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Ego Psychology of Depression With Implications for Treatment

IRVING

M. R O S E N

In an important paper that is often quoted because it brings the discussion of the psychodynamics of depression into the domain of ego psychology, Edward Bibring 1 located the source of depression in a tension within the ego. He observed that the ego cannot live up to its ideals, feels helpless, and loses self-esteem. The ego no longer realizes itself as being loved or strong or good and is then afflicted with a feeling of depression. Bibring saw anxiety and depression as primary ego reactions: anxiety as a reaction to danger indicating the organism's urge to survive, depression as a reaction to danger in which the ego senses an incapacity to meet danger and turns toward death. He considered the previous psychoanalytic thought on depression expressed in the classical papers of Abraham, 2 Freud, 3 and Rado 4 as too vague and inadequate and took issue with the emphasis on pregenital oral and anal phase specificity and on love-hate relationships. It should not be surprising that now, more than sixteen years after Bibring's paper, in my work with depressed patients I do not find that his conclusions quite hold up or are consistently adequate to explain what is happening in the psyches of these people. There are three inadequacies that, strictly from ease material, have caught my attention. First, depression seems to be a secondary emotion. The disorder afflicting IRVIN~ M. ROSEN, M.D., Director of Community Services of the Cleveland State Hospital, has been a frequent contributor to journals of psychiatry and pastoral care. He was recently president of the Clevelandbranch of the Academy.

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different patients or the same patient at different stages of treatment has subtle differences according to a predominant prior emotional reaction, whether anxiety, grief, anger, guilt, self-pity, pain, loneliness, despair, or apathy. Thus I see anxious depressions, guilty depressions, and so on. It would appear that if a person cannot resolve or channel one or more of his negative emotions, any of them may turn into depression. Conversely I have observed that when the negative painful emotion is resolved the depression, or a quantum of it, disappears. Thus prior observations that depression is somehow related to anger or grief or some other emotion are correct but partial statements. This observation that depression sets in with improper management Of emotions leads to two questions. W h y cannot the ego deal constructively with emotions and, second, what are these emotions, unresolved and presumably on the rampage, doing to the ego? First, the ego destined for depression appears deficient in that it becomes disorganized, lacks structure and the ability to think rationally when confronted by the stress of strong emotion. It suffers from excessive emotional awareness and may harbor the belief that emotion is more important as a guide than is thought or conscience. Thus certain autonomous functions have not been developed, have not been learned and made a firm part of the ego structure. This observation has direct implications for therapy: The patient needs, not primarily kindness or warm support or someone to handle his emotions for him, but rather he needs to identify with firmness, to learn to structure time, to think systematically, to organize tasks, and to solve problems or wait patiently until they can be solved. The patient's deficiency does not lie in his emotions; these are working all too well. Let us go on to the next question concerning the effects of powerful unchanneled emotions on the ego and the ways of putting them in order. At this point it is helpful to think of the emotions phenomenologically as "thingsin-themselves." Let us suspend our search for causes in underlying conflicts and consider the course and consequences of emotions once they are tripped off in the kind of ego that is defective as we have described and let us take a systematic look at some of the major negative or distressing emotions.

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Anxiety as a thing-in-itself tends toward escalation. To personalize it for convenience of discussion, it wants always to become a better, louder signal of danger in order to force the solution of some problem. The signal becomes so painful or is accompanied by so many physiological changes that the patient is actually traumatized by the anxiety signal, which precipitates further anxiety, and a vicious circle begins? A most insidious trauma occurs when the anxiety seems to attack the ego's values. As examples, the husband feels he no longer loves his wife or the mother gets a morbid idea that she wants to harm her baby. Since such feelings and ideas can become an inherent part of an anxiety syndrome, it is obvious that anxiety ha s within itself the force to drive a person toward confusion and panic. Now what are the possible channels for anxiety resolution? There are several, most of them obvious enough: appraisal of the specific problems creating the danger and development of a plan to solve them; a call to patience, endurance, and faith; a candid explanation of the havoc anxiety is capable of creating as a thing-in-itself; the use of tranquillizers when the problem is temporarily unremediable, such as when a loved one is incurably ill. The list is hardly exhaustive. And some dangers disappear when they are looked squarely in the face, like the trauma of anxiety itself. Anger, including bitterness, wantsmas a thing-in-itself to use the muscles to destroy or get revenge on an intruder to the self and its field. Some people have few techniques for resolving anger: physical attack, verbal abuse, turning against the self to get back at the offending other. Of course, there are better ways that have more favorable consequences: outdoing the other in competition, showing the other that one is better than he thinks, separation of self from the aggressor, understanding, forgiveness, reconciliation. Griefmas a thing-in-itself--wants to force the ego to deny a loss or to join the lost object. It can be resolved only through a process of mourning. Inherent in the emotion of guilt is a need to punish the self and a feeling of unworthiness. The resolution of sins of commission lies, of course, in confession, repentance, reparations; those of omission in taking action to do that which has been neglected. The neglect of action may occur at the point of initiation, continuation, or completion of a task.

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There are several other festering emotions encountered in treating depressed persons. Among them are self-pity (the value of this emotion to the patient is expressed in the saying, "Self-pity and a dime will get you a cup of coffee"), alienation, loneliness, and despair. Alienation appears to be a combination of grief, anger, and guilt with reconciliation the major requirement for alleviation. Loneliness in the depressed patient yields best to solutions that help him to get in touch with neglected parts of himself, such as conscience or common sense, rather than to solutions that look to others. In fact, relying on others to relieve loneliness may well drive them away; people are drawn to poise and strength. Furthermore, we must inevitably spend time alone and thus should learn how this is best accomplished. Despair begins to set in when the person cannot visualize himself moving into the future. All the negative emotions tend to block the hopeful view of the passage of time. The feelings of apprehension of future dangers, of unworthiness to act, of unwillingness to go on without a lost object, of the need to rebel all make it hard to move on. It is not surprising that apathy or suicidal impulses will accompany such unresolved emotions. Sometimes there is real fatigue from struggling, in addition to apathy or paralysis of will. Stagnating emotions may produce symptoms for a long time indeed. A recent patient of mine whose prolonged depression was characterized by sadness and a continual teariness had a sudden very strong mourning reaction over his father deceased twenty-eight years before. It is noteworthy that religion has over the millenia developed much of key constructive value for the resolution of all our potentially disruptive emotions. Faith, patience, endurance, repentance, forgiveness, reconciliation, and mourning are part of the age-old armamentarium of the clergy. In the light of the discussion so far it would appear that the ingredients of depression consist of 1) one or more of the primary emotions precipitated in 2) an ego inadequate in firmness, structuring ability, and constructive outlets plus 3) the associated phenomenological tendencies inherent within the emotions plus 4) the sense of helplessness that, not surprisingly, ensues. The helplessness carries several messages: a cry for help, an excuse for lack of coping ability, a sulk, an assault. It has been my experience that, as the in-

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gredients of this mixture were removed, the depression gradually diminished. And when it had disappeared the patient had learned what had gone into the makeup of his depression and, one might hope, how to combat it with less dependence on external assistance. Coping knowledge and ability are clearly direct antidotes to helplessness and thus to depression itself; this, I think, is what modern ego psychology is all about. 6 The treatment approach to the depressed patient can now be formulated into a procedure, the core of which is a systematic review of the primary emotions. What, if anything, is the patient anxious about? W h o m is he angry at now? What is he guilty about? Whom did he lose? The awareness of these emotions is usually close to or at the surface of his mind and available quickly. Then ensues a review of exactly what the patient is doing about his emotions and problems. Various alternatives are discussed with cool objectivity. The patient is not told what to do; the emphasis is on the use of his own common sense and conscience to explore what he thinks is right for him. This coping approach to depression is a splendid antidote to despair in the patient (and perhaps in the therapist). Itserves to firm up the "wishy-washy" ego, to create a structure within which treatment occurs, and to provide a model for identification that is an invaluable part of the learning process. A word about drugs. Since depressions vary according to the predominant primary emotions, the prescribing of drugs (of course by physicians) should proceed with considerable discretion. For example, one does not give energizers to all depressed persons. If the patient is anxious, a tranquillizer may be in order, one that is not so strong that it prevents activity and problem solving. At times a depressed patient suffers from severe apathy and other emotions are not apparent. An energizer is appropriate to allow the patient to act, thus preventing any build-up of guilt and despair. Careful evaluation of the patient is required ar this point to insure constructive rather than selfdestructive acts. It is vital that the patient help himself as much as possible and that he understand the nature of his treatment step by step. If too much reliance is placed on powerful external interventions such as drugs, shock, and hos-

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pitalization, the patient will be weakened even as his mood lifts. The same weakening effect can occur from reliance on explanations about events from his remote past, or unconscious conflicts that, by definition, he cannot be expected to find himself. All-giving and all-knowing personal helpers also can debilitate by enhancing dependence. Such forms of help actually teach the patient to rely heavily on forces outside himself, since they may give temporary relief. He will become prey to helplessness and develop a pattern of quick relapse, or he may never quite recover. The treatment, potent for the acute episode, must not, as it often does, become a contributing factor to later relapse. Simple solutions and impulsive approaches such as inviting catharsis of hostility or slipping into sympathetic kindness may be of no value or may aggravate the disorder. The antidote to excessive emotionality is not more emotionality or its relatives, sentimentality and sympathy. This is not to say that the therapist cannot appreciate that depression is an exceedingly distressing, painful, and sometimes dangerous condition. Constructive thought leading to constructive action "that speaks louder than words" should not be confused with morbid thought whereby the patient dwells on all the horrible eventualities that might come to him or on all the nasty ways he can revenge himself on a frustrating person. Such thinking is driven by emotion rather than being detached and objective about emotion. Beck, in his recent book on depression, places considerable importance on the patient's cognitions and goes into much detail about ways of distinguishing the valid from the invalid.7 It is not necessary to suppose that the patient's emotions are sick or are giving him wrong information, or that his judgment is defective or his ideals too high, or wrong, or that he is excessively conscientious, or even that he is pathologically manipulative. His disorder lies rather in his inability to make best use of his good awareness and emotional warmth and interpersonal skills and to live up to his ideals. I am not yet convinced by the recurring statement that the ideals of the depressed patient are often inappropriate or unreasonable, though they may be quite exacting. Movement, constructive action and doing are vital to a person wallowing in his feelings, clinging to another, neglecting what he himself considers to

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be his duties, drowning in a sea of words and excuses. In tackling action, patients (and many others) may have particular difficulty in initiating, continuing, or terminating tasks. Because of the forbidding, looming tendency of unfinished work, it is often helpful for the patient to know the points of most difficulty and to establish careful priorities. Small accomplishments relieve guilt and release energy for further action. Such acts move the patient into the future, combat despair, improve self-esteem, and channel stagnating energy. The ideas in this paper will not shed light on all depressions, nor will the methods always be usable. Some patients, at least initially, are beyond a talking treatment. They are highly disturbed and irrational and leave us no choice but forceful intervention. These cases are, in my experience, much fewer than those with whom talk can be carried on. There are also schizoid and compulsive persons whose depression resembles battle fatigue, who typically are cold and unaware and emotionally inhibited. Emotion to them is "silly" or "childish" or "sick" o r "unimportant." The one emotion that breaks through finally is a pervasive anxiety, which on close examination is often what the patient means when he complains of depression. The more common and typical depression in the unstructured or underdisciplined ego is, however, related to the cyclothymic disorder in which the patient fluctuates from high to low, from elation to sadness and immobility, and is related also to various of the impulsive character disorders where the patient's actions are damaging and where the treatment would have many elements in common with the approach presented here. While I am focusing on the ego psychology of depression in this paper, we should not forget that depression may and does occur as a consequence of various serious organic diseases, particularly those of the brain and gastrointestinal tract, and that the differential diagnosis of types of depression must precede treatment plans,

Summary Concepts suggested by autonomous ego theory and a phenomenological ap-

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proach to emotions make it possible to think again about depression and its treatment in order better to explain clinical observations. Depression appears to be a secondary emotion, not primary, made up of the following ingredients: 1) one or more primary emotions--anxiety, anger, guilt, and grief particularly, as well as self-pity, loneliness, alienation, apathy, and despair--precipitated in 2) an ego inadequate in channeling emotions constructively, 3) the associated phenomenological tendencies inherent within the emotions, and 4) the sense of helplessness that ensues. Thus the treatment required would consist of a systematic, somewhat detached, cognitive approach to the problems the emotions are indicating, and what should be done to resolve them. These problems include those precipitated by the workings of the emotions as things-in-themselves. The treatment is oriented toward enhancing the patient's understanding of the disorder and his coping ability to the end that the patient is not weakened even as he is relieved.

References 1. Bibring, E., "The Mechanism of Depression." In Greenacre, P., ed., Affevtive Disorders. New York, Internat. Univ. Press, 1953, pp. 13-48. 2. Abraham, K., "Notes on the Psychoanalytic Investigation and Treatment of ManicDepressive Insanity and Allied Conditions." (1911) In Selected Papers on Psychoanalysis. New York, Basic Books, 1960, pp. 137-156. , "The First Pregenital Stage of the Libido." (1916) Loc. vit., pp. 248-279. , "A Short Study of the Development of the Libido." (1924) Lov. tit., pp. 418-501. 3. Freud, S., "Mourning and Melancholia." (1917) In Collected Papers by Sigmund Freud, Vol. 4. London, Hogarth Press, 1950, pp. 152-172. 4. Rado, S., "The Problem of Melancholia," lmemat. ]. Psychoanal., 1928, 9, 420-438. 5. Rosen, I. M. "Practical Approach to Anxiety and Its Concomitant Symptoms in Brief Psychotherapy," Diseases of the Nervous System, 1956, 17, 343-346. 6. Lifschntz, S., "A Brief Review of Psychoanalytic Ego Psychology," Social Casework, 1964, 4Y, 63-67. 7. Beck, A. T., Depression. New York, Harper & Row, 1967.

Ego psychology of depression with implications for treatment.

Concepts suggested by autonomous ego theory and a phenomenological approach to emotions make it possible to think again about depression and its treat...
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