little. We find a pleasant distraction. We might seek and find sympathy or permit ourselves to make our own ruling to say 'that doesn't matter' or 'I'll do better next time'. We brush off the blues and move on to our next challenge. 

Some people are good at doing that. Others are not.

Self-esteem is arguably a manifestation of many possible issues that are more likely to live at the root of the depression. A clinician would better serve the patient by addressing and co-managing solutions where existent: 

  • Abuse,
  • Abandonment,
  • Rational and/or irrational fear,
  • Persistent boredom,
  • Physiological conditions (creating digestive issues, communication problems, appearance issues etceteras),
  • Sleep disorders,
  • Attention deficit disorders,
  • Transitory hormonal conditions (i.e.: teens),
  • Mania (bi-polar or manic depressiveness),
  • Dependency issues,
  • Life passages,
  • Loss,
  • Grief, and so on

Likely the most dangerous occurrence of depression in society is a chronic condition that is asymptomatic, leading to severe depression. A moderately depressed person may exhibit no identifiable symptoms to lay people or may exhibit masking symptoms that draw social reactions to exacerbate the problem. They don't know they are depressed nor does their close family. (Masking of depression can sometimes lead to obnoxious behaviours that fetch much disapproval.) 

I know that public health officials wish to identify features and share speculation on family impact analysis to help the public identify which of its members may be suffering, but as a clinician, attempting to map out such global impact predictions is hazardous. I am a little stuck. I need the help of a caring and sharing family. I won't scare them off with dark predictions of depression's infectiousness. That doesn't really exist.

"People who live with depression are at a greater risk of getting depression themselves," is by itself not a true statement. Given that depression in any measure must be treated and that some instances must be institutionalized, family impact depends on the severity and oddity of the subject's behaviour. 

Much also depends on the family players themselves. Susceptible people are exactly that. Genetic predisposition is also another issue to consider. In a family where caring and sharing are the bywords of life, love will prevail. It is no less true that living with a depressed person can be a huge trial and test of ones love, care, and patience. One should only take on what they are capable of achieving without harming their own health. In addition to treating the ill person, counseling for the entire family is also indicated. A good counselor should be on the watch for emerging health risks or vulnerabilities within the family unit and take remedial action as needed.

Think of this figurative illustration of a depressed person. Imagine this unkempt individual being curled up in a fetal position deep in the midst of a long, narrow, dark culvert. In the case of mild depression, stretching out a caring hand to the person while doing some soft coaxing in a loving manner will inevitably draw them out. In the case of more severe depression, that won't work. One might need to get around behind them and do some pushing and prodding to get them out of that awful place. One might need protective gear because the sufferer will snarl and scratch and howl and bitch. How much of that are you willing to tolerate? Not much. That's why professional help is needed to identify the measure of the illness and plan the solution. In severe cases, the ill person may need to be removed to a hospital, group home or other 'away' place for some learning and healing to take place.

A person prone to depression with only nominal coping and cognitive skills could well be at greater than normal risk under any circumstances but could also benefit from the treatment experience. Consider this. If within your family a person was diagnosed with moderate or severe depression and that diagnosis was shared with the family while participating in the remedial treatment -- some family counseling etc. -- each family member has their own private opportunity to identify and make some judgments on the causes and effects of depression. This is a good learning experience. Learning about depression is helpful to its cure and a positive contributor to its prevention.


Helping another person in any crisis is a sound method for helping one's self. 

A communicating, caring and sharing family will go a long way toward defeating this horrible illness. Such an enriched family has far more power for prevention than do all the clinicians and researchers of the world.


Micheal J. O'Brien


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