Two Faces of Depression Trevor Hjertaas Abstract Using the perspective of Individual Psychology, the author examines two variants of clinical depression proposed by Sidney Blatt (2004): the anaclitic and the introjec- tive. The author finds both of these to have similarities to key concepts in Individual Psychology: the need for belonging and the striving for perfection. Clinical depression is both a biopsychosocial disorder and a painful emotional state that has enormous impact on the afflicted individual and on those close to him or her. It decreases quality of life, erodes important relationships, and reduces the ability to function effectively. Mood dis- orders are among the most common psychiatric disorders both in North America and worldwide. Lifetime rates for the occurrence of Major De- pressive Disorder in the general population have ranged from 4.9% to as high as 24.4% among recent epidemiological studies (Goodwin, Jacobi, Bittner, & Wittchen, 2006). Major depression also occurs twice as frequently among women as among men, and it is generally found to be more com- mon among members of ethnic minority groups and among members of groups with lower socioeconomic status. With such suffering ensuing from a mental health condition, the psychotherapist must have sufficient means to comprehend and treat the disorder. In this article, I focus on psychological perspectives of depression, especially from an Adierian framework. The Traditional Adierian Perspective on Depression Some Adierians considered it an error to discuss psychological "types," as this does some harm to the phenomenological understanding of the unique individual. Nevertheless, Alfred Adler did acknowledge typologies as having some use as "a conceptual device to make more understandable the similarities of individuals" (as cited in Ansbacher & Ansbacher, 1956, p. 166). In this paper, I discuss some hypothetical types with the understand- ing that no such construct perfectly matches any distinct person and that, overlap between types is not uncommon. In his case histories, Adler (2005) warned of the veiled aggressive or vindictive element often seen in conditions such as depression and wrote The journal of Individual Psychology,\/o\. 66, No. 4, Winter 2010 ©2010 by the University of Texas Press, P.O. Box 7819, Austin, TX 78713-7819 Editorial office located in the College of Education at Georgia State University. Two Faces of Depression 341 of attempts to succeed through displays of weakness or to conquer with tears. He also noted that depression could be used as a weapon to elevate one's position and that dysphoria and complaining could force others into one's service. With his keen clinical insight, Adler perceived how those who felt a certain degree of entitlement could use affective distress (such as depression) to control, enslave, and punish others. Such people use depression mucb like a weapon in tbeir war against those close to them. Kurt Schneider (1959) described "depressives who are chilly, surly, bitter, suspicious, irritable, nagging, and indeed malicious and ill-intentioned" (p. 21). Such a de- scription could serve well to characterize what one might call a "vindictive" depression, where the idea and use of social interest is poorly developed. There are also individuals who have endured a difficult early situation, who have been systematically discouraged, or who have reached mistaken conclusions concerning life and their place in it. However, their depression does not usually manifest with such overt hostility. Adler (2005) stated, "An individual who fears a failure in life, or for whom failure has overtaken, can point to depression or melancholy as the reason for the failure, thereby freeing himself of responsibility by demonstrating his own weakness and needs for help" (p. 245). This type often exhibits a "display of helplessness," an early occurring lifestyle strategy described by Dreikurs and Soltz (1964). Adler (2005) wrote of a patient of this type: "She can become a focus of at- tention again, and once more an actress on the stage of life, by playing the role of an entirely bopeless person" (p. 15). Adler also stated that depression can be a barricade erected by the person himself or herself, with the aim to block the approach to the real business of life. One might think of sucb an individual as a "profoundly discouraged" type. It may be tbat there is a continuum of such individuals, witb those who are profoundly discouraged on one end of the spectrum and those who are more vindictive or manipulative in their depression on the other. Both exploit the social interest of others, but the dynamics are not identical. Clinical examples of both are also seen in Adier's writings. Tbese types of individuals are, unfor- tunately, very common, and most Adierians have focused on the dynamics of such clients when considering the phenomenon of depression (K. Adler, 1961 ; Mosak & Maniacci, 2006; Rasmussen & Dover, 2006; Slavik & Croake, 2006). There are, however, other reasons depression arises and—significantly—these reasons, or exogenous factors, also reflect Adierian concepts. Two Further Constructs of Depression As common as the vindictive and profoundly discouraged classical Adierian variants are, they are not the only manifestations of depression. Noted psychoanalytic researcher Sidney Blatt (2004) described two common 342 Trevor Hjertaas types of depression, which he termed the anaclitic (dependent) and the in- trojective (self-critical). These two depressions arise because of dynamics well conceptualized in Adier's model of human nature. In Adierian terms, these two constructs of depression represent serious difficulties either in the area of "belonging" (Dreikurs, 1990) or "striving for perfection" (Ansbacher & Ansbacher, 1979). Anaclitic depression. Individuals with anaclitic depression (Blatt, 20Ö4) have usually experienced some kind of difficulty or loss in their early attachment relationships (Bowlby, 1988), which has discouraged them and contributes to the construction of a somewhat mistaken style of life. If they maintain some degree of courage, those who are classified as anaclitic tend to be agreeable, to value relationships, and to have constructive and sup- portive interactions with others. However, although their relationships are usually fairly secure and harmonious (at least on the surface), these people are often submissive and placating, tending to sacrifice self-interest for the sake of the continued goodwill of the other. As Arieti (1977) pointed out, such individuals may live more for the "dominant other" than for them- selves. This dependent style (Millón, 1999) seems to involve being finely attuned to the feelings and wishes of others, and this strategy often facil- itates getting their emotional need for belonging met. However, any risk to the cherished relationship evokes intense anxiety and any actual loss is experienced as catastrophic. Millón and Grossman (2007) noted of such de- pendent individuals: "Their depression often represents a logical but overly extreme response to real or potentially threatening events" (p. 99). Unfortunately, should such individuals have less courage, even greater difficulties arise. Blatt (2004) stated that those who have this underlying need for dependency but who are not successful in directly meeting it (through the establishment of close, supportive relationships) will manifest a wide range of psychopathology. Over-sensitivity to possible rejection or abandonment could be apparent. A chronic feeling of emptiness or uncer- tainty concerning identity and place in the world is also not uncommon. Depression, suicidal ideation, and parasuicidal behavior may be seen, often with the somewhat desperate motive of attempting to coerce caring from an unresponsive or indifferent other. Of course, the classical Adierian un- derstanding is evident, where the motive of harming the self serves as an accusation against those who the person feels should care. As Alexandra Adler (1959) noted, "Psychogenic depressions usually occur in individuals not prepared for disappointments" (p. 182). The person also may turn to substances to both numb the loneliness experienced and to form a type of "relationship" with something which can be relied upon to be there when needed (Benjamin, 2003). Gabbard and Bennett (2006) stated that dyspho- ria around feelings of abandonment, loss and loneliness is often seen. An Two Faces of Depression 343 avoidant or hesitating dynamic of both longing for—and dreading—rela- tionships may also develop. Pancner (1993) cited Hirschfield, Klerman, & Clayton's (1983) research indicating that those with depression often show "a dependent, emotionally unstable and introverted personality" (p. 124). A lack of feeling a true sense of belonging and connectedness with others lays at the root of all of these problems and the depression which results. Introjective depression. The second variant is the introjective type. These individuals particularly suffer from what Adler (as cited in Ansbacher & Ansbacher, 1979) called "[humanity's] dark longing to reach perfec- tion" (p. 33). Blatt (1995, 2004) maintained that introjective types tend to be achievement-oriented individuals, often perfectionistic, with a rigid or driven quality in their relationship to self (and often toward others as well). These high expectations may manifest as irritability, resentful ness, and criti- cism of themselves and other people. They may often be somewhat hostile and unpleasant to be around. However, such