Judith Hamilton M.D., F.R.C.P. - Psychiatrist/Psychoanalyst - Freudian and Lacanian Orientation
Psychoanalysis - First Year - 3 Seminars on DEPRESSION 
Student Outlines

Seminar 1: History and Basic Concepts

BASIC CONCEPTS 
 A. Affect 
 B. Mood 
 C. Depressive affect 
 D. Depressive mood 
 E. Depressive illness 
 F. Mourning  
 G. Melancholia  
 H. Narcissistic object choice 
 I. Narcissistic injury 
 J. Object loss 
 K. Narcissistic regression 
 L. Introjection 
 M. Ambivalence 

OUTLINE OF SIGMUND FREUD’S FORMULATION OF MELANCHOLIA (1917)  (Derived from the summary by Dr. David Kligman) 

 A. Predominance of narcissistic object choice (e.g. Alan Eisnitz (1969)- cathexis is primarily to the self-representation and secondarily to the object representation; may also speak of a narcissistic path) 

     p. 249:  “the object-choice has been effected on a narcissistic basis” 
     p. 250:  “the disposition to fall ill of melancholia…lies in the predominance of the narcissistic type of object-choice” 

 B. Narcissistic injury (Recall 3 aspects of self-regard: residue of primary narcissism; the “omnipotence” that is corroborated by experience - ie. fulfillment of the ego ideal; and satisfaction of object-libido.) 
 
     p. 249:  “a real slight or disappointment” 
     p. 251: “slighted, neglected or disappointed” 
     p. 253: “a purely narcissistic blow to the ego” 

 C. Ambivalence 

     p. 251: “can import opposed feelings of love and hate into the relationship or reinforce an   already existing ambivalence.  This conflict due to ambivalence…among the preconditions of melancholia.”  
     p. 256: “In melancholia the relation to the object is no simple one; it is complicated by the conflict due to ambivalence.  The ambivalence is either constitutional….or else it proceeds precisely from those experiences that involved the threat of losing the object.” 

 D. Object loss (refers to an active process) 

     p. 249: “the forsaken object” “the object cathexis was brought to an end” “the abandoned object” 
     p. 251: “the object itself is given up” 
     p. 252: “the object has been got rid of” 

 E. Narcissistic regression (the ‘great divide’ between the less severe states of narcissistic injury and the depressive illnesses) 
  
     p. 250: “process of regression from narcissistic object-choice to narcissism”       
     p. 258: “Of the 3 preconditions of melancholia - loss of the object, ambivalence, and regression of libido into the ego” 

 F. Other points 
     1. In mourning it is reality that compels the decathexis of the object; in melancholia it is hostility/hatred. 
     2. In mourning, the reaction reflects a predominance of object-libidinal investment; in melancholia, a predominance of narcissistic-libidinal investment.   

 
ELEMENTS OF KARL ABRAHAM’S FORMULATION OF MELANCHOLIA (1911, 1916,1924) 

 A. Comparison of melancholia and obsessional neurosis 
   1. Anality and sadism 
   2. Inference of two substages in the sadistic-anal stage 
       a. Expulsive – Destructive (earlier) 
       b. Retentive – Conserving/Controlling (later) 
   3. Foreshadowing of the concept of object constancy:  
        p. 432 ‘This differentiation...’ stable vs. unstable ambivalence 
  
 B. Introjection in melancholia 
  1. Further regression in melancholia
  2. Inference of two substages in the oral stage       
      a. Sucking – Incorporating – preambivalent (earlier) – identification as first object tie 
      b  Biting – Devouring sadistic (later) 
  3. Support for Freud’s idea of object loss in melancholia as an active abandonment of the 
     object 
  4. Example: the “elimination dream” – expulsion of the object 

 C. Psychogenesis of melancholia 
   1. The self-directed ambivalence of the melancholic  
   2. The precipitating narcissistic injury is an event experienced as a repetition of a childhood
     trauma 
   3. Etiological factors 
      a. Constitutionally heightened oral erotism 
      b. Oral fixation 
      c. Severe infantile narcissistic injury 
      d. ...before the Oedipal resolution 
      e. Later repetition of the primary disappointment   
   4. Dual introjection into conscience and ego   

 D. Primal parathymia 


A PSYCHOANALYTIC CLASSIFICATION OF DEPRESSIVE PSYCHOPATHOLOGY 
 
 A. Uncomplicated states of narcissistic injury (ie. without significant narcissistic regression) 
    1. a ‘purely narcissistic blow to the ego’ 
    2. disappointment in an object 
      a. with retention of the object - pining 
      b. with abandonment of the object - limited, as long as the subject’s whole world is not focused on the object 

 B.  Depressive illness (ie. with significant narcissistic regression in object relation and mode of self-esteem regulation)
    1. melancholia 
    2. benign stupors and less severe retarded depressions 
    3. Henseler’s ‘euphoric’ suicides 
    4. others 

 C.  Characterological depressions 
    1. Conflict over (sexual and aggressive) drives with inhibition 
    2. Dormancy  

Seminar 2: Depressive Illness
A psychoanalytic theory of depression presupposes a "multiple factor" genetic approach, taking into account: the drives involved in the conflict, and in the instinctual constitution; the ego, the super-ego and ego ideal; developmental psychogenetic aspects, including the factors of sequence and timing.  We see the development of these ideas through the authors following Freud and Abraham.   

 EDWARD BIBRING’S MECHANISM OF DEPRESSION (1953) 
 (As the ego’s response to narcissistic injury.)
   A.  Depression is an ego-psychological phenomenon, a 'state of the ego', an affective state (p. 21), the emotional expression of a state of helplessness and powerlessness of the ego.  In all cases, there is a blow to the person’s self esteem. (p. 24) 
   B.  Three sources of self-esteem: 
         1.  The wish to be worthy, to be loved, to be appreciated; that is, to be loved by the ego ideal. 
         2.  The wish to be strong, superior, great, secure; that is, to satisfy remnants of the ideal ego (infantile narcissism).
         3.   The wish to be good, loving, not aggressive, hateful nor destructive; that is, to love the ego ideal. 
Depression sets in when one or more of these conditions fail and the ego feels helpless to resurrect them. Its main characteristics are a decrease of self-esteem, a more or less intense state of helplessness, a more or less intensive and extensive inhibition of functions, and a more or less intensely felt particular emotion.  It often includes fatigue and anxiety. 
   C. Narcissistic aspirations of each psychosexual level can be frustrated and lead to depression: oral, anal, phallic. 
   D.  Traumatic narcissistic injuries early in childhood predispose a person to later neurotic and probably also psychotic depression.  
 Not all depressions occur in “orally-oriented” persons. 
 Aggression against the self is not always present. 

 EDITH JACOBSON'S VIEWS ABOUT DEPRESSION  
 Edith Jacobson 1953  
 Depression (simple, psychotic, endogenous (psychosomatic) features, in cyclothymics) consists of a triad of symptoms: periods of depressed mood, inhibition of thinking, and psychomotor retardation.  The central psychological problem in depression - narcissistic breakdown: loss of self-esteem, feelings of impoverishment, helplessness, weakness, and inferiority; or, in the melancholic type, of moral worthlessness and even sinfulness.   
Premorbid manic-depressive personality - richness of their sublimations, delightful companions, full genital response, emotional warmth and unusual affectionate clinging to people they like. Remarkable intolerance toward frustration, hurt, and disappointment.  The object choice has been on a narcissistic basis, which permits them to regress easily to the narcissistic identification with the love-object.  They require a constant supply of love and moral support from a highly valued love-object (whom they idealize) while their self-representations retains the infantile conception of a helpless inadequate self.    
 Jacobson 1971
   A. Critique of Bibring - Bibring downplays the role of aggression.  In part, he limits himself to the depressions reflecting a tension within the ego (between the ego and the ego ideal); he leaves out the occasion of "hostile deflation of self-image, and he leaves out, or considers it only "complicating", the depressions in which there is tension between the ego and the superego (guilt).  Also, in concentrating on the ego and narcissistic feelings of frustration, he downplays the role of ambivalence (the instinctual point of view). 
   B. Feelings of security, depression, and elation are characteristic states of normal or disturbed narcissistic equilibrium.  Agreeing with Mahler, elated and depressive responses can be found at an early age as a result of experiences of narcissistic gratification or frustration.  
    C. Clear distinction between neurotic, borderline, psychotic, and between the different types of depressive states. 
   D. Drives must be included to understand - The basic conflict in all depressed states:  "Frustration arouses rage and leads to hostile attempts to gain the desirable gratification.  When the ego is unable (for external or internal reasons) to achieve this goal, aggression is turned to the self-image.  The ensuing loss of self-esteem is expressive of the narcissistic conflict, ie. a conflict between the wishful self-image and the image of the deflated, failing self.  The nature of the mood condition that then develops depends on the intensity of the hostility and the severity and duration of frustration and disappointment." (p. 183)   

 JOSESPH SANDLER (1967) (from "On disorders of narcissism" in From Safety to Superego, 1989
 (Depression from the point of view of the clinical response to a narcissistic injury without using the concept of drives.)   
 The basic form of unpleasure in disturbances of narcissism is an affective experience of mental pain.  Mental pain reflects a substantial discrepancy between the mental representation of the actual self of the moment and an ideal shape of the self.  Lack of self-esteem, feelings of inferiority and unworthiness, shame and guilt, all represent particular higher-order derivatives of the basic affect of pain.  These are determined and influenced by the manifold and complex elements that enter into the formation of the ideal self. 
A narcissistic disorder: Its central feature is the existence of an overt or latent state of pain that has constantly to be dealt with by the ego.  The defensive and adaptive maneuvers that are responses to it can assume pathological proportions.  These include the so-called seeking of narcissistic supplies, overcompensation in fantasy, identification with idealized and omnipotent figures, pathologically exaggerated forms of narcissistic object choice, compulsive pseudosexuality, many aspects of homosexual activity and other perversions.  Various forms of self-punishment may be seen, particularly when superego factors predominate in causing pain.  Self-damaging and self-denigrating activities may be sexualized and reinforced by masochistic trends. 
Depression: If the individual's adaptive and defensive maneuvers fail, and he is left helpless and hopeless in the face of the (conscious or unconscious) state of pain, he may then develop a depressive reaction.  This view places the depressions in the wide realm of narcissistic disorders.   

 ALAN PARKIN (1976) (From "Melancholia: a reconsideration")
(Following one tradition in metapsychology, Parkin separates the ego-ideal and the superego into two equivalent functions, the first loving and rewarding, the second critical and punishing.)   
 The basic mechanism of all simple depression is the abandonment by the ego ideal of the ego as a loved object, resulting in the fall of self-esteem (Bibring, 1953); a sense of inferiority; loss of the ego ideal's love. 
 The distinguishing mark of melancholia - the heightening of the criticisms of conscience; increased attacks by the superego on the ego; sense of guilt or moral inferiority; expression of the superego's hatred (Schafer, 1960) 
 Later Freudians (Ego psychology) – conceptualized melancholia as a profound instinctual defusion in which the loosened sadistic-component came to hold "sway in the super-ego; as it were, a pure culture of the death instinct...” The regression was to the preambivalent stage of object relationships.  
    A. Regression to preambivalence – 
 (Preambivalence - in which the separated "good" and "bad" objects, with their instinctual cathexes of libido and aggression respectively, are not yet integrated in a state of fusion.  This stage is characterized by the attempt to maintain a “purified pleasure” self through the aim "to introject into itself everything that is good and to eject from itself everything that is bad" (Freud, 1925) Thus arise the separated "good" and "bad" objects, the former introjected into the self, initiating the establishment of the differentiating grade of the self-ideal, the "substitute for the lost narcissism of...childhood" (Freud, 1914), and the latter projected into the outer world.)   
 Although the premelancholic has reached the next, ambivalent, anal-sadistic stage in development, under the threat of object loss (through rejection), he reverts to the previous state of preambivalent object relations.  In this reversion, the “good” object is introjected into the ego ideal, which is now unattainable, and the "bad" (disappointing) object is introjected into the superego where it criticizes and punishes the ego.   
    B. Double introjection  
    Sandor Rado (1928) formulated the process in melancholia as a doubleintrojection of the lost object.  The twin introjects are the "good" and "bad" objects arising out of the instinctual and ego regression to the preambivalent object stage.  The "bad" object is introjected into the ego, the "good" into the superego.   
      Jacobson (1953) confirmed the idea of a double introjection.  However, she proposed that the inflated, good or bad, punishing, powerful parents are introjected into the superego, while the deflated, bad, worthless, weak parents are introjected into the ego.   
      Parkin (1976) The premelancholic seeks in his love object those characteristics of the self's own internal ideal that lie beyond its grasp.  The object is loved for its potential to restore the state in which the self was its own ideal (the narcissistic object relation) - a longed-for extension of the self, treated in accordance with the desire to bring it into the realm and under the control of the self. 
When the narcissistically loved object disappoints, it loses its function to the patient as the projection of his own ideal and as the haven of the "good" aspect of his ambivalently loved and hated object. Narcissistically, it is a "lost" object.  In the ensuing reintrojection of the lost perfection into the patient’s ego-ideal, the patient is thrown back once more upon his own internal self-ideal, which lies outside his attainment.  He feels depleted and helpless, and it is in this helpless loss of self-esteem that depression is manifested.   
  When what is sought in the love object is some form of perfection pertaining to the later preoedipal stages of development, simple depression develops on disappointment and loss. 
   When what is at stake is the recovery of earlier and more archaic forms of grandeur through the establishment of the loved object as the externalization of more primitive forms of the self-ideal, the loss of the loved object may precipitate, not only a fall in self-esteem, but also a re-emergence of the "bad" object.  Thus, the object is not only lost in its "good" aspect, but also must be dealt with in its separation as a "bad" object, one which has hatingly frustrated the wishes of the patient.  As such, it not only becomes the target of reactive rage, but is fantasized by projection as a raging, punishing, and depriving aggressive object in itself.  As an external inhibitor of wish-fulfillment and prohibitor of need-satisfaction, it is introjected by incorporation within the context of the series of hating introjects that constitute the precursors of the superego, resulting in severe feelings of guilt and self-reproach.   
 
RUTH LAX'S CONCEPT OF 'THE NARCISSISTIC DEPRESSION' IN THE ANALYSIS OF CHARACTER NEUROSIS (1989) 
 (Illustrates the change in focus from symptoms to the character.)   

Pathological character traits develop in a child in response to various extreme parental demands and responses, or following object loss or physical or psychological abuse.  The child has a narcissistic investment in the functioning of these traits, in their adaptive, gratifying and reactive capacities. When these traits are analyzed (becoming ego-dystonic), the patient suffers a narcissistic injury to his self-image, which leads to a depression.  
 The patient “becomes aware of real and/or imaginary helplessness, and of an incapacity to live up to both conscious and unconscious goals.  This is exacerbated further by his recognition of the discrepancy between his goals, aspirations, and the realization of the unacceptable nature of the underlying unconscious motives.  Whereas the patient previously may have felt good and righteous, he now feels bad and considers himself unlovable."   He "may experience intense feelings of forlornness, abandonment, and helplessness.  His goals may not have changed, but he now sees them as so exalted he no longer hopes ever to attain them.  The loss of a sense of mastery evokes feelings of humiliation and shame.  Conversely, the goals may now be changed and the patient, when middle-aged, may despair about wasted years and misdirected energy." (p.88)      


Seminar 3:   Controversial Issues and the Treatment of Depressed Patients 
 
REVIEW
 
            Freud’s view of the predisposition to melancholia, precipitant and dynamic processes.
            Abraham’s view of the typical pathogenesis
            Bibring’s view of the ego’s response – helplessness and hopelessness (Dorpat 1977)
            Jacobson – importance of the operation of the aggressive drive.
       Parkin's elaboration of the double introject.
NEW
 
Charles Brenner (1991) – a good example of the evolution of Freudian theory
                                    Depression is an affect not an illness.  It arises when a calamity has already happened.  It is one of  the four components of a compromise formation resulting from conflict regarding an unconscious drive.
                                    Depressive affect may [acting as a signal] initiate defense.
                                    Identification occurs in normal life; not always associated with object loss.  It acts as a defense against the feelings aroused by object loss.  If the loss occurs in the context of severe ambivalence, depression results.
                                    Depression can develop following all psychosexual levels of loss (p.35)  Not all cases reflect inadequate mothering, nor oral conflicts.
                                    Aggression turned against the self is not the cause of depression but the result of it.
 
Leo Stone (1986) -  reports his findings on 23 patients with depressive illness managed as out-patients, 14 in classical psychoanalysis, 9 in psychoanalytically oriented psychotherapy 2-3 times a week.  He also provides a comprehensive review of the literature from Freud on, discussing the various differentiating features of the theories proposed.
            Stone maintains that Freud’s use of the term “narcissistic object” choice in the predisposition to melancholia does not refer to the narcissistic object described as a contrast to the anaclitic object.  Rather it indicates an  “…original failure of fundamental separation [from], an island of continuity with primary identification…” with the mother. (p. 333)
            Stone reports from his experience of “the preeminent importance of an archaic characterological core in depressive illness.”  “This core…usually includes the following in varying proportions: pathological narcissism, rarely without an unrealistically exigent ego ideal; strongly ambivalent and generally powerful orality (broadly stated); intense sadistic aggression, readily available to a severe superego; and the capacity, via hostile “identification,” to experience the materialization of such components in the torture of “painful dejection,” often with guilt, and self-accusation  - a complex which (in extreme instances) is synergistically oriented, like a compass needle, toward suicide.” (p. 336)
 
Robert Lupi (1998) Panel at the Fall Meeting of the APA, 1995.
           Nersessian – anxiety and ambivalen are is always features in both mourning and melancholia.  The pain of mourning is more intense and longer in duration when there are more hostile and hateful feelings than affectionate ones in the relationship.
           Leon Hoffman – supported Freud’s theorizing against those who criticize it.  “Freud’s discovery of transference, as well as his attempts to integrate Adler’s and Jung’s criticisms into a comprehensive theory, led him to consider the theoretical importance of relations between the individual and objects and the  mentalization of these relations, and to eventually develop the structural theory.”
           Stephen MitchellHe described Freud as here describing how internalization happens, but notes that the theory is entirely drive-based.  In discussing identification, Freud comes close to articulating the idea that became important to object relations and relational theory,” that identifications have an emotional primacy in their own right and are not simply a compensation for lost objects; instead, primary object relatedness might be a basic motivating factor.”
            He quotes Fairbairn’s phrase, “when the tie  to the object…has been exclusive, adhesive, and addictive that loss is more likely to precipitate and be omnipotently preserved through pathological depression.”.
           Otto Kernberg – Proposed that “identification is regarded as the internalization of a significant object relationship, a representation of the object interacting with a representation of the self under the impact of a dominant affective state.  The more significant the relationship, the more intense the affect…”  He proposed a “genetic disposition to … excessive rage, anxiety, and despair under conditions of early frustration and object loss.”  These lead to a “hypertrophic” superego and a predisposition to depressive reactions.
            Arnold Rothstein – “the loss of fantasied aspects of the self are central in narcissistic and masochistic pathology.  Similarly, he said, the self-directed rage in melancholia is not simply the displaced object-directed rage now aimed at the internalized identification; it is also a critical, self-punitive response for not being able to omnipotently prevent the calamity.”
 
 Pierre-Gilles Guéguen (2009) – Depression is “part of an ideology that propagates the ideal of happiness for consumption…its residue which has to respond to the Master’s will by erasing itself through more consumption of the objects ‘medication’.”
           Lacan suggests that depression  “isn’t a state of the soul, it is simply a moral failing…which is ultimately only situated in relation to thought...” It indicates that the subject does not find a voice in which to express its state of being, which includes the body.  Treatment involves offering to the patient the opportunity to establish a social bond through speech, supporting the transference, making maximum use of “the transforming action of speech and the dialectization whereby symptoms change.”
 
                                   
Considerations in the Treatments of Depressed Patients
 
A. Presentation
            1. Stage of the illness - pre-depression anger at the object, abandonment, regression and internalization, consciously self-accusing, unconsciously struggling with alternately clinging and rejecting, towards the end – object as worthless or exhaustion.
            2. Symptomatology
                        fixity
                        depth of regression, ego strengths (eg. reality testing), superego qualities, object relations, defenses employed.
            3. Suicidality - identification with the aggressor, satisfaction of masochistic aims, fusion with the "good" object (Asch, 1980).
 
B. Character underlying
            1. Cyclothymic/Manic-depressive
            2. Obsessional
            3. Narcissistic
            4. Hysteric
            5. Borderline
            6. Paranoid
 
C. Social context
            1. Partner -
Jacobson, 1971 - "my experience has shown that however exaggerated the patient's hurt, disappointment, and hostile derogation of their partners may be, their complaints are usually more justified than may appear on the surface."
            2. Family -
Jacobson, 1971 - "the depressive never fails to make his partner, often his whole environment, and especially his children feel terribly guilty, pulling them down into a more and more depressed state as well.  This explains why the supposedly healthy partner, in defense, so often becomes amazingly aggressive and even cruel toward the patient,…"
 
D. Opening steps
Jacobson, 1971 - "the patient started his treatment with a suspiciously strong enthusiasm for the analyst and for his future analytic work.  His transference fantasies reflected his idealization of and closeness to the analyst, who had become the most valued part of himself." - improved rapidly, feeling better, more hopeful; "markedly improved for at least a year." However, we know that unconsciously he is ambivalent, so:
                                    - "begin early during the period of positive transference to connect interpretations of the illusory nature of the transference expectations with warnings for the future."  Later, "refer back to them". e.g. say, “There may come a time when you don’t feel so positive…”
 
E. Working alliance - Consider the contribution of the frequency of the sessions. 
Jacobson, 1971 - "Many depressives tolerate four or even three sessions weekly much better than six or seven.  Giving these patients the opportunity to put some distance (in terms of both time and space) between themselves and the analyst tends to reduce their ambivalence rather than increase it.  Daily sessions may be experienced as seductive promises too great to be fulfilled, and then again as intolerable obligations which promote the masochistic submission."
 
F. Transferences
            1. Positive
            2. Ambivalent (including masochistic)
            3. Negative (including paranoid)
 
G. Countertransferences
            1. Sympathy with the pain, or with enormity of the loss.
            2. Identification with the "victim", eg. revenge fantasies, rescue wishes.
            3. Fear of the patient's suicidality
            4. Hopelessness, paralysis, eg. about the intractability
            5. Anger, irritation, eg. at the display
            6. Guilt due to the patient's disappointment accusations.
            7. Sleepiness, eg. because of the retardation, withdrawal from objects.
            8. Rejection, due to sado-masochistic collusion.
            9. Mutual idealization and complacency in the context of the initial "spurious"
transference success. (Jacobson, 1971)
      10. Withdrawal, eg. because of any of the negative countertransference feelings
 
H. The ongoing process of treatment
            1. Attention to the details of precipitants, to the original condition and to the repetitions of "loss" and depression that occur during the course of treatment.  This may be frank object loss with oral conflicts, and/or "losses" associated with conflicts of the anal or phallic stages (Brenner, 1991).  In each episode, highlight and enlarge the idea of "loss", moving toward the narcissistic injury involved.  This injury is frequently in the area of loss of the (narcissistic) feelings of security, safety, being loved or valued, helped with certain activities, being in control, being successful, competent, or given or having achieved a certain social status.  So look for eg. Exactly what has been lost, and how does that make you feel.
Asch (1980)"In our therapeutic work with such patients, the analytic task is to reconstruct gradually the specific hidden by the abstraction; to uncover the object the patient has chosen fate to screen; to trace out the genetic origins of the object he has chosen as his executioner."(p.55)
            2. Identify the various ego states; specify, elaborate, eg. through fantasy, through memories of past similar experiences.  Search specifically for derivatives, in the present and in the past, of primary narcissistic experience (feelings of "well-being" (Joffe and Sandler, 1965), of security, safety, being loved, valued, cared about, helped).  Interpret the defenses involved in the patient's inability or unwillingness to get comfort from these states.
            3. Be quite active.  Do not let negative ego states of, eg. withdrawal, guilt, being abandoned, being persecuted, to develop too long or too far before intervening with reality, eg. your existence, a superego interpretation, your attentive presence, an indication of safety (Jacobson, 1971).  The patient's regressions can be quite quick and profound and are not, by themselves, analytically useful.  In fact, they can be more demoralizing and result in further spirals of hopelessness. helplessness, self-blame.  On the other hand, do not "talk too long, too rapidly, and too emphatically; that is, never to give too much or too little." (Jacobson, 1971)
                        Another way of thinking about this is to remember that you are standing in for the "conditional introject" (Kligman, 1988).  The person who gets seriously depressed needs the actual presence, from time to time, of the "other" to re-establish a stable, safe, loved inner object environment, ie. a loving ego ideal introject.
            4. Identify any examples, in the present and in the past, of the patient's, justifiable-to-himself, aggression.  This is a useful affect (because of its strength, directedness and somatic, muscular concomitants) around which to organize experience.  As long as being aware of its existence does not lead to more guilt, the awareness of it gives the patient a feeling of initiative, power and mastery of at least a bit of his situation.  That is, it supplies a bit of self-generated narcissistic satisfaction. 
                        In the latter stages of the depression, the patient can be usefully made aware of his own tendency to (aggressively) abandon the disappointing object, a concept which is completely outside his conscious experience early on.  This tendency should be tracked throughout the patient's life, because it becomes part of the self-knowledge that can lessen the tendency toward depression in the future.
                        Expressing anger to another person, especially the "lost", disappointing object is a separate issue.  When the patient finally does this, competently, in a controlled way, and without fear or guilt, it means they are nearing the end of the depression.  However, early on, expressing anger to the object can make things worse because they still very much need the object for the original narcissistic reasons.  Expressing anger early on is often out-of-control (and so demoralizing), desperately (impotently) trying to get the object to comply with the patient's increasingly regressed demands for love, etc. (Rado, 1928).  This usually results in more rejection by the object, more abandonment of the object by the patient, and a deeper rung to the depressive spiral.
            5. Make use of every example of the development of depressive reactions to experiences in the analysis, eg. week-end separations, holiday separations, experiences of not feeling understood or loved or valued or cared about in the right way.    In the context of the therapeutic alliance, this recognition of current affects and ideas then becomes part of the route into the re-affectualization of similar experiences in the past.
            6. Interpret the patient's devotion to conventional methods of achieving narcissistic satisfaction.  eg. "I must have a deep intimate relationship, with a life partner, to be happy."  Clearly, conventional methods suit certain personality and constitutional types more than others, and real, healthy people are capable of getting real satisfaction from the most varied sources and activities.  People who are disposed toward depression need particularly to develop sustaining, satisfying sublimations.  Sublimations, which are less personal, less object-dependent, may be less likely to disappoint.
            7. The analyst may need to actively support the patient's attempts to develop narcissistically satisfying sublimations, including achievements and participation in cultural and/or natural activities (Jacobson, 1971, Joffe and Sandler, 1965).  Because of the patient's readiness to be disappointed, and their concentration on getting narcissistic satisfaction from their primary object (conditional introject), the patient may interpret their  turning toward other sources of satisfaction as disloyalty to the object leading to (causing) the object's withdrawal of attention and love.   A sustaining interest by the analyst in other sources of satisfaction for the patient can be internalized by the patient (the analytic introject) and added to the ego ideal introject, eventually modifying the ego ideal. 
                        Similarly, the analyst may need to actively interpret the patient's acquiescence to the patient's superego's view of things.  This may even go so far that the analyst would have to momentarily "stand up for" the patient's "right to exist" in an actual aggressive stand against the superego. (Jacobson, 1971) This involves a sudden intrusion of reality into what the analyst considers is a dangerous emotional and cognitive regression.  It may, of course, deprive the patient of a more deeply held masochistic aim and, therefore, satisfaction, which will emerge in the aftermath of the analyst's activity and will, thus, become available for interpretation, then or later.
            8. Issues specific to each underlying character type.  These have to do with the different nuances in the transferences and in the countertransferences, different experiences of and uses of affects in general and the various affects in particular, and the degree of masochism and sadism present.
 
I. Depression as a part of the treatment process -
Joffe and Sandler, (1965) "The association of depression with that individuation that occurs during the course of analysis is, to some extent, imposed by the analytic process itself.  If a patient is confronted with a painful state that he has been defending against, and if all his further defensive attempts are aborted by interpretation, depression as a result of the narcissistic injury that ensues) may follow as a natural consequence.  Recovery from this depressive response may be associated with gradual working through and individuation with the help of the analysis."  However, the lifting of depression "does not imply that the painful state of affairs that prompted the depressive response has been resolved.  In many instances, it is associated with nothing else but the bringing into play of more effective defenses,…" (p.178-9)
 
J. Conjunctive use of medication - meanings to the patient and the analyst.
 
K. Termination Issues
   1.     Repetition of the depressive experience, with differences.           
   2.     Opportunity for review, of the dynamics and the solutions discovered in the course of analysis.
   3. Encourage the sense of ongoing accessibility to and use of, in reality and in fantasy, of
the analyst/introject.  Encourage the possibility of appointments in the future, either brief
 or extended.
   4. Encourage the practice of “self-talk” in order to stop the practice of internalizing
depressive developments; encourage disbelief in the self-accusations; develop a sense of       being a subject independent of the depression.
   5.Encourage the patient to pay attention to their self-care: rest and sleep, food, decreased
stress.
   6. Think about/search out the advantages of the situation the patient finds himself in.
 
Jacobson, 1971 - "The therapeutic success with depressives can best be gauged by their ability to remodel an unfortunate life situation which prior to analysis was bound to precipitate depressive states."
 
   7. Consider individual psychotherapy for the partner of the patient (Jacobson 1971).
 
 
    
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