Two Faces of Depression

Home , Individual psychology, Sidney Blatt

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 introjective. 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 disorders 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 common 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 understanding 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

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 attention 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, unfortunately, 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 introjective (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 supportive 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 themselves. 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 dependent 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 understanding 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 dysphoria 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—relationships 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 perfection" (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 irascibility is not always the case, especially if the person has adopted the belief that one should be friendly and personable (even if not genuinely feeling that inside). What is generally true is the strict adherence to movement on the vertical plane (Sicher, 1992)—the unrelenting pursuit of "success" and the phobic avoid- ance of "failure." Blatt (2004) stated that such people are very sensitive to possible ridicule or to revealing any inadequacies and that this may be partly why they often maintain an emotional distance from others. Blatt further explained that such individuals often perceive others as harsh, uncaring, and unsympathetic, noting that this view may relate to unpleasant early develop- mental experiences and, thus, is likely reflected in the person's lifestyle. From this "internalization" of punitive, overly demanding or barsh early attachment figures, Blatt derives a name for the kind of depression as an "introjective" one. As Lorna Benjamin (2003) stated, they have learned to treat themselves as others have treated them. Such individuals are plagued by intense feelings of inferiority should their achievements be less than perfect (Rom, 1971). As Kurt Adler (1961) explained, extremely elevated goals are too difficult to attain and discouragement, demoralization, and depression naturally follow. Similarly, Horney (1964) stated, "To be rendered helpless is particularly unbearable for those persons for whom power, ascendancy, the idea of being master of any situation, is a prevailing idea" (p. 40). Fail- ing to actualize their exaggerated ideals, individuals with an introjective depression are likely to feel worthless, inadequate, inferior, and hopeless. Their strict code of self-conduct and unforgiving stance toward any errors or failings leaves them vulnerable to terrible experiences of guilt, shame, and self-loathing, which can easily lead to self-destructive behavior and even suicidality. Gabbard and Bennett (2006) noted that such people often manifest a sense of failure and a perception that their autonomy and control has 344 Trevor Hjertaas been lost; depression soon ensues. Blatt and Zuroff (1997) maintained that extensive psychological research indicates that high levels of perfectionism create a vulnerability to depression. Validity. Interestingly, Blatt's two types are very similar to Aaron Beck's (1983) cognitive behavioral model of two types of individuals prone to depression: the sociotropic type (those with a strong need for interpersonal attachment and affiliation) and autonomous types (those with a strong need for achievement). The similarity of perspectives from two varying theoretical schools argues strongly for the existence of these types of clinical presenta- tions, which were extensively explored by Adler.

Assessing the Roots of Depression

In the Psychodynamic Diagnostic Manual (Psychodynamic Diagnostic Manual Taskforce, 2006), anaclitic depression and introjective depression are classified as depressive personality disorders, with the underlying traits such as dependency or perfectionism being emphasized. Although this focus on personality traits is undoubtedly important (and is sometimes overlooked in the literature on mood disorders), there is perhaps some difficulty with perceiving these clinical constructs purely in this manner. A depressive personality disorder suggests that the individual has experienced a chronic dysphoric affect at least from adolescence onwards. Although this can occur, not all individuals who manifest anaclitic depression or introjective depression will have been depressed throughout their lives. Millón (1999) postulated that transient clinical syndromes (such as depression) arise from vulnerabilities in the personality pattern, and 1 feel this is a more useful conceptualization. Millon's perspective is also consistent with Adier's because in Individual Psychology conditions such as depression are believed to arise from lifestyle errors (Dreikurs, 1956). As Millón (1999) argued, using such a personality-based approach to understanding clinical syndromes such as depression allows therapists to integrate the apparent discrepancies between what the DSM-IV-TR (2000) terms Axis I and Axis II conditions. As Dreikurs (1956) stated, this form of analysis allows a holistic understanding of why a particular individual develops certain problems given the current difficulties he or she is facing in life. An examination of lifestyle is essential. Much of the arising dysphoric or anhedonic affect seen in depression may be related to basic mistakes or interfering ideas (Shulman & Mosak, 1988). As Aaron Beck (1973) noted, depression is often somewhat para- doxical: An individual will develop a puzzling and often extreme dichotomy between his or her self-image and what seem to be objective facts. A caring and honest person may view himself or herself as a corrupt sinner; a Two Faces of Depression 345 physically attractive person may perceive the self as ugly or disfigured; a successful person comes to believe he or she is a miserable failure. This paradox is not accidental, and it has its explanation in the failure of or risk to that which is cherished or valued by the person, in conjunction with some loss of courage on the part of the individual. As Bockian (2006) stated, people become depressed for a reason, and that reason is frequently related to their personalities or, as Adler termed it, their lifestyles. Similarly, Millón and Grossman (2007) have noted, "Cognitivists, in general, interpret depression as stemming from reality misinterpretations and a faulty logic that derives from a persistent pessimistic orientation" (p. 97). As an early constructivist/ cognitive theoretician, Alfred Adler pioneered this view (Watts, 2003). Although not always translatable to diagnostic formulations such as the DSM-IV-TR, the errors in logic and pessimistic orientation of the individual are often apparent in the early recollections—especially when an individual is in a depressed state (Clark, 2002; llgenfritz, 1979; Mosak & Di Pietro, 2006) and the clinician can use these to help ascertain any mistaken beliefs. In addition, signs denoting these two different manifestations of depression can sometimes be found on projective tests, such as the Thematic Appercep- tion Test (Kwon, Campbell, & Williams, 2001) and the Rorschach (Fowler, Hilsenroth, & Piers, 2001).

Inferiority Feelings in Depression

Exaggerated feelings of inferiority are typically seen in depression. In both anaclitic depression and introjective depression, intense inferiority feelings are also likely to play a crucial role. As Aaron Beck (1973) stated.

Low self-esteem is a characteristic feature of depression. Self-devaluation is apparently part of the depressed patient's pattern of viewing himself as deficient in these attributes that are specifically important to him . . . Often the sense of deficiency is expressed in terms such as "I am inferior" or "I am inadequate." (p. 20)

Similarly, Kristeva (1989) has written that modern psychoanalytic practice has led to the understanding of "another form of depression . . . sadness which points to a primitive self-wounded, incomplete, empty. Persons thus affected do not consider themselves wronged but afflicted with a fundamen- tal flaw" (p. 12). Although the goals differ (affiliation versus achievement), the profound sense of inadequacy and discouragement is the same, and the depression and hopelessness, to some extent, represent means to avoid a dreaded failure. Rasmussen (2005) explained that, from an evolutionary perspective, "depression is associated with a general retreat from life. 346 Trevor Hjertaas an escape from an unwinnable situation" (p. 261). Wben one is facing the difficulties of life and feels inadequate to meet tbem, it is extremely difficult to persevere.

Further Issues in Depression

Alfred Adler (2005) opened his classic text. Problems of Neurosis, with the statement, "The problem of every neurosis is, for the patient, the difficult maintenance of a style of acting, thinking, and perceiving which distorts and denies the demands of reality" (p. 2). For individuals who have either an anaclitic depression or an introjective depression, the lifestyle error appears to involve an inflexible and exaggerated need—often a compensation for an earlier lack—which leaves the person vulnerable to any failure. As Ness (2006) noted, "A tendency to have only a few attachments or only one big life goal provides fewer options when things go badly" (p. 168). As Adierian theory posits, human connectedness and movement toward competence are basic desires; however, if an individual is rejected by a cherished group or person or if an individual fails in a valued endeavor, he or she still needs to feel he or she has worth (Dreikurs, 1990). It is this capacity, tbe belief that our "place" in life is still secure despite our inadequacies or less-than-ideal situations, whicb tbese individuals with depression lack. As Rom (1971) noted, "We are not obligated to give up because difficulties seem to be over- whelming" (p. 19). If an individual has not developed a certain degree of psychological tol- erance, when a cherished hope or relationship is lost then the experience of major depression can arise quite naturally (Klein, Shankman, & McFarland, 2006). A dysphoria or anhedonia emerges, with prominent unhappiness or lack of pleasure in daily activities. Energy level decreases as hopelessness grows, for who would evoke the energy to pursue a bopeless aim (Minkowski, 1970)? Despair disturbs one's sleep and there is either little appetite for food or—more rarely—there is an attempt to comfort the self through an increased intake. Guilt may arise, either as a self-condemnation to avert attention from the perceived failure (Mosak, 1977) or as a nonconsensual rationalization of why a rejection might have happened. Neurocbemical changes also occur (Delgado & Moreno, 2006), but, viewed holistically, these are difficult to perceive as causal in most situations (Dreikurs, 1973). Some may argue that the anaclitic type or introjective type is not true depression but is either reactive (representing an adjustment disorder) or is a sort of unusual bereavement (as something valued has been lost). However, Alexandra Adler (1959) explained that clinical depression does arise from such causes and merely represents an exaggeration of normal reactions (perhaps being exaggerated because of the lifestyle vulnerabilities, as discussed Two Faces of Depression 347 above). This is similar to what Pancner (1993) emphasized: that depression is a universal human emotion, becoming a "disorder" when the ability to function (i.e., to meet the tasks of life) becomes impaired. Further, Pancner noted that the majority of clinicians are prepared to recognize exogenous factors in the development of depression. Unless the particular therapist is personally invested in a purely biological perspective, he or she will likely be able to locate some loss, defeat, or disappointment in the vast majority of depressive disorders (Dreikurs, 1973). As Kristeva (1989) stated, "The wound I have just suffered, some setback, or other in my love life or my pro- fession . . . such are often the easily spotted triggers of my despair" (p. 43). As Alfred Adler and later theorists, such as Horney (1964), Bibring (1953), and Rogers (1989), all noted, the discrepancy between one's ideal- ized and actual self can be a source of profound pain. Anaclitic depression and introjective depression can readily be understood as arising in individuals who have succumbed to hopelessness because they had exaggerated, difficult-to-achieve ideals or goals. As Ness (2006) stated.

Intense ambition, strong attachments, fear of being alone, and a tendency to put all of life's meaning on one large goal are all traits that make it more likely that a person will find himself or herself trapped in pursuit of an unreachable goal. (p. 164)

Similarly, Gabbard and Bennett (2006) noted that one's aspirations often involve either love and belonging, or superior accomplishment, and "the ego's awareness of its actual or imagined inability to measure up to these standards produces depression" (p. 390). There can also be confusing clinical pictures when a blending between the classical Adierian view of depression and the anaclitic type or the introjective type may be discerned. For example, an individual manifesting an anaclitic depression involving his or her rejection by significant others may begin using the illness to try to elicit some sympathetic feelings from people. Alternately, an individual manifesting an introjective depression because of a professional failure may decide, although perhaps with little awareness, to attempt to regain importance through tyrannizing his or her family with complaints. In such complicated cases, all the underlying factors involved in the depression will need to be explored.

Strategies in the Treatment of Depression

Both the psychoanalytic and cognitive-behavioral schools offer some specific recommendations for the treatment of these types of depression. 348 Trevor Hjertaas

Those with an anaclitic depression will likely prefer a more informal, supportive approach to therapy, where they can look to the clinician for emotional nurturance and assistance in coping with life difficulties. The empathie therapeutic relationship is likely to be instrumental in their recovery. The danger will be that they will become dependent on the therapist and resist any idea of termination. However, Blatt (2004) recommended being supportive and reactive with the client despite any transferential issues of dependency which might arise. Blatt stated that such patients are likely to be concerned about such issues as dependability, reliability, and affection—both from other people in their lives and from the therapist. Therefore, taking the attachment perspective of Adler and, later, Bowlby (1988; Hjertaas, 2008; Weber, 2003), Blatt emphasized the need for a caring, compassionate therapist as necessary if the individual is going to be willing to examine his or her core beliefs. As part of his or her overall recovery, a client with either type of depression needs to develop the area which was overlooked. Those individuals with anaclitic depression need help in countering their thoughts that they do not belong, along with help developing a sense of autonomy and agency. They need to come to value the movement toward competence, something that is often either underdeveloped or which has been abandoned in order to appease a significant other who is threatened by the personal growth of the client (Arieti, 1977). This can be facilitated by encouraging the individual to engage in minor success experiences, building on the person's strengths to progressively develop competencies (Millón & Grossman, 2007). Examina- tion of core lifestyle beliefs of self, others, and life also will assist the person (Shulman & Mosak, 1988). An individual with introjective depression will likely prefer a more formal, directive, problem-focused approach where the demoralization is immediately addressed, homework is assigned, and efforts to modify cog- nitions are strenuously made (Beck, 1983; Friedman & Thase, 2006). This approach will help the person make some progress in therapy, but it is likely insufficient on its own. As Blatt (2004) emphasized, what these individuals prefer is not necessarily what is good for them: The individual with introjective depression needs to learn to consider the needs of others to a greater degree and focus more on a sense of connectedness and belonging. As Pirot (1986) noted, perfectionists are often self-absorbed, so creating outside importance becomes key. Perfectionistic striving can certainly interfere with the ability to col- laborate with and to consider the rights and feelings of others (Blatt, 2004; Mosak, 1977). This will naturally cause difficulties in clients' lives and in the therapeutic relationship as well. As Blatt (2004) warned, these individuals are usually preoccupied with issues of self-worth and autonomy and are Two Faces of Depression 349 likely to focus on concerns about power, control, achievement, competition, and anger. They may also enact such issues within the session, viewing the closeness of therapy with some distrust. Although somewhat difficult for them to tolerate, the therapeutic relationship can serve gradually to broaden the options these individuals have, providing a means of learning how to cooperate with others and offering a venue to explore interpersonal difficulties that arise in their lives. Blatt (2004) noted that neurotic perfectionism arises from a conviction that nothing is quite good enough, so that the individual perpetually lacks any sense of accomplishment from contributions: "Deep seated feelings of inferiority and vulnerability force the individual into an endless cycle of self- defeating overstriving in which each task and enterprise becomes another threatening challenge" (p. 62). They need assistance with reducing their perfectionistic strivings and over-ambitious self-ideals. Adler would state to the patient: "Now we do not want to talk any more about what prevents you from being the first, but how you have come to want to reach the goal, as if on command" (Ansbacher & Ansbacher, 1979, p. 193). Redefining success as conscientiousness and contribution can be helpful, and self-acceptance can be aided through the idea of the courage for imperfection (Lazarsfeld, 1966). Likely the best cure for anaclitic depression and introjective depression is the same one Alfred Adler offered to those with vindictive or profoundly discouraged forms. Once the lifestyle errors have been explained to the person, in order to clarify what was experienced as unfathomable and therefore anxiety-provoking and demoralizing, a means must be found to reconnect the person to life. This initially is done through the therapeutic relationship, where the discouraged individual finds a concerned and understanding other (Ansbacher & Ansbacher, 1956). Adler then advised that his patients first contemplate and then actually do small things to please others within their social circle. This would serve to counter their passivity, create connectedness with others, and help them feel useful and worthwhile. In this way, Adler was encouraging the client to take a proactive approach related to acting in a socially interested way toward others. Eor Adler believed and claimed that the root of the discouragement related to these forms of psychological impairment was the lack of social interest. Such a strategy would likely slowly show the individual with anaclitic depression that he or she can achieve a feeling of belonging without having to depend on the goodwill of a single significant other. The individual with introjective depression might gradually realize that life can involve more than a relentless vertical striving (Beecher & Beecher, 1986; Sicher, 1992), and the emerging feeling of belonging might then progressively challenge the painful conviction that the person is "never enough." 350 Trevor Hjertaas

Case Examples

The following two case examples are fictional composites, derived from multiple, similar individuals that 1 have seen. Case No. 1. Ms. A. was seen on an inpatient basis. She was a woman in her mid-50s who suffered from a profound depression of the anaclitic type. She would spend most of her day on one of the hospital ward couches, doing very little except staring into space with either a blank expression on her face or an expression of utter despair. Her movements were pain- fully slow, as was her verbal fluency so that talking was somewhat laborious for her. The smallest task, such as walking down the hall to the therapist's office, seemed to exhaust her. Results on both the Rorschach and Millón Clinical Multiaxial Inventory-Ill indicated dependent personality traits and severe depression. Ms. A. was suicidal, believing that her loneliness was too intense to bear and that everyone associated with her would be better off if she were dead. However, she worried a great deal about her cat, and this worry seemed to be her most salient reason for living (Strosahl, Chiles, & Linehan, 1992). Ms. A. had had a difficult childhood, her father being a violent alcoholic, and many of her early recollections involved her feeling helpless in the midst of unpredictability or when faced with the anger of others. Later, she had unfortunately perpetuated this early pattern by marrying a bitter man who also drank. She remained with him until her two children were grown and then left him, moving to another city. Although this was a courageous decision on her part, Ms. A. believed she had failed in her marriage and now felt isolated from her family. Ms. A. had a small but devoted circle of friends who expressed great concern about her while she was hospitalized. However, while depressed, Ms. A. seemed to "forget" about the importance of these friends and how this represented a meaningful area of connectedness for her. As she became more encouraged through the therapeutic process, this "apperceptive sco- toma" was challenged and Ms. A. realized that, prior to her depression, she had, in fact, been successfully meeting her dependency needs (as well as being a good friend herself) but, in her rigid, absolutistic thinking, had dismissed this source of strength. The experience of empathie understanding and encouragement obtained through the therapeutic relationship helped Ms. A. regain an awareness of her competence in many areas of life. Al- though not fully recovered, Ms. A. eventually returned home to her cat and her regular visits with friends. She also found means to have somewhat increased contact with her adult children. Case No. 2. Mr. B. was a man in his late 30s with a wife and two children, who was seen in a private practice setting. He presented with a serious Two Faces of Depression 351 depression of the introjective type. Having been unsuccessful in a competition for an eagerly expected promotion at work, he had become deeply depressed to the extent tbat he needed to go on short-term disability. Mr. B. would readily express depressive thoughts, speaking angrily of how he was a failure and, at times, becoming tearful (something wbicb appeared to humil- iate him deeply). Although be was generally lethargic, doing very little but sitting on his couch staring at the television, on occasion he would become restless and agitated, bitterly denouncing himself and bis inadequacies as he paced back and forth in his living room. Results on the Millón Clinical Mul- tiaxial Inventory-Ill indicated severe depression and narcissistic personality traits. Tbese results were supported by those on the Rorscbach, which also suggested features of painful self-loatbing. Mr. B. was also suicidal, believing that be was a worthless failure and that there was little hope for him. Early recollection themes were focused on competition between siblings and friends, and he perceived his parents as ambitious and somewhat cold. Mr. B. was difficult to engage in therapy. Although he was clearly suffering and had sought help at the urging of his family physician, he was wary of the therapist's empatbic communications and often seemed suspicious of his credentials. Other than some exploration of these dynamics, therapeutic efforts with Mr. B. were targeted at countering his rigid ideas of success. Viewed objectively, Mr. B. actually had not failed, he had merely not attained the "height" on the vertical plane (Sicber, 1992) that he had so desperately sought. Slowly, patient and repeated confrontations (Shulman, 1973) along with careful examination of his interpersonal interactions, in- cluding those with the therapist, helped him to see that if he altered his approach to one of making contributions to further the good of the orga- nization he worked for rather than merely vying for promotion over his coworkers, he might have the opportunity of attaining a sense of meaning and well-being which he had rarely experienced as well as ultimately being perceived as mature enough for an upper-management position. In other words, Mr. B. needed assistance in learning how to cooperate with others rather than merely competing with them. In time, Mr. B.'s depression lifted, and be was able to return to work. He reported improved relations witb his wife and children as well.

Conclusion

Although tbere is certainly overlap among tbe vindictive, profoundly discouraged, introjective, and anaclitic types of depression as well as the frequent presence of multiple tendencies within the same individual, such constructs do help widen our understanding of the dynamics wbich are 352 Trevor Hjertaas involved. The perspective of Individual Psychology also helps us comprehend the interaction between lifestyle and more transient clinical syndromes. As Alfred Adler (as cited in Ansbacher & Ansbacher, 1956) warned us, ev- erything can always be different, and the clinician needs to be mindful of this fact in order to avoid a potentially disastrous misunderstanding, especially when attempting to discern why a unique individual has developed the problems that he or she has. It is also remarkable how Adier's insightful comprehension of human nature continues to be affirmed by new develop- ments in psychology.

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