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Some Subtypes of Depression and Their Implications for Psychoanalytic Treatment

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Some Subtypes of Depression and Their Implications for Psychoanalytic Treatment Int. J. Psycho-Anal. (1996) 77, 935 SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS FOR PSYCHOANALYTIC TREATMENT HUGO B. BLEICH MAR, MADRID The author argues the case for the need to develop an integrative clinical psychoanalytic model of depression which takes into account various pathways leading to different subtypes of depression. Some factors intervening in the genesis and maintenance of depression (aggression, guill, narcissistic disorders, persecutory anxieties, ego deficits, masochism, identification with depressive parents and fixation to traumatic events in which the subject felt helpless) are examined, as well as certain dynamic interrelations between them. The relationship between aggression and depression is analysed, with particular attention devoted to the steps through which aggression turns into depression. The origins of guilt are reviewed, including those conditions which are independent of aggression. Psychoanalytic interventions that could be pertinent for a given subtype of depression, but which .could prove counterproductive when applied to another subtype are discussed. Clinical examples are given to provide support for the ideas presented, recognising that further studies are required to establish more specific correlations between the different depressive configurations and the types of psychoanalytic inter­ ventions best suited for changing them. In Mourning and Melancholia (the basic text companied by a persistence of the desire for for our psychoanalytic understanding of de­ that object and by a representation of its pression), Freud did not simply enumerate unattainability. That is, the object must be the symptoms of depression, but searched psychically constructed as lost. Freud points for a universal condition that would explain this out in Inhibitions, Symptoms and Anxiety the different types of depression. Freud char­ when he underscores the 'unsatisfiable acterised depression as the reaction to the cathexis of longing' (1926, p. 172) as that loss of a real or an imaginary object: 'a which is distinctive in the reaction to the loved person, or to the loss of some abstrac­ loss of the object. This 'unsatisfiable cathexis tion which has taken the place of one, such of longing' is an affective state with a double as one's country, liberty, an ideal, and so component. The first, an ideative one: the on' (1917, p. 243). Freud posited the depres­ desire for the object is represented as unful­ sive state as a reaction, because the essence fillable. The second, an affective one: the of the depressive phenomenon resides not in feeling of pain that arises as a result of the loss itself, but in how that loss gets representing the desire as unfulfillable. This codified; in the unconscious fantasies and depressive affect possesses a specific quality, conscious thoughts which organise the way different from anxiety as an anticipation of that loss is experienced. For depression to danger (Brenner, 1982; Hoffman, 1992). appear, the loss of the object must be ac- What we find in depression, therefore, is 936 HUGO B. BLEICHMAR a sense' that a wish that is central to the the lack of fulfilment of attachment wishes, subject's libidinal economy (not just any wish or of wishes for instinctual satisfaction can qualifies) is unfulfillable. In an encompassing be experienced by the subject narcissistically formulation, Joffe & Sandler characterised as caused by his own inability to fulfIl such this wish as one aimed at an ideal state of wishes, as a failure in his fulfIlment of nar­ weU-being and happiness (Joffe & Sandler, cissistic wishes of control over the object, or 1965; Sandler & Joffe, 1965). The wish may of being able to provide himself with instinc­ vary in its thematic content, in what consti­ tual satisfaction. tutes its ultimate objective. It might, among Correlative to the sense of hopelessness other things, consist of: for wish fulfilment is the representation the a) Wishes for instinctual satisfaction and person makes of himself as powerless, as for experiencing low levels of physical and helpless to modify the state of things: he/she mental tension (Freud, 1915). cannot stop wishing, nor succeed in fulfilling b) Attachment wishes, ranging from more the wish. The depressive state thus consists normal ones of being in physical contact not only of the unrealisability of the wish, with the object, sharing emotional states etc., but also, and more significantly, of a self­ to more pathological ones of fusion with the representation as powerless to fulfil the wish, object (for a revision on attachment see to impose direction upon one's life. Due to Parkes et a!. , 1993). the close relationship between the subject's c) Narcissistic wishes, ranging from more self-representation and his/her level of cor­ normal wishes (mastering impulses, emotions, poral and mental functioning, to the extent mental functioning, andlor the surrounding that the self is represented as helpless/power­ medium; being loved andlor appreciated), to less, the motions tending towards the object more pathological ones (being an ideal self of desire are deactivated; hence, the apathy of physical, mental or moral perfection; re­ and inhibition that constitute a central com­ ceiving unlimited admiration; having om­ ponent of the depressive state. nipotent control over one's self or over others) Bibring (1953) has emphasised the central (Kohut, 1971; Kernberg, 1975). The unreal­ role played by the sense of helplessness and isability of these types of wish would give powerlessness in the constitution of the de­ rise to depressions with a predominantly pressive phenomenon. Bibring suggested that narcissistic component (Bib ring, 1953; Jacob­ the object loss is not as defining a charac­ son, 1971; Kohut, 1971; Lax, 1989). teristic of depression as the subject's own d) Wishes related to the object's well-be­ representation of his incapacity to attain ing. If the subject sees himself as being the goals, among them, the presence of the loved causal agent of the harm or suffering of the object. Bibring considered that the predis­ object, a depression with a predominant guilt position to depression is determined by a component could ensue (Abraham, 1911 , 1924; fixation to experiences of helplessness and Freud, 1917; Jacobson, 1971; Klein, 1935, powerlessness, experiences that leave imprints 1940). on the psyche. Thus, each time the depressive This categorisation of different types of person feels impotent to carry forth his as­ wishes is not exhaustive. Nor are the differ­ pirations, all those experiences in which the ent types of wishes mutually exclusive. A feeling of helplessness dominated (either real certain degree of overlap exists among them, or imaginary) are automatically reactivated. and various types of wishes can coexist Haynal's (1977, 1987) revision and detailed within a given person. Thus, for instance, analysis of the bibliography on depression 1 The tenn 'sense' is employed throughout this paper to connote an affective state with cognitive components, similar to the common use of the expression 'sense of guilt' to refer to an ideative-affective state. SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 937 also assigned the feeling of helplessness a restorative effort can be re-enactment by central role in the onset of depression. means of fantasy, by imprinting the desired Elaborating on the Freudian concept of course of events on to the fantasy (Renik, Hilflosigkeit, Haynal highlighted the inti­ 1990). In other cases the depressive may mate relationship existing between the loss resort to crying as a plea for help. Also of the object, the feeling of impotence and utilised are defensive self-reproaches meant the depressive state. to decrease feelings of guilt and to recover To summarise, the components that could the love of the superego, and self-reproaches be considered as defining elements of the that constitute a true form of self-punish­ depressive state are: ment (Rado, 1928, 1951). a) Existence of a wish that occupies a When the pain of depression is prolonged, central place in the libidinal economy of the the restorative mechanisms prove insufficient subject; fixation to a wish which cannot be for maintaining the illusion that the wish replaced or compensated by other wishes. can be fulfilled . The psyche's final defensive b) Sense of helplessness/powerlessness to strategy may consist of mobilising defences fulfIl that wish 2 A self-representation as pow­ against mental functioning itself, attempting erless to fulfIl the wish. to abolish wishing, thinking and feeling al­ c) Sense of hopelessness not restricted to together. This might be the case with the the present, but also encompassing the future. mental states described by Spitz (1946) as d) Affective and motivational consequences the fmal phases of hospitalism, or in the of the sense of helplessness/powerlessness to severe detachment process tha t takes place fulfil the wish: depressive affect and psycho­ after an important loss is not compensated motor inhibition. by an adequate substitute object (Bowlby, It is also important to differentiate be­ 1980). Ogden (1982) describes an extreme tween the following: (a) factors that lead to form of defence in certain schizophrenic pa­ the depressive state (the paths through which tients who have faced conditions of pro­ the individual arrives at the depressive state); longed unbearable suffering, a defence which (b) the depressive state itself; (c) the clinical he calls the 'state of nonexperience'. depressive disorder which is constituted by There are moments when the depressive defensive restorative attempts, complications affect drops to a secondary plane and is re­ of the depression and secondary benefits placed by a feeling of danger produced by the (Bibring, 1953; Jacobson, 1971 ; Joffe & San­ loss of an object that so far had been felt as dIer, 1965); (d) states of diminishment or protective, or by the loss of confidence in disappearance of the desire. the selfs capacity to confront different types When a subject is confronted with the of dangers. When certain depressive patients painful depressive state, a range of defensive manifest anxiety as one of his/her central processes are set into motion.
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