Major Depressive Disorder and the Alderian Art Therapy

Identification and Diagnosis

Major Depressive Disorder (MDD), or clinical depression, is a mood disorder characterized by persistent depressed mood and/or a loss of interest or pleasure lasting at least two weeks. In addition to these, an individual must experience up to four of the following symptoms over the two week period: significant fluctuations in weight and marked changes in appetite; sleep disturbance including sleeping an unusual amount or having trouble falling or staying asleep; psychomotor agitation such as pacing or psychomotor retardation such as slowed speech; lowered or loss of energy; lowered self-esteem or feelings of guilt; disruptions in ability to think, concentrate, or make decisions; and reoccurring thoughts of death, suicidal ideation or attempts, or forming a suicide plan. These symptoms must cause social impairment or otherwise cause distress, and should not be explainable by substance use or other medical condition (American Psychiatric Association, 2013).

MDD is distinct from Bipolar Disorder in that the individual does not experience manic episodes, which are characterized by feelings of elation, increased energy, being easily startled, rapid speech, irritability, racing thoughts, and grandiosity (National Institute of Mental Health, 2016). These mood episodes last 13 weeks on average before the cycle starts again (Nurnberger, 2010). MDD is also distinct from attention deficit disorder, which is characterized by a hyperactivity, inattention, and impulsivity, though both conditions may result in irritable mood (American Psychiatric Association, 2013). In addition, MDD is also distinct from adjustment disorder, also called situational depression, which is characterized by a state of emotional distress during a period of adaption after a major change, such as a divorce or loss of job. The depressed subtype of adjustment disorder may share many symptoms in common with MDD, though it tends to lessen after six months. MDD is thought to be more generalized and not necessarily in direct response to any single event, though adjustment disorder can turn into MDD if it persists for more than six months. (Greaves & Hunt, 2011).

Relevant Clinical Issues

Self-injurious behavior or self-harm is a risk factor amongst populations with MDD, though is not necessarily indicative of suicidal intent. Often times an individual with MDD that self-harms will do so to distract themselves from depression-related distress, counter feelings of numbness, take control of something in their lives where they otherwise feel helpless or powerless, calm overwhelming emotions, or self-punish (Froeschle & Moyer, 2004). Clinicians should be aware of these factors when treating individuals with MDD, and be aware that self-harming behaviors need to be replaced with alternative coping mechanisms instead of simply taken away or discouraged, otherwise the client may resort to other unhealthy behaviors to cope.

MDD has a high mortality rate, accounted for by suicide. Suicidal ideation, threats, attempts, and plans indicate a suicide risk, and clinicians should be vigilant for them at all times. Women with MDD have a higher risk for suicide attempts, while men with MDD have a higher risk of suicide completion (American Psychiatric Association, 2013). The risk for suicide increases significantly if the individual is not heterosexual or cisgender (The Trevor Project, n.d.). Suicide assessments are a vital part of training for clinicians working with clients with MDD, and clinicians should be on the lookout for suicidal risk in clients at all times.

Adlerian Foundational Principles

Adlerian theory, and, by extension, individual psychology, is particularly well-suited to the treatment of individuals with MDD due to its rejection of more epistemological approaches such as psychoanalysis in favor of an approach that focused more on the uniqueness of the individual’s experience. Adler rejected the psychoanalytic notion that human behavior is motivated by unconscious sexual drives, and instead posited that humans are socially motivated and have an innate need to belong and connect with others (Ferguson, 2010).

With humans being creatures whose behavior is largely curated by emotions, Adler defined two types of emotional responses in humans: conjunctive emotions, or those that connect people such as joy, modesty, or empathy, and disjunctive emotions, or those that disconnect people such as anxiety, sadness, or anger. An overabundance of disjunctive emotional experiences or responses, whatever their source may be, has the potential to lead to chronic disconnection. Since humans possess the aforementioned innate need to belong, this disconnection or lack of communal sense could cause a decreased interest in community wellbeing, also known as social interest, and contribute to the formation of MDD (Adler, 2006).

Adler defined social interest as “a feeling of community, an orientation to live cooperatively with others, and a lifestyle that values the common good above one’s own interests and desires” (Guzick et. al., 2004) and defined its presence as an indicator of mental wellbeing. In Adlerian terms, depression, consequently, is caused by a lack of communal feeling and an inward turn to protect oneself from feelings of inferiority that may arise from chronic othering or disconnection (Waller et al., 2006). Social interest’s presence or lack thereof can therefore simultaneously be a cause of and a result of MDD. An individual with depression may be too inwardly turned or otherwise exhausted to express interest in or concern for other’s wellbeing, especially if they are independently struggling to express interest in their own wellbeing. Meanwhile, the ostracizing an individual with little social interest may experience, whether it be self-imposed or imposed upon them by others, may cause a sense of disconnection and isolation that may, in turn, promote the development of MDD as well as disjunctive responses to the feelings of inferiority that may arise from this disconnection (Walle et al., 2006).

Inferiority feelings are “are those universal human feelings of incompleteness, smallness, weakness, ignorance, and dependency included in our first experiences of ourselves in infancy and early childhood…for the well-adapted individual…these feelings serve as spurs to effort and as a source of motivation to overcome obstacles, to grow and to improve oneself and the community” (Griffith & Powers, 2007). As previously mentioned, inferiority feelings may become overwhelming if an individual has a poor communal sense and thusly low social interest, which may lead to the individual withdrawing in effort to protect themselves against this feeling. Adler defined these five life tasks as universal and something that all humans must attend to throughout their lives.

He did, however, acknowledge the uniqueness of each individual’s experience through the concept of lifestyle. Adlerian theory is teleological and thusly views human behavior as a continually striving to achieve the future goals an individual has deemed important through their lifestyle, or the way in which an individual uniquely and socially reacts and interacts with others. Term fictional finalism is used to describe the imagined future or goals an individual acts to move towards (Corey, 2017). The basis of this lifestyle and subsequent goals are formed in childhood through personal experience with and observation of others, often through parenting and can be affected by the aforementioned rejection or pampering.

Adler believed that these future goals and lifestyles related to three basic life tasks: work, social relationships or friendship, and love or intimacy, and the lack of fulfilling these could lead to a lack of social interest and thusly disconnection that could potentially lead to conditions such as MDD. Because Adlerian theory is a holistic approach in that it considers the individual in context of all aspects of their lives, Adler saw these three tasks as interrelated. He defined them respectively as: “How to find an occupation which will enable us to survive under the limitations set by the nature of the earth; how to find a position amongst our fellows so that we may cooperate; how to accommodate ourselves to the fact that we live in two sexes, and that the continuance and tolerance of mankind depends on our love life.' (Adler, 2010).

Social Relationship Task

Adler defines the first task of life is “the problem of relationship to other men” (Dreikurs & Modak, 1966), and being that Adlerian theory is based on the predisposition that all human behavior is socially motivated, this task is especially important and linked to the previously discussed social interest and lifestyle. This task is deeply linked with all other tasks, and the lack of fulfillment of this task in particular is most likely to cause disruptions in other life tasks, being that they are all socially based. In the context of depression, a lack of fulfillment in this area has already been discussed in terms of disconnection and a lack of communal sense. Therapy is in itself about social relationships, whether they be the client’s relationship with others, with themselves, or even with their clinician. Dysfunction in this area would be, from an Adlerian perspective, largely an effect of the maladaptive or inappropriate perspectives in an individual’s unique lifestyle, and therapy would be utilized to explore and modify these.

Love and Intimacy Task

Though the task of love and intimacy is also intrinsically socially based, it has been noted that it tends to be the least urgent of the three original tasks. “The tyranny of our stomachs compels us to work lest we starve, and the tyranny of loneliness compels us to make certain gestures toward our fellowmen, lest we become insane. But men and women can evade the solution of the sexual problems and still live. It is the problem most frequently left unsolved” (Wolfe, 1931). Though this task is important and disruptions in it, especially if they are part of an individual’s future goals and lifestyle.

Work or Occupation Task

Finding fulfilling and meaningful work is a way of expressing social interest, in that ideally an individual would find fulfillment in work that benefits the whole community. A maladaptive individual who is lacking in social interest may struggle to find satisfaction in a traditionally meaningful job due to the lack of satisfaction they derive from contributing to their community as a whole. Contribution to the greater good aside, a lack of social interest may also affect one’s ability to collaborate with others in a work environment, being that they are so inwardly turned as to lack the ability to cooperate (Ansbacher & Ansbacher, 1956).

Spiritual Task

The spiritual task was later added by Adlerian theorists Dreikurs and Mosak, who worked directly with Adler. The spiritual task is defined as how an individual relates to the world existentially, how they find meaning in life, how they relate to the concept of a higher power whether they choose to believe in one or not, and what that self-defined concept of a higher power or lack thereof says about their social context and fellow humans, which in turn affects the other life tasks (Dreikurs & Mosak, 1967b). A lack of spiritual fulfillment or definition, or an incongruence between one’s lifestyle and ones beliefs may cause a disruption via existential disturbance. For example, an individual that practices Christianity externally, but finds that they are inwardly atheistic may find the spiritual community they’re attempting to belong to difficult to form significant connections with, causing further disruptions in the initial social relationship task.

Self-Task

Meanwhile, the self-task is defined as getting along with oneself, finding a balance between the outer actor and inner observer, coming to terms with the innate dualistic experience of having willpower and constantly struggling to do what one’s lifestyle deems is right, for with this perspective, we always simultaneously win and lose. To fulfill this task, one must find a unity and acceptance within this struggle rather than promoting self-guilt and self-shame when the observer disagrees with the actor’s actions or vice versa. Our success within the self-life task, in turn affects our ability to perform and fulfill the other tasks, (Dreikurs & Mosak, 1967a). As self-acceptance and consequently self-assurance or confidence affects self-efficacy, a person with a maladaptive lifestyle or unrealistic future goals may experience a lack of self-confidence or self-efficacy, and thusly a disruption in the ability to accept oneself, leading to the aforementioned inward turning that can negate an individual’s ability to experience or express social interest.

Psychological Types

In addition to life tasks and lifestyle, Adler theorized that there were four personality types, defined by high or low social interest, and high or low energy. It is important to note that Adler, possessing a holistic view on human nature, emphasized that these psychology types were only to be used as a source of guidance rather than definitive, categorical labels (Ansbacher & Ansbacher, 1956).

Ruling Type

This personality type is high energy, but possesses low social interest. These individuals are characterized by their dominant nature and their tendency to inflict that high energy on others through exploitation or otherwise tyrannical or sadistic actions. In the context of MDD, if this energy is turned inward, the individual may experience high self-criticism, inflict self-harm, and even complete suicide (Mosak, 1999).

Getting or Leaning Type

Getting or leaning types exhibit low activity, and low social interest. These individuals are generally passive, and tend to depend on others for energy and for their needs to be met. Due to this dependence, individuals that fit this psychological type may be prone to anxiety or phobias, which in addition to the absence of social interest may impede their ability to fulfill many of their life tasks, leading them to disconnection and thusly depression (Mosak, 1999) (Lundin, 1989).

Avoiding Type

Another low activity, low social interest psychological type is the avoiding type. Instead of depending on others, these turn inwards as a means of avoiding the exertion of what little energy they have, tending to avoid life tasks and thusly connections with other people. This type is especially conducive to MDD due to the deliberate disconnection this type has a tendency towards (Lundin, 1989).

Socially Useful Type

The ideal psychological type, according to Adler, was high energy and high social interest, or the socially useful type. This individual has the desire to and energy to express concern for and contribute to the greater good and society. This is, according to Adler, the most mentally healthy type. In the context of MDD, the socially useful type is a model for what one should aim for as a goal of treatment.

Art Therapy and Individual Psychology

Since art therapy is primarily used to bring forth one’s inner and personal experiences and perspectives, Adlerian theory’s holistic approach is especially applicable. As with all Adlerian approaches, the overall goal is to encourage the client to experience and express more social interest. The mere presence of the therapeutic relationship may serve as both a model and an opportunity for the client to experience social interest as well as overcome feelings of inferiority, as therapists are encouraged to walk alongside clients rather than act as a figure of authority.

Material considerations when working with clients with MDD may include being mindful of the clients’ self-harming history and the presence of suicidal ideation, and be mindful of any precautions that would need to be taken in light of this to ensure client safety. Being mindful of an knowledgeable about a client’s triggers is vital. For example, the presence of tools like x-acto knives, pins, or any tools involving extreme heat could potentially trigger a self-harming impulse in a client, especially if they are finding the therapeutic environment to be stressful as they are processing things.

Alternatively, with the Expressive Therapies Continuum in mind, moving a client from affective state where they are turned inwardly and focused on their own feelings, to a more cognitive place where they are able to examine their lifestyle and feelings of inferiority and properly address them may be useful in the treatment process. Beginning the client, or clients in the case of group therapy, with a media like watercolor, which is fluid and more affective, and gradually moving them towards a more resistive and therefore cognitive material like water color pencil and then colored pencil may be useful as the therapist works alongside the client to assist them in challenging their pre-established perspectives (Hinz, 2009).

However, to achieve this, the source of this deficit must be uncovered. As previously discussed, according to Adlerian theory, depression can stem from any number of sources, including a maladaptive lifestyle, an inability to fulfill life tasks, or a dysfunctional psychological type. In individual therapy, a possible directive would be defining and challenging some of these areas from which dysfunction may be stemming. Art can be used rather openly during this exploration phase alongside traditional talk therapy, as the clinician would also be assessing the client’s preferences and abilities as they move along the Expressive Therapy Continuum. Simple prompts like asking a client to abstractly depict what disjunctive emotion their depression feels like—sadness, anger, fear, etc.—can be conducive to finding a way to increase social interest. In addition, using art to describe how an individual feels they’re performing in each life task may be beneficial, especially for those exhibiting suicidal ideation (Randick, 2016). Early recollections, another important aspect of Adlerian theory, may also be addressed, depicted, and discussed as a means of uncovering the origin of inaccurate perceptions and beliefs that affect an individual’s lifestyle (Balcome, 2016).

As the nature of Adlerian theory calls for connection, group art therapy is especially useful for fostering a sense of community and reducing feelings of isolation. In this situation, possible directives may include encouraging cooperation, reducing feeling of communal inadequacy, and developing empathy and thus social interest. Through collaboration, which could take the form of many art directives from mural creation to communal quilting, the idea would be to move a client from being inwardly turned and self-oriented to outwardly turned, socially interested, and task-oriented (Puller, 2008).