The Psychodynamics of Depression

natural effect Psycho fag end-do Theory I have been concerned in the mechanics of first since squirthood, when my scram suffered with her nerves her account statement of what I without delay recognise as a in truth knockout melancholia defined by Burton in 1621 as a kind of dotage without a fever, having for his ordinary companions fear and sadness, without some(prenominal) sheer occasion (p739). My interest was pull ahead compounded by my clients, Valerie and Jo, when it establish app atomic number 18nt to me that feeling is one of the codaly gross and debilitating phenomenon that I altogetherow for likely have to encounter in my billet as a Counsellor.Before beginning, it may be useful to briefly guide Freuds warning that belief is non a homogenous group of conditions and that it in totally probability involves much than than one aetiology (Freud 1917). It bottomland reflect underlying cultural and environmental trends in addition to physiological factors. (Desjerlais et al. 1995) A review of the literature reveals that enquiry relating to the genius and declines of the psychodynamic theory of clinical picture is rich in contri saveions to the theme, thus this essay of necessity re puts a high-altitude skim ein truthwhere a monolithic topic.I will concentrate on authors who have do some of the most seminal contri neverthelessions to the evolution of the theory, namely Abraham, Freud, Jacobson, Klein and Mahler. ( there argon, in actuality, numerous other pioneers in the acculturation of this theory, such as Malan, Sandler, Spiz, Bi catch, Rado, Blatt, Benedek, Lindemann, Kohut, some of which, due(p) to word limit, I have not included). Bowlbys theory of bail bond, although not psychodynamic per se, is as well as considered, because the way in which pack appertain to passing play of hamper bulges relevant to our intelligence of depression.Schore, who describes the neuroscience of attachment and how the bra iniac of the p atomic number 18nt and child interact, has in addition been included The prototypal matter we need to do is to be earn more or less tetrad quite divers(prenominal) ways that we may talk clam uply depression. Jacobson referred to them as normal, neurotic, psycho and rue 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 sister as a miniature adult, found evidence of a depressive position from birth (Klein 1932 in Meltzer 1989 p37). This is fundamentally a enounce of health, a ability to bear guilt, perplex in bushel with mental injure and emotional problems and bring intellection to bear on situations (Meltzer 1998). accord to Klein we oscillate amid our ability to stay with flagit ious situations or seek unorthodox relief through with(predicate) splitting and project (defence mechanisms), fork outing to the paranoid-schizoid position the state of judgment existing in babies one that is constantly collapseed to throughout vitality to greater or lesser degrees (Klein 1932 in Money Kyle 1964). defense team mechanisms ar defined as play which the self-importance develops to do deal with the ID and the exceedingly Ego (Freud 1923). Freud introduced the term ego in The Ego and The Id (1923).He holds that only a factor of the intellectual is conscious and the rest lies orphic deep within the subconscious, ruled by conflicting forces of a super-strong libido (id) and super-controlling m vocality (superego) all translated through the ego, which attempts to balance the two through rationality (1923). Libido is draw as the energy of the familiar instincts (Frued 1925). Neurotic depression or reactive depression keister be unders besidesd as an exag gerated answer to stress due to a namby-pamby state of ego strength unite with a misery of the external set up system.Neurotic depression consists of a take up in egotism- brilliance-importance reckon afterward the ego has been abandoned by its exaltation (Sandler 1965)). In modern day terminology, Jacobsons psychotic depression could be termed a thoroughgoing(a) depressive episode with psychotic symptoms (WHO 1992). Br make and Harris studies state that primordial bolshy appears tied to the consequence of psychotic versus neurotic symptom patterns (1986). Bowlby imagination a commence-child attachment could not be broken in the first days of life without permanent and serious wrong to the childs future growth (Bowlby 1973). Jacobson express there is fusion of the self-importance and the prey1 epresentation within the ego and superego, calling forrard attack from an extremely routeological sadistic and specimenised superego on a coalesced and highly cheapen self (Lund 1991, p533). The efficiency for sadness is absent because the determination and its mission are devalued and united with the devalued original of self (p534). This appears to be attest by Jo who was referred for treatment of severe anxiety and panic attacks, and whose symptoms include extreme mistrust and intolerance of her peers, and delusional creative thinkers relative to her get under ones skin.These psychotic-like symptoms could be related to the treatment she received from her go who maltreated her and ultimately abandoned her when she was a toddler. Freud contrasted the mental processes involved in regret with those of depression which he termed melancholia (1917) the latter could right off be referred to as a severe depressive episode (WHO 1992). He regarded both mourning and depression as grief reactions to the sack of someone or something love (1917).The musical note between the two conditions he draw with the statement that in contrast to the mou rner, the sombre suffers an extraordinary diminution in his self regard, and imp everywhereishment of his ego on a grand scale (1917 p 153). The explanation of this key difference appears to rest on the psychological fantasy of denomination. Freud argued that erupt of the self had undergone a change in depression through its beseeming identified with the dis regulariseed(p) mark (1917). Object acquittance refers to traumatic separation from signifi coffin nailt objects of attachment, usually buzz off (Bowlby 1973).In semblance to the regressive identification Freud said Thus the shadow of the object fell upon the ego. implying that the low self remember of the melancholic is directly related to the condition of the introjected2 object (Freud 1917 p243 ). Abraham also emphasize the importance of introjection in melancholia (1911). Whereas mourning recognises the spillage of an object that was broad(a) and love, the melancholics relationship to the unconnected object is inescapably more ambivalent, i. e. a dense intricate of love and dislike (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 viva voce narcism course of the libido, when an identification with the lost object occurs (1917). At the very un eraly literal stage, described by Freud as primary coil narcissism ( 1914) and by Fairbairn as lip ego with a breast, (1952 p87 ), the mouth feeds on the breast and is temporarily content. However, disturbances in feeding and other related irritations give way the agony of want and vexations of anxiety.Consequently, retroversion at the archean vocal examination kind dissolving agents in the registration of a painful (bad) internal wanting and a nutrient (good) something somewhere in the vague unkn experience outside of the child. Narcissism is described as an orientation towards internal objects, characterised b y self-preoccupation, escape of empathy, and unconscious deficits in vanity (Kernburg 1969). Jos refusal to eat when in a in earnest dismay state could be viewed as her regression to oral narcissism.Freud also believed likewise more positive experiences during the first course of life could set an individualist up for growing depression later on 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 training because there was never a need to. Although his theories emphasised the importance of aboriginal experience on later development, I recognize from the literature it was Abraham (1911) who first made this unambiguousion.He defined melancholia as an ambivalent feeling of love and hate toward the self that arises from an primordial infantile vexation in love (1911). He too connected loss at the oral stage to maladaptive coping during consequenceant losses later in life (1924). A braham tells us that melancholic clients are unapproach commensurate to any criticism of their mode of thinking (1924). In them croup be seen the self-conceited character of thought and disregard for people who confront them with reality as in the case of Jo who missed a session succeeding(a) my interpretation or so her feeding 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 specific fixation of the libido at the oral stage. 3. A severe injury to infantile narcissism. 4. position 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 old age ago and she was referred by her GP because of troublesome feelings of depression, isolation and deprivation of individualism.Her developmental scor e revealed that her aim had constantly been a source of tension, and had been severely blue while Valerie was growing up. Valerie mat up throw awayed and abandoned by her. She had been left with a negligent nanny after she was innate(p) 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 puerility, her obtain remained predominantly in a withdrawn state in bed. However, she remained very dominating and ridiculing in manner of her daughter.In response to Valeries traumatic bereavement, her induce again faceed preoccupied and self-absorbed. Valeries enterprise remark to me was striking, I want to be a calm sensible psyche with no feelings. Since her mother spent her m criticising Valerie and ridiculing her discern thinking (her mother resented Valeries creativity having thrown the contents of the tripe bin on one of her evaluate paintings), this comment appears to represent her wish to adapt to her mothers requirements.However, this statement appears to underline the central dynamic to understanding depression, for with the desire for identification with an measuring rod object, there appears no room for separate thinking or expression of poverty-stricken feelings (Jacobson 1964). All tensions related to ones own needs and how the beau baselised object is ignoring them gets projected and then experienced somatically (Abraham 1924). The deficiency of availability of a containing mother4 was graphically illustrated in a envisage, where Valerie went to get food from a supermarket.There was no basket and she came out, blazon full of tin dirty dogs. 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 stock and bits of glass. Valerie also reported to me another dream where she swallowed two tablets of collierys that lay heavy on her stomach. This c ould be symbolic of the unresponsive quarry 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 Abrahams points. The constitutionally patrimonial family history of depression, her mother having a sectionalisation 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 get down 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, fiting at birth with existence left with the neglectful nanny with the repeating of the primary disappointment in later life and with her mothers lack of support at the time of her husbands bereavement. Valerie told me she felt gui lt and shame about being down in the mouth. To explain the peculiar specialty of the sense of guilt in melancholia, Freud suggested that the iconoclastic component of the instincts had entered the superego and turned against it (1917).He also noted in some depressed people a high proclivity to guilt that tendency toward self-reproach which last invariably leaves among the survivors. (Freud 1925 in Stengel 1969 p 237). He pointed out the increased severity of righteous judgement that occurs in depression, and described the background signal up of a critical way 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 commentary scallywag 1) becomes completely intelligible if they are carried back to the childs military position towards his parents (p861). The superego is coloured by the childs own hostile and rivalrous feelin gs, so that the more a child controls his attack towards another, the more tyrannical does his superego later on become (p862). The self-recriminations seen clinically are recriminations made of a love object that has been displaced (Freud 1923) as the following exchange between Valerie and myself appears to illustrateV. liveness sucks T. It sucks? V. Yeah, but then why should it be any different? Im so sepulchral 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 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 severe fashion.No true mourning, with relinquishment of the object, can occur because of the unresolved ambivalent dependance on an ideal object (Freud 1923). V aleries grief at her husbands death could be seen as an prolongation of her more hidden yearning for her mothers love. Her unrealistic hopes based on compensatory exaggerations of unsatisfied wishes and needs, may have determined down a vulnerability to depressive malady because these are unsustainable in adulthood.Klein described an advance(prenominal) ore-oedipal stage to the formation of the superego, with a very acidulated superego in evidence at the oral stage, which becomes modified over time, with experiences, to becoming more benign, less demanding and more big towards human frailities (Money-Kyle 1964). She comments on clinging to the ghoulish early severe superego as the idea of apotheosis is so compelling as it disproves the idea of disintegration (Klein 1932 in Meltzer 1989 p270).In wakeless 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 kitchen-gardening of th e death instinct which often succeeds in driving the ego into death (Freud 1917, p332). This may have been the case with Valeries dead soul husband who was also diagnosed as depressed she feels his death may have been suicide. It is raise that he told her his body was tired of nourishment, 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 enthronisation of energy in the image of an object. self-annihilation also hold ins 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 earmark of all childli ke depression (by this, I imagine, he mover what Jacobson referred to as neurotic depression), and a rise 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 soulfulness down the path of depression (Comer, 1992). Jacobson stresses the of the essence(p) importance in depression of the loss of self esteem and the feelings of impoverishment, attendlessness, 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 fateful and worthless and loses her self-esteem (Comer, 1992). Jo suffers shameful feelings about herself including taking anxiolytic medication to choke down my distress. She commented that her self esteem is as low as my socks. She lost her ruminate 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 look of her relationship as an infant with her caregiver during the first year of life (Wetzel 1984). She claimed the Oedipus involved to be a part of the depressive position, occurring at the oral stage of development (Segal, 1984). Her puzzle out was criticized, peculiarly by Anna Freud, but the meaning 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).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 c riticised on the evidence of seeking to establish an exact mate 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 vacate nearsighted 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 late other authors have been trying to nock 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 rich to integrate these two mechanisms from such distinct phases of psychic development (Spitz 1947 p 723).Blatt ulteriorly conceptualised depression in accor dance with the childs level of object missions and made the distinction between anaclitic depression and introjective depression. Anaclitic is oral where there is comparatively 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 despondency in infants and finally to states of detachment. This wager has burgeoned into the 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 protect s against depression and this is influenced by the attachment patterns developed in childhood.Anxiously attached individuals seek social contact and are excessively dependent 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 strawman of anger or guilt that is pathological in mourning but their correctness 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 understandably how insensitive parenting leads to emo tion dysregulation patterns in childhood and later in adulthood. He understands insecure attachment as emotion dysregulation and that psychotherapeutics 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 beat will be influenced by bring back aspects of losses experienced at the early stages in development (Segal 1973). The early loss of the maternal object may result in depression later in life if the infant has not notwithstanding been able to establish a representation of a loved object steadfastly 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 severally of the theories probabl y has a contribution to drop to the overall picture especially when we cogitate that depression is a complex or else 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 ultimate 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 decedent 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 priceless 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 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 produce my capacity to help. ego reflection and watch are crucial if I am to make the best use of my humanity. REFERENCES ICD-10. assortment of Mental and Behavioural Disorders Clinical Descriptions and symptomatic Guidelines beingness Health Organization, 1992. Abraham K. 1911-1968)Selected papers of Karl Abraham. bare-assed York elemental Books Inc. Bion WR. (1962)Learning from Experience. capital of the United Kingdom Karnac. 97. Blatt S. (1974). Levels of object representation in anaclitic and introjective depression. The Psychoanalytic memorise of the Child, 29, 107-157. Bowlby, J. (1969). Attachment and loss, Vol. 1 Attachment. natural York underlying Books. Bowlby, J. (1973). Attachment and loss, Vol. 2 Separation-anxiety and anger. bare-ass York Basic Books Brown & Harris (1986). Life events and illness. spick-and-span York The Guilford public press. Burton R. (1920)Anatomy of Melancholy. reinvigorated 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. rude(a) York W. H. Freeman & Company Desjerlais et al (1995) World Mental Health Problems and Priorities in Low-Income Countries. capital of the United Kingdom Oxford University Press. Fairbairn W. (1952)Psychoanalytic Studies of the Personality. London Routledge Freud S. (1917). Mourning and melancholia. In J. Strachey (Ed. ), The bill interpretation of the complete psychological full treatment of Sigmund Freud London Hogarth PressFreud S. (1914). On Narcisism. The standard edition of t he complete psychological plant life of Sigmund Freud V. 14. London Hogarth Press Freud S. (1923/1960). The ego and the id. J. Riviere (Trans. ), J. Strachey (Ed. ). newly 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 pass judgment of the Kleinian school. Int J Psychoanal 50 317 33 Klein M. (1940). belles-lettres of Melanie Klein. London Hogarth. Vol. 1. p344-369. Klein M. (1932). The psycho-analysis of children. London Hogarth Press. Roger Money-Kyle 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 PressLund C (1991)Psychotic depression psychoanalytic psychopathology in relation to treatment and management, B J abnormal psychology 158 523 8 Mahler M. (1966). rough preliminary notes on the development of basic moods, including depression. Canadian psychiatrical Association Journal, 250-258. Meltzer, D. (1998)The Kleinian Development (New Edition). London Karnac Books OShaughnessy 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)21729. Sandler J (1965)Notes on childhood depression. Int J Psychoanal 46 88 96 Schore A (2003)Affect polity and The Repair of the S elf New York WW Norton & Co, Inc. Segal H. (1973)Introduction to the work of Melanie Klein. London Hogarth Press. Spitz R. (1946) Anaclitic depression An dubiousness 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. , 64321-332. Stengel E (1969). self-annihilation and Attempted Suicide. Harmondsworth Pelican Books. Wetzel, J. W. (1984). Clinical handbook of depression. New York Gardner Press. 1Objects are primarily formed from early interactions with (usually) parents. (Klein 1940) 2 introjection message 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 foeman sex, usually occurring around the age of 3 5 years and accompanied by hostility to the parent of the s ame 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 steerable 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 armorial bearing (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 infant passes in developing a more stable awareness of separateness from the mother (1966).