The Psychodynamics of Depression

Depression Psychodynamic Theory I have been interested in the mechanics of depressive disorder since childhood, when my m different suffered with her steel her explanation of what I now recognise as a genuinely severe melancholia defined by Burton in 1621 as a kind of senility without a fever, having for his ordinary companions fear and sadness, without any app atomic number 18nt occasion (p739). My interest was further compounded by my clients, Valerie and Jo, when it become app atomic number 18nt to me that depression is one of the near common and debilitating phenomenon that I w consumptive probably have to encounter in my role as a Counsellor.Before beginning, it may be multipurpose to briefly consider Freuds warning that depression is not a homogenous group of conditions and that it probably involves more than one aetiology (Freud 1917). It can forge underlying cultural and environmental trends in addition to physiological factors. (Desjerlais et al. 1995) A review of t he literature reveals that re look relating to the nature and origins of the psychodynamic theory of depression is rich in contri yetions to the theme, thus this essay of necessity represents a high-altitude skim over a massive topic.I allow concentrate on authors who have make whatsoever of the most seminal contributions to the ontogenesis of the theory, namely Abraham, Freud, Jacobson, Klein and Mahler. ( in that respect 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). Bowlbys theory of bail bond, although not psychodynamic per se, is also considered, because the way in which people relate to liberation of appurtenance appears relevant to our agreement of depression.Schore, who describes the neuroscience of adherence and how the brain of the parent and child interact, has also been included The first thing we n eed to do is to be clear about four quite diametrical ways that we may talk about depression. Jacobson referred to them as normal, neurotic, psychotic and tribulation 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, currency Kyle 1964), more than any other psychoanalytic pioneer viewed the infant as a miniature boastful, found evidence of a depressive position from stemma (Klein 1932 in Meltzer 1989 p37). This is essentially a state of health, a capacity to bear offense, stay in touch with mental pain and emotional problems and bring thought to bear on situations (Meltzer 1998).According to Klein we oscillate between our ability to stay with painful situations or seek temporary relief finished splitting and ejection (defence mechanisms), returning to the paranoid-schizoid pos ition the state of sense existing in babies one that is constantly returned to throughout lifetime history 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 The Ego and The Id (1923).He holds that just now 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 unders withald as an exaggerated response to stress due to a weak state of ego strength combined with a failure of the remote support system.Neurotic depression consists of a fall in self hatch after the ego h as been abandoned by its ideal (Sandler 1965)). In current day terminology, Jacobsons psychotic depression could be termed a severe depressive episode with psychotic symptoms (WHO 1992). Brown and Harris studies state that proterozoic 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 violate to the childs future reading (Bowlby 1973). Jacobson said there is fusion of the self and the disapprove1 epresentation within the ego and superego, calling forth attack from an extremely pathologic sadistic and idealised superego on a fused and highly debauched self (Lund 1991, p533). The capacity for sadness is absent because the heading and its representation are devalued and united with the devalued representation of self (p534). This appears to be evidenced by Jo who was referred for treatment of severe anxiety and panic attacks , and whose symptoms include extreme suspiciousness and superstition 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 grief 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 love (1917).The distinction between the two conditions he described with the statement that in contrast to the mourner, the melancholic suffers an extraordinary decline 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 spark off of the self had undergone a c hange in depression through its be advance identified with the lost target area (1917). Object loss refers to traumatic separation from significant intents of attachment, usually mother (Bowlby 1973).In relation to the regressive identification Freud said Thus the shadow of the object fell upon the ego. implying that the pathetic self esteem of the melancholic is directly related to the condition of the introjected2 object (Freud 1917 p243 ). Abraham also accentuate the importance of introjection in melancholia (1911). Whereas mourning recognises the loss of an object that was darling and loved, the melancholics 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 t he very early oral phase, described by Freud as primary narcissism ( 1914) and by Fairbairn as verbalise 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 regard and pains of anxiety.Consequently, fixation at the early oral phase results in the adjustment 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 course towards internal objects, characterised by self-preoccupation, lack of empathy, and unconscious deficits in self-pride (Kernburg 1969). Jos 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 subsequent 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 festering because there was never a need to. Although his theories emphasised the importance of early experience on later on 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 globe 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. accompaniment 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 married man died four years ago and she was referred by her GP because of troublesome feelings of depression, isolation and lack of identity.Her developmental history revealed that her mother had always been a line of descent 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 i n bed. However, she remained very dominating and ridiculing in manner of her daughter.In response to Valeries traumatic bereavement, her mother again seemed preoccupied and self-absorbed. Valeries opening remark to me was striking, I want to be a calm sensible person with no feelings. Since her mother spent her time criticising Valerie and ridiculing her separate thinking (her mother resented Valeries 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 mothers 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 ones own needs and how the idealised object is ignoring them gets projected and then experienced somatically (Abraham 1924). The lack of availabilit y of a containing mother4 was graphically expatiated in a dream, where Valerie went to get nourishment from a supermarket.There was no basket and she came out, arms full of tin cans. Suddenly, her mothers sister shouted from a house window Where is your mother? Valerie dropped the cans and opened her mouth to speak. It was full of blood and bits of churl. Valerie also reported to me another dream where she swallowed two tablets of stones that lay heavy on her stomach. This could be symbolic of the unresponsive stone breasts of her mother. as well 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 Abrahams points. The constitutionally inherit 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 t he 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 mothers unresponsiveness.The first disappointment pre-oedipally, starting at birth with being left with the tatterdemalion nanny with the repetition of the primary disappointment in later life and with her mothers lack of support at the time of her conserves 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 settin g up of a critical agency as part of child development, which henceforth will judge the ego (Freud 1923 in OShaughnessy 1999 p861).This is the superego and Freud suggested that the relationship between the ego and the superego (see definition page 1) becomes completely intelligible if they are carried lynchpin to the childs attitude towards his parents (p861). The superego is coloured by the childs own hostile and rivalrous feelings, so that the more a child controls his intrusion 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 illustrateV. Life sucks T. It sucks? V. Yeah, but then why should it be any different? Im so ghastly and useless I dont deserve to be happy. When Valerie announces Im so ghastly and useless I dont deserve to be happy, she is perhaps not real ly 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). Valeries grief at her husbands death could be seen as an extension of her more hidden yearning for her mothers love. Her impossible 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 charitable towar ds human frailities (Money-Kyle 1964). She comments on clinging to the pathological early severe superego as 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 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 Valeries 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 tired of living, 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 objec t. 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-object5, 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 assay-mark 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 Freuds 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 meditate 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, it can symbolize ones 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, oddly by Anna Freud, but the significance of her theory appears to be that, if individuals have not had the early ex periences that enable them to impute a good object, then mourning as adults will be complicated by significant depression (Wetzel 1984).Kleins interpretation to the origin of depression closely resembles that of Abraham and Freuds 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 childs 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 Kleins 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 period6 (1966). More recently other authors have been trying t o 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 generative to integrate these two mechanisms from such distinct phases of psychic development (Spitz 1947 p 723).Blatt subsequently conceptualised depression in accordance with the childs 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 sick person 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 playing area 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 overly 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 refine 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 Kleins 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 th e 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 Bowlbys 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 fr om 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 substantial 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 cerebrate with Bions 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 stir 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. 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(1952)Psychoanalytic Studies of the Personality. Lon don Routledge Freud S. (1917). Mourning and melancholia. In J. Strachey (Ed. ), The standard edition of the complete psychological works of Sigmund Freud London Hogarth PressFreud 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) calm 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. 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New York Gardner Press. 1Objects are primarily formed from early interactions with (usually) parents. (Klein 1940) 2 introjection means to incorporate (characteristics of a person or object) into ones 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 opposition 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 infants emotions 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 relations 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 mirroring self object is loosely translated as mother, for in the external world it is most often the mother who performs the function. The gleam in her eye mirrors the infants self. (Bion 1962). 6 Mahler described separation-individuation as the steps through which the infan t passes in developing a more stable awareness of separateness from the mother (1966).