Experiences of Depression

Experiences of Depression reflects Sidney Blatt's long career.  Blatt proposes a synthesis of two types of depressive experience, namely the anaclitic and the introjective.  He begins with Freud's observations in 1895.  This does not mean the Blatt gives only the classic or Freudian psychoanalytic slant, but rather moves quickly into a more contemporary view of these phenomenological dimensions.  Mentioning these two royal roads to depression, one of course must then hold that these are in some way connected to the idea that impairments in the establishment and impairments of the representation of care-giving relationships, not just Bowlby-like, but more intricate than that, contributes to the etiology of the experience of mood states that reflect on of the two, and the questionnaires Blatt and his group developed with these as factors, the famous Depressive Experiences Questionnaire (DEQ) and also object relations assessments.

As so often is the case, Blatt's view of depression was colored by his early experience in training analysis, and two early index clients, referred to often as representing the dichotomy, or rather the thesis-antithesis-synthesis that would color his life work in the field.

From this epistemology thus emerges his integrative theory that informs on what he believes are the typology of human experience under the influence of the mood disorders, and are clearly illuminated in the narrative of depressed patients, given in verbatim examples throughout.

Early on, and beginning with the Austrian Maestro himself, Blatt examines the classical beginnings of theory in melancholia and mourning, moving on through Spitz and Wolf, Segal and Winnicott, Klein, Abraham in counterpoint with each other, and after Rado, the unitary theories of depression as postulated by Bibring, Fenichel, but with reference to an acknowledgment of different developmental levels at which the clients' experience occurred. The first was a primarily oral phenomenon, the second a loss of self-esteem in the Oedipal experience.  Ignoring the cultural implications in those cultures that deny the Oedipal stage, and the feminist critiques of such positions, this is the origin of ideas of subtypes of depression emerging, one more primitive, one more advanced and involving views of significant others.

In this way, Blatt began to distinguish between a simple anaclitic depression and a more complex introjective depression.  The former arises from the disruption of the primary care giving relationship with the primary object, the second from a harsh, punitive, unrelenting critical superego that creates the feelings of worthlessness that colour depression of this subtype, introjection referring to the superego development of introjective identification, in this case of a harsh object.

Having then explained these in detail, Blatt moves on to more contemporary theories of depression, as I mentioned above, beginning with Bowlby, predictably, given his views above.  Moving on through Arieti and Bemporad's interpersonal model, and then of course Aaron Beck's cognitive behavioural model, describing the initial idiosyncratic cognitive schemas, and then the later more linear individual schemas, and then specific primal mode theory, which supposes that on activation, draws on congruent systems to implement the goal of the mode, with varying thresholds of activation, and thus various intensities of outcome, not necessarily dysfunctional. This all supposes an evolutionary value to such experience, tolerating the propensity or at list the threatened risk of pathology in the balancing of these higher functions and their value/threat, even if risky, in responding to the force of evolutionary pressure.  The mode is however in reality a cognitive schema that derives from the interaction of proto-schemas and congruent life experiences, a little reminiscent of other, earlier psychodynamic formulations, and still congruent with Blatt's formulations given that the core beliefs here include the self concept and the primitive views of others.  This lead Beck to his own dichotomy, namely two major personality dimensions, sociality and individuality, which Blatt again likens to Arieti and Bemporad, Blatt, and Bowlby.

Blatt then moves on to integration of the theoretical perspectives that he has elaborated on, and to object representation in depression, focusing on Klein, Segal and others of that ilk.  It's a brilliant chapter, a work that stands alone in the book, and the next chapter focuses on the examples of how he and his colleagues see these two types of depression expressed in the clinical context.  This is done extensively with detailed case histories, which dominate the chapter around the anaclitic-introjective split.

Part two moves on to a discussion of the value of assessing these modes of depression, and of the use of the DEQ and the Object Relations Inventory (OBI). Two attempts were made to develop measures, which evaluated the outcomes of care giving relationships in depressed patients' histories.

The first (chapter three) was an attempt to develop a systematic tool to provide a reliable and valid measure of the two types of experience, and the second, chapter four, the development of an OBI.

Akiskal and others have set out over the years to examine the affective disorders across the unique and disorderly spectrum that constitutes such illnesses.  The amount of variance within a category rivals the variance between categories, and in some cases is wider, with all types of symptoms bleeding in to the primary ones, a mix of all types of things is possible, in the Fulds-Bedford way.  There is a need to establish subtypes of depression that do not depend on such a wide spectrum of symptoms, but on some other criteria.

To this end these devices are thus created, including a DEQ for adolescents, loading strongly on three factors, namely dependency, self-criticism and efficacy.  The adult and adolescent items look vaguely similar, but the important differences are also clear: however, the factors are stable, and cluster around interpersonal and self-critical issues.  Connected to this are the subscales embedded in the first factor, namely neediness and relatedness, factor two which is related to self criticism, and factor three, lack of efficacy.

Other measures of the anaclitic-introjective experiences are discussed, including the Sociotropy-Autonomy scale (recall Beck) and the Personal Style Inventory, as well as the Dysfunctional Attitudes Scale, all with their own psychometric problems.  A tiny section dealing with experiences of gender, race and social mobility is both fascinating and hopelessly too short, given the nature of cross-cultural experience as well as the influences of gender in society, but some other references follow in later chapters.

Section three is composed of a series of commentaries on the distal and proximal antecedents of the anaclitic and introjective experiences within depression, both within clinical and non-clinical groups, but with a particularly interesting section on depression and substance abuse, but more substantially opiate addiction given the centrality of depression on opiate use, across many pages.  Non-clinical settings are also expansively annotated here, with special focus on children and adolescents.  These extensive discussions have led to the author putting in a summary, which is most needed given the plethora of research findings, which beg an informed conclusion.  Mostly, this gives Blatt an opportunity to reinforce his beliefs, namely, that self-critical individuals are more introverted, isolated and distant from others, and consequently their interpersonal interactions are unpleasant, with the convergence then of several measures of the introjective person.  In contrast, on the DEQ, individuals with elevated scores on the dependency-interpersonal factor tend to be the opposite.

The promised work on gender is here too.  Girls are more likely to report anaclitic depressive symptoms than boys, especially with regard to somatic preoccupations, sad affect, and loneliness.  Boys are more likely to have externalizing disorders and report introjective depressive symptoms that include antagonism, aggression and an inability to work.  "Differences in socialization may contribute to these gender differences in the expression of psychological distress" (page 185). I won't go there on feminist grounds, but will merely point out what Gilligan said about it all: women speak with a different moral voice, not an incomplete Oedipal accent.

In terms of the distal, or developmental origins, as compared to proximal, or precipitating events, chapter 6 focuses on negative caring experiences that create distortions in the representation of self and others in interpersonal relationships. Chapter seven then, on the much wider putative contextual experiences seen as proximal causes, has a more reactive slant.  Distortions of representation means the individual will struggle to retain the necessary contact with the object, and thus in introjective depression, elements of the individual will be sought after without consolidation of the whole relationship, a kind of ambivalent, replacing the need gratification as soon as possible with some other aspect or some other object.  There is a fair amount of reliance on research into the mother here, as primary love object, as well as with retrospective studies on parenting overall.

The proximal events chapter that follows is only half as long, expected in a book with such an intrapsychic slant to it.

In the concluding section, made up of a chapter which considers the therapeutic implications of such theories, Blatt examines the four above, namely Arieti and Bemporad, Beck, Blatt and Bowlby, in terms of their influence on how one goes about the business of therapy, and of course the inference is there in all four approaches of the need to stress the centrality of impaired cognitive structures in depression. Three concentrate on the therapeutic relationship, with experiences within therapy contributing to a change in outcome, but all agree on the cognitive aspects that require therapeutic change in mental representations.

An outstanding work if you follow any of the four orientations, and certainly much more palatable if you have more than just a working knowledge of twentieth century psychodynamic theory. As with so many works, the Euro or Americo-centric version of the world is rather amusing to those outside, from non-Western backgrounds, where seldom has the psychodynamic view of the development of human cognitive and emotional structure been uncritically accepted.  I have had the opportunity to work with people who believe that everyone we interact with in our day to day existence is dead and a zombie, and that as individuals we do not exist at all, with one brother confessing to a crime his brother committed, seeing no difference between himself and even distant, but clan or skin related relatives. One child I saw in Africa referred to multiple mothers and fathers, all of whom he related to as a birth child, and if he had problems with Oedipus, it would have been in the midst of a de-individuated mob seen with who knows what dynamics: family therapy no good there either, he counted 91 first degree relatives living in his family home, and my room was not that spacious.

However, within this genre, and even if you struggle with psychodynamic principles, this is a master at work, and he makes it all very easy to access and comprehend, and engenders a desire, just as Freud did before him, to want to go right to work with this material and apply it to the next client you see.  Perhaps it is more so to me, being old enough to recall being taught about the Wolf Boy, and certainly completing my MA degree in feminist and family therapist criticisms of psychodynamic theory, and therefore still part of my own psyche.

But especially for those who are new to the area, this will fill a huge gap for them, and done so well, it is both filling and fulfilling.

© 2005 Roy Sugarman

Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.