PSYCHODYNAMICS OF MILD DEPRESSION

In contrast to the individuals described in the previous chapter, those to be considered in this chapter are not so impaired that the affect of depression overwhelms all other psychic contents. They actively want to be rid of their feelings of depression and try to fight them off. These patients attempt to reestablish the pathological equilibrium that they had achieved prior to being depressed. They do not collapse in the face of overwhelming despair so that their psychic life is devoid of all content except for the repetitive painful ruminations which enhance the misery of their affliction. These individuals, while depressed, manage to function in their everyday lives, albeit often in a reduced capacity.

They are capable of reasoning and normal cognitive abilities, and an insight-oriented approach to therapy may rapidly be initiated. Some somatic symptoms such as anorexia or insomnia may be present but are not 390 pronounced. Psychomotor retardation and constipation are not seen, but loss of libido is not uncommon. Most significant, perhaps, is that these less severely depressed individuals maintain their relationships to others: in fact, they may frantically search for comfort and support from other people. They do not withdraw from interpersonal relationships into a silent world of solitary suffering. Such individuals are typified by the presence of the affect of depression which may be constant or fluctuate in intensity. As will be further discussed, this sense of mental anguish may take a variety of forms— from an agonizing awareness of loss to a despairing conclusion that life is pointless and lacks any form, purpose, or meaning. Regardless of the cognitive variations, the basic mood of depression is definitely present.

Before proceeding with an analysis of such individuals, it may be worthwhile to consider the conceptual status of depression as an affect as I view it, since this view naturally will influence the interpretation of depressed patients. As described in chapter 2, the psychodynamic interpretation of depression has 391 undergone numerous transformations in the history of psychoanalytic thought. Some authors have attempted to explain the experience of depression as a complex metapsychological phenomenon, such as an aggressive cathexis of the self-representation, or as a conflict between the punishing superego and the helpless ego. Others have presented the less complicated position that depression is actually a primary affect that cannot further be reduced to more basic constructs. I definitely lean toward this latter conceptualization and agree with Sandler and Joffe’s (1965) statement that “if depression is viewed as an affect, if we allot to it the same conceptual status as the affect of anxiety, then much of the literature on depression in childhood (and this could be extended to adults) can be integrated in a meaningful way” (p. 90). [14] However, considering depression as a primary affect does not automatically imply that it is a simple emotion devoid of complex cognitive components.

As indicated by Arieti in chapter 5, different emotions presuppose a greater or lesser cognitive maturity and intellectual understanding. Depression appears 392 to be a third-order emotion necessitating some awareness of the past and the future, some linguistic ability, and some recognition of the effects of human beings on one another. This particular painful feeling automatically arises whenever the individual “senses” that he has either irrevocably lost or never will achieve a needed state of well-being of the self. I have put the word senses in quotes because this awareness is not necessarily explicit; rather, it is the unconscious cognitive system that seems to give rise to emotion. By unconscious cognitive system I mean a structure of aspirations, fears, and general expectations from the self and from others that guide the individual’s behavior but of which he may not be explicitly aware.

These systems of belief are postulated to be at a different level of consciousness than the superficial pessimistic distortions which occur subsequent to the onset of a depressive episode. These deeper cognitive systems are the cause rather than the result of the manifest experience of depression and are not so readily available to being clearly spelled out in conscious awareness. For example, an individual may become depressed after a loss but remain unclear as to the manner in which the loss has affected him. 393 Similarly, other individuals may become depressed without any precipitating environmental trauma or without knowing why they should experience a sense of dysphoria at this particular time of their lives. Freud (1917) astutely noted this lack of awareness: he observed that even when the melancholic relates his plight as resulting from the loss of someone, “he knows whom he has lost but not what it is he has lost in them.” What has been lost is an environmental prop that allowed the perpetuation of a needed state of self.

The depressive does not appear to grieve for the other; rather, he grieves for himself—for being deprived of what the other had supplied. He grieves over his state of self without the other or without his all-important goal (as seen in socalled reactive depressions). Or the individual may grieve over a state of self that finds no meaning or gratification in life, unaware that his unconscious cognitive system has forced him to inhibit himself so that he shuns meaningful achievement or pleasurable activities (as seen in so-called characterological depressions). The philosopher Kierkegaard was well aware that the true cause of despair is despair about one’s own self, regardless of the 394 apparently precipitating events.

He wrote that “when the ambitious man whose watchword as ‘either Caesar or nothing’ does not become Caesar, he is in despair thereat. But this signifies something else, namely, that precisely because he did not become Caesar he cannot endure to be himself” (1954, p. 152). In describing depression resulting from an environmental loss, Kierkegaard observed: A young girl is in despair over love and so she despairs over her lover, because he died, or because he was unfaithful to her .... No, she is in despair over herself. This self of hers, if it had become “his” beloved, she would have been rid of in the most blissful way, or would have lost, this self is now a torment to her when it has to be a self without “him” (1954, p. 153) Kierkegaard beautifully and concisely revealed the self-centered aspect of depression as well as its cause that ultimately resides in the deprivation of something which is needed to transform the self and to give the self a sense of worth and well-being, whether this something is the achievement of an ambition, a continued relationship with a needed other, or the maintenance of a particular mode of life. Therefore depression may be conceptualized as a complex emotion that arises 395 when an individual is deprived (or deprives himself) of an element of life that is necessary for a satisfactory state of self.

 However, most if not all mature individuals experience such episodes of mental pain during their lives without becoming clinically depressed. Some marshall their inner resources and continue to press on for fulfillment with renewed hope. Others tolerate the shattering of their wished-for state of self and readjust their aspirations or seek other avenues of meaning. Still others do not give in to their depression but defend against it by various external or internal means: external defenses are usually drugs or alcohol, and internal means are commonly states of depersonalization or an obsession with hypochondriacal concerns. Many individuals, however, progress from the initial depressive psychobiological reaction as described by Sandler and Joffe (1965) to a true clinical depression. These individuals are predisposed to depressive attacks; that is, they have a particular premorbid personality which leaves them vulnerable to repeated bouts of depression.

These pathological personality patterns are always present; so that depression has been described by some authors, such a Bonime (1962), as a practice, a way of life, rather than a 396 periodic illness with healthy intervals. According to this view, Bonime has further implied that the predisposed individual decompensates when his maladaptive interpersonal transactions are no longer effective in bolstering a specious sense of self. This position can be widened to include the role of one’s concept of self and others in the role of depression. When such a concept either obviates the possibility of meaning or is transformed by a loss or frustration so that meaning is no longer possible, depression ensues.