Depression is not one thing.
The word covers everything from a persistent low mood and reduced pleasure to severe episodes of total withdrawal, an inability to function, and thoughts of suicide. What runs through all of it is a kind of disconnection. From pleasure, from other people, from any sense of future possibility, and from yourself.
And it does not respond to effort or encouragement, which is one of the loneliest things about it. Being told to pull yourself together, or to go for a walk, or to count your blessings, tends to confirm to a depressed person that nobody has understood.
The causes interact rather than queue up neatly: genetic vulnerability, neurobiology, life events and losses, early attachment patterns, sustained stress, and the particular psychological structures that make some people more susceptible than others. Perfectionism. Self-criticism. A harsh internal relationship with oneself that never lets up.
Which is why treatment has to be built around the particular presentation rather than applied as a protocol.
When depression does not look like sadness
One of the most common forms, and the most frequently missed, is high-functioning depression.
This is the person who is outwardly successful, often very. Their entire life-force has gone into work, while their personal life has quietly emptied out. They perform, sometimes brilliantly, and feel genuinely low underneath. It is usually the last thing anyone around them would guess.
The work is the shield. And the higher the role, the more effective the shield becomes, because the title itself sits between the person and any real relationship. People respond to the position. Very few get past it, and after enough years it stops occurring to anybody to try.
What is missing here is not pleasure. They often have a great deal of that. What is missing is happiness, which comes through other people, and which an emptied-out personal life can no longer supply.
So the work is not simply lifting the mood. It is rebuilding the connections that the depression has starved.
I have written about this at greater length in The Desert of Isolation and the Garden of Solitude.
What the therapy involves
I work integratively, which means attending both to what has triggered or is maintaining the current episode and to the deeper structures underneath it that created the vulnerability in the first place.
Jungian-informed work is particularly useful where the depression has a meaning dimension: where it is carrying a message about a life that has drifted away from what the person actually values, or where it has arrived alongside a significant transition or a loss of identity. Not every depression is like that. Some are, and treating them as a malfunction to be corrected misses what they are saying.
Where there is a clear trauma component, EMDR can be part of the work. Where words feel inadequate, or where the depression involves a real dissociation from feeling, art therapy often reaches material that talking does not. The approach follows the presentation rather than the other way round.
Medication
I do not prescribe. Where your GP or psychiatrist has recommended medication, I work alongside that rather than against it.
For moderate to severe depression, the evidence suggests that medication and psychotherapy together are more effective than either alone. For milder presentations that is less clear-cut. The first consultation will clarify what is likely to be appropriate for you, and I will say so honestly if I think you should be speaking to a doctor as well as to me.
If things are worse than that
If you are having thoughts of ending your life, please do not wait for a therapy appointment.
Samaritans answer at any hour, free, on 116 123. If you feel at immediate risk, go to A&E or call 999. Your GP can also arrange urgent support, and NHS 111 will direct you if you are unsure where to start.
None of that is a lesser option than therapy. It is the right first step, and the work we might do together can begin once you are safe.
Common questions
What is high-functioning depression?
Depression hidden behind success. The person functions well, often at a senior level, while their personal life quietly empties out and their whole energy goes into work. They feel genuinely low underneath, cut off from the connection that brings happiness, and it is often the last thing anyone around them would guess.
Can you have depression without feeling sad?
Yes, and it is common. Many people describe flatness rather than sadness: nothing is enjoyable, nothing matters much, and the day is got through rather than lived. Others notice it first in the body, as exhaustion or disturbed sleep, or in irritability rather than low mood.
Do I need medication, or will therapy be enough?
It depends on severity. For moderate to severe depression the evidence suggests medication and psychotherapy together work better than either alone. I do not prescribe, but I work alongside your GP or psychiatrist where medication has been recommended. The first consultation clarifies what is appropriate for you.
How long does therapy for depression take?
It depends on whether we are working with an episode or with something longer-standing. A depression triggered by an identifiable event often shifts more quickly than one rooted in patterns established early. I would rather give you an honest view after the first consultation than a number now.