The Psychodynamics of Depression

Depression – Psychodynamic Theory I have been interested in the mechanics of depression since childhood, when my mother ‘suffered with her nerves’ – her explanation of what I now recognise as a very severe melancholia defined by Burton in 1621 as â€Å"a kind of dotage without a fever, having for his ordinary companions fear and sadness, without any apparent occasion† (p739). My interest was further compounded by my clients, Valerie and Jo, when it become apparent to me that depression is one of the most common and debilitating phenomenon that I will probably have to encounter in my role as a Counsellor. Before beginning, it may be useful to briefly consider Freud’s warning that depression is not a homogenous group of conditions and that it probably involves more than one aetiology (Freud 1917). It can reflect underlying cultural and environmental trends in addition to physiological factors. (Desjerlais et al. 1995) A review of the literature reveals that research relating to the nature and origins of the psychodynamic theory of depression is rich in contributions to the theme, thus this essay of necessity represents a high-altitude skim over a massive topic. I will concentrate on authors who have made some of the most seminal contributions to the development of the theory, namely Abraham, Freud, Jacobson, Klein and Mahler. (There are, in actuality, numerous other pioneers in the cultivation of this theory, such as Malan, Sandler, Spiz, Bibring, Rado, Blatt, Benedek, Lindemann, Kohut, some of which, due to word limit, I have not included). Bowlby‘s theory of attachment, although not psychodynamic per se, is also considered, because the way in which people relate to loss of attachment appears relevant to our understanding of depression. Schore, who describes the neuroscience of attachment and how the brain of the parent and infant interact, has also been included The first thing we need to do is to be clear about four quite different ways that we may talk about depression. Jacobson referred to them as normal, neurotic, psychotic and grief reactions (1971 p19). What Jacobson (1971) referred to as normal depression, appears to be akin to what Klein referred to as the depressive position (Segal 1973). She, who it appears from my literature search (Klein 1940, Meltzer 1989, Spillius 1983, Money Kyle 1964), more than any other psychoanalytic pioneer viewed the infant as a miniature adult, found evidence of a â€Å"depressive position† from birth (Klein 1932 in Meltzer 1989 p37). This is essentially a state of health, a capacity to bear guilt, stay in touch with mental pain and emotional problems and bring thinking to bear on situations (Meltzer 1998). According to Klein we oscillate between our ability to stay with painful situations or seek temporary relief through splitting and projection (defence mechanisms), returning to the paranoid-schizoid position – the state of mind existing in babies ; one that is constantly returned to throughout life to greater or lesser degrees (Klein 1932 in Money Kyle 1964). Defence mechanisms are defined as tactics which the Ego develops to help deal with the ID and the Super Ego (Freud 1923). Freud introduced the term ‘ego' in â€Å"The Ego and The Id† (1923). He holds that only a portion of the mind is conscious and the rest lies hidden deep within the subconscious, ruled by conflicting forces of a super-strong libido (id) and super-controlling morality (superego) all translated through the ego, which attempts to balance the two through rationality (1923). Libido is described as the ‘energy of the sexual instincts‘ (Frued 1925). Neurotic depression or reactive depression can be understood as an exaggerated response to stress due to a weak state of ego strength combined with a failure of the external support system. Neurotic depression consists of a fall in self esteem after the ego has been abandoned by its ideal (Sandler 1965)). In modern day terminology, Jacobson's psychotic depression could be termed a severe depressive episode with psychotic symptoms (WHO 1992). Brown and Harris’ studies state that early loss appears tied to the emergence of psychotic versus neurotic symptom patterns (1986). Bowlby thought a mother-child attachment could not be broken in the first years of life without permanent and serious damage to the child’s future development (Bowlby 1973). Jacobson said there is fusion of the self and the object[1] epresentation within the ego and superego, â€Å"calling forth attack from an extremely pathological sadistic and idealised superego on a fused and highly devalued selfâ€Å" (Lund 1991, p533). The capacity for sadness is absent because the object and its representation are â€Å"devalued and united with the devalued representation of selfâ€Å" (p534). Th is appears to be evidenced by Jo who was referred for treatment of â€Å"severe anxiety and panic attacks,† and whose symptoms include extreme suspiciousness and intolerance of her peers, and delusional ideas relative to her mother. These psychotic-like symptoms could be related to the treatment she received from her mother who maltreated her and ultimately abandoned her when she was a toddler. Freud contrasted the mental processes involved in mourning with those of depression which he termed melancholia (1917); the latter could now be referred to as a severe depressive episode (WHO 1992). He regarded both mourning and depression as grief reactions to the loss of someone or something loved (1917). The distinction between the two conditions he described with the statement that in contrast to the mourner, the melancholic suffers â€Å"an extraordinary diminution in his self regard, and impoverishment of his ego on a grand scale† (1917 p 153). The explanation of this key difference appears to rest on the psychological concept of identification. Freud argued that part of the self had undergone a change in depression through its becoming identified with the lost object (1917). Object loss refers to traumatic separation from significant objects of attachment, usually mother (Bowlby 1973). In relation to the regressive identification Freud said â€Å"Thus the shadow of the object fell upon the ego†¦. † implying that the low self esteem of the melancholic is directly related to the condition of the introjected[2] object (Freud 1917 p243 ). Abraham also stressed the importance of introjection in melancholia (1911). Whereas mourning recognises the loss of an object that was â€Å"good† and â€Å"loved,† the melancholic’s relationship to the lost object is necessarily more ambivalent, i. e. a dense complex of love and hate (Klein 1940 in Money-Kyle 1998 p 142). Freud stressed the importance of heightened ambivalence in melancholia. He suggests that melancholia involves a regression to the oral narcissism phase of the libido, when an identification with the lost object occurs (1917). At the very early oral stage, described by Freud as primary narcissism ( 1914) and by Fairbairn as â€Å"mouth ego with a breast,† (1952 p87 ), the mouth feeds on the breast and is temporarily content. However, disturbances in feeding and other related irritations generate the agony of want and pains of anxiety. Consequently, fixation at the early oral phase results in the registration of a painful (bad) internal wanting and a nourishing (good) something somewhere in the vague uncharted outside of the child. Narcissism is described as an orientation towards internal objects, characterised by self-preoccupation, lack of empathy, and unconscious deficits in self-esteem (Kernburg 1969). Jo’s refusal to eat when in a severely depressed state could be viewed as her regression to oral narcissism. Freud also believed too many positive experiences during the first year of life could set an individual up for developing depression later on in life (Comer, 1992). He posited that if an individual is nurtured too much as an infant, she will not develop beyond the oral stage of development because there was never a need to. Although his theories emphasised the importance of early experience on later development, I understand from the literature it was Abraham (1911) who first made this distinction. He defined melancholia as an ambivalent feeling of love and hate toward the self that arises from an early infantile disappointment in love (1911). He too connected loss at the oral stage to maladaptive coping during subsequent losses later in life (1924). Abraham tells us that melancholic clients are inaccessible to any criticism of their mode of thinking (1924). In them can be seen the narcissistic character of thought and disregard for people who confront them with reality as in the case of Jo who missed a session following my interpretation about her eating habits. Expanding on this theme, Abraham summarised the dynamic factors underlying depression, as follows (1924): 1. A constitutional factor of an over accentuation of oral eroticism. 2. A special fixation of the libido at the oral stage. 3. A severe injury to infantile narcissism. 4. Occurrence of the primary disappointment pre-oedipal. [3] 5. Repetition of the primary disappointment in later life. These points appear to be evidenced by Valerie, my client in her late forties. Her husband died four years ago and she was referred by her GP because of â€Å"troublesome feelings of depression, isolation and lack of identityâ€Å". Her developmental history revealed that her mother had always been a source of tension, and had been severely depressed while Valerie was growing up. Valerie felt neglected and abandoned by her. She had been left with a negligent nanny after she was born and was ill with jaundice and gastro-enteritis. It took three months for the neglect to be discovered and for her to be returned home. Throughout her childhood, her mother remained predominantly in a withdrawn state in bed. However, she remained very dominating and ridiculing in manner of her daughter. In response to Valerie’s traumatic bereavement, her mother again seemed preoccupied and self-absorbed. Valerie’s opening remark to me was striking, â€Å"I want to be a calm sensible person with no feelingsâ€Å". Since her mother spent her time criticising Valerie and ridiculing her separate thinking (her mother resented Valerie’s creativity having thrown the contents of the rubbish bin on one of her prize paintings), this comment appears to represent her wish to conform to her mother's requirements. However, this statement appears to underline the central dynamic to understanding depression, for with the desire for identification with an ideal object, there appears no room for separate thinking or expression of needy feelings (Jacobson 1964). All tensions related to one’s own needs and how the idealised object is ignoring them gets projected and then experienced somatically (Abraham 1924). The lack of availability of a containing mother[4] was graphically illustrated in a dream, where Valerie went to get food from a supermarket. There was no basket and she came out, arms full of tin cans. Suddenly, her mother's sister shouted from a house window: â€Å"Where is your mother? † Valerie dropped the cans and opened her mouth to speak. It was full of blood and bits of glass. Valerie also reported to me another dream where she swallowed two â€Å"tablets of stones† that lay heavy on her stomach. This could be symbolic of the unresponsive stone breasts of her mother. Also it reminds me of the Ten Commandments, two tablets of stone not to be disobeyed (her mother). The oral origins seem apparent, with the brittleness of the breast and the aggressiveness to it. This history seems to confirm all Abraham's points. The constitutionally inherited family history of depression, her mother having a breakdown when Valerie was born; The fixation of the libido at the oral level, with the sensation of having swallowed the tablets of stone breasts when depressed and also the oral aggressiveness, with the cut glass in the mouth. The severe injury to infantile narcissism was evidenced by her mother's unresponsiveness. The first disappointment pre-oedipally, starting at birth with being left with the neglectful nanny; with the repetition of the primary disappointment in later life and with her mother's lack of support at the time of her husband’s bereavement. Valerie told me she felt ‘guilt and shame’ about ‘being depressed‘. To explain the peculiar intensity of the sense of guilt in melancholia, Freud suggested that the destructive component of the instincts had entered the superego and turned against it (1917). He also noted in some depressed people a high proneness to guilt; ‘that tendency toward self-reproach which death invariably leaves among the survivors. ’ (Freud 1925 in Stengel 1969 p 237). He pointed out the increased severity of moral judgement that occurs in depression, and described the setting up of a ‘critical agency’ as part of child development, which ‘henceforth will judge the ego’ (Freud 1923 in O'Shaughnessy 1999 p861). This is the superego and Freud suggested that â€Å"the relationship between the ego and the superego (see definition page 1) becomes completely intelligible if they are carried back to the child’s attitude towards his parentsâ€Å" (p861). The superego is coloured by the child’s own hostile and rivalrous feelings, so that ‘the more a child controls his aggression towards another, the more tyrannical does his superego subsequently become’ (p862). The self-recriminations seen clinically are recriminations made of a loved object that has been displaced (Freud 1923) as the following exchange between Valerie and myself appears to illustrate: V. Life sucks T. It sucks? V. Yeah, but then why should it be any different? I’m so ghastly and useless – I don’t deserve to be happy. When Valerie announces ‘I’m so ghastly and useless – I don’t deserve to be happy,’ she is perhaps not really criticising herself, but a purported ideal that has let her down. The self-tormenting is then a tormenting of the ideal object (mother) that had abandoned her at a time of need. The sadomasochistic process of self-criticism, that so dominates depression, goes on in a relentless fashion. No true mourning, with relinquishment of the object, can occur because of the unresolved ambivalent dependence on an ideal object (Freud 1923). Valerie’s grief at her husband’s death could be seen as an extension of her more hidden yearning for her mother’s love. Her unrealistic hopes based on compensatory exaggerations of unsatisfied wishes and needs, may have laid down a vulnerability to depressive illness because these are unsustainable in adulthood. Klein described an early ore-oedipal stage to the formation of the superego, with a very harsh superego in evidence at the oral stage, which becomes modified over time, with experiences, to becoming more benign, less demanding and more tolerant towards human frailities (Money-Kyle 1964). She comments on clinging to the pathological early severe superego as: â€Å"the idea of perfection is so compelling as it disproves the idea of disintegration† (Klein 1932 in Meltzer 1989 p270). In healthy development the superego may take on, over time, a benign guiding role, but in those with a predisposition to depression, the superego can be â€Å"a pure culture of the death instinct which often succeeds in driving the ego into death† (Freud 1917, p332). This may have been the case with Valerie’s deceased husband who was also diagnosed as depressed; she feels his death may have been suicide. It is interesting that he told her his body was â€Å"tired of livingâ€Å", perhaps suggesting that the ego was located in the body awaiting to be attacked by the superego. The ego can only kill itself if, as a result of a return to the object-cathexis, it can treat itself as an object (1917). Object cathexis occurs in the Id and is the investment of energy in the image of an object. Suicide also harbours murderous feelings towards others (Campbell & Hale 1991). Kohut viewed depression as coming from a lack of good experiences with what he termed the mirroring self-object[5], such as having interested and involved parents (1971); this results in problems with self-esteem regulation. Parkin considers that a fall in self esteem is the hallmark of ‘all simple depression’ (by this, I imagine, he means what Jacobson referred to as neurotic depression), and a heightening of self criticism to be the hallmark of melancholia (I imagine, he is referring to Freud’s theory. ) (Parkin 1976). It is the loss of self-esteem, many psychodynamic theorists claim, that starts a person down the path of depression (Comer, 1992). Jacobson stresses the crucial importance in depression of the loss of self esteem and the feelings of impoverishment, helplessness, weakness and inferiority (1971). Freud believed feelings of anger and self-hatred develop from thoughts about unresolved conflicts. As a result of feelings of self-hatred, the individual feels shameful and worthless and loses her self-esteem (Comer, 1992). Jo suffers shameful feelings about herself including taking anxiolytic medication to ‘dampen down my distress‘. She commented that her self esteem is ‘as low as my socks. ’ She lost her job as a result of her panic attacks. Gaylin (1968) reasons, if a person is depressed over the loss of a job it is not because the job symbolizes a loved object but, like a loved object, â€Å"it can symbolize one's self-esteem† (p. 7). Klein said that whether an individual loses her self-esteem depends on the quality of her relationship as an infant with her caregiver during the first year of life (Wetzel 1984). She claimed the Oedipus Complex to be a part of the depressive position, occurring at the oral stage of development (Segal, 1984). Her work was criticized, especially by Anna Freud, but the significance of her theory appears to be that, if individuals have not had the early experiences that enable them to internalise a good object, then mourning as adults will be complicated by significant depression (Wetzel 1984). Klein's interpretation to the origin of depression closely resembles that of Abraham and Freud's theories that an individual can develop a predisposition for the illness, but her contributions appear to have been criticised on the grounds of seeking to establish an exact parallel between the child’s developmental stages and adult depressive illness (Spillius 1983). I understand from the literature that most psychoanalysts accept infantile precursors to depressive illness but stop short of Klein’s view. Mahler acknowledged that the mother-child relationship is crucial in the development of basic moods, including depression (1966). However, in contrast to Klein, she believed the depressive position does not occur at the oral stage, but later in toddler-hood, during the separation-individuation period[6] (1966). More recently other authors have been trying to differentiate two types of depression basing themselves in part on the writings of Freud on the processes of oral incorporation and superego formation, and considering that it would not be fruitful to integrate these two mechanisms from such distinct phases of psychic development (Spitz 1947 p 723). Blatt subsequently conceptualised depression in accordance with the child’s level of object representations and made the distinction between anaclitic depression and introjective depression. Anaclitic is oral where there is relatively low evidence of guilt. Introjective depression is more oedipal based where the sufferer may harbour intense feelings of guilt because the superego is overly harsh (Blatt 1974). Bowlby thought depression resulted from a failure of secure attachment early in life (1973). He described a series of attachment and protest behaviours which, if not responded to, would proceed to a state of despair in infants and finally to states of detachment. This work has burgeoned into the field now known as attachment research. To summarize this extensive body of research very briefly, we now know the attachment that the child establishes with the caregiver during development may be the prototype for all subsequent bonds with other objects (1973). The capacity to develop close and loving relationships in adulthood protects against depression and this is influenced by the attachment patterns developed in childhood. Anxiously attached individuals seek interpersonal contact and are excessively dependant on others. Compulsively self-reliant individuals are excessively autonomous and avoid close intimate interpersonal relationships (1973). Both of these preoccupations can create a vulnerability to depression. In agreement with Klein, Bowlby suggests that anger and guilt are part of mourning reactions. It is not the presence of anger or guilt that is pathological in mourning but their appropriateness that is the crucial issue (1969). Schore describes the neuroscience of attachment and how the brain of the parent and infant interact (2003 ). He speaks in depth about the neurobiology of the developing mind during the first three years of life and how the right brain processes are integrally involved in attachments and the development of the self. He spells out very clearly how insensitive parenting leads to emotion dysregulation patterns in childhood and later in adulthood. He understands insecure attachment as emotion dysregulation and that psychotherapy is the process of changing neural patterns in the brain, the right brain in particular. There are clear points of contact between the attachment perspective and some psychodynamic ideas. As mentioned, one of Klein’s hypotheses was that the reaction to loss occurring later in the life cycle will be influenced by revived aspects of losses experienced at the earliest stages in development (Segal 1973). The early loss of the maternal object may result in depression later in life if the infant has not yet been able to establish a representation of a loved object securely within herself (Segal 1973). There appear to be clear parallels between this formulation and the idea of maladaptive internal working models of attachment in Bowlby’s thinking about early loss and depression. Evaluation Each of the theories probably has a contribution to make to the overall picture especially when we recollect that depression is a complex rather than a unitary phenomenon (Freud 1917). Common to all these theories is their invoking of the crucial role of the infantile phase of development. Each of them asserts that problems in the trajectory to eventual adulthood commence in early childhood and can constitute a vulnerability to depression. Following my research, I am hopefully better placed to help my clients. For instance during our sessions Valerie is able to reflect how her deceased husband had provided her with an experience of being loved and cared for that she had longed for from her mother. Working through unresolved feelings of loss arising from initial losses and disentangling them from feelings related to present losses may be invaluable in the resolution of her depression As for Jo, we have spent considerable time exploring her panic attacks and her fear of expressing her depressive feelings. She fears that ‘If I start crying, I may never stop’ and that nobody will be able to bear her pain. This links with Bion’s concept of containment (Bion 1962) as defined on page 5. If I can contain her pain and grief then this may help Jo internalise a sense that her pain can be borne and thought about. Finally, I am reminded that my own experiences of depression can either interfere with or enhance my capacity to help. Self reflection and supervision are crucial if I am to make the best use of my humanity. REFERENCES ICD-10. Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines: World Health Organization, 1992. Abraham K. 1911-1968)Selected papers of Karl Abraham. New York: Basic Books Inc. Bion WR. (1962)Learning from Experience. London: Karnac. 97. Blatt S. (1974). Levels of object representation in anaclitic and introjective depression. The Psychoanalytic Study of the Child, 29, 107-157. Bowlby, J. (1969). Attachment and loss, Vol. 1: Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation -anxiety and anger. New York: Basic Books Brown & Harris (1986). Life events and illness. New York: The Guilford Press. Burton R. (1920)Anatomy of Melancholy. New York: Tudor Campbell & Hale (1991). Suicidal acts. In J. Holmes (Ed. ), Textbook of psychotherapy in psychiatric practice (pp. 287-306). Comer R. (1992). Abnormal psychology. New York: W. H. Freeman & Company Desjerlais et al (1995) World Mental Health: Problems and Priorities in Low-Income Countries. London: Oxford University Press. Fairbairn W. (1952)Psychoanalytic Studies of the Personality. London: Routledge Freud S. (1917). Mourning and melancholia. In J. Strachey (Ed. ), The standard edition of the complete psychological works of Sigmund Freud London: Hogarth Press Freud S. (1914). On Narcisism. The standard edition of the complete psychological works of Sigmund Freud V. 14. London: Hogarth Press Freud S. (1923/1960). The ego and the id. J. Riviere (Trans. ), J. Strachey (Ed. ). New York: W. W. Norton. Freud S. (1914). Beyond the Pleasure Principle. The standard edition of the complete psychological works of Sigmund Freud V. 14. London: Hogarth Press Freud S. (1925)(trans. J. Riviere) Collected Papers. Vol. I. , London: Hogarth. Jacobson, E. (1964) The Self and the Object World. New York, International Universities Press Jacobson E. 1971)Depression: Comparative Studies of Normal, Neurotic & Psychotic Conditions. New York: International Universities Press Kernberg O, (1969)A contribution to the Ego-psychological critique of the Kleinian school. Int J Psychoanal 50: 317 – 33 Klein M. (1940). Writings of Melanie Klein. London: Hogarth. Vol. 1. p344-369. Klein M. (1932). The psycho-analysis of children. London: Hogarth Press. Roger Money-Kyl e The Writings of Melanie Klein. (Ed. ). 4 Vols. New York, Free (1964-75)Press. Kohut H. (1971)The Analysis of the Self. New York, International Universities Press Lund C (1991)Psychotic depression: psychoanalytic psychopathology in relation to treatment and management, B J Psychiatry 158: 523 – 8 Mahler M. (1966). Some preliminary notes on the development of basic moods, including depression. Canadian Psychiatric Association Journal, 250-258. Meltzer, D. (1998)The Kleinian Development (New Edition). London: Karnac Books O'Shaughnessy E. (1999)Relating to the Superego. Int. J. Psychoanal; 80, p861-870. Parkin A (1976)Melancholia: A reconsideration, J Am Psychoanalytical Assoc. 24: 123 – 39 Parkes C. 1972) Bereavement: Studies of grief in adult life. New York: International Universities Press. Rubin R 1989Neuroendocrine aspects of primary endogenous depressiion VIII. Psychoneuroendocrinology; 14(3):217–29. Sandler J (1965)Notes on childhood depression. Int J Psychoanal 46: 88 – 96 Schore A (2003)Affect Regulation and The Repair of the Self New York: WW Norton & Co, Inc. Segal H. (1973)Introduction to the work of Melan ie Klein. London: Hogarth Press. Spitz R. (1946) Anaclitic depression: An inquiry into the genesis of psychiatric conditions in early childhood II. Psychoanalytical Study of the Child, 2, 53. Spillius, E. (1983). Some developments from the work of Melanie Klein. , Int. J. Psychoanal. , 64:321-332. Stengel E (1969). Suicide and Attempted Suicide. Harmondsworth: Pelican Books. Wetzel, J. W. (1984). Clinical handbook of depression. New York: Gardner Press. ———————– [1]Objects are primarily formed from early interactions with (usually) parents. (Klein 1940) [2] introjection means to incorporate (characteristics of a person or object) into one’s own psychic unconsciously (Klein 1940). 3] Oedipal can be described as unconscious sexual desire in a child, especially a male child, for the parent of the opposite sex, usually occurring around the age of 3 – 5 years and accompanied by hostility to the parent of the same sex. Pre-oedipal means prior to the oedipal phase in development (Freud 1923). [4] containing mother refers to the process whereby the infant’s emo tions can be held in mind and ‘digested’ by the mother, who can then return them in a more manageable form. Infants need repeated experiences of containment (Bion 1962), in order to develop ways of dealing with their own distress, i. . before they can introject the containing ‘good enough mother’ (Winnicott 1960a) and feel the mother as a definite internalized presence (Bion 1962). [5] â€Å"mirroring self object† is loosely translated as â€Å"mother,† for in the external world it is most often the mother who performs the function. The gleam in her eye mirrors the infant’s self. (Bion 1962). [6] Mahler described separation-individuation as the steps through which the infant passes in developing a more stable awareness of separateness from the mother (1966).