The essential features of a major depressive episode is a depressed mood or the loss of pleasure in nearly all activities. The individual may also experience changes in appetite, weight, sleep, a decrease in energy, feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death, suicidal ideation or attempts. The episode may also be accompanied by significant distress or impairment in social, occupational and other important areas of functioning.
The person may complain of “feeling down it the dumps” or “blah”, having no feeling or anxious. Loss of interest or pleasure is almost always present. Individuals may report having less interest in hobbies, “not caring anymore” or not feeling enjoyment in activities that were previously considered pleasurable. Family members might notice a social withdrawal and a loss of interest in previously pleasurable activities (e.g. golf). In some individuals there is a significant loss of sexual desire or interest.
Appetite is usually reduced and many individuals have to force themselves to eat. Other individuals may have an increased appetite and may crave particular foods like sweets or carbohydrates. Individuals typically have insomnia and wake up in the middle of the night and have difficulty falling back to sleep.
The sense of guilt and worthlessness may include unrealistic evaluations of one’s sense of worth. These people interpret trivial day to day events as evidence of their personal defects and have an exaggerated sense of responsibility for incidental events.
This is precipitated often by loss and the person’s inability to mourn the beloved. This kind of depression results from the person turning angry feeling about the beloved on to the self. This causes a drop in self-esteem. A a primary reason this happens is not only that he/she is guilty about his/her aggressive feelings, but that he/she has never really seen the beloved as a separate person. He concluded that because the beloved did not love him/her, he/she is not loveable. Depression is alleviated if he/she can be helped to really see the beloved as a separate person. He/she needs to see that it’s not that he/she is unlovable, but that the beloved was never capable of loving.
The same process is linked to chronic depression where the person is unable to mourn that the parent was not the ideal parent they longed for.
Dynamics of Depression
Depression is often caused by loss. The individual is unable to mourn the loss. There are similarities between mourning and depression. Both involve painful feelings of dejection, cessation of interest in the outside world, loss of the capacity to love and the inhibition of all activity.
However, with depression there is a lowering of feelings of self regard that culminates in a delusional expectation of punishment. Mourning is the same as Depression with the exception of the loss of self esteem in Depression.
Work of Mourning: involves a turning away from external world and internally giving up the person by withdrawing one’s emotional investment in the memories. (I.e. The person regularly remembers the good times and the bad times. They realized that the loved one is absent and accepts it eventually. The loved one becomes less and less important.) In all of this the person stays attached to the representation or memory of the beloved.
Sometimes it is not a person, but an ideal of some kind. Mary is jilted by John. She loses the dream that they will be married. She loses the “idea” that John really loves her. She grieves the loss of this idea and all that was implied by it (i.e. that they would get married some day.)
Depression: The person knows whom she has lost, but not what she has lost. Whom = John’s gone. What = John’s love is gone and all the many things that he has meant to me and hasn’t meant to me. All the affects, conflicts, and memories connected to John. The depressed personality is aware of some absence plus a bone crushing, ideationally absent depression. The representation of the beloved has been withdrawn from consciousness, whereas in mourning there is nothing about the beloved that is unconscious.
In mourning the world has become poor without the beloved. In depression the self has become poor and there is a fall in self esteem.
The person represents himself as worthless, incapable of any achievement and morally despicable. He reproaches and vilifies himself and expects to be cast out and punished. He doesn’t see that any change has taken place, but feels he has always been that way.
Normal and pathological mourning
Normal mourning involves consciousness; pathological mourning has more to do with the unconscious because the person cannot perceive what he has lost. In both there is a loss of interest in the outside world, because the person is preoccupied with the loss. However, in pathological mourning there is a loss of self esteem. Self accusations and self abasement are uppermost.
These self reproaches fit someone else whom the person loves or should love. Key to understanding this is that the self reproaches against the loved one have been shifted to the self.
One part of the mind has set itself against the other and judges itself critically, as if it were the beloved. This agency is called conscience. It has become more severe in depression. It demonstrates that conscience can have an independent function.
The break with the outside world and withdrawal
In normal mourning the individual is able to give up the beloved and withdraw emotional involvement from the beloved so that the person is now free to attach itself to a new person. In melancholia, the individual does not withdraw emotional involvement from the lost beloved but identifies with it because the beloved was never seen as a separate person but only as a source of self esteem.
Normal mourning: sadness
Sally was angry at her husband and saddened by him. She had a dream that 1) He would take care of her and 2) that they could work together in their business. She had come to realize that this would not be possible. 1) He was not going to be able at his age to make the kind of money that would allow her to retire comfortably. 2) He was too unresponsive to her separate needs for them to work comfortably together in business.
He had a tendency to take charge and ignore her separate agenda. She presented herself tearfully, dysphorically and saddened over the loss. She was angry and frustrated with her husband. However, both consciously and precociously she knew that she was angry at him. She was also saddened at the loss of a dream – a dream of comfortable retirement and of the two of them being able to share their work life together. She did not however succumb to depression.
People who relate to people only as a source of self esteem are vulnerable to succumbing to depression in the face of loss. They identify with the beloved because they don’t see the beloved as a separate person. The beloved becomes installed unconsciously and subsequently all negative feeling are directed at the beloved. Self esteem plummets.
Dana was a social isolate. She was fearful of involvement with men because of her vulnerability to rejection. Her self esteem rose and fell depending on whether or not the man approved of her or not. Sensing this vulnerability to her need to be loved, she protected herself by social isolation and devoting herself to her dog. (She loved the dog as she wanted to be loved as a child and simultaneously felt loved because she was identified with the dog.) She was typically depressive in her need for approval and validation of her self worth.
For example, she experienced her need for space, her need to be silent (i.e. like running out of words during a conversation), her fatigue and not wanting to clean her apartment, as unacceptable. These traits branded her as unlovable. That is, she felt that if she couldn’t be what ever her beloved wanted her to be and this would make her unlovable.
Matthew had recently discovered that he had a melanoma and needed surgery to remove it. Although there was some loss of body hair, he had gotten a clean bill of health and was thrilled to be alive. He wanted to do all the things that he was too shy to do previously. This High school teacher with a lumber jack type personality who lived in San Francisco, knew Dana from college, but had been reluctant to approach her. Now he was pursuing life with a passionate intensity.
He wanted instant intimacy. He would come down from San Francisco for their weekend date. He would stare into her eyes and say, “You are fantastic.” Dana found this very gratifying. She had a strong need to be approved of by a man, but she could not in all honesty respond in kind. She felt she was just beginning to get to know Matthew. He was hurt that she was not as instantly enthralled with him as he was by her. She felt that he did not see her and that he was in love with a phantasy. She would also like to spend quiet times when they were not talking. He would take her need for space as a rejection. She felt she was being smothered by him. He wanted to see her a lot. She felt she wanted to slow things down; she felt rushed and overwhelmed. She wanted him, but not so fast. He took that as a rejection and ended the relationship in spite of her reassurance that she cared very much for him.
Dana succumbed to a severe depression: 1. I’m incapable of love she would cry out. I’m incapable because I couldn’t be more responsive to Matthew. (This reproach was really about Matthew, who could not tolerate separateness without feeling unloved.) 2. I am too lazy and without energy for any man to want me. Dana’s strong need for approval precluded her seeing Mathew as a separate person. This made her vulnerable to identifying with him and unable to mourn him as a separate person.
For the most part, there wouldn’t be mourning at the ending of the relationship, there would be simple depression. Depressed people have a difficulty bearing the pain of mourning. The implication of depression is truncated mourning. The therapist needs to stimulate mourning to alleviate depression.
Not only does the treatment of depression require helping the patient to engage in a mourning process but to help the patient see someone they have never really seen. This is necessary not only to help the patient recover from depression, but to develop a capacity in them to see people that will make them less likely to succumb to depression when faced with losses in the future. I asked the following.
Therapist: What do you miss about Matthew?
Patient: I miss the time when we were at the restaurant and how loved I felt by him when he looked into my eyes. (She remembers a positive memory.)
Therapist: (Remind her of a negative memory.) But you forget that you didn’t feel seen by him.
Patient: remembers the times when she felt loved, Therapist: reminds her of when she felt unloved and therefore stimulates mourning and the conscious reliving of the positive and negative experience with the beloved so that the person is eventually given up.
Patient: He left me because I can’t be what he wants me to be. I’m incapable of loving because I need to withdraw.
Therapist: You forget that you at times needed to withdraw because you felt smothered or got tired of the pressure to keep up the conversation all the time. (Clarify what there was in the past that made her need to withdraw.)
This is not simply fostering an externalization of blame, but it’s helping the person to remember the relationship and see Matthew in terms other than their own needs for approval. Dana never really saw Matthew. She related to him only in terms of whether or not he approved of her. She did not relate to him in terms of whether he had qualities that she valued independent of how these qualities served her need for approval. If a man pursues Dana she feels wanted and loved; she doesn’t look deeper at the man.
As she is helped to mourn Matthew both negative and positive memories come to consciousness spontaneously. Previously there were only positive memories and the negative memories were unconscious. Mourning was truncated and aggression was turned against the self. Therefor depression.
This explains suicide. The person kills themselves, (i.e. in opposition to natural self love). Only if it can treat themselves as the lost beloved.
I would now like to talk about chronic depression. Chronically depressed personalities complain of profound feelings of worthlessness and low self-esteem since childhood. They have generally led isolated lives because of a fear of making insatiable demands. The relationships that they do establish tend to be relatively superficial, because they fear that if anyone got to know who they really are, they would reject them. They feel hungry to be loved. If you are sensitive to depression, you may feel when you are with them an unspoken demand to love them, feed them, but they are too frightened of rejection to let you really know them. They present themselves as the person that they think you want them to be, while inwardly fearing making insatiable demands. They are angry that demands to be loved have not been met. Their mother withdrew from them when they made demands to be loved as a child. They concluded that their very neediness is destructive. This belief is at the core of their belief that they are unworthy of love. They fear making demands on their adult partners and instead establish superficial relationships.
The depressed personality generally feels something is missing and their whole life is affected by what they feel as a fundamental lack. They often feel cheated, robbed and crippled.
The origins of the depression lie in their experience of inadequate mothering. The child does not really recognize that there is a difference between internal or psychic reality and external reality. When they are well cared for, they believe that the satisfaction of their needs came from within themselves. They feel self-sufficient and that they need not seek anything outside themselves. There is an illusion of self-sufficiency and of having created their own nurture.
The depressed personality does not get good care in childhood and is not able to develop self-confidence based on the illusion of self-sufficiency. Self-esteem will suffer from feelings of inadequacy and feelings of helpless vulnerability. They feel unlovable because they were not loved. They believe they were not loved because of some deficiency in them and not because their mother was deficient in her ability to love them. They fear making insatiable demands that will destroy their relationship.
Good and Bad Introjects
The infant cannot experience either good or bad during early stages of development; this only happens later. Badness is eventually associated with frustration. Initially they feel frustration, then anger, then a capacity to hate. Some people who have suffered from inadequate mothering, have not been able to feel anger. Instead they feel grossly inadequate to meet life’s tasks. They can’t structure a picture in their mind of a mother who has failed them.
Hate is not as inevitable as frustration. To feel hatred means that there is an awareness of love. To feel frustrated, presupposes that there must have been some gratification. The depressed personality must know something about feeling loved or gratified to feel hatred, frustration and develop a picture in their mind of a mother who failed them. [This is called a bad introject.]
When the child complains about bad treatment on the mother’s part, the mother of the depressed personality typically withdraws. The child experiences this as a failing in themselves and comes to feel that their very need for love destroys the relationship. They become afraid of complaining. Any dissatisfaction with the mother is turned against the self. This turning of anger at not being loved against the self produces a chronic depression. The depressed personality becomes afraid of making demands. You cannot have an intimate relationship if you are frightened your demands will drive your beloved away. You can only have a superficial relationship. This is a major barrier to falling and staying in love for the depressed personality.
Often depressed personalities are more comfortable giving to others than demanding care for themselves. They are afraid to make demands on their beloved and typically choose partners like themselves; people who are afraid to make demands and who fear that demands have the potential to destroy a relationship. A superficial relationship typically exists between the depressed personality and their beloved where each partner is terrified of making any demands for fear of destroying the relationship.
The depressed personality has a more stable identity than the borderline, the schizoid or the narcissistic personality. This is so because there is generally evidence that the person received some maternal tenderness in spite of the person’s inept childhood surroundings. Mothers will give some nurturance that is sufficient for the person to develop a nurturing picture of mother in their mind. So, they are able to nurture themselves at times when they need comfort and solace. Depressed personalities are also able to draw on this to nurture others as well. They develop maternal attributes, for example. The central core position of the picture in their mind of their mother becomes the source of stability in the depressed personality and becomes a source of strength to draw sustenance from.
The need for a caretaker
The depressed personality was deprived as a child. While they themselves needed to be nurtured they are often forced into a position of mothering others. They feel cheated and enraged. They are unable to protest and express their rage because of:
1) They come to feel very guilty about demanding care.
2) They fear that their anger at not being cared for is terribly destructive.
3) They fear that if they gave into and expressed their needs to be cared for, they would be rebuffed. If they were rebuffed they would be too hurt and fearful to reveal their helplessness in an ambience that could do nothing to help them.
Thus their anger is seen as dangerous and equated with being bad. Often a defensive superstructure of caring for others is erected. It works well but occasionally gives way to the longings of the underlying needy self. When the needy self strives to express itself, the person frequently succumbs to an agitated depression.
I want to say a few words about the maternal introject. There is the external representation of the mother. The person fears that they will be abandoned by mother if they express how angry they are at not being given to. They also fear that current people in their life will abandon them if they complain. There is also an internal representation of the mother. The mother’s nurturing function is internalized. This is the nurturing introject that provides soothing, basic safety and a generalized feeling of wellbeing. When anger over frustrated dependency needs begins to emerge, the person fears that they will destroy the nurturing introject and will be left unprotected in a state of resourceless dependency. The person succumbs to an agitated depression because they fear the angry needy self will destroy the nurturing introject.
When the emergence of the needy self causes the person to shift from being a caretaker to someone demanding care for themselves, great anxiety is generated. They always viewed the world as if it were in a state of precarious balance, which might suddenly collapse. The fear of destroying the nurturing introject stimulates fears that the rug is being pulled out from under them. Other’s fear catastrophes in nature, holocausts, nuclear attacks, earthquakes. However, it is the aftermath that they fear the most. They are afraid of economic collapse and famine in which they would find themselves helpless to provide for themselves and their families. Their lives were oriented against protecting themselves against such contingencies. They held back making any demands out of fear that demands on the beloved would cause a total loss of love and support. They held back making demands for fear of destroying the nurturing introject. They would then be left helpless and starving in the same way they feared they would be as a child.
It is because they fear that the nurturing introject has been destroyed, that they are unable to sleep at night. The blackness of the night makes them feel alone and abandoned. They feel too unprotected to relax enough to sleep. Sleep only comes at sunrise when the warmth of the sun reassures them that they have not been abandoned.
In spite of vigilance, they believe they cannot create a situation which could give them security. The depressed personality is chronically anxious and always thinks they are being rebuffed by those they need.
These difficulties arise from the following childhood situation: The person was to force to mother their own mother by demands and coercion. The mother fights rather than gives. She pulls away. She resists the child’s expressed demands since this mother is modeled after a mother who, because of problems of her own, has nothing to give or has not been able to give. The crisis then is the outcome of a struggle to extract something from someone who has to withdraw.
These fears are transferred onto one’s beloved. A huge barrier to falling and staying in love occurs if one is fearful that any demands one makes on one’s beloved is destructive. Therapy involves a reversal of this negative experience. A principal vehicle for doing this is a focus on the depressed personality’s relationship with the therapist. The person transfers the fears that they had with their parent to the therapist. They are very fearful of making emotional demands on the therapist for fear of destroying the needed therapeutic relationship. They see their neediness as bad. The person needs to be helped to see that it is not they who are bad and deficient. What they really fear is that the therapist is deficient. They fear that the therapist is too depleted or uncaring to want to give to them. The childhood situation that gave rise to the depression is thus reversed by examining the relationship with the therapist in the present. The person becomes less frightened of making demands and a major barrier to loving is removed. The chronic depression is also alleviated in this way.
Case Study: Chronic Depression
Emily, a woman in her mid 40’s, became severely depressed at an occasion that should have been joyous. A party was given at work for her to honor her achievements. She became severely depressed following this party. An agitated depression occurred. (Drugs, husband accompanied her)
Emily was the oldest child of an impoverished family from the South. She did well in school, but had to leave to go to work to help support her family. Her father had become an invalid, her mother was emotionally unstable and so the burden of financial support for the family fell on Emily from an early age.
Emily married an insecure man who was addicted to gambling. Whenever he accumulated enough money to make an investment, he would lose it at poker. Consequently, Emily was supporting him. She was able to adjust to these demands, although she suffered from a mild chronic depression. Since Emily had succumbed to her severe agitated depression following the party to honor her, the husband for the first time in his life was supporting her.
She presented herself initially as miserable and hopeless. Most of the sessions were devoted to her demonstrating how miserable and hopeless she was. Whenever, she acknowledged that maybe she had potential, she became overwhelmed with fright. Emily confessed that her primary fears were 1) her power to destroy the therapist and 2) the therapist’s greed and envy of her.
The therapist interpreted that she was projecting hateful parts of herself onto him. That she needed to do this to experience some of her early relations-particularly to her helpless mother whom she felt to be inadequate and incompetent. She was reliving these early relationships with her mother as an attempt to disengage herself from her. Her descriptions of the therapist were strikingly similar to how she described her mother. Emily elaborated that she was furious at her parents and felt that everything that might have worked to her advantage was taken away from her. She had been able to get scholarships so she could put herself through college, but could not accept them because she had to remain home to care for her family. Even after her parents died, she found herself looking after her siblings. She was expressing her resentment about this for the first time in her therapy.
Emily’s defensive superstructure of caring for others worked well, but occasionally gave way to longings of her underlying needy self. However, when the needy self would strive to express itself, Emily demonstrated an agitated depression. She became very frightened of owning how much she needed.
The precipitating event for Emily’s breakdown was her being honored at work. Her identity was based on misery and hopelessness. The party that was given to honor her made it difficult for Emily to cling to her hopeless orientation. She experienced panic as she began to perceive some pleasure in the honors bestowed on her and then felt miserable. Her panic was an expression of her terror of being overwhelmed by her regretful, needy self.
To be made aware that she had good things that others might value awakened her needy self. To expose her neediness might also lead others to withdraw like her mother did, because they would be unwilling to relinquish their own needs.
Emily’s core conflict is her fear that her neediness is destructive. She inhibits expression of her neediness not just with her parents, but in her current relationship with her husband. She turns her anger at not being gratified on herself and becomes depressed. Emily concluded that because her mother withdrew from her when she expressed her neediness as a child, her neediness was bad. She was too young to realize that it was not that she was destructive, but that mother was deficient in her capacity to give. The principle barrier for depressed personalities to falling and staying in love is their fear of expressing their neediness directly to their beloved.
Emily was helped by therapy to understand her fears of needing the therapist. Therapy with people like Emily is best done when the focus remains on the relationship with the therapist in the present. They get too overwhelmed if the focus is on the parent. She recovered from her chronic depression after several years of treatment. She became freer to fall and stay in love.