Depression and Self-Criticism

Like many other humans, I’ve felt depressed at times. But my periods of depression have had markedly different flavors: grieving a romantic relationship, “hitting the wall” during COVID, and experiencing intense self-criticism during my adolescent years.

Depression is diverse. Different causes and symptoms may respond best to particular treatment approaches..

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In my own experience, the depression characterized by self-criticism was the most painful and challenging to work through. Whereas other feelings of depression were tied to external events and seemed to abate over time, the self-criticism that I experienced during my teens and 20s seemed pervasive and intractable. It felt like who I was, rather than something I was going through.

As I studied depression in graduate school, I became more and more convinced that a “one size fits all” treatment strategy was insufficient. I’m now a clinical psychologist treating adults with a range of mental health stressors and symptoms, and I’ve become very curious about different kinds of depression—not only in terms of the severity or timing of the symptoms—but also with respect to the felt substance of the depression and the ingredients that promote recovery.

For instance, for individuals who become depressed after trauma, it’s often helpful to provide psychotherapy that addresses the impact of the trauma rather than interventions that focus on the depression alone. Similarly, racism impacts both depression and mental health treatment. Grief may look similar to depression on the surface, but because grief’s course and prognosis diverge from those of depression, it’s helpful if health providers understand the differences between them.

Depressed people with high levels of self-criticism often respond differently to treatment than do other patients. For instance, patients with greater self-criticism can show fewer benefits from cognitive therapy than patients with less self-criticism. To a self-critical patient, cognitive interventions might come across as, “You’re depressed because your thoughts are unhealthy. You’re not even good at thinking—that’s another thing that’s wrong with you, and it’s your own fault you’re depressed. You don’t even know how to think as well as I do.”

The evidence shows that compassionate mind training and lovingkindness meditation are effective ways to reduce self-criticism and related distress. Instead of trying to convince patients to suppress self-critical thoughts, these approaches involve generating kindness. This process seems to work by activating brain regions involved in emotional processing and empathy. I discuss these and other evidence-based strategies to reduce self-criticism in my new book, The Self-Talk Workout.

When a patient comes to therapy and describes symptoms of depression, I try to understand the factors that have contributed to the depression, as well as the specific symptoms of depression that the person is experiencing. I find that the Beck Depression Inventory-II (BDI-II) self-report measure helps this process, because it separates the physical symptoms of depression (such as changes in appetite and energy) from depression symptoms that involve negative thoughts and emotions, including self-criticism.

When patients indicate self-criticism, I explain that self-criticism is often a learned behavior, rather than an innate personality characteristic. For instance, childhood abuse, bullying, racial discrimination, and homophobia each significantly contribute to self-criticism. In those and in other cases, self-criticism reflects the absorption of others’ mistreatment, rather than a personality trait. I also communicate that self-criticism is a powerful mental habit, but that there is solid evidence that it’s a habit that can be changed.

Studies show that disparate dimensions of depression differently impact physical health and therapy treatment responses. Research investigating specific types of items within the BDI-II indicate that the questionnaire items about self-criticism seem to group together into their own “sub-dimension” of depression.

Of course, sometimes people become self-critical about other depression symptoms (“What’s wrong with me? Why can’t I feel better or just snap out of it?”), so I’m also interested to know about the progression of symptom development. The evidence shows that when self-criticism is present, dissolving self-criticism meaningfully lowers levels of depression. In research involving over 500 participants with a range of depression symptoms, reducing self-criticism emerged as the strongest predictor of improvement.

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When treating depression, I also take patients’ personal preferences into account, as providing patients with choices aligns with ethical principles and can also enhance patient engagement. I let patients know that because many treatments have been shown to help depression, they can consider whether one or more of the following evidence-based interventions sounds appealing: psychotherapy, mindfulness meditation, self-compassion, physical exercise, expanding social support, or behavioral activation (engaging in planned activities).

Prominent self-criticism isn’t limited to depression, but also influences anxiety, eating disorders, addictions, social phobia, and posttraumatic stress. Now that I have my antennae up for the role of self-criticism across mental health conditions, I make sure to look out for self-criticism whenever patients show it, and to explain the evidence-based approaches that can reduce self-criticism.

In coping with my own self-criticism, it’s helped me to read some of the many research studies about the factors that can lead to self-criticism. This reading helped me view my self-criticism as a normal consequence of what I’d experienced, rather than just another bad thing about me. However, loving-kindness meditation offered another kind of resolution to my self-criticism. It helped me establish a felt sense of inner compassion. It also provided a specific technique that I could use to quit the habit of self-criticism and to develop a new habit of relating to myself in a kind, understanding, and nonjudgmental way.

Depression is complicated. Because people with depression often have different kinds of symptoms at the same time, several types of treatment approaches may be helpful. It's always important to assess thoughts about self-harm or suicide and to prioritize safety planning if such thoughts are present. For physical symptoms of depression, I often recommend behavioral activation; for self-criticism, I recommend mental exercises to change the habit of self-criticism.

In writing about self-critical depression, I’m not trying to suggest that depression with self-criticism should become a separate diagnosis. Rather, I hope that people with depression and health providers can become increasingly informed and empowered to treat diverse depression experiences, including those with a substantial self-critical component, with the most effective approaches available.

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