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. These proc­ symptoms, display a generalised phobia, or esses are attempts to alleviate the suffering present hypochondriac preoccupations (symp­ produced by the depressive state (Brenner, toms non-existent prior to the depression), this 1982; Grinberg, 1992; Haynal, 1977; Hoff­ could be because the initial sense of powerless­ man, 1992; Jacobson, 1971 ; Klein, 1935, 1940; ness towards wish-fuIftlment has coloured the Kohut, 1971; Stone, 1986). Rado (1928, 1951) subject's entire self-representation. The sub­ had noted coercive rage as one of the at­ ject's sense of potency for confronting reality tempts to recover the lost object. Another is reduced, and the imagined dangers in-

2 The double connotation of the term 'helpless­ that he lacks external assistance to fulm his wish, ness'- lack of external support and lack of personal and those in which the emphasis resides on the power- permits, in its ambiguity, to cover two dif­ representation of hislher own inability to fulfil the ferent states: those in which the subject mainly feels wish . 938 HUGO B. BLEICHMAR creased. Representations of the self as inca­ other predominates, sometimes to the com­ pable, as inferior, as weak and impotent, plete exclusion of the other. Certain narcis­ establish a psychic condition that makes every­ sistic personalities (those who fit Kemberg's thing appear threatening. In such cases, the description of this disorder and who display inhibition of the depressive state is replaced grandiose fantasies, omnipotence, denigra­ by agitation and by a hypervigilance caused tion of the object, destructive aggression etc.) by the constant anticipation of danger. (Kern berg, 1975) get depressed when they cannot satisfy their grandiose fantasies. De­ pression sets in when they have to bear what WHY THE EMPHASIS ON THE REALISABILITY they perceive as the humiliation of not being OF THE WlSH? able to give their aggression free reign, which makes them feel that they do not attain the As the formula that equates depression desired identification with an omnipotent, with the reaction to the loss of an object destructive, ideal self. By contrast, in other opened a crucial path in the understanding depressive disorders, aggression towards the of depressive syndromes, the question that object is questioned from the superego, giv­ would seem to follow is: what progress did ing way to intense feelings of guilt. Freud's concept of the 'un satisfiable cathexis Guilt is the result of a preoccupation with of longing' represent in the elucidation of the well-being, with the suffering of an object the depressive phenomenon? In other words, that is thought to have been harmed by wherein lies the importance of taking the certain actions or inactions performed by subject's perception of the realisability of the the subject. At the same time, when guilt is wish as the main axis around which depres­ felt, there is a self-representation in which sion revolves? The limitation of the formu­ the subject is depicted as being mean, ag­ lation 'reaction to the loss of the object' is gressive, damaging, undignified, as incapable that it does not specify what this reaction of meeting the standards of a good self. Such consists of. The loss of the object can cause feelings of inadequacy indicate that the area depression, or the complex phenomenon known of self-evaluation, of the comparison between as separation anxiety, with its various mani­ a self-representation and an ideal of moral festations (Quinodoz, 1991). Specifying that worth is also involved, accompanying the depression's primary component is a sense preoccupations for the object. of impotence and hopelessness towards wish­ Taking these two different dimensions (pre fulfilment would help us differentiate the occupations with the object's well-being and depressive phenomenon from the state of with the subject's self-worth), what will hap­ powerlessness that arises in the face of dan­ pen when a subject feels he/she has damaged ger and produces a feeling of panic, not of the object or has not adequately protected depression. it will depend greatly on which of the two Sometimes the sense of helplessness can dimensions predominates. In conditions in be interpreted by the subject from a narcis­ which preoccupation with the object's well­ sistic standpoint as a testimony of inferiority. being dominates (identification with the ob­ In other cases, the emphasis can be placed ject), guilt and actions oriented at benefiting on worrying about the object's well-being, the object will be set in motion (attempts at on becoming preoccupied with the damage reparation) (Klein, 1937). By contrast, when which the subject inflicts upon it. In the feelings of narcissistic inadequacy take prece­ latter case, feelings of guilt predominate. One dence, the compensatory psychic mechanisms frequently finds cases of depression in which will tend towards a disregard for the object's guilt and narcissistic preoccupations coexist, well-being and will be aimed at recapturing but there are also cases in which one or the an image of self-worth. SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 939

THE QUALITY OF THE WISH one of these paths is driven by different factors, or areas of pathology, which we will When the essence of depressive disorders analyse. Subsequently, we will refer to the is defined in the manner described (by a way these different factors can, in turn, be sense of helplessness, powerlessness, and hope­ interrelated. lessness towards the fulfilment of a wish upon which the subject is intensely fIxated) it could prove useful to ask ourselves a series of AGGRESSION AND DEPRESSION questions, upon encountering a depressive case: I) Is the subject's wish unfulfillable be­ The intimate relationship that exists be­ cause of a pathology of the wish itself'? Does tween aggression and depression has been the wish set goals that are excessively high, repeatedly emphasised in psychoanalytic stud­ far removed from the possibilities of the ies of depression (Abraham, 1911, 1924; Freud, subject? Examples of this would include nar­ 1917; Jacobson, 1971; Klein, 1935, 1940). cissistic personalities who have grandiose No definite agreement exists, however, on models with which they aspire to identify. the role aggression plays in the genesis of 2) When the wish appears to be in ac­ depression. The corresponding positions fall cordance with reality, is it unfulfillable because along several main lines: (a) Aggression as of certain characteristics of the subject's per­ a necessary universal condition present in sonality: undervalued self-representation, su­ every depression and as a fundamental causal perego severity, various types of pathologies agent of the latter. Klein (1935, 1940) is the that provoke failure, as occurs with certain most radical representative of this line of borderline personalities, obsessions and com­ reasoning, following the original postulations pulsions, ego deficits etc.? by Abraham (1911, 1924). (b) Aggression as 3) Is the wish perceived as unrealisable a causal agent of depression, but forming because of a fIxation with past experiences part of a larger process that consists of that taint the lens through which present frustration, rage and .hostile attempts to gain circumstances are looked at, giving them a the desirable gratification. This line of think­ negative appearance? Is it unattainable because ing states that when the ego is unable (for of an actual reality that proves overwhelming external or internal reasons) to attain goals, for the subject (presence of a pathological aggression is turned towards the self, with fIgure to whom the person is subjected, se­ an ensuing loss of self-esteem (Jacobson, vere illness, situations of war etc.)? 1971). (c) Aggression being present in certain 4) Why can this wish not be replaced by cases but the central and universal cause another? What are the emotional reasons being a decrease in the subject's self-esteem behind the fixation with this particular wish caused by fixations to experiences of help­ which makes its unrealisability a cause for lessness (Bibring, 1953). (d) Aggression as a depression? secondary phenomenon in response to the failure of the external object, which generates pain and narcissistic rage in the subject (Ko­ DIFFERENT PATHS LEADING TO DEPRESSION hut, 1971, 1977) Regardless of whether or not we consider If the sense of helplessness and hopeless­ aggression to be the main cause of depres­ ness for wish-fulftlment constitutes the com­ sion, clinical experience suggests that it is mon nucleus of every depressive state, it is one of the important pathways leading to possible to arrive at the said sense (and depression. We should therefore tum our therefore at depre!!sion) through multiple paths, attention to the question of why different none of which are obligatory conditions. Each forms of aggression can lead to feelings of 940 HUGO B. BLEICHMAR helplessness and of impotence towards wish­ like the patient mentioned above, continually fulfilment. Using the accompanying diagram attack those around them out of rivalry. As as a guide for the exploration of this topic, a result, nothing appears worthy of their we will differentiate between effects ag­ esteem. No project escapes being subjected gression produces when directed at the to a denigrating set of questions. The attack representation of the object or at the rep­ and destruction of the object leads to a world resentation of the self, from the effects it devoid of valued or stimulating objects, a produces when it is acted out against the world which is inevitably compared to the real external object or against the functions subject's imaginary world, full of idealised of the self. objects that appear unattainable. a) Aggression and deterioration of the This aggression towards the object can be internal object defined further by asking the question: is Abraham (1924) maintained that aggres­ the aggression directed at an object that sion destroys the object, describing the fan­ constitutes a 'narcissistic possession' or is it tasies of oral and anal attacks that make directed against an object which enables the the subject feel as though he destroyed, ru­ subject to carry out an activity that is nar­ ined or annihilated the object, with the en­ cissistically cathected? By 'narcissistic pos­ suing sense of guilt. As the subject internally sessions' we mean all those objects (people criticises the object, this latter loses its status or things) whose worth or unworth falls as valued object. This devaluation of the back directly upon the representation of the object has consequences for the subject's self. The patient's husband, in the example narcissism, particularly when the subject is mentioned above, represented a narcissistic dependent on the object to maintain a bal­ possession for the woman. A narcissistic anced self-esteem. Let us take as an example possession is also what a child can signify a patient whose pathological narcissism led to a parent. The object's worth or unworth her to attack her husband out of the rivalry is added on to that of the subject. Narcissistic she felt towards him. This patient would possessions can come in the form of a house, seize every opportunity to denigrate her hus­ a car, a collection of art books or stamps. band and thus transform him from a pre­ It can be a friend who is valued and dis­ viously idealised object into a completely played for his fame, status or fortune. The devalued one. But because the husband func­ feeling for the subject is one of an increase tioned for this patient as a narcissistic pos­ in self-esteem, of fusion with the worth that session (as well as functioning as a rival), the object seemingly carries. Similarly, the her self-representation as someone married group to which an individual belongs can to a devalued other made her feel that she constitute a narcissistic possession, be it a was a failure in life, without any hope of political party, a religious organisation, or being able to have a satisfactory relationship. an ideological movement. The value judge­ When taking the effects of aggression into ment made about the group, whether positive account, nothing is more appropriate than or negative, reflects directly upon the subject. the expression 'destruction of the object', An 'object of narcissistic activity', by con­ not because the person fantasises about trast, is one that allows the subject to per­ physically destroying the object in multiple form an activity that grants him narcissistic sadistic ways (he/she mayor may not do so) worth. It is the object-instrument for an but because, in the individual's psychic re­ activity of the self which has been narcissis­ ality, the denigration of the object leads to tically cathected, an object without which its loss as a stimulant object capable of the activity or function cannot be carried underpinning the narcissism of the self. This out. Examples: the patient and his body for is the process that takes place in people who, the surgeon, the piano or violin for the SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 941 musician, the student for the professor, the which depend on this object and which game and the opponent for an athlete, the contribute towards sustaining not only the car for the racing driver. Any job, hobby subject's self-esteem, but his/her mental or­ or profession that allows a function of nar­ ganisation as well] cissistic worth to be carried out can be an b) Aggression acted out against the ex­ object of narcissistic activity. The object of ternal object narcissistic activity, in terms of the functions If the subject not only displays aggression of the self as perceived from a narcissistic against the representation of the objects within standpoint, plays a role equivalent to that himself, but also acts out in the external of the object of the instinct, allowing it to world (thereby destroying friendships and attain its goal: 'the object of an instinct is family relations, work relations and real life the thing in regard to which or through opportunities), he/she begins to see the grad­ which the instinct is able to achieve its aim' ual deterioration of real-life situations, of (Freud, 1915, p. 122). If narcissism is as impotence for fulfilling amorous wishes and important a force in human motivation as for attaining success and recognition from the sexuality of the erogenous zones, then it the outside world. Depression is, in these would seem that it must also possess specific cases, the result of a failure in the creation objects. The absence of 'objects of narcissistic of conditions that allow for the realisation activity' may explain the profound imbalance of wishes that are central to the person. This often experienced by certain people during is observed in those people who spend a weekends or vacations. large part of their lives attacking that which, There are individuals who attack their in their omnipotent denial, they think they 'objects of narcissistic activity'. They deni­ can recover later on, only to realise at a grate their job or their profession by citing certain age that reality impedes the mainte­ its lack of importance, by listing the poor nance of defensive illusions, leading them to conditions under which it is carried out, or feel the depressive sense of irretrievable loss the scarce material rewards involved. These and irreparable damage. attacks cause the subject to feel impotent c) Aggression directed against the self towards the fulfLlment of personal narcissistic In two very different papers, one from a wishes which are dependent upon these ob­ perspective which takes into account the role jects. The profession or activity in question of conflict, aggression and the special fea­ appears unworthy when compared to others tures of the superego (Kern berg, 1988), and (idealised objects) that are felt as unattain­ the other which emphasises the failure of able. This gap gives rise to the unsatisfiable the external object (Markson, 1993), the im­ cathexis of longing mentioned by Freud portance of masochism for depression is (1926). This is often at the root of chronic carefully discussed (see also Glick & Meyers, depressions observed in patients who remain 1988). These contributions, as well as the attached to a job or a relationship that they knowledge we have about the relations which perceive as denigrating and which they there­ the subject maintains with himself and about fore perform in a bureaucratic unrewarding the sadism of the superego (Freud, 1923), style. All attacks or devaluations of the 'ob­ aUow us to understand why aggression di­ ject of narcissistic activity' leave a vacuum rected against the self plays such an impor­ in the self for carrying out those functions tant role in depression. Aggression in the

3 The 'object of narcissistic activity' must be dif­ In both these cases what is primarily modified is the ferentiated from a 'selfobject' (Kohut), an object self-representation. The 'object of narcissistic activ­ which mirrors the self or which allows the self to ity' modifies the functioning of the self and, secon­ fuse with its grandiosity-'idealised parental imago'. darily. the self-representation. 942 HUGO B. BLEICHMAR form of continuous self-criticism deteriorates the unconscious id' (Freud, 1923, p. 51) . the representation of the self. But self-ag­ Thus, guilt is the natural, logical consequence gression also has a negative impact on the of the quality of the desire: given that what functioning of the self. The subject, hating is desired is transgressive, it seems natural himself, consumes his energies in an internal that the person would feel guilty. war, attacks and inhibits the functions of b) Guilt due to the codification of wishes his ego and forbids any movement towards Along with guilt due to unconscious wishes, fulfilment of his wishes. The consequence: another explanation exists which does not an impoverished self incapable of providing depend on the quality of the wish nor of sustenance to hislher self-esteem. In the cases the impulse but on the codification the where the individual is fmally able to realise subject makes of it. In On Narcissism: An how he has attacked himself, a sense of guilt Introduction , Freud says: may develop. Grinberg (1992) has insisted on the importance of taking into account The same impressions. experiences, impulses and not only the process of mourning caused by desires that one man indulges or at least works the loss of the object, but also the mourning over consciously will be rejected with the utmost of aspects of the self which are experienced indignation by another, or even stilled before they as lost as a result of aggression. enter consciousness .. . We can say that the one man has set up an ideal in himself by which he measures his actual ego, while the other has AGGRESSION AND GUILT formed no such ideal (1914, p. 93).

Just as the relationship between aggres­ The crux of the argument no longer re­ sion and depression is complex, so is the sides in the quality of the wish or of the relationship between aggression and guilt. impulse, but on the fact that the ideal and Let us therefore examine it. Freud's concep­ the evaluative critical agency are different in tion of the conditions that generate guilt some from in others. A few years later, once evolved in the course of his writings. As has Freud established the structural model of been the case with other psychoanalytic con­ the mind, the existence of guilt in some cepts, the complexity of Freud's ideas have subjects and not in others is explained by given rise to various schools of thought the development of the superego. Herein lies which base themselves upon Freud's find­ a radical change with implications for treat­ ings. We can acknowledge, within Freud's ment: we are no longer dealing with the work, at least four conceptions of the origins analyst discovering that his patient has un­ of guilt. conscious guilt and thus having to find the a) Guilt due to the quality of the uncon­ repressed unconscious wishes that triggered scious wish it, but rather, with the analyst having to From his earliest works, Freud considered look for the reasons why the patient's su­ the sense of guilt to be a product of the perego codified these wishes as aggressive or existence of certain sexual and hostile desires harmful, something which someone else's that appear at odds with the prevailing rep­ superego might not have done. Accounting resentations of the subject (i.e. Freud, 1897, for the superego's codifying influence on 1909). Once the structural model of the mind wishes and impulses will not convey to the was developed, this conception (that it is the patient the conception that 'you feel guilty existence of a disreputable desire in the sub­ for having those wishes' but will allow him ject's psychic reality that leads to guilt), to ask himself the question: why are my found confirmation in the proposition that wishes perceived from a perspective that the 'superego knew more than the ego about makes them appear transgressive? And for SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 943

the analyst: which conditions led to the es­ object, that is, the replacement of the tablishment of a superego with such tyran­ cathexis of the object with identification. The nical standards, with such a severe critical difference is that, in Mourning and Melan­ conscience, with a sadism that constantly cholia, the identification suffered by the ego searches for an opportunity to attack? is with the external object towards whom c) Guilt through identification the aggression is directed, that is, with the In The Ego and the !d, Freud affirms: object of reproach, with the object hated. In 'borrowed' guilt, however, the identification One has a special opportunity for influencing it is with an object which itself feels guilty. It is when this Ues. sense of guilt is a 'borrowed' something existing in the external object (its one- when it is the product of an identification feeling of guilt) which the subject identifies with some other person who was once the object with. What is significant is not so much the of an erotic cathexis (1923, p. 50). introjected aggression as the effects of the structural identification with the pathology of In this case, it is not that a given indi­ the object that moulds the self-representation, vidual arrives at the unconscious conclusion generating the feeling of guilt. that he is bad due to his wishes or to the The four different conceptions of guilt in codification his superego makes of them. Freud's work do not so much contradict as Rather, it is the existence of a global identity, complement one another. The different psy­ that of being bad, of being aggressive, a choanalytic schools tend to emphasise one representation of the self as harmful, a dis­ or another of the mechanisms involved in order of the self-representation from which the psychogenesis of guilt. We find a spec­ the subject will conclude that he is bad on trum ranging from those analysts who, when every occasion, letting what he feels in that detecting unconscious guilt, look for the re­ particular moment reinforce everything he pressed aggressive impulses driving it, to the previously believed. This is the case of those opposite end, comprised by those analysts who identify with guilt-ridden parents. The who believe that guilt is the result of the libidinal desires towards the object that guide influence of the external figure and that the identification determine that when the conflict plays a secondary role (when the object is pathological, the object's attributes son/daughter feels responsible for the suffer­ will be incorporated indiscriminately; among ing of the parents, 'This is not simply the these, the sense of guilt. Guilt can also result creation of unconscious fantasy; in overt or from the image that the significant other covert ways the parent's suffering is attrib­ inculcates in the subject, rather than with uted to this underenjoyed or unenjoyed child' what this other is, making the subject believe [Markson, 1993, p. 932]). he is aggressive and bad (Markson, 1993). Fairbairn provided a sophisticated expla­ d) Guilt through introjection of the ag­ nation for the origin of guilt which takes into gression against the object consideration the internal process through In Mourning and Melancholia (Freud, 1917), which it comes to exist: the child, desperately self-reproach and self-blame are seen as the needing to feel protected and loved by his result of the introjection of aggression origi­ parents, prefers to think that he is bad: nally directed against the object: the self is reproached in the conscious, the object in taking upon himself the burden of badness which the unconscious. One could think that this appears to reside in his objects. By this means he condition is the same as the one described seeks to purge them of their badness; and, in pro­ above (guilt through identification), given portion as he succeeds in doing so, he is rewarded that in Mourning and Melancholia Freud puts by that sense of secnrity which an environment of forth secondary identification with the lost good objects so characteristically confers (1943, p. 65). 944 HUGO B. BLEICHMAR

This is accomplished through a complex ation, rather than guilt, predominate' (1989, process, including defences against internal­ p. 88). This leads us to the difference between ise9 bad objects, which Fairbairn called 'moral shame and guilt. With respect to shame, defence' (p. 66). The child, feeling he/she is Rizzuto, in an ample review of the topic in bad and not that hislher parent is loving or which she discusses how shame has been sadistic, can maintain the illusion of exerting conceptualised by the different psychoanalytic a certain omnipotent control over reality: if schools, considers that only he behaved well, then he would get his parents' love and protection. Guilt as a de­ shame is related to a self-evaluation (ego and fence, as a way of recapturing a sense of superego) of being undeserving of a desired control for determining the course of events, affective response. It concerns the narcissistic com­ becomes a coping strategy for dealing with ponent of any experience or fantasy, be it pre­ situations which the psyche experiences as oedipal, oedipal, or post-oedipal (1991 , p. 304, traumatic (see also Grotstein, 1994; Kill­ my italics). ingmo, 1989). Rizzuto's conception of shame as a prod­ uct of a negative self-evaluation falls along NARCISSISTIC DEPRESSION the same lines as that of authors who un­ derstood the sense of shame to be the prod­ Though aggression and guilt have occu­ uct of a failure in achieving the goals set by pied an important place in our psychoana­ the ego and ideal self (Broucek, 1991; Lewis, lytic understanding of depression, various 1987; Morrison, 1989; Sandler et aI., 1963; authors have questioned the notion that they Wurmser, 1987). There is a dimension which are an indispensable components of all types appears to be essential for the feeling of of depressions (Bib ring, 1953; Haynal, 1977; shame: the presence, real or jantasised, of a Jacobson, 1971 ; Lax, 1989). Kohut (1971, significant other who is witness to the sub­ 1977, 1980) has insisted on the existence of ject's narcissistic failure: 'shame as a result depressions where guilt does not form part of conflict affecting the sense of self and of the disorder. Rather, the feeling of frus­ narcissistic evaluation in the presence of the tration in the attainment of narcissistic as­ significant object' (Rizzuto, 1991 , p. 298, my pirations of the self is what constitutes the italics); 'In order for shame to occur, there core of depression. Kohut (1980) metaphori­ must be a relationship between the self and cally summarised the difference between guilt the other in which the self cares about the and narcissistic suffering in his formulation other's evaluation' (Lewis, 1987, p. 108). This of the 'guilty man' and the 'tragic man'. In is quite different from what happens with the detailed clinical case presented by Tolpin guilt in which the centre lies in the preoc­ (1983), the patient's depressive states are not cupation with the damage and suffering in­ explained in relation to feelings of guilt but flicted on the object (there is an identification in relation to structural deficits in the for­ with the other who is suffering) and not mation of a cohesive nuclear self. with the subject's narcissistic inferiority in Kernberg differentiates depressions in which front of a real or fantasised witness. there are more authentic guilt feelings from 'Depression which has more of the quality of impotent rage, or of helplessness-hope­ DEPRESSION DUE TO A PRIOR NARCISSISTIC lessness in connection with the breakdown DISORDER of an idealised self concept ... ' (1975, p. 20) . Lax maintains that 'In a narcissistic Two different conditions are usually con­ depression, feelings of shame and humili- sidered in the psychoanalytic literature as SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICA nONS 945 narcissistic disorders: firstly, those charac­ self-esteem or when the offerings to the su­ terised by permanent low self-esteem or by perego take on the form of personal achieve­ a difficulty in sustaining a valorised self-rep­ ments, any failure in the functioning of these resentation and a cohesive self (Kohut, 1971, two modalities of underpinning narcissistic 1977; Stepansky & Goldberg, 1984; Stolorow balance results in depression (Arieti & Bem­ & Lachmann, 1980); secondly, those found porad, 1978; Blatt et aI., 1982; Blatt & in personalities with an incapacity to depend Zuroff, 1992). on another person, personalities who display In the second type of narcissistic disorders omnipotence and envy, who attack and dep­ (grandiosity and omnipotence through the recate their objects, and show a defensive denigration of the object) depression is not fusion of ideal self, ideal object and self-im­ chronic. It appears in the moments in which ages, aggression playing a central role in there is a collapse of the person's grandiosity their pathological internal and external ob­ after having disavowed reality as well as ject relationships (Kernberg, 1975; Rosen­ personal limitations (Kern berg, 1975). De­ feld, 1964). pression results from the damaging effects The paths through which each of these of a destructive narcissism on interpersonal two types of narcissistic disorders lead to relations, insertion in reality, and on the depression are also different. In the first type, person's self-care. characterised by poor self-representation, de­ pression can originate: (a) directly, because a poor self-representation makes the subject P ERSECUTORY ANXIETY feel impotent, incapable of attaining the ob­ ject of desire, which is taken for lost. In Persecutory anxieties (Klein, 1935, 1940) such cases depression is more or less chronic can lead to depression because of the con­ and forms part of the personality. (b) indi­ sequences they have upon mental functioning: rectly, due to the consequences of putting they disturb the development of the ego, defences at play. For instance, in order not object relations, sublimations and reality testing. to expose oneself to situations that produce The defences activated to diminish persecu­ fear or shame, the person becomes inhibited, tory anxieties (aggression, phobic avoidance, renouncing interpersonal contact and learn­ obsessive rituals and other characterological ing experiences, with a consequent impover­ disorders) seriously limit the subject's capaci­ ishment in the development of ego resources ties, making himlher feel impotent to master and a loss of real-life opportunities. This not just reality, but especially hislher mind. sequence of narcissistic disorder/shame/pho­ To provide an example, the circuit of persecu­ bic avoidance/ego deficits/and losses in real­ tory anxiety/phobic character/inhibition/fail­ ity, concludes in the sense of impotence for ure to gratify cherished wishes/deterioration the fulfilment of wishes. In this condition, of self-representation/depression, gives an in­ depression is secondary to a mutilating pho­ dication of the importance of persecutory bia, a phobia not resulting only from a anxieties as a condition which lies at the distorted representation of the object, but root of some depressive disorders (as illus­ essentially from the perception of the self as trated later). diminutive in comparison to the object. As one patient explained to me with great irony and wisdom: 'Tarzan is not afraid of lions IDENTIFICATlON AND DEPRESSION because he believes himself Tarzan'. That is, the valued self-representation determines the The importance Freud granted to identi­ power attributed to the object. When the fication in character formation (1923; see external object is used as a way of supporting also Baudry, 1983) raises the question of the 946 HUGO B. BLEICHMAR role that identification with depressive par­ lytic work) provide support for the notion ents may play in the origin of depression. I that parental fantasies influence the structure am not referring here to the correlation be­ of the child's emotional world (Hellman, tween parental depression and its effects upon 1978). their children (Morrison, 1983), or to the In the case of one patient, Hellman states: consequences of the depressed parent's lack 'He developed an identification not only with of response to the child's developmental needs his mother, but with her image of him which (Anthony, 1983), nor to the atmosphere of she conveyed in words and actions' (p. 488); sadness and guilt that depressive parents 'Analysis further showed she [the mother] generate (Markson, 1993). Rather, I am saw David as she imagined her own mother speaking of the child's identification, as a had seen her' (p. 487). This would lead to characterological trait, with the parent's de­ the consideration that Bibring's thesis on the pression. Regarding childhood depression, fixation of the ego to experiences in which Anna Freud stated: it felt powerless and helpless may need to be completed with the thesis that those ex­ periences do not necessarily have to be lived What happens is that such infants achieve their by the person: the parents' history remains sense of unity and harmony with the depressed unconsciously incorporated in the son's or mother not by means of their developmental achievements but by producing the mother's daughter's unconscious. Just as there is a mood in themselves (1965, p. 87). 'borrowed sense of guilt' (Freud, 1923) there may also be a 'borrowed sense of impotence and hopelessness' playing a part in some There are people who are raised from a cases of depression. very young age with messages, both con­ scious and unconscious, of the type 'we can't do that' or 'we will never be able to attain EGO DEFICITS that'. Such messages are incorporated by the subject as fundamental conceptions inopreg­ The sense of impotence in wish-fulfilment nating all desires, making them appear im­ may result from an actual deficit of ego possible from the start: renunciation occurs resources and not just from disorders in the before a conscious wish even appears, be­ representation of the self. Ego deficits may cause the result is perceived as negative in include: structural deficits in cognitive, ex­ advance. pressive and relational capacities, deficits in The role played by identification, however, the control of impulses and of anxiety, defi­ may intervene not just in the construction of cits in differentiating between one's emo­ the self-representation, but in the repre­ tional states and those of others, deficits in sentation of reality as well. Parents' fantasies reality testing etc. Any condition that pro­ of reality, whether they perceive life as in­ duces ego deficits (inner conflicts, traumatic trinsically frustrating and overwhelming, or reality, parents' ego deficits etc.) diminishes as pleasurable and exciting, establish the the possibilities for sublimation, for estab­ unconscious ways in which a son or daughter lishing satisfactory relationships, for being will relate to reality, what helshe will come able to take advantage of real-life opportu­ to expect from it. The studies on simultane­ nities, for compensating losses. The subject ous analysis of parents and children at the thus comes to feel helpless and powerless to Hampstead Child Therapy Clinic (carried fulfil hislher wishes. In some cases of patho­ out by two different analysts who in most logical mourning following the loss of a job cases did not communicate with one another or of a loved one (death, divorce etc.) the so as not to interfere with each other's ana- subject's incapacity to get a new object, SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 947

because of hislher lack of ego resources, take into account the subject's real history determines that the lost object begins to and any traumatic realities he/she may have undergo a progressive process of idealisation. experienced (for a revision of the complexity This fixation on the lost object does not of reconstruction in analysis of infantile psy­ depend on the subject's ambivalence and chic trauma see Baranger et aI., 1988). It is guilt, as we see in other cases. It is a return worth pointing out that what clinical psy­ to the lost object because of the subject's choanalysis suggests about the influence of limitations in replacing it. This secondary traumatic experiences on the genesis of de­ fixation to the lost object is different from pression is backed up by the findings of the cases of pathological mourning where Brown & Harris (1989). Using sophisticated the idealisation of the object preceded its tools of analysis, they examined the impor­ loss. tance of the loss of the object in generating depression, both in early infancy and later on in life, defining loss in a broad sense: TRAUMATIC EXTERNAL REALITY loss of a person, of the subject's physical health, or of a cherished idea, or disruption There is no doubt that lived experiences of expectations of someone else's commit­ acquire their psychic significance on the basis ment, or incidents that challenge the sense of the fantasy from which they are perceived. of identity (p. 61). These studies suggest that At the same time, however, these fantasies the loss of the mother and, especially, the do not surge exclusively from an intrapsychic absence of adequate care by substitute pa­ creation but are subject to unconscious and rental figures after the loss, are important conscious parental discourses and fantasies variables in the predisposition to depression. (Hellman, 1978), and to the external reality The authors state: the subject has been exposed to. It is a back and forth process of continual feedback, of We would rather emphasise that the events almost assimilation of the external through the in­ always threatened some core aspect of identity and ternal, and of accommodation of the internal self-worth, and perhaps, leaving aside the drama to the external. So, although an individual's of tragic events, this is what in essence defined external reality is mediated by the internal them (p. 65). one, there are situations in which the external reality is itself overwhelming and plays a In addition, regarding types of traumas central role in creating the feeling of hope­ and forms of depression: lessness and impotence. Situations of pro­ longed subjection to pathological, sadistic or tyrannical personalities (person & Klar, 1994; In this context, it is interesting that there is some evidence that types of early loss experience can have Steele, 1994), or to serious and disabling an influence on the form of depression ... In two illnesses (particularly early in life), to con­ separate studies of depressed patients, early experi­ ditions of abandonment and uprootedness, ence of death was found to be associated with a to parental failures (Balint, 1968; Winnicott, 'psychotic' picture of depression and early experi­ 1965; Kohut, 1971), or to the thousand and ence of separation with a 'neurotic' picture (p. 57). one forms of physical and psychological pain, can be incorporated into the psyche as an underlying feeling that nothing can be done INTERRELATIONS AMONG THE DIFFERENT vis-a-vis reality (Bibring, 1953). Thus, the FACTORS world is experienced as overwhelming. Any model trying to explain depression Although depression can be arrived at would therefore be incomplete if it did not through pathways that are independent of 948 HUGO B. BLEICHMAR one another, where anyone of the various tence and hopelessness, and finally, a depres­ factors mentioned above plays the determi­ sive disorder. nant role and generates types of depression c) Guilt, due to any of the conditions (described as paradigms by Klein, 1935, 1940; mentioned above, followed by masochistic Kohut, 1971; Jacobson, 1971), it is also pos­ renunciation andlor compulsive pathological sible for those factors to appear in combi­ compensations towards the object, or by nation. This synergistic operation of different superego punishment, ensued by defensive factors is highlighted by Stone (1986). We aggression; then, more guilt and finally de­ might distinguish two different ways in which pressIon. the various factors can combine themselves: (a) as a complementary series whose elements overdetermine depression; that is, depression UTILITY OF AN INTEGRATED MODEL is the result of the simultaneous participation of various factors; (b) as a sequential series What we would like to highlight is the in which a leading determinant factor pro­ advantage of having integrated models that duces consequences and defensive move­ will encourage us to look at depression as ments which, in a subsequent step, activate an ongoing process; models which recognise another factor (or group of factors), which the multiple paths through which a person in tum, activatels others, or reactivates the can go from one circuit dominated by one previous one; a succession of steps and cir­ factor to another, and the dynamic reasons cuits which finally leads to depression. Let for these transformations. Depression would us illustrate this sequential form of interre­ otherwise appear to be a closed category. If lation among factors. certain circumstances or vital events can gen­ a) A narcissistic disorder with poor self­ erate a depressive episode, it is possible that representation (which could generate depres­ they do so through some of the circuits sion in its own right) might lead to depression described above, which end up in depression. through a more complex circuit: by giving Similarly, if the family or the broader social rise to defensive aggression which, through environment can contribute to the onset of projection, generates persecutory anxieties that depression, it is because they act through block the person's mental functioning and paths like the ones outlined above, or others his/her cognitive and affective development. which remain to be detailed. This produces ego deficits and real-life fail­ An integrated model of depression would ures with an increase in the narcissistic dis­ allow us to locate within it the contributions order and the precipitation of the depression. that different authors have made towards our Alternatively, the sequence could be: narcis­ understanding of depressive phenomena. Thus, sistic suffering/defensive aggression/feelings for instance, Abraham and Klein centred of guilt/masochistic renunciation/depression. their analyses of depression on the relation­ b) The identification with depressive parents ship of aggression/guilt/depression. Within (which could in itself generate depression) this area, they made undeniable contribu­ could make the subject feel that everyone is tions. But the clinical applications of their more powerful than him, lead him to fear discoveries can run the risk of becoming others, to renounce competing not out of reductionistic if other factors are not con­ moral masochism but out of persecutory sidered as well. Taking another author, Ko­ anxieties. This leads to a failure for obtaining hut for instance, we see how his fruitful narcissistic gratifications, to feelings of infe­ clinical work has contributed to the compre­ riority and to narcissistic withdrawal as a hension of certain narcissistic depressions, defence against the fear of experiencing though playing down the role of aggression, shame, which creates more sense of impo- guilt and, especially, of conflict. SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATrONS 949

Regarding the need to differentiate among tients with these types of depression could types of depression, in Mourning and Mel­ not be helped by psychoanalytic treatment ancholia Freud highlighted that the mecha­ (Jacobson, 1971 , 1975). Kernberg also adopts nism he was describing (the introjection of a structural focus rather than a purely symp­ aggression) corresponded to one type among tomatic one to differentiate the depressions the broad field of depressive disorders, but found in masochistic character structures from that there were others to bear in mind such those found in borderline conditions, differ­ as 'a loss in the ego irrespectively of the ent personality disorders, and psychoses. The object- a purely narcissistic blow to the ego differences are considered basically to reside .. . ' (1917, p. 253). A similar approach of upon the level of differentiation between self showing the multiplicity of depressive sub­ images and object images (ego boundaries, types can be found in the works of Jacobson diffusion of identity), level of superego in­ (1971 , 1975), or the differentiation with im­ tegration, pathology of internalised object plications for therapy that Blatt makes be­ relationship, more or less primitive levels of tween anaclitic and introjective depressions splitting, projective identification and ide­ (Blatt et aI., 1982; Blatt & Zuroff, 1992). alisation, drives involved (giving special Jacobson (1971) emphasised that what dis­ importance to aggression and to libidinal tinguishes neurotic, psychotic and borderline investment in pathological self-structures), personality depression from one another is and capacity for reality testing (Kernberg, not just a question of content (the subject 1975, 1992). matter of the conflicts), but of the structural Another important issue is the difference components: the level of ego and superego between normal mourning and depressive development, the degree of their integration disorder, a question Freud raised in Mourn­ and proneness towards regressive fragmen­ ing and Melancholia (Freud, 1917). An exam­ tation; the tendency of the superego to as­ ination of uncomplicated mourning is beyond sume excessive control over the ego or to the scope of this paper (for a comprehensive disintegrate and merge with object and self and critical revision of the literature see representations; the degree of pathological Hagman, 1995). But, at least, we would like fusion between self and object repre­ to highlight one aspect: the role that the sentations; the libidinal and aggressive drives process of mourning (taken in its broadest investing the self and object representations; sense of working through different types of the mechanisms of defence employed. With losses and not just referring to the death of regards to psychotic depression, Jacobson dis­ a loved one) may play for mental growth tinguishes between depressions corresponding and health. Different analysts (Klein, 1940; to manic-depressive disorders and depres­ Grinberg, 1992; Haynal, 1977; Hagman, 1995) sions corresponding to schizophrenic disor­ have described how the insights patients ders not only on phenomenological grounds begin gaining into their previously denied but also in terms of the depth and the nature omnipotent, aggressive, or generally patho­ of regression involving ego, superego, self logical traits give rise to feelings of sadness and object representations. with respect to what has been lost, but Following Freud and highlighting the im­ sadness with a peculiarity: it is accompanied portance of certain psychological factors in­ not by hopelessness and impotence but by cluded in the complementary series of causal a fresh vitality and by a feeling that it is factors, Jacobson reaffirmed her belief in the possible to live differently and, especially, by importance of the role played by constitu­ real reparation moves, quite different from tional neurophysiological processes in the defensive attempts of restoration. Equally, origin of psychotic depression. This does not the reconciliation with the object, be it through mean, however, that she thought that pa- accepting its shortcomings or its goodness 950 HUGO B. BLEICHMAR

(when conflict and hostility prevented their SOME IMPLICA nONS FOR THERAPY recognition) generates feelings of sadness but not of impotence and hopelessness (Klein, I would now like to tum to some clinical 1940). Combining psychoanalytic clinical ob­ examples to illustrate how an integrated model servations with the application of psycho­ can be useful in helping us gain a general analysis to biographies of creative figures, orientation of which conditions are sustain­ Pollock (1989, Volume II, part IV) also ing the depression in a particular patient (i.e. emphasises the importance of the mourning narcissistic disorder, feelings of guilt, aggres­ process for mental health and for creativity. sion, persecutory anxiety, identification with That is why he speaks of mourning as 'the depressive parental figures, fixation to trau­ mourning-liberation process', because of its matic situations of impotence, etc.). If one utility and adaptive significance (p. ix). were to detect that pathology resides basi­ Depression may be: cally in one of the areas mentioned above, a) A component of many different kinds then our therapeutic interventions would be of disorders depression being a symptom primarily oriented towards modifying that resulting from the subject's sense of help­ area. Primarily, but not exclusively, because lessness/powerlessness to overcome the bur­ there is always the risk that a preconceived dens occasioned by the disorder's principal orientation on the part of the analyst may elements. The components which characterise detract from the psychoanalytic listening at­ the main disorder are in the foreground, titude of free-floating attention4 while depression colours the disorder as a Mr K, a man in his mid-forties, came to background mood, although it occasionally treatment as a result of a severe case of takes prominence. depression (dissatisfaction with himself and b) A nosological entity in itself which with those around him, loss of appetite and dominates the whole mental life: the feeling sexual desire, difficulties carrying out his job, of helplessness/powerlessness permeates the and occasionally being unable to get out of representation and functioning of the self bed due to what he described as lack of due to the importance which the wish that energy). We started working with a fre­ is felt as unfulfillable plays in the libidinal quency of three sessions per week during economy of the subject. This depressive con­ two months, and then moved to four sessions dition comprises: the depressive state, re­ per week. Mr K would usually walk into storative attempts, complications of the my office with a sullen expression on his depression, and secondary benefits. Depres­ face, would lie almost completely motionless sion as a disorder may coexist with another on the couch, and speak in a low, monotone disorder but have an independent origin, for voice about how depressed he was, and example a phobic disorder, caused mainly particularly, about the repeated injustices by projection of hostile impulses, coexisting committed against him by others who were with a depression which originates in the invariably depicted as aggressive. After six current loss of an object, a loss which reac­ months in analysis, Mr K brought a dream tivates the mourning of an earlier and much in which three animals appeared. The first more important loss that has never been animal, a large and aggressive one, was biting worked through. the smallest one with an expression ofpleasure

4 Psychoanalytic listening requires that we make ation of the reasons that could support a particular various tasks compatible: free-floating attention to intervention (including its content, form, emotional the patient's associations and emotional experiences. tone, timing etc.). The perfect balance being an ideal free-floating attention to our own feelings and only achieved in occasional circumstances. thoughts, and simultaneously, a pondered evalu- SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 951 on his face. This small animal looked towards gantic claw. I told him that it appeared as the third one for help, but this latter simply though when he was confronted with the joined the larger one in biting and attacking fear of being attacked, he needed to bestow the small one. After recounting the dream himself with a fantasised sense of power (the Mr K went on to talk about his boss, whom giant claw) and thus to be himself the one he described as a tyrant. He said his other who attacked. colleagues were always trying to please the Mr K's aggression was not only a defence boss but that he refused to do so because against feelings of persecutory anxiety. It he was not 'a miserable servant'. This was was also an expression of his rivalry and said in a tone of voice full of contempt and feelings of envy towards people he felt to irritation. Mr K, at this point, also began be superior. This became apparent to me on criticising psychoanalysts, accusing them of a day when he arrived looking uncharacter­ being profit-driven and of lacking any kind istically affable and relaxed, a sign which I of social solidarity. took to mean that he was not feeling threat­ In the light of this material, and given ened. Upon entering my office, and noticing what we had been working on in previous a new object (a small sculpture) which I had sessions in which Mr K repeatedly tried to placed on a table, Mr K suddenly changed get me to join him in his indignation against moods. He made the comment that psycho­ the supposedly aggressive others, I consid­ analysts earned a lot of money, and that we ered several possible lines of interpretation. were privileged given the economic recession I could have oriented Mr K towards making through which the country currently trav­ him see his own aggressiveness projected on ersed. His voice began to die off and I felt to the attacking animal and clearly mani­ that he was getting depressed. He remained fested in the pleasure with which he had quiet for some moments, and then, with criticised his co-workers and psychoanalysts. renewed enthusiasm, he said that the new Denied aggression was undoubtedly an im­ sculpture had a stain on it, and concluded portant characteristic of Mr K's depression. that I must have purchased it at a marked Yet my experience with him, and what was down price. He remained silent for a moment taking place during that particular moment and then continued to criticise the sculpture. of our relationship, led me to think that this Mr K then told me about a friend who would have made him feel accused, which had just taken him for a ride in his new car would have increased his need to defend which had a very powerful motor. Mr K himself through more aggressive criticisms said he considered the powerful motor use­ of myself and others. less, as neither traffic conditions nor speed A different line of intervention which ap­ limits allowed for the full implementation of peared more appropriate to me at the time the motor's power. I reminded him that only was to point out to Mr K that it seemed a month ago he had been contemplating as though he viewed me as someone who upgrading his car, but that he had discarded joined forces with those who attacked him, the idea upon concluding that he could not rather than as someone who wanted to help meet' the credit payments. I also asked him him against his enemies. Mr K did not if he could find any relationship between respond at a conscious level to what I said this and his criticism of his friend's car. After and returned to the dream, adding something a few seconds he told me, almost in a con­ which he had not recounted before: the small fessional tone, that his initial reaction upon animal escaped the attack of the others and seeing the object on my table was to think tore a bush off the ground with one of his that it was quite pretty. 'But only before paws which had been transformed into a gi- seeing the stain', he immediately added. I 952 HUGO B. BLEICHMAR told him that perhaps we could now under­ 'the bunch of mediocre people' (he frequently stand his need to discredit the object and used this expression) that surrounded him. his criticism of me in the previous session: Furthermore, because Mr K had with him­ he criticised that which he valued and ap­ self a relationship in which he fantasised that preciated but which he thought he could by means of punishment he could oblige neither be like nor possess. I emphasised himself to be the way he wished (a grandiose 'thought' to make it clear to him that I did self), he would get angry with himself for not mean that he was inferior, but that he being depressed, saying that he was 'stupid, represented himself as being inferior. weak, soft'. This identification with a sadistic At that moment, the line of interpretation superego led Mr K to beat himself up, which was for him to realise that his criticisms and only reinforced his depression. aggression did not mean that he was intrin­ I understood Mr K's depression as being sically a bad person, but that they were the primarily a product of a pathological nar­ result of his self-deprecation and of his ide­ cissism with grandiose fantasies of power alisation, on a more profound level, of the (the complexities of the case are greater than sculpture and of myself; the denigration be­ the isolated elements I have given); patho­ ing only a superficial defence. Mr K's ag­ logical narcissism which set into motion ag­ gression had still a third source feeding into gression against his significant objects, which it. In his fantasy, aggression had become a he denigrated. But because these denigrated magic tool through which he was able to objects also constituted narcissistic posses­ subject others to his wishes. For instance, sions for Mr K (his wife, his son, his analyst he had once commented, with great admi­ etc.), the denigration would backfire, leaving ration, on how a dictator had the world Mr K to feel that he was surrounded by terrified over the possibility that his country objects that he did not value, but that he might be in possession of nuclear armaments. could not do without. The devaluing of his Mr K made me ask myself a series of significant others robbed Mr K of much of questions: (a) what relationship was there the pleasure of being a father, a husband, between his aggression and his depression? an employee of the firm for which he (b) was his depression a direct result of the worked. A similar dynamic was at work in guilt caused by his aggression towards oth­ his analysis, for when he criticised the work ers? Taking up this last question, though we did together he would get even more every psychoanalyst has doubts as to how depressed, as he saw no hope for his recov­ profoundly he/she has explored a given pa­ ery. Aside from the internal effects of Mr tient's unconscious, neither in Mr K's asso· K's attacks on others, there were also the ciations, nor in his dreams, did I find support external consequences of these attacks: he for concluding that significant feelings of repeatedly failed to gain promotions, his wife guilt followed his attacks on the object (he would sleep in a separate bedroom, his son displayed an utter lack of sympathy for the avoided him. These events only caused him suffering of those around him). I thus be­ greater humiliation and perpetuated the cycle came increasingly convinced that Mr K's of narcissistic frustrationldepressionlaggres­ depression was a result of the frustration sionlnarcissistic frustration. and humiliation experienced when the recipi­ A relevant question raised by this case is: ents of his aggression (his wife, his boss, why place so much emphasis on the patient's myself) failed to succumb to his emotional aggression when this seemed to be a product, outbursts. He experienced this as humiliating in part, of persecutory anxiety and, espe­ impotence, feeling inferior when he had to cially, of a pathological narcissism driven by accept that he had to conform to reality like grandiose expectations? Why not focus first SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 953 on the patient's deficient self-image and the exceptional figure, as someone who is some­ use of grandiose expectations as a defence, how set apart from the rest of the figures hoping that he would no longer feel the need in the patient's life. This idealised bond could to attack once the wounded narcissism was generate a set of expectations that would restored? From my perspective, the response inevitably lead to frustration, to the reacti­ is that, once aggression had become an es­ vation of defensive aggression, and eventu­ tablished mode of relationship between him any towards depression. and his objects, as a way of overcoming a sense of inferiority, he attacked the object In clear contrast to the previous case, I despite the latter's attempts to help him. I would now like to refer to the case of Mrs repeatedly corroborated this in the transfer­ 1, an attractive woman in her early forties ence: even if I had an attitude which I who came to treatment because she felt a considered of emotional understanding of complete absence of pleasure in an aspects his suffering, Mr K ended up attacking me. of her life. She derived no satisfaction from With this patient, I had the opportunity to her job or from her sexual relations with see that empathy and warmth, although a b­ her husband, and took care of her two solutely indispensable, and without which children out of a sense of obligation, but nothing of what we accomplished would without happiness or joy. Even eating had have been possible, were not enough, and become a burden for her. In our first meet­ that he required a constant interpretation of ing, Mrs 1 said that she was not sure whether his aggression and, above an, of the reasons she would be able to get anything useful out behind it. This coincides with what lacobson of analysis as she had 'always been this way, argues: and I am too old to change'. Nevertheless, she was willing to try, mainly because her The patient will be less and less able to tolerate husband had insisted upon it, and we ar­ the analyst's warmth and sympathy, which, fail­ ranged to have four sessions per week. ing to elicit an adequate libidinal response, will The relationship Mrs 1 established with only increase the disappointment and the hostile me was an affectionate one, but one replete claim for a more powerful love. In his fear of a with passivity and fatalism. She would come complete breakdown of the object image, the pa­ to session and tell me her daily worries, tient regresses a step further. We realise that the often mentioning problems with her eating deserted child prefers an aggressive, strong love (lack of appetite, bad taste in her mouth, object to its loss. Correspondingly, the patient may now attempt to hold on at least to the reanimated difficulty with digestion, feeling unduly fun) image of an omnipotent, not loving, but punitive, but she had no expectation that I might be sadistic object. This manifests itself in the patient's able to help her. The devalued image Mrs increasing, masochistic provocation of the analyst's 1 had of herself ran contrary to the one that anger, to a show of aggression which may bring I had begun forming of her. The question temporary relief but will actually promote the patho­ I asked myself (without making it explicit logical process (1971 , p. 239). to her so as not to impose my sense of reality upon her) was: what had happened Furthermore, in the hypothetical case that in the life of this woman who, despite being the analyst succeeded in generating an ide­ intelligent, attractive, relatively successful in alised transference (through an increased ef­ her job, and having a good marriage, was fort towards empathic comprehension and unable to see herself that way? attunement to the patient's needs) without Mrs l's childhood history revealed that facing the negative transference, the patient she had come from a profoundly unhappy could come to regard the analyst as an family. The father was described as an affec- 954 HUGO B. BLEICHMAR tionate man who was afllicted by a chronic I therefore let the exploration of the trans­ illness that had forced him to spend months ference drop temporarily to a secondary plane at a time in bed. Whenever he recovered, (without abandoning it entirely), and focused the family lived in perpetual uncertainty of on uncovering material that seemed of a not knowing how long his good health would more emotional nature for her. The recon­ last. The mother (according to Mrs J's child­ struction of her childhood, and particularly hood memories and current encounters) was of her father's illness, began to awaken these a woman characterised by her self-sacrificing kinds of feelings. She remembered how her attitude and by performing her duties be­ mother used to tell her 'Don't make any cause she was resigned to 'the fate God has noise. Your father is fmally sleeping'. She granted me'. also remembered returning from camp one The absence of any type of manifest con­ vacation to find that her father had had a flict in Mrs J's relationship with me led me severe relapse, for which she felt extremely to wonder whether she was not repressing guilty. I had the feeling at this point that her negative emotions out of a sense of guilt we had tapped into something important: towards an ailing father. This assumption aside from an identification with a passive seemed to fmd support when I once an­ mother, her renouncing pleasure was related nounced to her, in a moment in which she to feelings of guilt. Mrs J's guilt was not was feeling great need of me, that I would rooted in aggression (this was the firm im­ be away for two sessions, to which she pression I received), but in equating pleasure responded: 'Yes, of course, you must rest'. with abandonment of the object to its suf­ I said that it must have been hard to get fering. It was from the suffering of the object angry with a sick father, but my comment that her fantasies and behaviour (which did not appear to resonate strongly with her. had no more aggression than the inevitable I thought that I might have been wrong in amount found in the pre-oedipal and oedipal assuming the existence at that moment of a development of any given person) were sig­ well-developed anger which was in a state nified as harmful. of repression, because for anger to appear, To summarise, I would say that Mrs J's there must frrst be an expectation, which depression had a central component of renun­ subsequently gets frustrated. But Mrs J had ciation of pleasure born out of moral maso­ become used to having almost no expecta­ chism, as well as out of a self-representation tions at all, to going through life and through of impotence. This self-representation was analysis with total resignation and with the essentially the result of an identification with same absence of pleasure her mother had. a father whom the patient had loved, and Aside from identifying with a passive-mother, whose death had left her with a sense of Mrs J had identified with her father's sense hopelessness for achieving a level of intimacy of impotence in relation to his body and to which she needed and desired. Once we had life in general. She would often feel sick (her succeeded in analysing some of the infantile frequent troubles with digestion) and would roots of Mrs. J's moral masochism and fears feel powerless to do anything about it. of emotional involvement, she was increas­ I tried to take advantage of every oppor­ ingly able to become closer to me and to tunity provided by the treatment to touch risk having a more emotional, conflictive upon Mrs J's lack of expectations and de­ and assertive relationship with me. mands made of me. But such transferential interpretations on my part were received by Let us look at a third case. Ms N, a her as bits of intellectual information, not young woman of 22, came to treatment as statements bearing any affective weight. because she was having problems at school SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICAnONS 955 and in her social life. She had recently been Throughout this period, Ms N described abandoned by her boyfriend because, ac­ her parents as a united couple who had very cording to her, after months of attempting few overt marital problems. They owned a to have sexual intercourse, her vaginismus small business and had had only one child. had made penetration impossible. When she Ms N's mother had once had a panic crisis, first came to see me, Ms N was accompanied on account of which Ms N now accompanied by her mother and appeared highly demor­ her everywhere. The mother would not leave alised, showing little regard for her physical the house unless the husband or the daughter appearance, thinking she was a complete were with her. The father was described as failure and that she ought to give up study­ a timid man who was obsessed with not ing. She cried repeatedly throughout the in­ breaking the law and who was always afraid terview and said she was unable to convey that someone would come and tell him he correctly to me what was wrong with her. had been doing something wrong. Ms N's She appeared to be very frightened. She childhood seemed to have been a happy one. failed to make eye contact with me and, Her problems appeared (or at least, became upon leaving, did not shake my hand, but evident) during adolescence, when she had rather, limply stretched out hers, which was to leave the sheltered atmosphere of her cold and sweaty. We began treatment with family life and face the rivalry of her female a frequency of three sessions per week. peers, and especially the sexual advances of Ms N would come into my office and men. That was when her paranoid anxieties position herself on the couch with her feet became intensified, provoking a significant dangling ofT to one side and would clutch regression towards a symbiotic dependence her handbag throughout the session. This, with the mother, who in turn, needed her when coupled with her childish and fright­ daughter as a counterphobic companion. ened attitude, reminded me of the way a It did not appear as though Ms N's dif­ child holds on to a transitional object when­ ficulties with sex were a product of feelings ever he meets a stranger. I found myself of guilt, or of an aggression projected on to speaking to Ms N in a very cautious tone, men, or of a dissatisfaction with her body as though dealing with someone who was image (she considered herself attractive), or fragile, and who could easily be harmed by of a persecutory inner mother who threat­ any sudden remark. For practically the first ened her for her incestuous wishes. Neither six months of treatment, my interventions were her academic failures the product of a were almost exclusively restricted to asking demanding superego projected on to her her questions and to pointing out that I professors. It seemed, rather, that the pho­ understood how difficult it was for her to bic-paranoid world of her parents, perceived talk about certain issues. Ms N's limited and tinged from the standpoint of her own associations and absence of reported dreams fantasies, was what had created a world of would have made it risky for me to have internal objects that made her see everyone made any interpretations as to what lay at outside her family as a threat, which made the root of her depression. My feeling was her have repeated failures in reality (she froze that I had to allow her to adapt gradually during exams for which she was more than to the analysis, to let her be the one to prepared; she became terrorised by sex, she explore the relationship with me, without was terribly frightened of me). The accumu­ seeming invasive or overbearing (the image lation of these situations of failure made her of her vaginismus as a result of her boy­ depressed, for as the only child of parents friend's attempts at penetration were present who had idealised her, she had grown up in my mind reminding me to be cautious). expecting to triumph in life. 956 HUGO B. BLEICHMAR

The main impediment towards progress more than what I said, which had made me in the treatment arose from the fact that become 'one of the family ', instead of 'a part of her fantasies were inextricably inter­ foreigner'. It was in this most profound level woven with her mother's view of the world. of contact between us, almost in the way Subjecting such fantasies to analysis thus felt that an infant child learns to distinguish be­ to her as if she was questioning or criticising tween his caretakers and 'foreigners' (through her mother. This questioning caused Ms N their presence, their smell etc.) that the pos­ enormous anguish, not so much out of guilt, sibility opened up for her to really listen to as out of separation anxiety from an object me. The day when she left her bag on a which functioned as a source of security in chair and began to stroke the couch with her unconscious. I thought that Ms N would one of her fingers, I had the feeling that be unable to separate from her mother's something important had taken place: that suspicious view of people (which by now we fmally had a base (me, as transitional was part of her inner world) until she began object?) from which to begin her separation seeing our relationship as a source of security from her mother's world of paranoid fanta­ and stability. Furthermore, though I felt I sies. Does this mean that my interpretations understood the origin of some of her fanta­ during the previous period of the treatment sies, and would offer her my interpretations, were irrelevant? I would not say that. Does for a long time I had the conviction that it mean that the interpretations were the my interpretations did not reach her. I began decisive element? Not entirely. Parts of them to suspect that she regarded me as one of remained, but only once Ms N began viewing the 'foreigners', a term which her mother me as 'one of the family' did the memory used to refer to those who were not from of what I had said acquire a meaning (de­ their part of the country, and which, in my ferred action) that she could listen to and patient's mind, had become associated with incorporate. We were thus able to discuss a cross between some gypsies and some black her fears of men's genitals and of 'foreigners' people who appeared in one of her childhood from a new perspective. books as kidnapping small children. In line If we tried to summarise Ms N's case, with my assumption that she saw me as one her depression seemed to be the result of of these frightening foreigners, I said to her: paranoid anxieties that blocked her mental 'How can one believe in what a foreigner functioning and precluded her from having says without suspecting that he has ulterior a close, satisfactory relationship with people, motives in everything he says?' 'Right', she and a successful mastering of other aspects responded half-heartedly, without any con­ of reality. The repeated frustrations of her viction, as though my question really were legitimate narcissistic expectations led her to that of a 'foreigner' who was deviously trying depression. The narcissistic disorder was sec­ to get her to lower her guard. ondary, however, to her persecutory anxiety. This situation prolonged itself for about Despite having looked for them, I was unable a year, during which I tried to help her work to detect significant pathologies in the areas through her paranoid anxiety of me. My of grandiose expectations, of important feel­ impression throughout this time was that ings of guilt, of masochism, of deficit of what I said to her did not matter as much narcissistic supplies from the parents, or of as the tone in which I said it. The cadence, traumatic experiences that had left her with rhythm and timing of my interventions seemed feelings of impotence. to affect Ms N more than their actual con­ tent. More importantly, I felt that Ms N These three cases provide some support had begun getting used to my presence, to for the idea that it is necessary to have the office, to the couch, and that it was that, broad-reaching models of depressive disor- SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 957 ders. They also highlight the significance of parents who made the patient feel that every­ the idea of temporal accuracy, that is, of thing in life was dangerous and had to be the importance of the correct timing for any mistrusted, as in the case of Ms N; a given psychoanalytic intervention. Without phobia which may encase the patient in a it, it would be conceivable that, while we world full of limitations and frustrations, are embarking on examining the circuit of and prevent him/her from obtaining essen­ aggression, the patient in question has moved tial and legitimate narcissistic gratifications; on to a severe narcissistic imbalance, and a phobia not resulting from the projection that when we are focusing on narcissistic upon the object of aggressive impulses, nor anxieties, the patient has shifted towards from the displacement of fears of signifi­ persecutory anxieties or towards feelings of cant figures, but from a profound primary guilt. disorder in the representation of the self Having a more integrative model of de­ and objects. pression could diminish the risk of making It could also be inappropriate to concen­ interventions that, being pertinent for a given trate on the supposed failure of a significant subtype, could become inefficient, or even other when the depression results from the reinforce the pathology, when applied to a subject's aggression (based upon pre-oedipal different one. Just as in medicine, where or oedipal rivalry, or driven by a destructive even very useful medications have clear cases narcissism) (Rosenfeld, 1987) which leads to in which they are contra-indicated, perhaps repeated confrontations and loss of the ob­ psychoanalytic interventions should also be ject. Similarly, we could hinder the progress thought of as indicated or contra-indicated, of the treatment if we failed to detect that and not as universally applicable. To illus­ the depression is not the result of a deficiency trate the potential risks of lines of interven­ in the significant other's capacity to satisfy tion which are adequate for certain patients narcissistic needs, but rather, the reverse: but not for others one need only think of depression as the result of an inculcation in the dead-end street to which analysing a the patient of a megalomaniac self-image patient's supposed aggression can lead to that grants him a sense of exceptional self­ when the depression is essentially the result worth, and which leads himlher to disregard of having a guilt-ridden or devalued self-rep­ reality, to assume he/she is above and beyond resentation inculcated by significant others. the need to learn, to make an effort, to take In such a case, the analytic work could risk precautions. Such a megalomaniac self-rep­ reinforcing that which the significant others resentation leads to surprise and subsequent had conveyed to the patient: that he was depression when the subject is confronted aggressive and bad. There is no person en­ with repeated failures in reality. tirely devoid of unconscious or conscious Finally, J would like to point out that the aggressive fantasies. But an important issue model presented here is still within a pre­ is whether such fantasies actually play a liminary and somewhat general level of causal role in the person's depression or elaboration. Further studies would be re­ whether they are defences against it (i.e. quired, of which this one is intended as a acting as an imaginary way of acquiring a contribution, in order to fine-tune its propo­ sense of potency that extricates the person sitions. Such studies should aim towards from the painful perception of impotence integrating major psychoanalytic works that and helplessness). have contributed to our understanding of It would be unproductive as well to focus depression, and especially, towards making on a patient's aggression when the depression correlations between different depressive con­ comes as a result of a phobia, which, in figurations and those psychoanalytic inter­ tum, is the result of an identification with ventions best suited to changing them. 'D V. 00 Directed towards the {. } : - 'representation~ ------Aggression ------r - -Acted against -.

I of the I I• I I , 1• , PROJECTION OBJECT QELi'-] I .- ...... \ , Deterioration - ...... - \ ...... 4._ Self-criticism of the sense \ Hostile• detet'klrates PERSECUTORY \ response from s~f· of power for 1- ANXIETIES \ -. coptng with I I , representation the object \ reality I \ , , I "- , , , I "- ::x: , , I "- c::: Detertorallon, loss 01 , , I "- r- -- -- the obt8d as a .... , , Deterioration 8 valuabte obfeCt I . " , , of mental Loss of real-life I , , functioning, Desertion of the ?' .J ' , , Inhibitions, opportunities object I:J:l "- and - -- "- ego deficits t , " achievements / r;; , , / / If the obfect Is an "- " .. If the object Is a , , / / - 'obtect of the 'narctaslslle narcissistic If the , Deterioration / / , / / possession' : adlvly" : object Is , of seff· ~ contamlnaUon of deleriofaUon and 'el as a , representation / If the obfed was a the self with the loss of se/f protective , ;" narclsslstlc object ~ devaluation or 'unctions object , , used to sustain the object associated wtth , ./ ./ SeJ'-8steem the object L_--;;-_ __ , , /­ ...L ......

NARCISSISTIC Mertal, physical or social ~~ : ------1 ---- deterioration ------~------DEPRESSION .. If responsibility is felt for If responsibility is felt for GUILTY _ the well·being of the the well·being of the __ ------.j DEPRESSION ~- --- attacked object attacked object

I SOME SUBTYPES OF DEPRESSION AND THEIR IMPLICATIONS 959

TRANSLATIONS OF SUMMARY hungen zwischen diesen Faktoren untersucht. Die Beziehung zwischen Aggression und Depression wird L'auteur montre qu'iJ est oecessaire de deveiopper analysiert, besondere Beachtung wird dabei den un modele de depression psycbanalytique clinique Schritten geschenkt, durch die Aggression sich in De­ integratif qui prend en consideration divers chemins pression verwandelt. Psychoanalytische InteIVentionen, menant a des SOlls-typeS de depression difTerents. II die fiiI eine bestimmte Unterform von Depression examine certains des facteurs a I'oeuvre dans la genese geeignet waren, sich aber als eher schadlich herausstel­ et Ie maintient de la depression (I'agressioo, la cul­ len konnten, wenn sie bei einer anderen Unterform pabilite, Ies troubles narcissiques, les angoisses de angewandt wiirden, werden diskutiert. Klinische persecution, les deficits du moi, Ie masochisme, l'iden­ Beispiele werden herangezogen, urn die vorgestellten tification avec les parents depressifs, et la fixation aux Gedanken zu unterstiitzen: Der Autor meint, daB evenements traumatiques en sem desquels Ie sujet se weitere Studien notwendig sind, um spezifischere Kor­ sent desespere). ainsi que certaines inter-relations dy­ relationen zwischen den verschiedenen depressiven namiques parmi eux. Le rapport entre l'agression et La Konfigurationen und den zur Veranderung am besten depression est analyse, et I'auteur apporte un sain tout geeigneten Formen von psychoanalytischen lnterven­ particulier aux etapes a travers lesquelles l'agression tionen zu entwickeln. se change en depression. 11 passe en revue les origines du sentiment de culpabilite, y compris les conditions El autor debate el tema con la finalidad de desar­ qui sont independantes de l'agression. 11 traite des rollar un modelo integrativo clinico psicoanalitico de interventions psychanalytiques qui pourraient se depresion, que tiene en cuenta varias trayectorias que reveler pertinentes pour un sous-type de depression conducen a diferentes sub-tipos de depresion. Se ex­ donne, mais qui pourraient s'averer contre-produc­ aminan algunos factores que intervienen en la genesis tives lors qu'elles sont appliquees a un autre sous-type y en el mantenimiento de la depresi6n (agresividad, de depression. L'auteur donne des exemples pour culpa, conflictos narcisistas, ansiedades persecutorias, soutenir les idees avancees, tout en reconnaissant que deficits del Yo, masoquismo, identificaci6n con padres de plus amples recherches sont necessaires afin depresivos y fijacion a acontecimientos traumaticos d'etablir des correlations plus specifiques entre les en los que el sujeto se sintio desamparado), asi como ditTerentes configurations depressives et les types d'in­ ciertas inter-relaciones dinAmicas entre eUos. Se analiza terventions psychanalytiques qui seraient Ies plus ap­ la relacion entre agresividad y depresion, prestando propries pour les changer. particular atenci6n a los pasos a traves de los cuales la agresividad se convierte en depresion. Se revisan los Der Autor setzt sich fur die Notwendigkeit ein, ein origenes de la culpa, inc1uyendo factores que no de­ integratives, klinisches, psychoanalytisches Modell von penden de la agresividad. Se examinan intervenciones Depression zu entwickeln, das verschiedene Wege, die psicoanaliticas que podrian ser pertinentes para un zu unterschiedlichen Unterformen von Depression fiihrt, sub-tipo preciso de depresion pero que resu1tarian in Betracht zieht. Einige Faktoren. diezur Entwicklung inadecuadas para otro sub-tipo diferente. Se presen­ und Aufrechterhaltung von Depression beitragen, tan ejemplos clinicos para ilustrar las ideas que se werden untersucht (Aggression, Schuld, narziBtische desarroUan, reconociendo que se deberia profundizar Storungen, Ich-Defizite, Masochismus, Identifika­ mas para establecer correlaciones mas concretas entre tion mit depressiven Eltem und Fixierung an trauma­ las configuraciones depresivas diferentes y los tipos de tische Ereignisse, in denen sich das Subjekt hilflos intervenciones psicoanaliticas mas apropiadas para fUll1te); ebenso werden bestimmte dynamische Bezie- cambiarlas.

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Hugo B. Bleichmar Copyright © Institute of Psycho-Analysis, London, 1996 Diego de Leon, 44 _ 3° IZQ 28006 Madrid (MS. received 2119/95) (Revised MS. received 2712196) (Final version received 2214/96)