I understand depression as involving inner symptoms of extreme sadness, irritability, anger, guilt, shame, apathy, helplessness, hopelessness, low confidence, self-loathing, a sense of failure, and/or possibly suicidal ruminations. These can manifest as outer signs like eating, sleeping, or substance use disorders; excessive crying or flat affect; social withdraw; sloth and sluggishness; excessive dependence in relationships; giving or throwing precious things away; and suicidal plans or attempts. Though depression can be acute and transitory ("situational"), for many it is chronic, an entrenched negative sense of self that forms a negative lens through which we preemptively see the world as impossible to handle, which at the very least contributes to making it so.
I see two primary conditions coincident with severe chronic depression: loss and embarrassment. Loss happens regularly in the form of sacrifices and disappointments that don't rise to the level of our own or others' noticing. But big losses — of security due to attachment failures in childhood, of physical or mental ability due to aging or illness or accident, of status or a job or a loved one, of identity or integrity due to any of the above — are hard to miss. They can lead to symptoms and signs that fundamentally change how we see ourselves and others, as well as how we think others see us. That's where the embarrassment comes in with compounding force. On top of whatever the big loss(es), the loss of faith in self is profound and projected: we're sure others have lost faith in us, too.
In those conditions, esteem and efficacy are nowhere to be found.
So we go to a friend or family member for a listening ear and a strong shoulder and encouragement... That level of connection can assuage mild depression and grief. But if the depression is moderate to severe, the support system could at some point be overtaken by the relentless logic of self-loathing and despair. Deeply depressed or bereaved people are compelling in their reasoning as to how pervasively hopeless and embarrassing their situation is and will always be. They seem devoid of self-compassion, walled off from any possibility by their own beliefs (originally introjected/learned from others and eventually projected or assumed to be those of others), and after a while, it’s understandable that devoted family and friends would lose heart, too.
A good therapist carefully, compassionately, confidently approaches that wall in treatment, knowing it’s not as solid as it feels to the client and looks to family and friends. The wall represents distrust of and dissociation from unbearable/overwhelming losses and related embarrassment as well as opportunities for awareness and enrichment. For better and worse, the seriously depressed client copes with vicissitudes via separation from the full gamut of what many experience as normal emotions -- joy and sadness, hope and fear, clarity and confusion. Health ups and downs are somewhere on the other side of that wall.
Therapy chips away at that wall over time with the client’s permission and at times effortful participation. Therapy persistently, respectfully, and directly yet gently invites whatever the client’s relegated, compounded experience of being at a loss to come forward and be experienced, expressed, and respected. Treatment for recurring depression can take some time because the ruts of despair are well established and some therapeutic bushwhacking must occur for the client’s experience of self and life to enlighten a new direction.