Psychoanalysis - First Year - 3 Seminars on DEPRESSION
Seminar 1: History and Basic Concepts
C. Depressive affect
D. Depressive mood
E. Depressive illness
H. Narcissistic object
I. Narcissistic injury
J. Object loss
OUTLINE OF SIGMUND FREUD’S FORMULATION OF MELANCHOLIA (1917) (Derived from the summary by Dr. David
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”
(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”
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”
regression (the ‘great divide’
between the less severe states of narcissistic injury and the depressive
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
F. Other points
1. In mourning it is
reality that compels the decathexis of the object; in melancholia it is
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
1. Anality and sadism
2. Inference of two
substages in the sadistic-anal stage
a. Expulsive – Destructive (earlier)
b. Retentive – Conserving/Controlling
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
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
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
A PSYCHOANALYTIC CLASSIFICATION OF DEPRESSIVE PSYCHOPATHOLOGY
A. Uncomplicated states of narcissistic
injury (ie. without significant narcissistic regression)
1. a ‘purely narcissistic blow to the
2. disappointment in an object
a. with retention of the object -
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)
2. benign stupors and less severe
3. Henseler’s ‘euphoric’ suicides
C. Characterological depressions
1. Conflict over (sexual and
aggressive) drives with inhibition
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
BIBRING’S MECHANISM OF DEPRESSION (1953)
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.
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
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.
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
Not all depressions occur in “orally-oriented”
Aggression against the self is not always present.
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
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.
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.
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)
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.
(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)
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 - 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.
(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 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
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.
CONCEPT OF 'THE NARCISSISTIC DEPRESSION' IN THE ANALYSIS OF CHARACTER NEUROSIS (1989)
(Illustrates the change in focus from symptoms to
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
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."
Seminar 3: Controversial Issues and the Treatment of Depressed Patients
view of the predisposition to melancholia, precipitant and dynamic processes.
view of the typical pathogenesis
view of the ego’s response – helplessness and hopelessness (Dorpat 1977)
– importance of the operation of the aggressive drive.
Parkin's elaboration of the double introject.
Charles Brenner (1991) – a good example of the evolution of
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.
affect may [acting as a signal] initiate defense.
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
can develop following all psychosexual levels of loss (p.35) Not all cases reflect inadequate
mothering, nor oral conflicts.
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.
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)
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
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 Mitchell –He 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.”
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.
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
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.
of regression, ego strengths (eg. reality testing), superego qualities, object relations,
Suicidality - identification with the aggressor, satisfaction of masochistic
aims, fusion with the "good" object (Asch,
B. Character underlying
C. Social context
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."
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
"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."
Ambivalent (including masochistic)
Negative (including paranoid)
Sympathy with the pain, or with enormity of the loss.
Identification with the "victim", eg. revenge fantasies, rescue
Fear of the patient's suicidality
Hopelessness, paralysis, eg. about the intractability
Anger, irritation, eg. at the display
Guilt due to the patient's disappointment accusations.
Sleepiness, eg. because of the retardation, withdrawal from objects.
Rejection, due to sado-masochistic collusion.
Mutual idealization and complacency in the context of the initial
success. (Jacobson, 1971)
10. Withdrawal, eg. because
of any of the negative countertransference feelings
H. The ongoing process of treatment
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)
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.
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."
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
Identify any examples, in the present and in the past, of the patient's,
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.
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.
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.
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.
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.
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.
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.
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
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
J. Conjunctive use of medication - meanings to the
patient and the analyst.
K. Termination Issues
of the depressive experience, with differences.
for review, of the dynamics and the solutions discovered in the course of
Encourage the sense of ongoing accessibility to and use of, in reality and in
the analyst/introject. Encourage the possibility of
appointments in the future, either brief
4. Encourage the practice of
“self-talk” in order to stop the practice of internalizing
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
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
7. Consider individual
psychotherapy for the partner of the patient (Jacobson 1971).