Treatment-Resistant Depression
Sofia, 38, software engineer
Presentation
Four years of persistent depression unresponsive to two SSRIs, one SNRI, and 16 sessions of CBT. Functional but describes life as 'gray.' Sleep disrupted, anhedonia, loss of creative interests. Says: 'I've done everything right — therapy, meds, exercise. Nothing reaches wherever this lives.'
History
No trauma history she identifies. Loving family, stable career. First depressive episode at 24. Meditation retreat at 30 was the only time she felt 'something break through.' Interested in psychedelic-assisted therapy after reading about psilocybin research. Physician supportive.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Sofia's depression may not be a disorder at all. It may be lucidity. She has seen through the automated meanings that sustain most people — career, achievement, routine — and found them insufficient. The grayness she describes is the absurd: the confrontation between the human need for meaning and the world's silence. Camus would not try to restore the meanings that failed her. He would ask whether she can live without them — whether she can face the absurd and still choose engagement, pleasure, rebellion against the terms of existence. The question is not 'How do we make the gray go away?' but 'Can you live fully in a world that doesn't answer back?'
Weil would recognize Sofia's state as affliction (malheur) — not ordinary suffering but the condition in which suffering has destroyed the sufferer's capacity to want anything, including recovery. Affliction is characterized by social degradation, physical suffering, and a sense of being crushed by impersonal force. The danger is not the depression itself but the spiritual temptation to fill the void with false consolation. Weil would say the therapeutic task is radical attention — learning to wait in the emptiness without grasping, because genuine transformation requires the soul to be bare. This is the opposite of problem-solving.
Sofia is not sick. She is exhausted — by the achievement society that has replaced external discipline with internal compulsion. She is both the exploiter and the exploited, driving herself to perform while experiencing the failure of performance as personal inadequacy. Her depression is not the absence of meaning but the burnout of a subject who has internalized the imperative to optimize. The 'grayness' is what remains when the capacity for contemplation, rest, and genuine experience has been consumed by productivity. Therapy that aims to restore her 'functioning' simply returns her to the system that broke her.
7 Formulations
Select 2–3 modalities to compare side by side:
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.