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I love Art. When I am immersed in appreciating a work of art, I wonder about how the artists thought and felt in the process of creating a masterpiece. I believe that art is a powerful outlet that can bring out whatever is bottled up inside and when concretized, such thoughts and feelings can be explored more objectively. One example is Johnson Pollack, an American painter who expressed his depression through his complicated and magnificent paintings.
Not many have Pollack's talent nor luxury to sublimate depression into a creative process. I, for one, am aware that I had bouts of depression in a vulnerable time in my life when I was diagnosed with Epilepsy. What art is to Pollack, studying is to me when it comes to demystifying an enigma. Thus, I am finally conquering my fears and writing about depression for this paper. In reading about it, I realized the many depressive stages in my life and bore resistance to understanding them. Now, it is clear to me that such resistance was due to not wanting to touch on the depressive condition and come face to face with my own depression. I know that studying in-depth and writing about this sensitive topic would be beneficial not only to my readers but also to me as a psychotherapist and as a flawed being in the dark who finally wants to see the light.
This essay commences with the etiology of depression, followed by some psychodynamic theories about it. It then presents a clinical example of a case study that is analyzed using the discussed theories. A reflective critique then follows as I give my own opinions and views about the use of psychoanalysis in the treatment of depression.
Etiology of Depression in Summary
Depression is associated with "feelings of extreme sadness" which not only last for long periods of time, but it is also recurrent and may further develop into suicidal tendencies (NHS, 2010). It is usually manifested with negative behaviors stemming from negative emotions. Sometimes, the person experiencing it is not even aware that he is undergoing depression. Its concept as a serious and debilitating illness, one which has had great impact globally, has become recognised within general medicine and the public eye in more recent times (NHS, 2010).
Examples of symptoms which form the diagnostic criteria for depression include: depressed mood; fatigue or loss of energy and recurrent thoughts of death or suicide, which may be noticed in most circumstances through General Practitioners. In turn a diagnosis is generated following an interview of the patient with the application of one or more diagnostic classification systems (Lon Schneider, 1991; NHS, 2010). According to DSM-IV, the patient needs to have at least five symptoms from the list of nine symptoms given below sustained over a period of two weeks and the symptoms bring a transition from the previous functioning where at least one symptom is loss of pleasure or interest, or depressed mood (American Psychiatric Association, 2000). The list containing some of the nine symptoms mentioned by DSM-IV is as follows:
Depressed mood for a major part of the day on daily basis indicated either by others or by feelings of sadness.
Experiencing hypersomnia or insomnia almost daily
Experiencing fatigue almost daily
Feelings of guilt or worthlessness almost daily
A change of over 5 per cent in the total weight of the body in one month either through overweight or underweight without dieting, or change in appetite almost daily
Loss of pleasure or interest in almost every activity that makes part of the daily life almost every day
Psychomotor agitation or retardation
Diminished ability to think or concentrate, or being indecisive.
Recurrent thoughts of death, suicidal ideation or suicidal attempts
Since DSM-IV necessitates the presence of only five of the nine symptoms to diagnose someone with depression, there are several combinations that make the width of terrain covered by depression and the presence of a variety of symptoms for the same psychological condition in different people. The importance of gathering such information from the client is tantamount to the referral that the psychiatrist gives to the psychoanalyst during their collaboration in the treatment of the individual. It is important that both professionals are on the same page and completely understand each other when discussing the case of their common client. For example, the prescription of anti-depressant medication by psychiatrists should be understood because for some deeply depressed people, medication keeps them functional or else they would not have enough energy and motivation to go to the psychotherapist for their sessions.
Treatment of depression is multifaceted, involving talking therapies; the use of a variety of medication, dependent on the form of depression, and self help (Cuijpers et al, 2008; NHS, 2010). One kind of psychotherapy that has been thoroughly studied as an intervention for depression is Psychoanalysis.
Psychoanalytic Theories of Depression
Freud (1917) has developed his psychoanalytical theories to cover an individual's life span with the most crucial experiences coming from infancy to childhood. He first pointed out that the center of depression was the individual's association with something he has lost (Yassa & Smith, 2000). Depression was set in comparison with the strong feelings borne out of mourning and melancholia. Dramatically presented, it is "a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love and inhibition of all activity", (cited in Pedder, 1982, p. 329) coupled with a lowering of self-regard that induces self-reproach. From this, Freud has conceptualized the superego, ego and id and how individuals respond to separation and loss.
The general picture of melancholia and mourning justifies the correlation between the two (Freud, 1917). "I look at the way Freud made use of this seemingly focal exploration of these two psychological states [mourning and melancholia] as a vehicle for introducing - as much implicitly as explicitly - the foundation of his theory of internal object relations" (Person, 2009, p. 3). The environmental influences that serve as the exciting causes are the same for both melancholia and mourning. Mourning is defined as the reaction shown upon the loss of a beloved individual, or some abstraction's loss that has taken one's place like an ideal or a country etcetera. Some people experience melancholia rather than mourning because of the same influences and so they can be suspected of a pathological disposition. Mourning encapsulates departures from an individual's normal behavior towards life but it never happens in such a way that medical treatment can be taken for it. A vast majority of people tend to give it time to recede thinking that any intervention could be harmful and useless. The clinical importance of the theory of melancholia is immense particularly in the consideration of numerous forms of depression.
Freud (1917) explains that one's self-reproaches, self-hate and self-contempt as a reaction to melancholia cover up his ambivalence of love and hate for the lost object which he does not consciously display but is pervasively present. It is something the individual identifies with and becomes part of his ego. Mourning is "normal" grief which the individual slowly abandons the object but his identification to it is firmly kept in place. In Melancholia, the individual retains it by consistently identifying with it (Yassa & Smith, 2000).
Freud has emphasized upon the economic definition of mourning as well as grieving since it plays a role in binding of traumatic memories; an activity of ego that has absolutely no connection with the attenuation that generates from the time-based forgetfulness. Freud has elaborated the similarities with as well as differences from melancholia in which an individual seemingly loses self-esteem unjustifiably. Freud has identified an additional symptom associated with melancholia that is absent in mourning as, "an extraordinary diminution in [the subject's] self-regard, an impoverishment of his ego on a grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself" (Freud, 1917, p. 254 cited in Granger, 2004, p. 51).
Freud's theories on depression evolved into other concepts and developed by other theories. Abraham (1924) explains that depression comes from an individual's cycles of incorporation/devouring and expulsion/destruction of the lost object. Melancholia endlessly repeats these cycles which is a fruitless effort on the part of the individual. Yassi & Smith (2000) contend that for the melancholic, "expulsion succeeds incorporation - nothing is gained and nothing is lost" (p. 179)
Klein, as discussed by Segal (1964), sees the connection of Freud's concept of ego to an infant's experiences of anxiety, defence mechanisms and the formation of object-relations. The infant sees the mother as an object from which he derives both good and bad experiences. Depression sets in when the infant realizes that he has destructive impulses that may harm his mother whom he totally depends on for survival. Klein claims that the emotional problems in children can entirely be attributed to the fantasies that yield from the conflicts between the libidinal and aggressive drives instead of events that happen in the external world. Segal explains that Klein theorizes the infant to be exposed to the feelings of "mourning and pining for the good object felt as lost and destroyed, and guilt, a characteristic depressive experience which arises from the sense that he has lost the good object through his own destructiveness" (p. 57). Klein's theory relates to Bowlby's Attachment Theory (1969), which contends that an individual's success or failure in relationships or "attachments" depends on his success or failure with the first one he experienced in life, that of his attachment to his mother or primary caregiver (Brodie, 2012).
Segal (1991) agrees with the theories of Abraham and Klein and contends that the main reason for depression or one's inability to mourn is his on ambivalent feelings towards the lost object in general and to his oral-sadistic and incorporative drive tendencies in particular. He concludes that "the depressive conflict is localized to the arena of internalization, where introjection contrasts with incorporation" (cited in Yassa & Smith, 2000, p. 180). If the individual gets to accept the separation and absence of the object, then, the depression would be endurable and capable of being worked through.
The goals of Psychoanalytic therapy are settling unresolved conflicts in a person's past that deeply affect his current patterns of behavior and personality. It may involve bringing repressed painful memories to resurface to be dealt with consciously through the techniques of free association, dream analysis, hypnosis, transference, and analysis of resistance handled by a skilled psychoanalyst. This tedious process intends for the client to reach a level of self-understanding for him to be able to move on with his life without the heavy emotional baggage he has been carrying all his life. This understanding is necessary for an eventual change in character (Corey, 2005).
A Psychoanalytical Sketch of Depression: Case Study
David, a handsome and well-mannered young doctor in his thirties is apparently a successful man whose life seems to be in order. He spoke highly of himself, being an accomplished physician who lived in Australia for four years and has established himself as a renowned paediatrician. It was in Australia where he met his beautiful and equally successful girlfriend, Erica, whom he has brought back home to the UK to live together and eventually get married and raise a family.
David comes from a reputable family known in the community for their upright values. His father was a pastor in their church and his mother was a school teacher. His only sibling is an older brother, Michael, who lives in London. Known as the best quarterback in the history of their high school, David has always looked up to him and tried his best to emulate him. They are very close, and despite the distance, they keep in constant touch through phone calls and Skype. His brother is happily married and has two children whom David adores.
David has been sexually-molested as a young boy of eleven. It was the father of one of his friends who was the perpetrator. It happened one day when he and his friends were playing in his friend's house. Left in the tree house while playing hide and go seek, his friend's father climbed up to get him and sexually molested him there. David has never told anyone of this experience and has since then isolated himself from his friends and concentrated on his schooling.
His brother, Michael became his only trusted friend. Vicariously, he celebrated his success as an athlete, which David was not very good at. David was an honour student and that was his source of pride. His very conservative parents always made him and his brother that they were proud of them. David admired his parents for being upright people and was also proud of them for the way they raised him and his brother. He enjoyed the good standing of his family in the community and could never think of destroying their good name.
David admitted to feeling ambivalence with regards to dating girls. Michael would push him into dating, introducing him to various girls, but David was never interested. His good looks made him popular with the girls, and they would pursue him relentlessly. He gave in a few times, but had a nagging feeling that it was boys he was attracted to. He repressed such feelings until he started Medical school when he has his first relationship with his roommate. Although he enjoyed being intimate with him, David had no intentions of coming out in the open. To everyone else, he was straight. In Australia, he had sexual encounters with men but was very covert about it. He dated some ladies until he fell in love with Erica.
Reasons for Coming to Psychotherapy
David has been diagnosed with Depression and was referred by a psychiatrist friend who recommended Psychoanalysis for his therapy. Although he was aware of his bisexuality, it was manageable in Australia. However, upon coming back to the UK, with dreams of living his ideal life with Erica, he saw the man who molested him in a grocery store, now old and wrinkled and walked with a cane. The bad memories he pushed down his unconscious suddenly re-surfaced and he felt a stab at the pit of his stomach. He suddenly became withdrawn and suffered insomnia. He felt he was too tired to go to work in his clinic. He lost his appetite and started losing weight, he could not think straight, as the thoughts of the molestation kept intruding in his mind. He cannot function well sexually and was beginning to feel estranged from Erica. The overpowering feelings of guilt at what happened and the shame it will bring his family if they knew possessed him. It was what urged him to consult his former classmate in medical school who was a psychiatrist. He was prescribed some anti-depressants and was referred for psychotherapy.
Analysis of the Case:
David characterizes Freud's view of a melancholic person who has succumbed to low self-regard and an incessant self-reproach for a traumatic experience that happened to him during his childhood. Being molested by an older man was something he kept to himself because if he let out the truth, it will bring scandal to his family and taint their pristine reputation in the community. The ill feelings of the molestation festered within David over the years and may have been the cause of the development of his sexual ambivalence. Within the mourning and melancholia theory of Freud, David may have mourned his loss of innocence that was abruptly taken from him by a man he respected, being the father of his friend. That man betrayed his trust and caused him to feel shameful feelings and guilt at having to keep a secret from his family. David not only mourned his loss of innocence but also the loss of trust, pride and honesty that he used to have just moments before his molestation. The melancholia persists due to the sense of regret at not having grown up as normally as his friends whom he has altogether avoided for fear of being found out and bullied. His melancholia may also cover up his internal struggles at not identifying with the image etched in him by the trauma. Being molested by a man may have marked him to be a homosexual in his mind, and although he sometimes gives in to that quiet, always hushed self-fulfilling prophecy, he needed to show the world that he was a true man in order to be consistent with his family's image. Such is the representation of the duality depicted Psychoanalysisâ€¦in Freud's theory of mourning and melancholia, Abraham's expulsion/destruction and Klein's good and bad object.
Abraham's contention of depression being the result of the cycle of incorporation/ devouring of the lost object, in David's case, his innocence, wholeness as a person and free choice as to his sexual preference, and many more, is followed by thoughts of expulsion/destruction of the same. Upon realization of such loss, he dives into an abyss of regret and self-reproach and dwells in his depression.
With regards to Klein's Object Relations theory, the object, supposedly the mother or primary caregiver, is represented in David's case by his whole family. He derives much love, pride and support from them and has established a healthy attachment with them, worthy of Bowlby's approval of successful first relationships. Such successful early relationship with this family was bounds to spring him to successful and healthy relationships/attachments in the future. It seems he has indeed maintained close relations with his family and formed a healthy and loving relationship with Erica, but these are being jeopardized by the ghosts of his traumatic experience in the past. In Klein's theory, depression sets in upon the realization that one can hurt the object of his love and affection. David does not have the heart to hurt his family by coming out as a gay man, but at the same time, he longs to break free from the chains he has linked together in covering up his true sexuality. In this sense, his family (object) also holds a dual role of good object as his source of love and support and at the same time a bad object as the hindrance to his libidinal impulses to express his "gayness".
David's issues about his depression would require several goals in therapy. Initially, the following goals are recommended:
Acceptance of his sexual orientation
Recognition of the cause of his depression
Forgiveness of the past (including the perpetrator who molested him)
Building the courage to reveal his true self to his family and girlfriend
Rebuilding his self-esteem to live a productive life despite his traumatic past.
This case study is significant to me because it was the first case I handled as a psychotherapist. I thought after amassing the knowledge about psychotherapy, I would be ready for a real client. Although I was fully aware of my own reactions and responses to the client, it was to the point that I was self-conscious. I realized this is not the kind of case nor client who will be vulnerable to transference of his feelings to an object of his emotions onto me as the therapist, as his issues dealt with more abstract concepts. However, I realized I might be vulnerable to counter-transference. There are some factors in the patient that can influence the analyst's unconscious feelings and these can interfere with the treatment (Bethan et al., 2005). Initially, I was at a loss and had to resist the tendency to "rescue" him when he struggled in expressing himself especially when he talked about his traumatic experience. Upon reflection, I know I was empathizing with him and knew how he felt since I have been through depression myself. He reflected my own resistance to bring out the deeply repressed unconscious feelings into the conscious because it was difficult to deal with. Being self-aware, I know it would help me manage my own emotions in order to maintain objectivity.
As a therapist, I adopt Rogers' ideal of a therapist who is warm and caring and imbued with attributes such as congruence, unconditional positive regard and accurate empathic understanding (Corey, 2005). I listen to him without any hint of judgment, but only understanding. Creating a relationship is at the core of the therapeutic alliance with David. Two of Donald Winnicott's principles are very much part of my way of being with him. First, when Winnicott (1971) talks about the role of the therapist, he states that the setting is often more important than interpretations; by being on time, being there, being real we can create a secure space for the client that will facilitate in him a sense of basic trust. Secondly, Winnicott's idea of "holding" the client as "a form of love" (1965, p. 65), the love where reliability and empathy are crucial and sincere was applied to David under my watch. It does not necessarily mean physical holding, but a more supportive kind of listening without pressuring him. This is also consistent with Bion's ( ) concept of "containing" in making the client feel safe in the therapeutic environment.
Finally, I go further than what Psychoanalysis does in analyzing the client's personal past experience causing his depression. It is as if it implies that a person is imprisoned by his past experiences and that his horrible past determines his woeful future. It does not consider much the influence of the social and cultural environment that the individual lives in. As a therapist, I would put much value on the impact of David's supportive family and community in raising him to be the successful man he is. I believe it helps to highlight the positive aspects in his life so that he gets motivated to heal himself from his depression.
The Psychoanalytic theory is premised on the belief that human nature is greatly affected by a person's early childhood experiences and conflicts between impulses and prohibitions (Corey, 2005). Personally, I believe that requiring a client to undergo such a challenging journey to his past in order to gain enlightenment on his depression may have its advantages, and I believe in its goals of self-understanding. However, dwelling too much in the past may also be a waste of time, as what is more essential upon gaining such awareness is the process of moving forward.
My own experience with depression now becomes very helpful to me in understanding others undergoing the same thing. I believe it was the diagnosis of epilepsy that shook me into facing my own demons. Now, I know I needed to deal with my own depression if I am to help others deal with theirs.