Depression, Trauma and Child Welfare

(Previously unpublished)

By Dee Wilson, Nancy Grote and Marianne Harris

Introduction

 

This article is about the relationship among depression, self efficacy and poverty.  It is common for social workers and health care professionals to encounter impoverished depressed individuals who are difficult to engage and retain in social and / or mental health services and who confront significant barriers to obtaining services.  The unwillingness to seek out or accept poverty related services, parenting supports or mental health treatment or to join in common cause with others to improve social conditions often elicits moralistic reactions from professionals who feel it is not their job to overcome strong resistance to offers of help. Even professionals familiar with the hopeless/ helpless attitudes and beliefs characteristic of severe depression can be at a loss for how to respond to the unwillingness of persons with extreme needs to entertain the possibility that poverty related services or depression treatment could dramatically improve their lives.  

Andrew Soloman has written that “Poverty is depressing and depression is impoverishing, leading as it does to dysfunction and isolation;” and he adds that “Poverty’s humility is a passive relationship to fate, a condition that in people of greater ostensible empowerment would require immediate treatment.” Chronic depression greatly reduces the possibility that a person will struggle persistently to escape poverty or affiliate with others to improve social conditions for the poor.  Severe depression undermines the capacity of low income individuals to cope with the challenges resulting from their economic circumstances and with the interpersonal problems common to all social classes. 

 

Soloman accurately refers to depression among poor people as a disabling condition and he asserts that “Treating the depression of the depressed indigent often allows them to discover within themselves ambition, competence and pleasure.”  However, therapeutic dependence on medication management or on skills and activities that bring immediate symptom relief can serve as an end run around self defeating beliefs but leave the recovering person highly vulnerable to relapse. Social workers and other persons working with low income populations should be thoroughly familiar with the characteristics of depression and how depression affects thoughts about and attitudes toward the future.                                          

What is Depression?

           

Albert Bandura (1997) has asserted that depression is widely regarded as the ‘common cold’ of psychosocial functioning, an analogy that speaks to the pervasiveness of depression but does not do justice to its debilitating impact, especially in severe cases. Even in its milder forms, depression can negatively impact the ability to fulfill responsibilities and maintain positive social relationships.

           

The widespread personal experience with mild depressive symptoms may lead to overconfidence that depression is well understood; but this is not the case, at least for depression’s severe forms.  Monroe and Hadjiyannakis (2002) conclude that “depression investigators have a very difficult task facing them: not only do they have to consider what predicts and causes depression, they also have to consider what depression “is.”  For example, they ask the question “is depression a unitary disorder in terms of etiology and presentation, a heterogeneous group of disorders, or an amalgamation of dimensional problems and discrete disorders?” (p. 334). These authors notice that “different people diagnosed with major depression often display considerably different permutations of the requisite critical features” (p. 327); and, they acknowledge that while stressful life events are an important factor in the onset of depression, individuals leading attractive,  advantaged and relatively stress free lives are sometimes vulnerable to depression.

           

Poverty, stress, traumatic events, genetics and gender influence rates of depression; but many individuals who live in poverty for extended periods of time or survive traumatic events never succumb to major depression. How do some individuals at risk by virtue of socio-economic deprivation, trauma histories or genetic inheritance escape major depression while others are virtually incapacitated for long periods of time?

           

The causal relationships between and among common depressive symptoms are also unclear. Consider the following list: loss of energy, sadness, sleep disturbances, poor appetite, lack of ability to experience pleasure, emotional misery, apathy in the face of threat, hopelessness/helplessness and negative self appraisal. Careful examination of these symptoms reveals a combination of affective and cognitive elements, and several items, for example, hopelessness/helplessness, contain both cognitive and affective dimensions.  Altered brain chemistry presumably underlies both the affective and cognitive elements of depression, but it would be as naïve to assume that brain chemistry causes depressive symptoms in a simple ‘A leads to B’ progression as to assume that cognitive elements cause affective states or vice versa.  It may be the case, however, that one or more of the items on this list have a crucial causal influence on the course of depression and/or the recovery process. For example, some theorists believe that “depressive ruminations” in the form of negative self talk is how depression is sustained.

           

At this point, it is useful to review the social phenomena with which depression is strongly associated: low rank in pecking orders, poverty, trauma and other highly stressful life experiences, alcoholism and other forms of substance abuse, anxiety disorders, the elderly living in nursing homes.  Women are also more prone to depression than men, about twice as likely in Western societies according to Solomon (2001).

           

Arguably, what persons in these groups often have in common is an enhanced expectation of aversive experiences and a visceral sense of powerlessness. Soloman asserts that persons who are both poor and depressed often feel “so helpless that they neither seek nor embrace support” (p. 335). Solomon also has this to say about women’s increased risk of depression:  “since the high rates of women’s depression do not reflect a genetic predisposition that we can currently locate, we can say with some assurance that the rates of depression among women could be significantly reduced in a more equitable society,” (p. 178), i.e., a society in which women had the same economic resources and power as men. The view that the group to which one belongs is relatively powerless or stigmatized feeds depression and (as Soloman notes) can make it difficult to distinguish depression from normal reactions to powerlessness and disadvantage.   

           

S.J. Rachman’s study of fear in combat (1978, 1990) emphasizes the importance of a personal sense of control and of personal confidence in managing rational fears.  He writes that “Fear seems to feed on a sense of uncontrollability, yet arises and persists when a person finds himself in a threatening situation over which he feels he has little or no control” (p. 38). This is also a formula for depression, which may be why anxiety disorders often accompany depression, as Seligman has noted in his work on learned helplessness.

           

Rachman describes how anxiety reactions among airmen in World War II were often followed by depression:  “The most common pattern was for air-crew members to show a gradual accumulation of adverse effects, such as insomnia, loss of appetite, tremor, extreme startle reactions, irritability and tension” (p. 41). The airmen became aware of declining control over their reactions.  “Muscle coordination was replaced by uncontrollable tremors, jerky movements and tension…their ability to sleep was impaired and they started to experience nightmares.  Various gastric symptoms such as nausea, vomiting and diarrhea appeared.  They also reported a loss of appetite and various pains and aches, with headaches and backaches being particularly common” (p. 41). Rachman maintains that “the fliers’ diminishing control over their own reactions and the objective dangers to which they were exposed resulted in deficits in motivation, emotion and cognition…their transient fears grew into constant apprehension, and anxiety spread ever more widely.  Cognitively, they suffered a growing pessimism about their chance of surviving. Some airmen became depressed and secluded themselves from their friends.  Their thinking and behavior deteriorated…” (pp. 41-42).

           

Mood disorders are siblings:  they have the same source, i.e., the anticipation of highly aversive uncontrollable events or conditions. These expectations may be grounded in trauma histories, or in experiences of long-term severe poverty, or in the awareness of social attitudes regarding race, sexual preference or gender. In addition, Rachman describes the airmen’s distress over their inability to control their physical or emotional reactions to fear.  Depression grows out of a sense that threatening life events and conditions are uncontrollable; but it is compounded by the person’s lack of control over their symptoms of panic, anxiety, trauma or depression itself.  Depression, in other words, is highly self referential.  It is possible, and even likely, to be depressed about being depressed, especially when depressive symptoms (or trauma symptoms) lead to social embarrassment or shame or violate self concept, e.g., a soldier’s belief that he is stoic in combat.

           

Rachman’s comments on the extent to which efficacy beliefs, i.e., a person’s sense of competence in dangerous situations, ameliorates fear; competent performance in response to threat builds confidence while inadequate performance feeds anxiety and undermines the willingness to take action  Erosion or loss of efficacy beliefs greatly increases vulnerability to mood disorders.

           

Negative self-appraisal is also involved in major depression. The implicit or explicit view that the person lacks the skills or resources to cope with anticipated aversive experiences or conditions can constitute a crisis of faith in one’s capacities or worth.   Possibly, the most insidious feature of chronic severe depression is that it leads to a self-fulfilling prophecy.  Rachman describes US airmen in WWII who became severely depressed as forgetful, preoccupied and limited in their ability to carry out purposive activities (p.42). Severe depression experienced over many months or years confirms the lack of self confidence in one’s ability to cope so that ultimately negative self-appraisal appears validated.

           

This account of depression is markedly similar to Martin Seligman’s concept of “learned helplessness.”  Seligman’s animal experiments induced the inability to learn in rats exposed to a series of unpredictable shocks or noises unrelated to the rat’s behavior.    “A rat exposed for long periods of time to what might be described as uncontrollable stressors had difficulty coping with a variety of tasks such as competing with another animal for food or avoiding social aggression” (Sapolsky, 1994, 1998, p. 253).

           

Sapolsky asserts that animals subjected to uncontrollable and unpredictable shocks will often not even attempt coping responses in a new situation; they have, in his view, a motivational problem and a cognitive problem, i.e., “something awry in how they see the world,” a curious description of learned behavior in animals purposely induced by researchers.  According to Sapolsky, learned helplessness has been induced in a variety of animal species, including rodents, cats, dogs and insects, as well as humans.   

           

Sapolsky believes that a major depression can result from particularly severe lessons in uncontrollability for those persons who are already vulnerable.  Sapolsky quotes Seligman, “according to our model, depression is not generalized pessimism but pessimism specific to the effects of one’s own skilled actions” (p. 257).

           

Seligman’s conceptualization of learned helplessness is one of the most cogent psychodynamic accounts of depression to date; but it offers no explanation of the variability in vulnerability to depression among persons exposed to similar adversities or some of the important affective characteristics of depression such as reduced ability to experience pleasure, emotional misery or indifference to circumstances.  The incapacitating loss of energy in major depression remains a mystery. There appears to be something profoundly disruptive of the capacity for enjoyment resulting from a closing down of the body’s energy sources.  This phenomenon is not well understood.  The modern tendency to appeal vaguely to brain chemistry when an emotional or physical reaction is poorly understood is not an adequate substitute for a plausible hypothesis.

           

On the other hand, Seligman’s concept of depression as a response to aversive experiences whose purpose is to protect a person from further pain is far superior to viewing depression as a disease arising from genetic pre-disposition or a generalized negativity.  Seligman’s explanation of depression also suggests why a depressive mind set is so difficult to unlearn:  persons experiencing major depression do not just expect painful events which are out of their control—they expect that their attempts to avoid or ameliorate aversive experiences or conditions will be severely punished.  Immobility (or the suppression of coping responses) to protect from pain (e.g., the crushing of hopes) leads to a most painful disabling of personal capacities.  In effect, major depression is a shutting down of the organism as a response to anticipated aversive experience with which the depressed person believes she (or he) cannot cope.

The Importance of Efficacy Beliefs

Albert Bandura (1997) has commented that “The things about which people get depressed take varied forms, but a profound sense of personal inefficacy to bring about positive outcomes that give satisfaction to one’s life is the central common factor in the different sub-processes of depression.”

         

In Bandura’s account, self efficacy is a set of beliefs regarding the ability to take potentially effective action. Confidence that one can regulate one’s own emotional states, thoughts and actions is critical to the belief that one can affect environmental conditions.  On the other hand, emotional dysregulation and obsessive self hurtful thoughts gradually create a profound sense of helplessness. One reason that traumatic events often lead to depression is the awareness of traumatized persons that they have little, if any, control over intrusive and highly charged memories, startle reactions and other reactions to stressors and over extreme avoidance reactions such as numbing and dissociation.

           

Soloman locates the origins of confidence in personal agency in infants’ interactions with maternal figures; but what if babies have repeated experiences that crying or affectionate overtures do not lead parents to respond to them in nurturing ways? Babies depend on caregivers to help them calm down and regulate emotional states; young children whose experience repeatedly indicates that caregivers are unavailable when they need to be fed or reassured or protected are likely to have difficulty in managing stress and approaching the world with confidence that their actions will lead to positive outcomes (Gray, pp.73-77).       

           

Bandura makes a critical distinction between perceived self efficacy and locus of control. In Bandura’s view, perceived self efficacy is the confidence that one can perform well in response to challenges; this is not the same as believing that one can control outcomes. Bandura asserts that persons with a strong sense of self efficacy will give persistent effort in the midst of difficulties while persons who have weak efficacy beliefs will quickly give up when faced with obstacles. According to Bandura, perceived self efficacy is a person’s belief in their ability to execute necessary or useful actions; it is not necessarily a belief that one can control events.  

           

In Bandura’s view, a low sense of personal efficacy combined with a harsh unresponsive environment is a formula for apathy and despair. Efficacy beliefs are effected by environmental outcomes.  Arguably, extremely punishing and persistently unyielding environments will eventually overcome strong perceived self efficacy of even most highly confident and resourceful persons. On the other hand, challenging environments which become more responsive and rewarding in response to skilled and persistent personal effort strengthen efficacy beliefs. Depression rates in various low income populations, i.e., welfare recipients, are arguably a barometer of the population’s views of the responsiveness of the social environment to their efforts to improve their condition. 

             

According to Bandura, efficacy beliefs are highly sensitive to social comparisons. Vulnerability to depression is greatly increased when a person sees that she is unable to perform actions or master skills readily attainable by others of similar standing living in similar circumstances.   

Poverty, Chronic Stress, and Depression

           

Persons living in poverty are more likely to be afflicted with depression and other mental health problems than the general population (DHHS, 1999; Williams & Collins, 1995). More specifically, poverty has been found to be consistently related to a two fold risk of major depressive disorder (Bruce, Takeuchi, & Leaf, 1991)  and higher rates of self reported depressive symptoms (Siefert et al., 2000). In a recent study of low income mothers receiving home visitation services, 45% of mothers reported symptoms of severe depression during a 9 month period (Ammerman et al., 2009).

Furthermore, poverty is associated with a host of chronic stressors such as financial hardship, crowded housing arrangements, unemployment, transportation problems, lack of community resources, inadequate health care and racial discrimination (Belle & Doucet, 2003).  Nevertheless, the role of chronic stress has often been overlooked in the literature on the links between stress and depression severity, with more emphasis usually placed on the causal influence of acute stress in the development of depressive symptoms (Wethington et al., 1995; Lepore, 1995). Acute stressors typically involve time limited events such as divorce, job loss, injury or illness, all of which involve a certain degree of life change. By contrast, chronic stressors represent continuously demanding or difficult situations that do not improve over time and are resistant to efforts to change them.   Mounting evidence suggests that people do not biologically or psychologically habituate to chronic stress (Herbert & Cohen, 1993; Lepore, 1995).  As their biological and psychological resources become depleted, individuals often experience repeated coping failures and become increasingly vulnerable to depression.  In addition, severity of chronic stress often magnifies the unfavorable effects of highly acute stress on depression. High levels of chronic stress increases psychological vulnerability to depression by stripping people of the biological and psychological resources necessary to deal with daily problems in living. Moreover, socio-economically disadvantaged individuals possess fewer community and neighborhood resources to deal with the multitude of chronic stressors to which they are exposed (McLeod & Kessler, 1990). 

           

To more fully understand the role of chronic stress, compared to acute stress, in the etiology of depression in socio-economically disadvantaged populations, Grote, Bledsoe, Wellman, and Brown (2007) conducted a study of 97 White and 97 African American women with low incomes (55% were pregnant) in the  public care Ob/Gyn clinic of a large, urban hospital.   They adapted an established acute and chronic stress scale (Watt-Jones, 1990) to be relevant to low income women of different races/ethnicities and of different sexual orientations.  Women in the sample, especially African American women, reported a greater number of chronic stressors relative to the number of acute stressors. The top three chronic stressors were running out of money, being behind on bills and being unable to afford a car.  Other chronic stressors identified by these women were living in an unsafe neighborhood, experiences with racial discrimination and inability to meet basic needs, such as obtaining food.  As expected, severity of chronic stress accounted for more of the variance in depressive symptoms than acute stress in this sample; and when acute stress was severe and chronic stress high, chronic stress amplified the negative effects of acute stress on severity of depressive symptoms.     

           

At the same time, persons living in poverty display wide variation in response to the adversity of acute and chronic stress.  Researchers have been particularly interested in identifying protective factors that modify the negative effects of adverse life circumstances on positive adjustment, not only in young children and adolescents (Luther & Cicchetti, 2000) but also in adulthood (Jackson & Huang, 2000; Kaslow et al., 2002; Siefert et al., 2004).   In the 2007a study described above, Grote et al. found that women with high levels of optimism and perceived control while exposed to high levels of acute and chronic stress reported less severe depression than women who were less optimistic and less confident of their ability to exercise control in their lives.  Racial differences did not affect the extent to which optimism and perceived control functioned as buffers to stress.    

Psychological and Cultural Barriers to Treatment for Depression

 

According to Lazear et al. ( 2008) “for low – income women and women of color, prevalence rates for maternal depression are twice as high as those for white women (25% vs. 12%) and depression is associated with more negative outcomes for low – income women and women of color.” (Warren, 1994a, 2008) asserts that African American women are at increased risk of depression because of their triple jeopardy status: “We live in a majority- dominated society that frequently devalues our ethnicity, culture and gender. In addition, we may find ourselves at the lower spectrum of the American political and economic continuum. Often, we are involved in multiple roles as we attempt to survive economically and advance ourselves and our families through mainstream society.”  

Despite the increased risk for and prevalence of major depression in low income populations (DHHS, 1999; Bruce et al., 1991), many low income persons either do not seek mental health services or drop out after an initial visit or as soon as their distress is alleviated (Greeno et al., 1999; Sue et al., 1991).   In a recent National Comorbidity Survey replication, Wang et al. (2005) found that most people with mental health disorders, especially racial-ethnic minorities and those with low incomes, remain either untreated or do not receive minimally adequate treatment.

A considerable literature has highlighted psychological and cultural barriers to care. Perceived stigma associated with mental illness poses a significant psychological barrier that discourages low income depressed individuals from seeking or continuing with mental health care.  People with depression or mental illness have been portrayed as incompetent, crazy, or violent, but nonetheless in control of and responsible for causing their condition (Corrigan et al., 2000).  Depressed individuals may internalize these common stigmatizing attitudes and avoid shame by refusing to seek treatment or discontinuing treatment prematurely (Sirey et al., 2001; Scholle et al., 2003). Depressed persons who feel additionally stigmatized because of poverty or racial/ethnic minority status may be even more likely to avoid seeking or participating in mental health care. “I’m already black. Do I have to be crazy too?” (English as cited by Levin, 2008, p. 1), one African American woman exclaimed to a researcher studying attitudes regarding mental health treatment.

           

Many African American women are reluctant or ashamed to admit they suffer from depression and often refer to depression as “just the blues” (Lazear et al., 2008)) African American women continue to be plagued by labels projected onto them by members of the dominant society such as “super black women,” “super woman” and “matriarch.”  African American women are keenly aware of the expectations implicit in these labels, expectations that are often reinforced by other African Americans.  The social expectation that African American women will be strong self reliant caregivers can result in suffering in silence from severe depression and refusing to seek out mental health services, or seeking help while continuing to resist mental health labels like depression as accurate descriptions of their condition.

             

There is strong cultural support for African American women refusing to acknowledge weakness or vulnerability. African American women have always provided care for their children, husbands and other family members and often for the children of White families as well. The care of others comes before self care; and when depression or other mental health problems interfere with caring for others, African American women often experience powerful guilt feelings. In these circumstances, depression may be viewed as an unacceptable sign of weakness unless family members, influential community members or helpers encourage seeking help and reframe mental health treatment as an indicator of competence and a means of strengthening personal health and well being essential for nurturing caregiving.        

           

African American women often feel that they are capable of managing their depressed moods without seeking professional help through spiritual beliefs or practices and through social support.  Given the importance of religion and spirituality to African American women, the attitudes of African American pastors toward mental health treatment can have a large impact on help seeking behaviors. According to English, “A 2003 survey of 99 African American pastors found that while 62% saw a biological basis for mental illness, the same proportion listed “stunted spiritual growth or “unconfessed sin” as contributing factors. In that same survey, only 25% of the pastors said they had ever referred parishioners to a mental health care clinician” (Levin, 2008, p. 2).

           

African American women are wary of mental health providers who appear to be culturally insensitive or unaware of the challenges posed by poverty and economic insecurity, racism, community violence, the burdens of care giving and inadequate social support. Cultural insensitivity may be manifested in a variety of ways. Clinicians may lack proficiency in recognizing the cultural context of a person’s depression and in understanding her or his culturally endorsed symptoms of depression (including somatic complaints such as chronic fatigue) and explanations for their depression. Clinicians sometimes forget or fail to operate from a strengths perspective (Saleeby, 1997) or show appreciation for the adaptive and resilient ways a depressed person has coped in the past, for example, through an emphasis on self reliance, social support or spirituality. For these reasons, it is not uncommon for African American women to “size up” a therapist regarding her or his level of cultural awareness and experience, genuineness and credibility before committing to a treatment process.  

 

Implications for Practice

Anytime social workers or health care professionals attempt to help persons discouraged or even hopeless regarding their ability to cope with life’s problems, effective engagement strategies are crucially important. It is as important to develop evidence based engagement strategies as to be able to deliver evidence based treatments; otherwise, a large percentage of persons needing help are unlikely to seek out or stick with treatments that have delayed effects or which are dissonant with cultural beliefs and attitudes.   

     

Research studies (Greene et al., 1996) indicate that 40 -60% of low income persons seeking mental health care in publicly funded settings do not return for a second visit.  One promising approach designed to address some of the practical, psychological and cultural barriers to depression treatment is the pre – treatment engagement session developed by Grote, Zuckoff, Swartz, Bledsoe, and Geibel (2007). The engagement session, delivered before treatment begins, is based on principles and techniques taken from ethnographic interviewing and motivational interviewing.  The engagement session offers an opportunity to empathetically explore barriers to care, to interpret depressive symptoms in ways that are non- threatening and psychologically acceptable to the person considering treatment and to identify personal and cultural strengths.     

             

Confronting resistance to treatment in culturally informed and empathetic ways is urgently needed to increase treatment retention rates for African American women and other women of color. Utilizing treatment approaches that help low income depressed women empower themselves is important. “Empowerment practice seeks to create community with clients,” to raise awareness of environmental factors that negatively impact their lives and to encourage personal and political action (Lee, 2001, p. 34).

             

Enhancing the capacity of low income individuals to more effectively cope with chronic economic stressors often has an immediate impact on depressive symptoms and increases the credibility of helping professionals. Effectively coping with chronic stress can involve mobilizing personal resources and accessing community resources, as well as helping depressed persons understand and gain a measure of control over their physical and emotional reactions to stress.

        

Increases in energy and more positive moods resulting from medication or a natural healing process provides an opportunity to confront self defeating efficacy beliefs regarding the ability to improve interpersonal relationships, economic circumstances, personal health, or a variety of other conditions. Chronically or severely depressed individuals are unlikely to be convinced by rational argument alone that their negative views of their possibilities are mistaken or highly questionable.  Repeated experience of initiative, skilled effort and collective action having  positive effect in reducing important life problems is needed to reduce the long term risk of depression for chronically depressed persons.

        

The historic oppression of African American women and other women of color has contributed to high rates of untreated depression. African American women may engage in self blame for their depression and for other conditions that negatively impact their well being.  Self blame can lead to or intensify depression and impedes the development of confidence in a person’s ability to make positive changes in the social environment. Effective interventions focused on efficacy beliefs must be culture based and gender sensitive and take an empowerment approach. Taking environmental challenges seriously and building on women’s coping strengths are likely to be important elements in increasing African American engagement rates in depression treatment.

              The most common outcome of trauma is depression. Trauma theorists (Herman, 1993) have emphasized the importance of empowerment practices for trauma victims.  Hopelessness in the face of terror is the common experience of trauma victims just as the powerlessness of groups in extremely threatening social environments is characteristic of historical trauma.  Groups that have experienced historical trauma have an urgent need to feel in control of their lives. Members of these groups are not likely to respond positively to renewed experiences of powerlessness in relating to social workers and health care professionals who expect highly compliant behavior with directions based on their professional expertise or official position.   

Discussion

           

It would be difficult to overstate the importance of being able to fully mobilize one’s energies and resources when living or working in harsh or threatening environments. Making full use of energies and resources can involve persevering in efforts to improve conditions despite strong resistance, refusing to become discouraged when initial efforts to achieve a goal are unsuccessful, being resourceful and prudent with material resources, being able to calm down or cheer up when under stress, putting anger to constructive use, taking pleasure in small things, joining with others in collective action, forming and maintaining supportive relationships, resisting the negative attributions of others, learning from painful experiences instead of suffering to no end, finding sources of spiritual strength and ethical behavior in extreme circumstances, and developing ways of communicating the depth of personal experience and the cultural experiences of groups as a therapeutic response to suffering.  

           

These are just a few of the capacities that are helpful in difficult or threatening circumstances, but depression undermines all of them. In its mild forms, depression is often an understandable reaction to disappointment or reversals of fortune. Severe chronic depression, however, is a withdrawal of emotional investment in hopes of a better future. This is possibly the reason depressed individuals often tenaciously insist on unduly negative and even distorted views of their possibilities. Severe depression serves a purpose, albeit a self hurtful one.

           

The hopeless / helpless attitudes characteristic of severe depression are based on explicit or implicit beliefs regarding limited self efficacy. It is these efficacy beliefs that therapies must counteract to have lasting effect. Efficacy beliefs concerning personal inability to cope with difficult circumstances are expressed through negative self talk (Bandura’s “depressive ruminations”) that generates self fulfilling prophecies. The more convinced persons are that they cannot master skills readily attainable by others in similar circumstances, the less likely they are to develop necessary skills and the more discouraged they are likely to be about their abilities and potential.                       

           

It is, of course, possible to be depressed about social conditions that cannot be changed by individuals or even well organized groups, no matter how skilled or determined. In these instances, depressive thoughts regarding personal deficiencies are cognitive distortions; and the path out of chronic depression may lie in collective action in pursuit of political goals or cultural strategies to blunt the emotional impact of intolerable conditions. The supposed conflict between therapies intended to reduce the suffering of individuals and political action on behalf of the common good is specious. Collective action is sometimes an urgently needed tonic for apathy and despair. Effective political action requires the capacity to regulate thoughts, feelings and actions, to persevere in the midst of conflict and bounce back from adversities.  

           

A major goal of depression treatment should be to counteract self defeating efficacy beliefs, and, in doing so, to restore the capacity of depressed individuals to struggle with difficult conditions and circumstances with full stores of energy, resourcefulness and determination.  Finally, the ability to help chronically or severely depressed persons articulate hopes for a better future and outline practical realistic steps for realizing these hopes is an important indicator of therapeutic success.              

 

References

 

English, A. (2008, June). Mood disorders in African American women. Paper presented at The University of Tennessee, Memphis, Family Medicine/Psychiatry Continuing Education Program.

Lee, A. B. (2001). The empowerment approach: A conceptual framework. In The empowerment approach to social work practice: Building the beloved community (2nd ed., pp. 30-55). New York: Columbia University press.

Warren J. (1994a). Depression in African-American women. Journal of Psychosocial Nursing, 32(3), 29-33.

Warren, B. J. (2008). Examining depression among African-American women from a psychiatric mental health nursing perspective (pp. 1-5). 

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