What Depression Protects

On rumination, the loop that won’t stop, and the frustration of trying to reach someone who has stopped believing they can be reached

Hyperarousal by Karina Da Paixao Teixeira

As a counsellor working across inpatient mental health units and private practice, I have learned that depression is one of the most complex presentation to work with, clinically. Because it is persistent. Because it returns. Because it organises itself around beliefs that feel, to the person carrying them, like simply the truth.

I want to write today about a frustration I feel in this work, one I think is worth naming rather than managing quietly. It is the frustration of sitting with someone who has been on medication for years, who is compliant, who is trying, and whose thinking is still caught in the same loop. Still returning to the same guilt. Still unable to leave the house without someone beside them. Still, after all this time, without hope.

As a therapist, this frustrates me. I am frustrated with what is being missed.

I want to explore what that is.

The system I work in

For context: in the mental health units I have worked in, the window for inpatient treatment is typically 21 days. In a private hospital setting, a multidisciplinary team has that window to help a person stabilise, begin to build capacity, and leave with something more than a revised prescription.

Twenty-one days is both a lot and very little, depending on what the person is carrying.

What I encounter most often in these presentations is not a person who hasn’t tried. It is a person who has been compliant with medication for years, sometimes decades, and whose dysfunctional thinking is still present, still organising their experience, still shaping what feels possible and what doesn’t. The biological treatment is addressing the neurotransmitter imbalance. Something else is not moving.

If the chemistry is being treated, what is maintaining the depression?

A case I keep thinking about

I want to tell you about someone I’ll call Anna.

Anna had not left her house without her husband in two years. She came into hospital following a deterioration that was visible in her body as much as her mind. Cognitive slowing. Psychomotor slowness. A quality of hopelessness that is different from sadness, more total, more certain of itself. She had been on antidepressants for a long time. They had not been enough.

Her history was one of profound early loss. A mother who was absent through repeated hospitalisation. A father who was abusive. From a very young age, she had functioned as her own parent, and in doing so had built a particular internal architecture: the belief that her needs were too much, that love was conditional, that the only safety available was the kind she could secure through vigilance and control.

That architecture had been running quietly for decades. The depression was not separate from it. The depression was, in a real sense, its current expression.

What struck me in working with Anna was how organised her suffering was. The rumination was not random. It returned, again and again, to the same beliefs. The same guilt. The same sense that she had failed in ways she could not quite name. This is what I mean when I say depression has an architecture underneath it. The thoughts are not symptoms so much as the structure speaking.

Why medication is not enough here, and what the research actually says

Aaron Beck understood something important early in his work on depression. The symptoms, the low mood, the fatigue, the withdrawal, were not the problem itself. They were the surface. Underneath was a structure: a set of beliefs about the self, the world, and the future that had become rigid, distorted, and self-confirming.

The depressed person does not just feel bad. They feel bad because of what they believe. And what they believe, they have believed with quiet certainty for a very long time.

This distinction matters clinically. Antidepressants work on the amygdala, our threat detection system, dampening the intensity of the alarm signal. That is genuinely useful. The person becomes available for the work that actually needs to happen. But the prefrontal cortex, where meaning is made, where the self reflects on itself, where the beliefs generating the depression actually live, that is where psychotherapy works. And they are not the same place.

A 2023 meta-analysis of over 52,000 participants, the largest of its kind, found that psychotherapy is equally effective as medication in the short term, and significantly more effective over time. I think medication does not build anything.

Medication removes a symptom. Psychotherapy installs a capacity.

The relapse rates on medication discontinuation are two to three times higher than for those who have also done the psychological work. I am not surprised by this. You cannot medicate a belief.

What rumination is actually doing

This is where I want to slow down, because I think rumination is often misunderstood as a symptom to suppress rather than a signal worth investigating.

Rumination is organised. It is loyal. It returns to the same beliefs because those beliefs are doing something, holding something in place that the system has decided must be held.

In Anna’s case, the guilt she carried about an inheritance dispute was not arbitrary. It activated a much older schema about not deserving care, about receiving love being dangerous. The rumination was, in a distorted and exhausting way, an act of loyalty to something. A vigilance that made sense once, in a childhood where not being vigilant had consequences.

Jeffrey Young’s schema therapy framework gives us language for this. The core schemas formed in early life, emotional deprivation, abandonment, defectiveness, vulnerability, these are not distortions to be corrected so much as conclusions that made sense given what a child experienced. The problem is not that they formed. The problem is that they never got updated.

Empathic confrontation is the term used in schema therapy for what is required here. Not confrontation in the sense of challenge or argument. Confrontation in the sense of gently, persistently, with warmth, refusing to collude with the schema’s version of reality. Chipping away, as I tend to think of it. Not breaking. Chipping. Slowly, carefully, over time.

The instinct when someone is in the loop of rumination is to interrupt it. But the more effective question is: what is this loop protecting? What does the system believe will happen if the certainty is released?

What the body holds that the mind cannot always reach

I have been reading Payne, Levine and Crane-Godreau on somatic experiencing, and something in it connects to what I observe in the room.

Levine’s work argues that trauma and chronic stress are not primarily psychological. They are a dysregulation of the body’s core response network, subcortical, autonomic, limbic. The nervous system under threat encodes the experience not as a story but as sensation, posture, the particular quality of readiness or collapse that becomes the body’s baseline.

This is why people can understand their depression intellectually, trace the patterns, name the beliefs, and still wake at three in the morning with a heaviness that does not respond to any of that knowledge. The story has been processed. The body has not received the memo.

For Anna, this meant that the cognitive work had to be accompanied by the body noticing something different. Not just thinking differently. Experiencing differently.

The walks outside the hospital

I want to tell you about the graduated exposure work we did with Anna, because it is the most concrete example I have of what I mean.

Anna had not left the building without her husband. The anticipatory catastrophising was total. Something bad will happen. I will lose control. I will not be able to manage.

We started with very small steps. And then she went for walks outside the hospital grounds. Not because the anxiety wasn’t there. It was there. The hyperarousal was present, the expectation of panic. The work was learning to stay with that experience rather than flee it. To discover, incrementally, that the feeling was survivable. That she could tolerate what she had believed she could not.

Each time she returned from a walk, something had shifted slightly. We don't find changes on her beliefs, yet. In her evidence. In what her own experience was beginning to tell her about herself.

This is what behavioural experiments do that cognitive restructuring alone cannot. They bypass the argument between the rational mind and the belief. They put the body in a situation and let it discover something new.

After many walks, she became confident in her own ability to self-regulate. That confidence did not come from thinking. It came from doing, from the nervous system accumulating a different kind of evidence.

Giovanni Liotti’s work on disorganised attachment and the therapeutic relationship is relevant here too. For someone like Anna, whose early attachment figures were also sources of fear and harm, the therapeutic relationship itself becomes part of the intervention. The experience of being in a relationship that is safe, that holds, that does not withdraw when things become difficult, is not incidental to the treatment. It is the treatment.

What I am still learning

I want to say something about rumination that I don’t have fully resolved.

The paradox of suppression is well established: the more we try not to think a thought, the more present it becomes. The standard approach, rumination postponement, scheduled worry time, creating distance from the loop without demanding it stop, helps. But I find the breaking of the rumination loop one of the more complex problems in this work, and I want to say that honestly.

What I observe is that the loop tends to break not through suppression or through direct challenge, but through the gradual development of a different relationship with the thoughts. The thoughts become less sticky not when the person stops having them, but when the thoughts stop feeling like facts. When there is enough space between the person and the belief that they can observe it rather than be entirely inside it.

Acceptance and Commitment Therapy points in this direction. You are not the thought. The thought is something that passes through.

That shift, from identification with the thought to observation of it, is slow. It does not follow a straight line. And I say this from both sides of the therapeutic relationship: there is no quick fix here. But progress can happen in a shorter time than people expect, if the intervention is targeting the right level.

Why I keep studying this

I have seen cases of genuine recovery from depression that everyone, including the person, had stopped believing was possible. I have also seen people give up on their lives. Both realities stay with me.

The frustration I feel when I sit with someone who has been on medication for years and is still in the loop, is not frustration with them. It is a kind of urgency that I have come to think of as part of the work. It keeps me reading. It keeps me returning to the research. It keeps me asking what else is possible, what I might be missing, what intervention might reach what the previous ones haven’t.

Depression is not a simple problem. It does not have a single cause or a single solution. But I believe strongly, and the research increasingly confirms, that the architecture underneath the depression is where the work needs to land. The beliefs that were formed, the schemas that organise the present through the lens of the past, the body that learned to carry what the mind could not name.

That is where the heaviness lives. And that is where something can, slowly, begin to shift.

If you recognise this loop, the one that returns at three in the morning, the beliefs that feel like facts, the sense that the life you are living is not quite yours, I want you to know that the loop is not a permanent feature of who you are. It is a pattern that was learned. And what was learned can, with the right conditions and the right support, begin to be updated.

The painting above is Hyperarousal, one of my watercolours. The forms are in motion, distinct and restless, nothing settled into background yet. That is what this work looks like from the inside of it.

With curiosity and care for your story,

Karina

If you’re curious…

Beck, A. T. (1979). Cognitive Therapy of Depression. Guilford Press.

Cuijpers, P. et al. (2023). Cognitive behaviour therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. Cognitive Behaviour Therapy, 52(1), 1–25.

Gautam, M. et al. (2020). Cognitive behavioral therapy for depression. Indian Journal of Psychiatry, 62(S2), S223–S229.

Liotti, G. (2012). Disorganized attachment and the therapeutic relationship with people in shattered states. In J. Yellin & K. White (Eds.), Shattered States: Disorganised Attachment and Its Repair. Taylor & Francis.

Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015). Somatic experiencing: using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology, 6, 93.

Voderholzer, U. et al. (2024). Enduring effects of psychotherapy, antidepressants and their combination for depression. Frontiers in Psychiatry, 15, 1415905.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A Practitioner’s Guide. Guilford Press.

Young, J. E., & Klosko, J. S. (1994). Reinventing Your Life. Plume. (If you’re looking for a place to begin understanding schema patterns in your own life, this is an accessible and genuinely useful starting point.)