A PSYCHOANALYTIC PERSPECTIVE ON DEPRESSION CHARLES BRENNEK, M.D. A correct tinderstanding of the role of depressve crffecl in triggering jqcliic coiiji’icl lends to a refonntilatioiz of the origins and the psyliodyiainics of depression as n feature of rrieiital illness. It also rnises seriotcs question about the validits of the diagnosis of depressive illness.
mental illness in which depression is a prominent feature is a major problem in psychiatry today. hlost current efforts to better understand and deal with the problem have approached it from the side of neurochemistry, pharmacology, electroconvulsive therapy, and biogenetics. T h e approach in the present paper is based on recently available data about a different aspect of brain functioning, namely, the psychological aspect as studied by the psychoanalytic method. Two conclusions, based on those data, are the principal points of the paper. The first has to do with the psychodynamics and psychogenesis of depression as a feature of mental illness. The second, based on the first, is that it is a mistake to base a nosology on the premise that the presence of depression distinguishes a class of mental illness in some fundamentally important way. Depression is an affect, not an illness. The current concept of depressive illness, whatever the words used to designate it, is more misleading than helpful. As a necessary introduction, two related topics will be discussed briefly: affects in general, and the role of affects in psychic conflict. (For a more complete discussion, see Brenner, 1982.)
W
I - i x r E v m N A m BE GIVEN TO IT,
Training and Supervising Analyst, New York Psychoanalytic Institute. Accepted for publication September 7, 1989.
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Affects are best defined as a combination of two elements: a sensation or experience of pleasure or unpleasure, and an idea o r ideas. What constitutes an affect as a psychological phenomenon is the combination of the two, of pleasure/unpleasure and ideas. It should be noted that either the ideas or the pleasurehnpleasure sensation may be unconscious as well as conscious. If the ideas are unconscious and the sensation of pleasure o r unpleasure is conscious, what results is what is often called a contentless affect, e.g., contentless anxiety. If the ideas are conscious and the sensation of pleasure or unpleasure is unconscious, what results is what is called isolation of affect. T h e affects that trigger psychic conflict are unpleasurable ones. Of these the one best known and best studied by psychoanalysts is anxiety. When unpleasure is combined with a conscious or unconscious anticipation of danger or calamity, we label that affect anxiety. If the unpleasure is intense, one speaks of terror or panic. If it is minimal, we call it worry or unease. If the ideational content has to do with loss or loneliness, the affect is called separation anxiety; if it has to do with castration, it is called castration anxiety. In brief, unpleasure plus danger, unpleasure plus anticipated calamity, is one or another variety of anxiety. Depending on the intensity of the unpleasure and on the nature of the ideational content, it may be classified as panic, terror, dread, worry, fear, apprehension, etc., but if a calamity is in the future, if it impends, the unpleasurable affect is, by definition, a variety of anxiety. Also by definition, anxiety without ideational content is an impossibility. It is possible for there to be an experience or sensation of unpleasure without ideational content, and it is plausible to assume that this does in fact happen during the earliest days and weeks of extrauterine life. For the term anxiety to be a meaningful one, however, unpleasure must he combined with an expectation of calamity. Anxiety is the unpleasurable affect that signals the advent of something bad, of calamity (Brenner, 1974, 1982). The role anxiety plays in triggering psychic conflict is too well known to require repetition. Freud (1926) first outlined its Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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role and listed four calamities or dangers as its ideational content in early childhood: object loss, loss of love, castration, and, after superego development, punishment, which comes to subsume the other three. Anxiety is not the only form of unpleasure that plays a major role in psychic conflict, however (Brenner, 1982). Unpleasure can also be combined with ideas that a calamity has already occurred. When this is the case, the affect is not anxiety, but misery-what I have labeled depressive affect because of its relation to what is called depressive illness in later life. A child who feels abandoned, unloved, castrated, and/or punished in any or all of these ways does not suffer from anxiety, i.e., from an anticipation of calamity. The calamity is not a danger, not a matter of the future, a matter of expectation. For that child the calamity is a fact of life, it is the child’s current reality. When a calamity is a fact of life, when it is in the present rather than in the future, the unpleasurable affect is, by definition, not anxiety, but depressive affect. Thus, for example, separation anxiety is unpleasure plus the idea(s) that one is to be abandoned in the future. Separation depressive affect, on the other hand, is unpleasure plus the idea(s) that one is abandoned already, that one is already alone. With suitable alterations the same is true for each of the other calamities of childhood Freud (1926) outlined. To sum up, beginning in childhood there are two kinds of unpleasure associated with the calamities of object loss, loss of love, castration, and punishment. One kind is anxiety; the other is depressive affect. The difference between the two is that in the one, anxiety, calamity is anticipated, it is a danger, while in the other, depressive affect, calamity is present as a fact of life. Whenever either anxiety or depressive affect of sufficient intensity appears in connection with a wish for gratification of a drive derivative, what ensues is psychic conflict. Unpleasure associated with gratification of a drive derivative is what triggers psychic conflict, whether the unpleasure is anxiety or depressive a ffect
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Conflict in psychic life has four components: drive derivatives, unpleasure in the form of anxiety and/or depressive affect, defense, and superego manifestations. These components interact in accordance with the pleasure/unpleasure principle, i.e., in such a way as to achieve the maximum pleasure or gratification and the least unpleasure in the form of anxiety and/or depressive affect. T h e result of the interaction, the consequence of conflict, is a compromise formation, one which may be either pathological or normal. A brief vignette, presented somewhat schematically, will be useful to illustrate these statements. A twenty-one-year-old man, living at home with his parents, had to check the gasjets in the kitchen several times whenever h e left home. When asked to talk about this behavior, h e told a recurrent fantasy: he left the house, unaware that a jet was burning in the kitchen; during his absence the burning jet set the house afire and it burned to the ground; his father, distraught by the calamity, suffered a heart attack and died, leaving the patient and his mother alone to struggle along as best they could. M7lm were the components of the patient’s conflict and what the resulting compromise formation? Clearly a part of the compromise formation was his compulsive ritual (checking the gas jets). Another part was his recurrent fantasy of what would happen if h e did not check the jets. As for the components of the conflict, the most obvious of the drive derivatives was the patient’s unconscious wish to destroy father and to possess mother. Unpleasure in the form of anxiety and depressive affect could be identified in the patient’s conscious anxiety whenever h e failed to check the gas jets or even imagined failing to do so, and in the sense of misery that was a conscious part of the denouement of his fantasy. His defenses were, as always, numerous. Prominent among them was repression. H e had repressed all feelings of sexual attraction to his mother and of sexual rivalry with his father, although he quite consciously disliked his father and was very much on his mother’s side in her many quarrels with his father. T h e ideational content of Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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the patient’s castration anxiety was likewise repressed. He was no more conscious of a fear that his father would castrate him than he was of wishing to possess his father’s penis. Displacement and disavowal can also be seen in the substitution of burning down his father’s house for the idea of killing him and the attribution of his father’s death to a heart attack. Moreover, he was conscious of his strong desire to save the house, rather than of any wish to destroy it, a kind of reaction formation. As for superego manifestations, he was conscious of guilt as well as of anxiety at the idea of failing to check the gas jets carefully. So much for the illustrative vignette. To return to more general considerations, conflicts that are intense enough to be clinically significant originate in childhood. The conflicts of later life are a continuation of childhood ones: in them the past lives on in the present. Childhood wishes never cease to be active in the mind until the brain, the organ of the mind, itself decays or stops functioning altogether. IVhat characterizes the wishes of childhood that figure in psychic conflict is a desire for libidinal and aggressive gratification, gratification which, in the absence of anxiety and depressive affect, would be intensely pleasurable. As Freud ( 1905) pointed out, libidinal gratification is closely tied to the erogenous zones. It is for this reason that one speaks of oral, anal, and phallic or genital wishes. Aggressive wishes are also connected with the erogenous zones, but less closely so than are libidinal ones. For present purposes it suffices to say that under certain circumstances wishes for libidinal and aggressive satisfaction (pleasure) can arouse intense unpleasure in a child’s mind. When this happens, conflict ensues. The child either fears object loss, loss of love, castration, or punishment in connection with one or more instinctual wishes, or the child experiences one or all of these calamities as having taken place, as being a fact of life, in consequence of its wishes. Whichever may be the case, whether it is anxiety that is associated in a child’s mind with its instinctual wish(es) or whether it is depressive affect, the child reacts to eliminate or Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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to mitigate the unpleasure it experiences, i.e., to mitigate or to avoid altogether the anxiety, the depressive affect, or both. Every effort made to accomplish this end of reducing unpleasure is part of what we call defense. The function of defense is to reduce unpleasure. Whatever accomplishes or assists that purpose is, by definition, defensive. In the main, defense operates by opposing the gratification of the instinctual wishes that caused upleasure. Defense, in general, is antiinstinctual. For that reason, Freud used the word conflict to designate the psychic events under discussion. There is conflict in the mind between a wish for pleasurable instinctual gratification and a desire to suppress the instinctual wish in order to eliminate unpleasure in the form of anxiety and depressive affect. This formulation is only approximately correct, however. Opposition or conflict between wish and defense is only part of what happens. The full story is somewhat different. Namely, a compromise is reached among the several tendencies within the mind, a compromise that follows the pleasure principle by avoiding unpleasure while achieving pleasure insofar as each is possible. In other words, the result of conflict is that the drive derivatives involved are gratified as far as they can be without arousing too much unpleasure, unpleasure in the form of anxiety and depressive affect is eliminated as much as can be done while at the same time allowing for some gratification of the wishes involved, and simultaneously the demands of the superego are obeyed as far as possible. In brief, the consequence of conflict is a compromise formation, a compromise among all the components of conflict, a compromise formation, it should be added, which may be either normal or pathological. Thus unpleasure in the form of anxiety and depressive affect are always part of psychic conflict. It is a sine qua non as far as conflict is concerned: no unpleasure, no defense, no conflict. Matters are somewhat different, though, when it comes to compromise formation. This can best be illustrated by considering anxiety in conflict and in compromise formation, since that form of unpleasure is the more familiar. Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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When a defensive effort is successful in eliminating anxiety, at whatever cost to an individual’s mental health, anxiety does not appear as part of that person’s conscious experience. To take a familiar example, if an adult’s anxiety over childhood drive derivatives can be eliminated as a conscious experience by staying away from airplanes or by avoiding some other everyday situation, then the person in question is free of anxiety even though he or she is clearly suffering from a neurotic symptom, a phobia. Anxiety is a component of the underlying conflict, but not of the resulting compromise formation. The same may be true for a patient who must check all the gas jets in the kitchen two or three times before leaving home. Anxiety may be avoided as a conscious experience as long as the patient’s obsessional ritual can be carried out. Again, anxiety is part of the conflict, but not necessarily of the resulting compromise formation. There are, however, patients who experience some degree of anxiety despite their phobic avoidance or obsessional ritual. Despite the defenses mobilized by those patients, some anxiety appears in the resulting compromise formation. Indeed, experience shows that a patient may experience some anxiety along with a neurotic symptom at some times but not at others. Whenever anxiety does appear as part of the compromise formation that results from a pathogenic conflict, we conclude that ‘for that patient at that time the defensive efforts have mitigated the patient’s anxiety without having eliminated it altogether as a conscious phenomenon. It remains as part of the patient’s pathological compromise formation despite the patient’s defensive efforts. T o repeat, even though unpleasure in the form of anxiety plays a major role in a pathogenic conflict, it does not necessarily do so in the resulting pathological compromise formation. A patient may be acutely and overwhelmingly anxious, may have no conscious anxiety whatever, or anything in between. As a symptom, anxiety may be prominent or absent dcspite the fact that it plays a major role in conflict. A pathological Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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compromise formation may or may not include anxiety as one of its features. The same is true for depressive affect. In every conflict, depressive affect plays its part in initiating defense, just as anxiety does. Sometimes anxiety predominates and sometimes depressive affect. Both play their part in all. It is not the presence or absence of depressive affect as an element of conflict that varies from patient to patient. Depressive affect plays a role in every patient’s conflicts. What varies is the role of depressive affect in the resulting pathological compromise formation. Like anxiety, depressive affect as an element of symptomatologymay be prominent, it may be absent, or it may be somewhere in between. In brief, then, unpleasure, whether it is anxiety or whether it is depressive affect, plays a crucial and necessary role in every patient’s psychic conflicts. It may or may not play a prominent role in a patient’s symptomatology. Yet in every case, whatever the outward manifestations may be, anxiety and depressive affect are present and active unconsciously. IVhat are the implications of all this for the understanding of the psychopathology and dynamics of those cases of mental illness in whose symptomatology depression is prominent? IVhat light do these findings throw on so-called depressive illness? These questions are best answered by reviewing briefly the development of the psychoanalytic theory of depression prior to the discovery of the role of depressive affect in psychic conflict. Psychoanalytic theories of the origin and mechanism of depression began with Freud’s (1917) Mourning and Melancholia. In it Freud advanced several ideas about depression that are still widely accepted. The first is that pathological depression has a normal analogue: grief and mourning for a loved person or thing that one has lost by death or separation. A patient who is depressed, said Freud, is in mourning for someone who is consciously or unconsciously believed to be dead and gone. In some cases the loss is a real one, as when a patient Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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becomes pathologically depressed after the loss of a spouse or loved one. More often a patient, angry at a loved one for whatever reason, wishes the loved one dead, kills that person in some unconscious fantasy, and mourns the loss, imaginary though it is. It may be noted in passing that by analogizing depression to mourning Freud was able to offer an explanation of why an episode of depression is often limited in duration. When one mourns, one usually does so for a limited period of time-for several months or a year, perhaps. Then one is through with mourning and returns, at least in many cases, to one’s pre-loss, pre-mourning state, just as a depressed patient returns to his premorbid state after a period of depression. The main point of the analogy between mourning and depression, however, was the assertion that depression is a consequence of losing a beloved person, that depression results from object loss. The loss may not be a real one; it may be only a loss in fantasy, said Freud. The patient may not even be aware of any feeling of loss, i.e., the perception of a loss may be quite unconscious. Nevertheless, on the basis of his own observations and those of his colleague, Abraham, Freud asserted that depression is a consequence of losing a beloved person, that it results from object loss, real or fantasied, conscious or unconscious. On the basis of clinical observations, Freud also linked depression with identification and with aggression. His reasoning went this way. When one loses a beloved person, one tends to become like the person one has lost. By doing so, one tries to mitigate or undo the loss. Such a reaction first appears very early in life. A small child, left by mother, will identify with mother by mothering a doll or a pet, as though to assure itself that mother is not gone, that she is still there as the child wishes her to be. This reaction, this identification with an absent and yearned-for object, Freud said, is a general characteristic of human mental life. Identification is a defense against object loss, is the way it is often put today, and it has, as Freud pointed out, a momentous consequence. The consequence results from Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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the fact that beloved persons, especially beloved persons who desert and leave one, are hated as well as loved. It is precisely when ambivalence is intense, when great love coexists with intense rage or hatred, that identification with a lost object produces depression. Freud went on to say that turning aggression against oneself in this way explains some of the symptoms often found in depressed patients: diminished self-esteem, self-accusations, self-injury, self-torment, and suicide-i.e., doing unto oneself as one would like to do to the loved and hated lost object. In his major contribution to the psychology of depression, Abraham (1924) made one significant addition to Freud’s ideas. He linked depression to orality. As he and later investigators put‘it, the predisposition to depression later in life consists in a psychological trauma and consequent fixation at the oral phase of development, i.e., the first 18 months of life. In everyday language, if a patient becomes depressed in later life, one can safely assume, according to Abraham and later authors, that in infancy the patient was abandoned or neglected by mother. To summarize, the main points of the psychoanalytic theory of depression prior to the discovery of the role of depressive affect in psychic conflict were: (1) in cases of depressive illness there was inadequate mothering during the oral phase, i.e., during the first 18 months of life; (2) depression, like mourning, is a consequence of object loss; (3) object loss leads to identification with the lost object, which is both loved and hated; (4) as a result of identification, hate or aggression becomes selfdirected. Once the role of depressive affect in psychic conflict is taken into account, however, it becomes apparent that the facts are otherwise. In some instances a patient’s symptom of depression is related to object loss and to inadequate mothering, but not in all. Similarly, oral wishes may predominate, but they do not always do so. In fact, the cases in which oral wishes and Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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inadequate mothering are the principal reasons for later depression may be in the minority. Phallic and anal conflicts are common and are often more important than oral ones. It is also true that identification may play a crucial role in a depressed patient’s dynamics, but there are many patients in whom that is not so. Finally, aggression turned against oneself is not the cause of depression. It is, in fact, a consequence of it. To repeat, depressive affect, like anxiety, may be associated with any of the calamities of childhood. It is not exclusively or primarily associated with object loss. It is true that mourning for a lost object, a lost loved one, is a normal analogue to a pathological depression, as Freud suggested in 1917, but the analogy is misleading if it is carried to the extent to which it was carried by Freud and has been carried by other analysts since. T h e universal and, in that sense, normal affect related to pathological depression is a variety of unpleasure that may be related to any of the calamities of childhood. Because of its relation to pathological depression, I have labeled that particular variety of unpleasure depressive affect. An alternative label, one that is closer to the subjective experience it refers to, would be misery. Calling it depressive affect serves the useful purpose of directing attention to its place in those pathological compromise formations of later life for which the term depression is commonly employed. Calling it misery serves to remind one that it is a universal affect that plays a role in all psychic conflicts, whether normal or pathological, iie., that it is by no means always a conscious part of a pathological compromise formation. In summary, then, mourning as a reaction to object loss is not the universal or normal affective experience that is always psychologically related to pathological depression. The universal, normal affect related to pathological depression is the variety of unpleasure I have labeled depressive affect or misery. Sometimes it is misery at feeling, consciously or unconsciously, alone, deserted and bereft. Sometimes it is misery at feeling Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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unloved. Sometimes it is misery at feeling castrated. Sometimes it is misery at feeling punished in any or all of these ways. Like anxiety, misery is part of the human condition. As far as we know every child feels both anxiety and misery at times in connection with instinctual wishes, anxiety and misery that are sufficiently unpleasurable to give rise to intrapsychic conflict in the form of defense and compromise formation. Among the many consequences of childhood instinctual conflicts in later life are those compromise formations we call psychogenic symptoms. Depending on the nature and effectiveness of a patient’s defenses, anxiety, misery, or both may be present in the symptom or syndrome of which a patient complains. Both affects always play a part in pathogenesis. They trigger every patient’s defenses. Either or both may be absent from a patient’s awareness, however. When misery in whatever form is prominent in a patient’s overt symptomatology, the patient is called depressed. The affect of misery a depressed patient manifests will, to be sure, vary from one patient to another. One weeps, another shuns company, another despairs, still another is filled with self-reproach or is self-destructive. If anxiety is prominent as well as misery, the diagnosis may be agitated depression. For most patients, however, the one diagnostic label, depression, is sufficient. One conclusion to be drawn from all of this is that it makes no more sense to base a diagnostic classification of mental illness on the presence of depressive affect as a conscious symptom than it would to base one on the presence of anxiety as a conscious symptom. Both depressive affect and anxiety are always part of a patient’s pathogenic conflicts, ~vhetheror not either or both appear as part of the resulting compromise formation, i.e., as part of the overt symptomatology. All that the presence of either in a patient’s syniptomatology tells us is how efficient the patient’s defenses are in avoiding or mitigating unpleasure. It tells something about that aspect of a patient’s symptomatology, but no more than that. It says nothing else about the nature Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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of the conflict or conflicts that cause a patient’s symptoms, nothing about the origins of a patient’s conflicts, nothing about prognosis or amenability to treatment. Depressive affect is part of every pathological conflict, whether or not it appears in consciousness in the resulting compromise formation. It is true that depressive affect is prominent in the overt symptomatology of every depressed patient, but its presence does not distinguish those patients in any fundamental way from other mentally ill patients. Depressive affect is present in all, whether it is openly displayed on the surface or concealed in the depths, just as is the case with anxiety. Depressive affect is of fundamental, causative importance in all cases of mental illness, not just in a certain group of them that is labeled depressive illness or depressive reaction, despite what Kraepelin said a century ago and what many psychiatrists and analysts have continued to believe ever since. More than this, unpleasurc in the form of dcpressive affect and/or anxiety triggers conflicts whose outcome are normal compromise formations as well as pathological ones, compromise formations that play a major role in all of conscious mental life (Brenner, 1982).This fact, the ubiquity of depressive affect and anxiety in helping to determine the nature of the human condition, raises serious question concerning the usefulness of making either affect the basis of any descriptive, diagnostic classification. Any such term as depressive reaction, to say nothing of a term such as depressive illness, says nothing special or distinguishing about the causes of a patient’s psychogenic illness. It does, indeed, tell something distinguishing about a patient’s compromise formations, in particular about the nature and efficacy of a patient’s defenses, but nothing more than that. Useful as it is to understand a patient’s defensive structure, one must not rate it as being more important than it is, which is what terms like depressive illness do. For all these reasons it would be advantageous if such diagnostic terms could be dropped. Advantageous though it might be, however, it is.unlikely to happen soon. Such terms will undoubtedly be with us Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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for a long time to come. The outworn concepts associated with the terms need not be so long-lived, though. Whatever diagnostic label one chooses in classifying mentally ill patients in whom depressive affect is prominent, the important thing is to understand clearly the nature and origins of each patient’s compromise formations and underlying conflicts. Misery or depressive affect is not necessarily a consequence of object loss, it is not simply aggression turned on oneself by way of identification, and it does not justify the assumption that a patient’s conflicts are chiefly oral ones, based on preoedipal trauma at the hands of the patient’s mother, or nonmother, as the case may be. Depressive affect plays the same role in psychopathology as does anxiety. It is an inevitable part of the mental life of childhood, it is associated with all the calamities of childhood, it is a trigger for defense and conflict, and it may or may not appear as a conscious or overt part of a patient’s compromise formations, depending on the nature and efficacy of the patient’s defenses. T h e more clearly one keeps all this in mind in one’s clinical work with patients, the better one is able to understand the nature and origins of each patient’s pathogenic conflicts and the more effectively one will be able to treat one’s patients psychoanalytically and/or psychotherapeutically, as the following case vignette illustrates. T h e patient was a thirty-three-year-old, unmarried woman who came for treatment complaining that she felt unhappy and did not know what she wanted to do in life. Nothing seemed to interest her, she said. She had worked in her family’s business for several years and had at first enjoyed being there, but she finally grew to dislike it and left. Since that time she had been at loose ends. What was striking about the patient was her affect. She looked much sadder than she complained of feeling, tears came frequently to her eyes, and she spoke slowly, with many pauses. It took little probing to discover that she was, in fact, not simply unhappy and at loose ends, but truly disconsolate and had been Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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increasingly so for many weeks. Nor was the onset of her symptoms difficult to discern. It coincided with the entry of her brother into the family business. Until that time the patient had been her father’s right hand in the business. When her brother, who was five years her junior and her only sibling, came into the business, it soon became clear to the patient that it was not she, but her brother, who was destined to be her father’s close associate and eventual successor. It was then that her symptoms began. In the course of her analysis it became clear that this patient’s conflicts centered about the fact that she was a girl, not a boy, and that they had done so since her brother’s birth. Her penis envy and her misery at having been born a girl, which to her as a child meant having been castrated, were intense. The following excerpts will give some notion of how intense they were. She mentioned on one occasion that for years she had not felt comfortable with her body. “Do you remember when you began to feel that way?” I asked. She thought for a moment, then answered, “When I was about twelve.” “When did you first menstruate?” I asked. “When I was twelve,” was her reply. To her, the onset of menstruation had meant the end of any possibility of being a man. Menstruation was conclusive and final proof that a girl was what she was and a woman was what she would always be. As another illustration of how she felt about being without a penis, she came into my office one day indignant because, when she had gone to use the lavatory just before, she had found the toilet seat up. “No one,” she said indignantly, “has any right to leave a toilet seat in that position!” “Why not?” I asked. “Because,” she said, “if looks so ugly that way!” Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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She explained that she had always felt one of the ugliest things in the world was a toilet with the seat up, i.e., in the position a man would use it for urination. If the seat was down, it looked tolerable, but she could never stand the way it looked with both lid and seat up. T h e patient’s envy of men arid her unconscious anger at every man for having the penis she so envied and wished for did not prevent her from enjoying sexual relations with men. It did, however, make it impossible for her to be happy with a man or to marry one. Marriage had the same significance for her as did her menarche. It meant being irrevocably a woman. To remain unmarried meant, unconsciously, to be a man, a gay blade with a stable of sexual partners to pick from and to exploit for her pleasure. To marry meant to be castrated, as numerous dreams and associations made clear. How is one to understand the depressive affect that played so large a part in this patient’s adult symptomatology? T h e precipitating events suggested and the initial analytic work confirmed that her brother’s advent into their father’s business was what made her feel so miserably unhappy. Before that time she had been functioning without conscious depressive affect. T h e compromise formation resulting from her conflict over her childhood envy of her brother, her wish to be a boy in order to be her father’s favored son, can be most succinctly described as her acting as her father’s right-hand-and presumptive successor. During several years her brother was busy elsewhere, she was close to her father, and she functioned as a man in a man’s world. When she was made to realize that her brother was preferred precisely because he was a man, her misery, her jealous rage, and her guilt and anxiety over her murderous and castrative wishes all intensified and a different compromise formation resulted, this time a pathological one, in which depressive affect played a prominent role. In addition to feeling depressed, she withdrew from contact with her father (and brother), and proceeded to torment both herself and her current lover, a man with a mild but obvious physical infirmity who Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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was old enough to be her father. That the patient’s pathogenic conflict was of childhood origin is likewise evident. She had reacted in childhood to her brother’s birth with the same depressive affect (= misery), the same jealous rage, the same castrative and murderous impulses, and the same guilt as she did later when she fell ill, as her reaction to menarche, her adult sexual adjustment, her inability to marry or to be happy with a man in a sexual relationship, her hatred of open toilet bowls, and her conviction that she was a second-class citizen in a man’s world all testified. Her wish to have a penis, to be her father’s favorite son, the misery associated with those wishes, the defenses aimed at avoiding or mitigating her misery, and her need to punish herself for them all arose in childhood and gave rise to various compromise formations throughout her life, including the pathological one that finally brought her to seek treatment. The reader will understand that this outline of the patient’s psychodynamics and pathogenesis is both abbreviated and oversimplified. It should suffice, however, to illustrate the principal points at issue about the role of depressive affect in conflict and in compromise formation. For one thing, it illustrates that adult conflicts are related to those of childhood or, more properly, that childhood wishes and conflicts persist and are active throughout life, a point so familiar as not to need any special emphasis. For another thing, it illustrates that in one compromise formation depressive affect may be prominent, in another mild, and in a third absent, even though it plays a major part in the conflict underlying each. The compromise formation that brought her to treatment is an example of the first, her lifelong conviction that she was a second-class citizen in a man’s world is an example of the second, and her mild sexual promiscuity is an example of the third. The vignette also illustrates that depressive affect as a symptom of mental illness is not necessarily related to object loss. In this patient loss of love and lack of a penis were much more significant calamities than object loss, in connection with her depressive affect. Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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I should add that, in my own experience with such patients, castration depressive affect has played the major role more often than not. Perhaps this explains why depressive illness which is so severe as to require hospitalization is twice as frequent among women as among men. It should be added also that all the calamities of childhood are present to some degree in every patient one sees, as are wishes from oral, anal, and phallic stages of development. All conflicts and all compromise formations are multiply determined. Thus in every patient, whether the patient is overtly depressed or not, if one looks carefully enough one will always find some conflict over oral wishes and some unpleasure whose ideational content has to do with object loss. Orality and object loss are universal. They appear in patients who are not depressed as well as in patients who are depressed. The question is not whether they are present in patients in whom depressive affect is prominent. The question is whether they are invariably the major sources of trouble in such patients. The answer is that they are not invariably so and, if my own experience is a reliable guide, they are not so in most cases. To repeat, the clinically important conclusion to be drawn is that in treating a patient in whom depressive affect is a prominent part of the symptomatology one’s approach is quite the same as in treating an anxious patient. It is to understand the nature and origin of the patient’s conflicts and to apply one’s understanding to the therapeutic task. Because one knows that symptomatic depression or anxiety is part of a conflict over drive derivatives of childhood origin, that neurotic symptoms, including depressive affect and anxiety, are compromise formations resulting from such conflicts of childhood origin, one is led to infer, to interpret, and to uncover the elements of those conflicts and to trace their origins and development from childhood on. Unless one does know that that is what symptomatic depression or anxiety really is, one can become hopelessly lost in the tangle of a patient’s associations and history. The old adage that knowledge is power is nowhere better illustrated Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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than in the treatment of patients in whose pathological compromise formations depressive affect and anxiety are prominent. Depression as a feature of mental illness is the misery of childhood translated into the present and active in the present as part of adult psychopathology. REFERENCES
ABRAHAM, K. (1924). A short study of the development of the libido, viewed in the light of mental disorders. In Select Papers. New York: Basic Books, 1953, pp. 418-479. BRENNER, C. (1974). On the nature and development of' affects. Psyhoaaal. Q.,43:532-556. (1982). The Mind in Corzpict. New York: lnt. Univ. Press. FREUD,S. (1905). Three essays on the theory of sexuality. S. E., 7. (1917). hlourning and melancholia. S. E., 14. (1926). Inhibitions, symptoms and anxiety. S. E., 20.
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1040 Park Avenue New York, NY 10028
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mental illness in which depression is a prominent feature is a major problem in psychiatry today. hlost current efforts to better understand and deal with the problem have approached it from the side of neurochemistry, pharmacology, electroconvulsive therapy, and biogenetics. T h e approach in the present paper is based on recently available data about a different aspect of brain functioning, namely, the psychological aspect as studied by the psychoanalytic method. Two conclusions, based on those data, are the principal points of the paper. The first has to do with the psychodynamics and psychogenesis of depression as a feature of mental illness. The second, based on the first, is that it is a mistake to base a nosology on the premise that the presence of depression distinguishes a class of mental illness in some fundamentally important way. Depression is an affect, not an illness. The current concept of depressive illness, whatever the words used to designate it, is more misleading than helpful. As a necessary introduction, two related topics will be discussed briefly: affects in general, and the role of affects in psychic conflict. (For a more complete discussion, see Brenner, 1982.)
W
I - i x r E v m N A m BE GIVEN TO IT,
Training and Supervising Analyst, New York Psychoanalytic Institute. Accepted for publication September 7, 1989.
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Affects are best defined as a combination of two elements: a sensation or experience of pleasure or unpleasure, and an idea o r ideas. What constitutes an affect as a psychological phenomenon is the combination of the two, of pleasure/unpleasure and ideas. It should be noted that either the ideas or the pleasurehnpleasure sensation may be unconscious as well as conscious. If the ideas are unconscious and the sensation of pleasure o r unpleasure is conscious, what results is what is often called a contentless affect, e.g., contentless anxiety. If the ideas are conscious and the sensation of pleasure or unpleasure is unconscious, what results is what is called isolation of affect. T h e affects that trigger psychic conflict are unpleasurable ones. Of these the one best known and best studied by psychoanalysts is anxiety. When unpleasure is combined with a conscious or unconscious anticipation of danger or calamity, we label that affect anxiety. If the unpleasure is intense, one speaks of terror or panic. If it is minimal, we call it worry or unease. If the ideational content has to do with loss or loneliness, the affect is called separation anxiety; if it has to do with castration, it is called castration anxiety. In brief, unpleasure plus danger, unpleasure plus anticipated calamity, is one or another variety of anxiety. Depending on the intensity of the unpleasure and on the nature of the ideational content, it may be classified as panic, terror, dread, worry, fear, apprehension, etc., but if a calamity is in the future, if it impends, the unpleasurable affect is, by definition, a variety of anxiety. Also by definition, anxiety without ideational content is an impossibility. It is possible for there to be an experience or sensation of unpleasure without ideational content, and it is plausible to assume that this does in fact happen during the earliest days and weeks of extrauterine life. For the term anxiety to be a meaningful one, however, unpleasure must he combined with an expectation of calamity. Anxiety is the unpleasurable affect that signals the advent of something bad, of calamity (Brenner, 1974, 1982). The role anxiety plays in triggering psychic conflict is too well known to require repetition. Freud (1926) first outlined its Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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role and listed four calamities or dangers as its ideational content in early childhood: object loss, loss of love, castration, and, after superego development, punishment, which comes to subsume the other three. Anxiety is not the only form of unpleasure that plays a major role in psychic conflict, however (Brenner, 1982). Unpleasure can also be combined with ideas that a calamity has already occurred. When this is the case, the affect is not anxiety, but misery-what I have labeled depressive affect because of its relation to what is called depressive illness in later life. A child who feels abandoned, unloved, castrated, and/or punished in any or all of these ways does not suffer from anxiety, i.e., from an anticipation of calamity. The calamity is not a danger, not a matter of the future, a matter of expectation. For that child the calamity is a fact of life, it is the child’s current reality. When a calamity is a fact of life, when it is in the present rather than in the future, the unpleasurable affect is, by definition, not anxiety, but depressive affect. Thus, for example, separation anxiety is unpleasure plus the idea(s) that one is to be abandoned in the future. Separation depressive affect, on the other hand, is unpleasure plus the idea(s) that one is abandoned already, that one is already alone. With suitable alterations the same is true for each of the other calamities of childhood Freud (1926) outlined. To sum up, beginning in childhood there are two kinds of unpleasure associated with the calamities of object loss, loss of love, castration, and punishment. One kind is anxiety; the other is depressive affect. The difference between the two is that in the one, anxiety, calamity is anticipated, it is a danger, while in the other, depressive affect, calamity is present as a fact of life. Whenever either anxiety or depressive affect of sufficient intensity appears in connection with a wish for gratification of a drive derivative, what ensues is psychic conflict. Unpleasure associated with gratification of a drive derivative is what triggers psychic conflict, whether the unpleasure is anxiety or depressive a ffect
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Conflict in psychic life has four components: drive derivatives, unpleasure in the form of anxiety and/or depressive affect, defense, and superego manifestations. These components interact in accordance with the pleasure/unpleasure principle, i.e., in such a way as to achieve the maximum pleasure or gratification and the least unpleasure in the form of anxiety and/or depressive affect. T h e result of the interaction, the consequence of conflict, is a compromise formation, one which may be either pathological or normal. A brief vignette, presented somewhat schematically, will be useful to illustrate these statements. A twenty-one-year-old man, living at home with his parents, had to check the gasjets in the kitchen several times whenever h e left home. When asked to talk about this behavior, h e told a recurrent fantasy: he left the house, unaware that a jet was burning in the kitchen; during his absence the burning jet set the house afire and it burned to the ground; his father, distraught by the calamity, suffered a heart attack and died, leaving the patient and his mother alone to struggle along as best they could. M7lm were the components of the patient’s conflict and what the resulting compromise formation? Clearly a part of the compromise formation was his compulsive ritual (checking the gas jets). Another part was his recurrent fantasy of what would happen if h e did not check the jets. As for the components of the conflict, the most obvious of the drive derivatives was the patient’s unconscious wish to destroy father and to possess mother. Unpleasure in the form of anxiety and depressive affect could be identified in the patient’s conscious anxiety whenever h e failed to check the gas jets or even imagined failing to do so, and in the sense of misery that was a conscious part of the denouement of his fantasy. His defenses were, as always, numerous. Prominent among them was repression. H e had repressed all feelings of sexual attraction to his mother and of sexual rivalry with his father, although he quite consciously disliked his father and was very much on his mother’s side in her many quarrels with his father. T h e ideational content of Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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the patient’s castration anxiety was likewise repressed. He was no more conscious of a fear that his father would castrate him than he was of wishing to possess his father’s penis. Displacement and disavowal can also be seen in the substitution of burning down his father’s house for the idea of killing him and the attribution of his father’s death to a heart attack. Moreover, he was conscious of his strong desire to save the house, rather than of any wish to destroy it, a kind of reaction formation. As for superego manifestations, he was conscious of guilt as well as of anxiety at the idea of failing to check the gas jets carefully. So much for the illustrative vignette. To return to more general considerations, conflicts that are intense enough to be clinically significant originate in childhood. The conflicts of later life are a continuation of childhood ones: in them the past lives on in the present. Childhood wishes never cease to be active in the mind until the brain, the organ of the mind, itself decays or stops functioning altogether. IVhat characterizes the wishes of childhood that figure in psychic conflict is a desire for libidinal and aggressive gratification, gratification which, in the absence of anxiety and depressive affect, would be intensely pleasurable. As Freud ( 1905) pointed out, libidinal gratification is closely tied to the erogenous zones. It is for this reason that one speaks of oral, anal, and phallic or genital wishes. Aggressive wishes are also connected with the erogenous zones, but less closely so than are libidinal ones. For present purposes it suffices to say that under certain circumstances wishes for libidinal and aggressive satisfaction (pleasure) can arouse intense unpleasure in a child’s mind. When this happens, conflict ensues. The child either fears object loss, loss of love, castration, or punishment in connection with one or more instinctual wishes, or the child experiences one or all of these calamities as having taken place, as being a fact of life, in consequence of its wishes. Whichever may be the case, whether it is anxiety that is associated in a child’s mind with its instinctual wish(es) or whether it is depressive affect, the child reacts to eliminate or Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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to mitigate the unpleasure it experiences, i.e., to mitigate or to avoid altogether the anxiety, the depressive affect, or both. Every effort made to accomplish this end of reducing unpleasure is part of what we call defense. The function of defense is to reduce unpleasure. Whatever accomplishes or assists that purpose is, by definition, defensive. In the main, defense operates by opposing the gratification of the instinctual wishes that caused upleasure. Defense, in general, is antiinstinctual. For that reason, Freud used the word conflict to designate the psychic events under discussion. There is conflict in the mind between a wish for pleasurable instinctual gratification and a desire to suppress the instinctual wish in order to eliminate unpleasure in the form of anxiety and depressive affect. This formulation is only approximately correct, however. Opposition or conflict between wish and defense is only part of what happens. The full story is somewhat different. Namely, a compromise is reached among the several tendencies within the mind, a compromise that follows the pleasure principle by avoiding unpleasure while achieving pleasure insofar as each is possible. In other words, the result of conflict is that the drive derivatives involved are gratified as far as they can be without arousing too much unpleasure, unpleasure in the form of anxiety and depressive affect is eliminated as much as can be done while at the same time allowing for some gratification of the wishes involved, and simultaneously the demands of the superego are obeyed as far as possible. In brief, the consequence of conflict is a compromise formation, a compromise among all the components of conflict, a compromise formation, it should be added, which may be either normal or pathological. Thus unpleasure in the form of anxiety and depressive affect are always part of psychic conflict. It is a sine qua non as far as conflict is concerned: no unpleasure, no defense, no conflict. Matters are somewhat different, though, when it comes to compromise formation. This can best be illustrated by considering anxiety in conflict and in compromise formation, since that form of unpleasure is the more familiar. Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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When a defensive effort is successful in eliminating anxiety, at whatever cost to an individual’s mental health, anxiety does not appear as part of that person’s conscious experience. To take a familiar example, if an adult’s anxiety over childhood drive derivatives can be eliminated as a conscious experience by staying away from airplanes or by avoiding some other everyday situation, then the person in question is free of anxiety even though he or she is clearly suffering from a neurotic symptom, a phobia. Anxiety is a component of the underlying conflict, but not of the resulting compromise formation. The same may be true for a patient who must check all the gas jets in the kitchen two or three times before leaving home. Anxiety may be avoided as a conscious experience as long as the patient’s obsessional ritual can be carried out. Again, anxiety is part of the conflict, but not necessarily of the resulting compromise formation. There are, however, patients who experience some degree of anxiety despite their phobic avoidance or obsessional ritual. Despite the defenses mobilized by those patients, some anxiety appears in the resulting compromise formation. Indeed, experience shows that a patient may experience some anxiety along with a neurotic symptom at some times but not at others. Whenever anxiety does appear as part of the compromise formation that results from a pathogenic conflict, we conclude that ‘for that patient at that time the defensive efforts have mitigated the patient’s anxiety without having eliminated it altogether as a conscious phenomenon. It remains as part of the patient’s pathological compromise formation despite the patient’s defensive efforts. T o repeat, even though unpleasure in the form of anxiety plays a major role in a pathogenic conflict, it does not necessarily do so in the resulting pathological compromise formation. A patient may be acutely and overwhelmingly anxious, may have no conscious anxiety whatever, or anything in between. As a symptom, anxiety may be prominent or absent dcspite the fact that it plays a major role in conflict. A pathological Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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compromise formation may or may not include anxiety as one of its features. The same is true for depressive affect. In every conflict, depressive affect plays its part in initiating defense, just as anxiety does. Sometimes anxiety predominates and sometimes depressive affect. Both play their part in all. It is not the presence or absence of depressive affect as an element of conflict that varies from patient to patient. Depressive affect plays a role in every patient’s conflicts. What varies is the role of depressive affect in the resulting pathological compromise formation. Like anxiety, depressive affect as an element of symptomatologymay be prominent, it may be absent, or it may be somewhere in between. In brief, then, unpleasure, whether it is anxiety or whether it is depressive affect, plays a crucial and necessary role in every patient’s psychic conflicts. It may or may not play a prominent role in a patient’s symptomatology. Yet in every case, whatever the outward manifestations may be, anxiety and depressive affect are present and active unconsciously. IVhat are the implications of all this for the understanding of the psychopathology and dynamics of those cases of mental illness in whose symptomatology depression is prominent? IVhat light do these findings throw on so-called depressive illness? These questions are best answered by reviewing briefly the development of the psychoanalytic theory of depression prior to the discovery of the role of depressive affect in psychic conflict. Psychoanalytic theories of the origin and mechanism of depression began with Freud’s (1917) Mourning and Melancholia. In it Freud advanced several ideas about depression that are still widely accepted. The first is that pathological depression has a normal analogue: grief and mourning for a loved person or thing that one has lost by death or separation. A patient who is depressed, said Freud, is in mourning for someone who is consciously or unconsciously believed to be dead and gone. In some cases the loss is a real one, as when a patient Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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becomes pathologically depressed after the loss of a spouse or loved one. More often a patient, angry at a loved one for whatever reason, wishes the loved one dead, kills that person in some unconscious fantasy, and mourns the loss, imaginary though it is. It may be noted in passing that by analogizing depression to mourning Freud was able to offer an explanation of why an episode of depression is often limited in duration. When one mourns, one usually does so for a limited period of time-for several months or a year, perhaps. Then one is through with mourning and returns, at least in many cases, to one’s pre-loss, pre-mourning state, just as a depressed patient returns to his premorbid state after a period of depression. The main point of the analogy between mourning and depression, however, was the assertion that depression is a consequence of losing a beloved person, that depression results from object loss. The loss may not be a real one; it may be only a loss in fantasy, said Freud. The patient may not even be aware of any feeling of loss, i.e., the perception of a loss may be quite unconscious. Nevertheless, on the basis of his own observations and those of his colleague, Abraham, Freud asserted that depression is a consequence of losing a beloved person, that it results from object loss, real or fantasied, conscious or unconscious. On the basis of clinical observations, Freud also linked depression with identification and with aggression. His reasoning went this way. When one loses a beloved person, one tends to become like the person one has lost. By doing so, one tries to mitigate or undo the loss. Such a reaction first appears very early in life. A small child, left by mother, will identify with mother by mothering a doll or a pet, as though to assure itself that mother is not gone, that she is still there as the child wishes her to be. This reaction, this identification with an absent and yearned-for object, Freud said, is a general characteristic of human mental life. Identification is a defense against object loss, is the way it is often put today, and it has, as Freud pointed out, a momentous consequence. The consequence results from Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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the fact that beloved persons, especially beloved persons who desert and leave one, are hated as well as loved. It is precisely when ambivalence is intense, when great love coexists with intense rage or hatred, that identification with a lost object produces depression. Freud went on to say that turning aggression against oneself in this way explains some of the symptoms often found in depressed patients: diminished self-esteem, self-accusations, self-injury, self-torment, and suicide-i.e., doing unto oneself as one would like to do to the loved and hated lost object. In his major contribution to the psychology of depression, Abraham (1924) made one significant addition to Freud’s ideas. He linked depression to orality. As he and later investigators put‘it, the predisposition to depression later in life consists in a psychological trauma and consequent fixation at the oral phase of development, i.e., the first 18 months of life. In everyday language, if a patient becomes depressed in later life, one can safely assume, according to Abraham and later authors, that in infancy the patient was abandoned or neglected by mother. To summarize, the main points of the psychoanalytic theory of depression prior to the discovery of the role of depressive affect in psychic conflict were: (1) in cases of depressive illness there was inadequate mothering during the oral phase, i.e., during the first 18 months of life; (2) depression, like mourning, is a consequence of object loss; (3) object loss leads to identification with the lost object, which is both loved and hated; (4) as a result of identification, hate or aggression becomes selfdirected. Once the role of depressive affect in psychic conflict is taken into account, however, it becomes apparent that the facts are otherwise. In some instances a patient’s symptom of depression is related to object loss and to inadequate mothering, but not in all. Similarly, oral wishes may predominate, but they do not always do so. In fact, the cases in which oral wishes and Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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inadequate mothering are the principal reasons for later depression may be in the minority. Phallic and anal conflicts are common and are often more important than oral ones. It is also true that identification may play a crucial role in a depressed patient’s dynamics, but there are many patients in whom that is not so. Finally, aggression turned against oneself is not the cause of depression. It is, in fact, a consequence of it. To repeat, depressive affect, like anxiety, may be associated with any of the calamities of childhood. It is not exclusively or primarily associated with object loss. It is true that mourning for a lost object, a lost loved one, is a normal analogue to a pathological depression, as Freud suggested in 1917, but the analogy is misleading if it is carried to the extent to which it was carried by Freud and has been carried by other analysts since. T h e universal and, in that sense, normal affect related to pathological depression is a variety of unpleasure that may be related to any of the calamities of childhood. Because of its relation to pathological depression, I have labeled that particular variety of unpleasure depressive affect. An alternative label, one that is closer to the subjective experience it refers to, would be misery. Calling it depressive affect serves the useful purpose of directing attention to its place in those pathological compromise formations of later life for which the term depression is commonly employed. Calling it misery serves to remind one that it is a universal affect that plays a role in all psychic conflicts, whether normal or pathological, iie., that it is by no means always a conscious part of a pathological compromise formation. In summary, then, mourning as a reaction to object loss is not the universal or normal affective experience that is always psychologically related to pathological depression. The universal, normal affect related to pathological depression is the variety of unpleasure I have labeled depressive affect or misery. Sometimes it is misery at feeling, consciously or unconsciously, alone, deserted and bereft. Sometimes it is misery at feeling Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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unloved. Sometimes it is misery at feeling castrated. Sometimes it is misery at feeling punished in any or all of these ways. Like anxiety, misery is part of the human condition. As far as we know every child feels both anxiety and misery at times in connection with instinctual wishes, anxiety and misery that are sufficiently unpleasurable to give rise to intrapsychic conflict in the form of defense and compromise formation. Among the many consequences of childhood instinctual conflicts in later life are those compromise formations we call psychogenic symptoms. Depending on the nature and effectiveness of a patient’s defenses, anxiety, misery, or both may be present in the symptom or syndrome of which a patient complains. Both affects always play a part in pathogenesis. They trigger every patient’s defenses. Either or both may be absent from a patient’s awareness, however. When misery in whatever form is prominent in a patient’s overt symptomatology, the patient is called depressed. The affect of misery a depressed patient manifests will, to be sure, vary from one patient to another. One weeps, another shuns company, another despairs, still another is filled with self-reproach or is self-destructive. If anxiety is prominent as well as misery, the diagnosis may be agitated depression. For most patients, however, the one diagnostic label, depression, is sufficient. One conclusion to be drawn from all of this is that it makes no more sense to base a diagnostic classification of mental illness on the presence of depressive affect as a conscious symptom than it would to base one on the presence of anxiety as a conscious symptom. Both depressive affect and anxiety are always part of a patient’s pathogenic conflicts, ~vhetheror not either or both appear as part of the resulting compromise formation, i.e., as part of the overt symptomatology. All that the presence of either in a patient’s syniptomatology tells us is how efficient the patient’s defenses are in avoiding or mitigating unpleasure. It tells something about that aspect of a patient’s symptomatology, but no more than that. It says nothing else about the nature Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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of the conflict or conflicts that cause a patient’s symptoms, nothing about the origins of a patient’s conflicts, nothing about prognosis or amenability to treatment. Depressive affect is part of every pathological conflict, whether or not it appears in consciousness in the resulting compromise formation. It is true that depressive affect is prominent in the overt symptomatology of every depressed patient, but its presence does not distinguish those patients in any fundamental way from other mentally ill patients. Depressive affect is present in all, whether it is openly displayed on the surface or concealed in the depths, just as is the case with anxiety. Depressive affect is of fundamental, causative importance in all cases of mental illness, not just in a certain group of them that is labeled depressive illness or depressive reaction, despite what Kraepelin said a century ago and what many psychiatrists and analysts have continued to believe ever since. More than this, unpleasurc in the form of dcpressive affect and/or anxiety triggers conflicts whose outcome are normal compromise formations as well as pathological ones, compromise formations that play a major role in all of conscious mental life (Brenner, 1982).This fact, the ubiquity of depressive affect and anxiety in helping to determine the nature of the human condition, raises serious question concerning the usefulness of making either affect the basis of any descriptive, diagnostic classification. Any such term as depressive reaction, to say nothing of a term such as depressive illness, says nothing special or distinguishing about the causes of a patient’s psychogenic illness. It does, indeed, tell something distinguishing about a patient’s compromise formations, in particular about the nature and efficacy of a patient’s defenses, but nothing more than that. Useful as it is to understand a patient’s defensive structure, one must not rate it as being more important than it is, which is what terms like depressive illness do. For all these reasons it would be advantageous if such diagnostic terms could be dropped. Advantageous though it might be, however, it is.unlikely to happen soon. Such terms will undoubtedly be with us Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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for a long time to come. The outworn concepts associated with the terms need not be so long-lived, though. Whatever diagnostic label one chooses in classifying mentally ill patients in whom depressive affect is prominent, the important thing is to understand clearly the nature and origins of each patient’s compromise formations and underlying conflicts. Misery or depressive affect is not necessarily a consequence of object loss, it is not simply aggression turned on oneself by way of identification, and it does not justify the assumption that a patient’s conflicts are chiefly oral ones, based on preoedipal trauma at the hands of the patient’s mother, or nonmother, as the case may be. Depressive affect plays the same role in psychopathology as does anxiety. It is an inevitable part of the mental life of childhood, it is associated with all the calamities of childhood, it is a trigger for defense and conflict, and it may or may not appear as a conscious or overt part of a patient’s compromise formations, depending on the nature and efficacy of the patient’s defenses. T h e more clearly one keeps all this in mind in one’s clinical work with patients, the better one is able to understand the nature and origins of each patient’s pathogenic conflicts and the more effectively one will be able to treat one’s patients psychoanalytically and/or psychotherapeutically, as the following case vignette illustrates. T h e patient was a thirty-three-year-old, unmarried woman who came for treatment complaining that she felt unhappy and did not know what she wanted to do in life. Nothing seemed to interest her, she said. She had worked in her family’s business for several years and had at first enjoyed being there, but she finally grew to dislike it and left. Since that time she had been at loose ends. What was striking about the patient was her affect. She looked much sadder than she complained of feeling, tears came frequently to her eyes, and she spoke slowly, with many pauses. It took little probing to discover that she was, in fact, not simply unhappy and at loose ends, but truly disconsolate and had been Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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increasingly so for many weeks. Nor was the onset of her symptoms difficult to discern. It coincided with the entry of her brother into the family business. Until that time the patient had been her father’s right hand in the business. When her brother, who was five years her junior and her only sibling, came into the business, it soon became clear to the patient that it was not she, but her brother, who was destined to be her father’s close associate and eventual successor. It was then that her symptoms began. In the course of her analysis it became clear that this patient’s conflicts centered about the fact that she was a girl, not a boy, and that they had done so since her brother’s birth. Her penis envy and her misery at having been born a girl, which to her as a child meant having been castrated, were intense. The following excerpts will give some notion of how intense they were. She mentioned on one occasion that for years she had not felt comfortable with her body. “Do you remember when you began to feel that way?” I asked. She thought for a moment, then answered, “When I was about twelve.” “When did you first menstruate?” I asked. “When I was twelve,” was her reply. To her, the onset of menstruation had meant the end of any possibility of being a man. Menstruation was conclusive and final proof that a girl was what she was and a woman was what she would always be. As another illustration of how she felt about being without a penis, she came into my office one day indignant because, when she had gone to use the lavatory just before, she had found the toilet seat up. “No one,” she said indignantly, “has any right to leave a toilet seat in that position!” “Why not?” I asked. “Because,” she said, “if looks so ugly that way!” Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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CHARLES BRENNER
She explained that she had always felt one of the ugliest things in the world was a toilet with the seat up, i.e., in the position a man would use it for urination. If the seat was down, it looked tolerable, but she could never stand the way it looked with both lid and seat up. T h e patient’s envy of men arid her unconscious anger at every man for having the penis she so envied and wished for did not prevent her from enjoying sexual relations with men. It did, however, make it impossible for her to be happy with a man or to marry one. Marriage had the same significance for her as did her menarche. It meant being irrevocably a woman. To remain unmarried meant, unconsciously, to be a man, a gay blade with a stable of sexual partners to pick from and to exploit for her pleasure. To marry meant to be castrated, as numerous dreams and associations made clear. How is one to understand the depressive affect that played so large a part in this patient’s adult symptomatology? T h e precipitating events suggested and the initial analytic work confirmed that her brother’s advent into their father’s business was what made her feel so miserably unhappy. Before that time she had been functioning without conscious depressive affect. T h e compromise formation resulting from her conflict over her childhood envy of her brother, her wish to be a boy in order to be her father’s favored son, can be most succinctly described as her acting as her father’s right-hand-and presumptive successor. During several years her brother was busy elsewhere, she was close to her father, and she functioned as a man in a man’s world. When she was made to realize that her brother was preferred precisely because he was a man, her misery, her jealous rage, and her guilt and anxiety over her murderous and castrative wishes all intensified and a different compromise formation resulted, this time a pathological one, in which depressive affect played a prominent role. In addition to feeling depressed, she withdrew from contact with her father (and brother), and proceeded to torment both herself and her current lover, a man with a mild but obvious physical infirmity who Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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was old enough to be her father. That the patient’s pathogenic conflict was of childhood origin is likewise evident. She had reacted in childhood to her brother’s birth with the same depressive affect (= misery), the same jealous rage, the same castrative and murderous impulses, and the same guilt as she did later when she fell ill, as her reaction to menarche, her adult sexual adjustment, her inability to marry or to be happy with a man in a sexual relationship, her hatred of open toilet bowls, and her conviction that she was a second-class citizen in a man’s world all testified. Her wish to have a penis, to be her father’s favorite son, the misery associated with those wishes, the defenses aimed at avoiding or mitigating her misery, and her need to punish herself for them all arose in childhood and gave rise to various compromise formations throughout her life, including the pathological one that finally brought her to seek treatment. The reader will understand that this outline of the patient’s psychodynamics and pathogenesis is both abbreviated and oversimplified. It should suffice, however, to illustrate the principal points at issue about the role of depressive affect in conflict and in compromise formation. For one thing, it illustrates that adult conflicts are related to those of childhood or, more properly, that childhood wishes and conflicts persist and are active throughout life, a point so familiar as not to need any special emphasis. For another thing, it illustrates that in one compromise formation depressive affect may be prominent, in another mild, and in a third absent, even though it plays a major part in the conflict underlying each. The compromise formation that brought her to treatment is an example of the first, her lifelong conviction that she was a second-class citizen in a man’s world is an example of the second, and her mild sexual promiscuity is an example of the third. The vignette also illustrates that depressive affect as a symptom of mental illness is not necessarily related to object loss. In this patient loss of love and lack of a penis were much more significant calamities than object loss, in connection with her depressive affect. Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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CHARLES BRENNER
I should add that, in my own experience with such patients, castration depressive affect has played the major role more often than not. Perhaps this explains why depressive illness which is so severe as to require hospitalization is twice as frequent among women as among men. It should be added also that all the calamities of childhood are present to some degree in every patient one sees, as are wishes from oral, anal, and phallic stages of development. All conflicts and all compromise formations are multiply determined. Thus in every patient, whether the patient is overtly depressed or not, if one looks carefully enough one will always find some conflict over oral wishes and some unpleasure whose ideational content has to do with object loss. Orality and object loss are universal. They appear in patients who are not depressed as well as in patients who are depressed. The question is not whether they are present in patients in whom depressive affect is prominent. The question is whether they are invariably the major sources of trouble in such patients. The answer is that they are not invariably so and, if my own experience is a reliable guide, they are not so in most cases. To repeat, the clinically important conclusion to be drawn is that in treating a patient in whom depressive affect is a prominent part of the symptomatology one’s approach is quite the same as in treating an anxious patient. It is to understand the nature and origin of the patient’s conflicts and to apply one’s understanding to the therapeutic task. Because one knows that symptomatic depression or anxiety is part of a conflict over drive derivatives of childhood origin, that neurotic symptoms, including depressive affect and anxiety, are compromise formations resulting from such conflicts of childhood origin, one is led to infer, to interpret, and to uncover the elements of those conflicts and to trace their origins and development from childhood on. Unless one does know that that is what symptomatic depression or anxiety really is, one can become hopelessly lost in the tangle of a patient’s associations and history. The old adage that knowledge is power is nowhere better illustrated Downloaded from apa.sagepub.com at Bibliothekssystem der Universitaet Giessen on June 8, 2015
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than in the treatment of patients in whose pathological compromise formations depressive affect and anxiety are prominent. Depression as a feature of mental illness is the misery of childhood translated into the present and active in the present as part of adult psychopathology. REFERENCES
ABRAHAM, K. (1924). A short study of the development of the libido, viewed in the light of mental disorders. In Select Papers. New York: Basic Books, 1953, pp. 418-479. BRENNER, C. (1974). On the nature and development of' affects. Psyhoaaal. Q.,43:532-556. (1982). The Mind in Corzpict. New York: lnt. Univ. Press. FREUD,S. (1905). Three essays on the theory of sexuality. S. E., 7. (1917). hlourning and melancholia. S. E., 14. (1926). Inhibitions, symptoms and anxiety. S. E., 20.
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