Advanced Psychopathology

Friday, February 24, 2006

 

Robert's Reaction #3: Freud, McW, Bowlby on Depression

Freud, Bowlby, and McWilliams all name object loss as a central etiological factor in depression. Freud’s and McWilliams’ accounts of the etiology of depression accord significantly; McWilliams refines the etiological mechanism Freud proposes in “Mourning and Melancholia” with clinical examples, post-Freudian theorists’ ideas, and her own theoretical advancements. While sharing with Freud an appreciation for the pain of object loss, Bowlby offers a different account of how object loss precipitates depression.

First, there’s Freud. Freud believed that three factors operate in melancholia: object loss, ambivalence, and a conversion of object-cathected libidinal energy into self-hatred via identification with the lost object. This third factor is for Freud the defining feature of melancholia, and that which separates it from normal mourning. It’s easiest to understand this process as a series of steps:
1. The object is lost.
2. Libidinal energy that had been directed at the object is now directed inward at the ego.
3. The ego, now possessed of new libidinal energy, forms an identification with the negative aspects of the lost object.
4. The ego attacks the hated parts of the identified, introjected object, directing hostility and criticism towards itself.
5. Sadistic/masochistic pleasure resulting from the self-attacks – the success of which is registered as dysphoria – reinforces the process.
Unconsciously employing this defensive style achieves several ends: first, it allows the subject to avoid the pain of the object’s desertion while offering an outlet (i.e., self-attack) for negative feelings. At the same time, denying the object’s hated aspects keeps alive the possibility of reunion with, and the idealized image of the object.

Bowlby rejects Freud’s hyrdaulic model and the centrality of identification in the etiology of depression. Bowlby states that intense “yearning” for the lost object – most importantly the mother – evokes pain; this is a basic, inviolable part of human experience and is evident in transient separation anxiety and instances of object loss. Such “yearning” and “mourning” is inevitable and evident on the continuum from normal to pathological functioning – “what is pathological is not so much the defensive processes themselves as their scope, intensity, and tendency to persist.” Infants and children, Bowlby contends, are particularly sensitive to object loss, and mourning processes experienced in early life are likely to overwhelm the child and increase the risk for pathological mourning later.

McWilliams agrees with Freud’s aggression-inward mechanism in the formation of depression, saying that the depressive’s guilt and dysphoric affect reflect an introjection of the object’s negative qualities and preservation (or idealization) of the object’s positive qualities. McWilliams goes beyond Freud in naming other contributing factors to depression. Echoing Bowlby, she names traumatic, premature loss as a frequent starting point to depressive tendencies (and as fuel for the “aggression-inward” mechanism). There are critical periods in development where a child simply cannot process major loss. For example, McWilliams states that “a major loss in the separation-individuation phase virtually guarantees some depressive dynamics.” Finally, McWilliams notes the culture of the family as a frequent contributing factor in depression. A family in which mourning is discouraged (especially by harsh criticism) can contribute to depression, leading the child to pathologize all dysphoric emotions and reactions. Extremes in parenting styles (e.g., mother clings to or pushes away the child during the separation/individuation phase to allay her own sense of loss as the child grows) and/or the presence of a depressive parent also can contribute to depression.

 

Gillian's Response #3

The antecedents of depression, particularly in in relation and contrast to a normal mourning process, have been considered extensively for many years. Freud’s “Mourning and Melancholia” distinguishes melancholia from the normal process of grief and mourning. For Freud, melancholia developes when there is some “loss” of an object. While in mourning this is almost always a death of a love object, for melancholia it could be any perceived withdrawal of love. For melancholia to develop in Freud’s model, there must be ambivalence present toward the object, that is magnified after the loss. Because of this ambivalence the libidinal energy easily re-directs itself from the object, however rather than attaching to a new object, the individual may turn libidinal energy toward and into the ego. When this happens, the ambivalence felt toward the object is transferred to the ego, such that one part of the ego criticizes and rails against another part, leading to the symptoms of melancholia. According to Freud’s model, the ambiivalence toward the object is unconscious, and only becomes conscious when it becomes the ego’s ambivalence toward itself. Freud connects this process with both narcicissm and sadism, suggesting that the ego regresses into narcissism after the love object is relinquished, to protect the love from annhilation. He also posits that the ego turns the sadism meant toward the object onto itself, and that often the fact of the illness, and certainly acts of suicide if they follow, are sadistic attacks on the object.

Bowlby rejects much of Freud’s theory, finding the basic etiology of depression in childhood loss, and resultant defenses against the pining for the lost object. Bowlby does not see ambivalence or anger toward the object as a component of pathological mourning, but rather sees these as necessary and healthy parts of a mourning process that only become pathologicall when taken to an extreme. Bowlby also rejects the centrality of identification with and assimilation of the lost object in the centrality of mourning and depression, whereas Freud’s model depends on the internalization of the libidinal energy once directed toward the object.

Nancy McWilliams puts forth causes of depression that are more congruent with Freud’s model. Developmentally, she attributes depression to the experience of a premature loss, in an enviroment where it is difficult for the child to understand what happened, or to grieve normally. She notes that introjection of the object is a common antecedent of depression, essentially meaning an incorporation of and identification with the object, specifically the negative aspects of the object. She echoes Freud’s connection with sadism when she posits that negative affect is turned toward the self in depression, however disagrees with Freud’s view that the depressed ego regresses to a narcissistic state. She posits that the idealization with the object that happens in depression differs from that of narcissism because it is organized around morality, instead of the status and power that drives most narcissistic idealizations.

Sunday, February 19, 2006

 

Matt's 2nd Reaction: DSM vs. Psychodynamic Diagnosis

The advantages of a DSM-style checklist approach to diagnosis are clear enough. The criteria are (relatively) more objective, diagnosis can be accomplished quickly, and clinicians will (mostly) agree on a label for a given patient. These advantages are good for research and the gathering of statistics. But I see at least two main problems with the bookkeeping approach. First, it helps to solidify the idea that different mental problems are discreet illnesses, each with neatly defined parameters, on a par with a diagnosis of the flu or cancer. Much of the research that the DSM facilitates furthers this line of blinkered thought by tethering treatments to narrowly defined problems. The notion that a patient “has” depression (or whatever) may be comforting to patients and clinicians alike, but it only restricts treatment that ought to be concerned with more global understanding of the patient’s inner world. The very fact that DSM diagnosis yields so much co-morbidity ought to be a warning sign that its basis is fundamentally flawed.
Second, the DSM’s rather extreme parsing of mental problems seems unsustainable to me. In its fourth edition, the book is already unwieldy, and the number of disorders and variants it lists makes it unlikely that many clinicians will take the time to accurately classify their patient’s problems in any sort of exacting way. Instead, they will rely on a small number of commonly encountered labels, stretching their definitions to accommodate many patients. (Among other problem, this at least partially subverts the statistics-gathering purpose for which the manual was created.) This issue occurs to me in the context of the notion of culture-bound disorders, of which the next DSM will be taking greater account. If we really want to understand mental functioning in a meaningful way, we must acknowledge that “culture-bound disorders” are really just culture-bound symptoms of disorders that transcend culture. Even if it is not there yet, a psychodynamic view of diagnosis is at least theoretically equipped to describe such fundamentals. The DSM’s symptom checklists are equipped only to get thicker.

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