A Cognitive Analytic Perspective of Depression
The aim of this article is to consider depression and lowered mood within a Cognitive Analytic Therapy (CAT) context; initially depression will be contextualised in terms (briefly) of a bio-medical, sociological, emotional, evolutionary and psychological background. The CAT literature has discussed models for conditions as diverse as borderline and narcissistic personality disorder (see Ryle A, and Kerr I, 2002), deliberate self-harm (Cowmeadow, 1994), treatment non-compliant diabetes (Fosbury et al, 1997), substance misuse (Leighton, 1995) and sexual abuse (Pollock, 1996). Yet, surprisingly little, apart from an article by Ryle (1991) and a few paragraphs in their introduction to CAT (Ryle and Kerr, 2002) has been written on a CAT perspective of depression. We shall attempt to construct a CAT model, or template, for depression together with an analysis on the role of the emotions. Two different ‘types’ or causal routes to depression will be considered together with an appreciation of the difficulties encountered whilst working with depressed individuals. Some suggestions for working with these difficulties will be considered.
A cautionary note:
It seems that the bio-medical model purports to offer a precisely defined and delineated set of observations reported by an impartial, unbiased ‘scientific’ observer; contrarily much of the psychotherapeutic literature offers an ‘insiders lived-in’ experience of the suffering of depression. Probably we are being unfair by describing one approach as ‘impartial science’ and another as ‘lived-in experience’ as both aspects are found in each approach; nevertheless, I have attempted to use these two styles of enquiry, with the first part of the paper having a ‘scientific practitioner’ style and the second having more an ‘insider’ therapeutic feel.
Even a cursory examination of the writing on depression show that no two writers seem to agree, even basic ‘facts’ are disputed: for example Brown and Harris (1993) suggest that low self-esteem is positively correlated with incidence of depression; disobligingly, Alladin and Heap (1991) contend “there is no evidence that low-self esteem is more common in people who develop depression than those who do not’. I suspect Anadin and Heap’s analysis of the evidence is overly reductive and pedantic; but the point to draw is that the literature on depression can seem confused, even contradictory. Perhaps any approach one takes to depression is at least in part a personally based construction. The best we can hope for is an account that fits with the available ‘evidence’, our own clinical experience and the lived experience of life and mood. The aim of considering differing traditions and styles is not to ‘compare and contrast’ or decide ‘who is right’; rather a range of perspectives will be considered to see what each contributes to an understanding of depression as a total entity.
Prevalence and diagnostics of depression
Most people experience low mood at some stage. Clinical depression is so common that Seligman (1975) described it as the ‘common cold of psychiatry’ and perhaps depression is present, as a subsidiary difficulty in the majority of psychiatric conditions. It has been estimated that 3-4% of the population suffers from significant or clinical depression and between 13-20% suffer significant levels of depressive symptoms or dysthymia at any point in time. More than 12% of this total will require professional treatment. Depression accounts for up to 75 % of psychiatric hospitalisations (see Boyd and Weissman, 1982 for an epidemiological review). Prevalence rates amongst the various socio-economic, age related, gender and ethnic groups is a tortuous area too complex to enter into detail, but we may note that the rate of depression among women in Western industrialised countries is approximately twice the rate of men. For women depression is most common between 35-45 yrs of age whilst with men incidence increases with age. Depression is more prevalent amongst divorced or separated persons and within socio-economic classes 1, 2 and 5.
As a diagnosis depression is probably over-popular amongst clinicians (Ryle, 1991), perhaps this is due to the availability of reliable pharmacological agents and psychological treatments. The role of ‘simple’ measuring tools such as the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983), the Beck Depression Inventory (Beck et al 1961) and the Hamilton Rating Scale (Hamilton, 1967) have also shaped the idea of depression being a ‘clinically testable’ and tangible condition.’ Depression’ can be considered a broad-sweep diagnostic label covering a range of conditions and symptoms and deriving from a range of ‘biopsychosocial’ causes (Harris, 2001); including: genetic predisposition, personality factors, familial history of depression or alcoholism, disturbed neurotransmitter functioning, physical or infectious illness, early life experience such as parental loss or neglect, significant current life events, a critical or hostile spouse or lack of a close confiding relationship, lack of adequate social support, socio economic deprivation and long term lack of self-esteem (Ostler et al, 2001). We do need to remember that given enough stress or trauma just about anyone has the potential to develop depression irrespective of his or her personal history or protective factors. Depression can be seen as part of the mainstream of human experience as opposed to some discrete psychiatric domain.
Depression or even ‘clinical’ depression as a diagnostic category represents another tortuous and confusing area. Goldberg et al (1987) in an otherwise humourless review comments ‘there has been a long controversy about the best way to classify depressive illnesses, and the non-psychiatrist is well advised to ignore it’, however, one could argue this is too important an area to ignore. No general agreement about the best way to classify depression exists, (Gelder et al, 1995). However, distinctions have been drawn between bipolar (i.e. bipolar-affective disorder) and unipolar depression, between endogenous melancholic (i.e. bio-medically caused) and reactive (or neurotic) depression. Related classifications include ‘dysthymia’ which can be seen as a milder form of depression not amounting to true ‘clinically significant’ depression; psychotic depression, which can amount to a qualitatively severe form of depression including hallucinatory and delusional elements. We should note also: agitated depression (i.e. symptoms of agitation concurrent with low mood); depressive stupor and retarded depression (i.e. psychomotor retardation is especially prominent); and masked depression. Often persons who present with an anxiety disorder (specific or general) will complain of lowered mood, which they then define as depression. Lastly we should not forget the adjustment disorders including Post Traumatic Stress Disorder (PTSD) and grief or bereavement reactions, milder depression often tapers off into feelings of sadness and unhappiness over some loss or trauma within the person’s life and can be considered a ‘normal’ phenomenon - albeit very distressing to the person concerned.
For the purpose of this article we are referring, in the main, to unipolar-depression, namely: depressive episode (F32. ICD 10: WHO, 1992), recurrent depressive episode (F33), dysthymia (F34.1) and mixed depressive and anxiety disorder (F41.2). However, as we shall see later, even the idea of a single type of unipolar-depression is open to question and we shall consider two different psychosocial routes to depression. A discussion of complex depression, for example depression complicated by personality disorder, will not be entered into here as this subject has been extensively covered in the writings of Ryle and other commentators whilst the more common condition of unipolar depression has remained largely unexplored.
Symptoms and signs
Depression can be classified in terms of mild, moderate or severe intensity. For diagnostic purposes the person is required to have reduced mood for at least two weeks. At least two symptoms, usually a complex mix, will be found, although some symptoms will be more prominent than others. Depression can be classified with or without biological symptoms, which include: early morning wakening, diurnal variation of mood, appetite and weight disturbance, anhedonia, decreased libido and psychomotor disturbance. Often thought of as a condition of 6 months duration 50% of sufferers still satisfy criteria for depression a year later (NICE, clinical guidelines 2003), there is also a marked tendency for depression, particularly if untreated, to reoccur; 50% of people following a first episode will have at least one more episode, with significant numbers suffering symptoms of depression for many years (NICE 2003). Up to 15% of depressive sufferers take their own lives by suicide.
The following symptoms and signs are based upon the ICD-10 general criteria for a depressive episode:
1. Lowering of mood, little variation on a day-by-day basis and unresponsive to external life circumstances.
2. Reduction of energy and decrease in activity, marked tiredness after minimum effort.
3. Reduced capacity for enjoyment, loss of interest is common in usually enjoyable activities.
4. Reduced concentration.
5. Disturbed sleep, possibly waking several hours before ‘usual’ waking time.
6. Disturbed appetite - decreased or increased.
7. Confidence and self-esteem are significantly lowered.
8. Ideas of guilt, self-reproach or worthlessness, deserving of punishment.
9. Hopelessness or a bleak view of the future.
10. Ideas and or acts of self harm or suicide
11. Diurnal variation of mood, often worst in the morning.
12. Anxiety, agitation, irritability, hypochondrias.
Perhaps hinted at, but often left out of the descriptive account, is the commonly held observation that depression ‘is not a feeling, but an absence of feeling. That is, depression is different from feeling sadness, loneliness, or disappointment. Rather, it is the experience [of] blankness, hollowness, or nullity.’ (Scheff, 2000), see also Ryle and Kerr (2002). Scheff argues there is ‘near consensus’ that the blunting of affect results from a suppression of feeling; so depression is a defence against emotional pain. It seems reasonable to suggest that ‘normal’ feelings of sadness and grief at one pole of human experience slowly merge into feelings of blankness and loss of affect as the depressive episode becomes increasingly severe. As noted under 2. above individuals who experience depression often appear lacking in energy feeling exhausted after minimum effort. Psychic energy also is low with disturbance of memory, concentration etc If a friend or a therapist offers a ‘helpful’ suggestion it is as though the person ‘can’t be bothered to help them-self’, or as if there is a lack of energy, (of libido in the psyche) which is necessary to fuel mental and emotional life. The psychoanalytic metaphor of energy attachment (libidinal cathexis) can prove useful here.
The ICD-10 description of depression is useful for identifying who is depressed and who is not, who needs medication and perhaps who is in need or suitable for therapy etc. However, variations in the symptomatic presentation of individuals can be enormous – a patient could have any number of combinations of between 2-12 symptoms! More significant, the description does not account for who is vulnerable to depressive onset, or the cause and course of depression; neither does the account seek to identify common or different causal pathways to depression. From the perspective of a Cognitive Analytic, or other psychotherapist, the intricacies of classification concerning this heterogeneous group of related disorders are perhaps of less interest than the nature of need of the person in distress; however, we do have an interest in the diverse elements that lead to depressive onset and a concern into which factors are ameliorable to intervention.
The biopsychosocial mix of depression
It seems that no single factor can adequately explain the occurrence of depression. Although lip service is paid to the multi-causality of depression, ‘the full-scale integration of perspectives implied by such homage is still slow to come about’ (Harris, 2001). Whichever theory has gained prominence none in its own right has proved convincing as a singleton theory. Most observers (see NICE, 2003) now believe a range of biopsychosocial elements increase an individual’s vulnerability to depression although how this mix configures in an individual’s pathology is difficult to ascertain in practice (Harris, 2002). Nuechterlein and Dawson (1984) advocate a stress-vulnerability model for mental disorder in which vulnerability factors interact with current social circumstances and stressful life events act as a trigger for a depressive episode – we take a similar stance in this paper. Although we do not have the space to enter into detail here we might agree that for a total treatment of depression to be effective effort needs to be divided amongst the disciplines of bio-medicine, social interventions, psychology, cultural, political and economic policy. We are interested in the depressed person as a whole: vulnerability, stress, triggers etc.
Biomedical treatment of depression
Antidepressant medication is the treatment of choice. Over the last 10 - 15 years SSRI’s (specific serotonin reuptake inhibitors) and related agents have become the most popular although the older tricyclic antidepressants and even on occasion MAOI’s (mono-amine oxidase inhibiters) are used. Occasionally benzodiazepines are used for brief periods to treat patients with depression and concurrent agitation or anxiety, with more complicated agitation or when symptoms verge into psychosis a major tranquilliser or antipsychotic may be tried. Patients with recalcitrant or episodic depression are sometimes prescribed prophylactic mood stabilizers such as lithium salts or other anti-epileptic preparations, in more extreme cases or when depression is considered to be ‘treatment resistant’ ECT (electro convulsive therapy) is considered. I base the above on a number of years of experience in various psychiatric establishments.
According to Ryle (1991) in deciding whether to use antidepressant medication both the current symptom pattern and the patient’s history must be taken into account, the more marked the symptomatic picture (particularly somatic symptoms) the more likely the need for medication; indeed, the severely depressed patient is unlikely to engage with other therapeutic modalities until the antidepressant has, to some extent, been able to stabilise and lift the patient’s mood. NICE (2003) guidelines suggest that antidepressant medication is not appropriate for milder cases of depression and that the patient be given choice of other treatment modalities. Based on my own experience, many psychiatric establishments take the view that the depressed should be given antidepressant treatment in the initial stages of management; if the patient does not show significant improvement within say six months then psychotherapy or other treatment options are considered. I am unsure as to how universal this view is but suspect widespread use. Often patients will profit from combined medication and psychotherapy.
Biological explanations of depression
Various biochemical explanations have been used to theorise how life stress and difficulty can be translated into the neurochemical changes that characterise depressive illness, Gelder et al (1996) suggest there may be a deficiency in neurotransmitters such as noradrenalin, dopamine and serotonin in certain areas of the brain involved in regulating reactions to stress and in altering behaviours commonly noted in depression. Another theory implicates abnormality in the functioning of the brain systems that regulate hormonal secretion and other important biological activity. Also noted is a disturbance of nerve cell function owing to an alteration in the distribution of certain positively charged ions (such as potassium and sodium) across the nerve cell membrane, which leads to a state of unstable hyper-excitability across the central nervous system (see Stern and Mendels, 1980).
Although there is some support for these hypotheses, often based upon the neurochemical effects of the antidepressants, they do not account for all the symptoms noted in depression; to what extent neurochemical changes represent a correlation as opposed to a causal factor in depressed mood currently remains unclear.
Sociological aspects of depression
According to Safran and Segal (1996) one of the more enduring criticisms levelled at psychological models has been the scant attention paid to environmental stressors faced by depressed persons, theorists then wonder why psychological interventions aimed at these psychological symptoms fail to assist. Harris (2001) comments that increasingly over the last decade there has been a ‘rapprochement’ between researchers investigating inner psychological cause and those investigating the outer social world. However, according to Gotlib and Hammen (1996) sociological perspectives have not attained the status of a cohesive model in the same way that psychological or bio-medical theories have. It seems that although CAT pays homage to the impact of the social and cultural life of an individual it remains essentially a dialogic theory as opposed to a systemic account. Dialogic refers to two individuals in relationship but does not take account of the wider social systems within which all operate. As we shall see the importance of systemic social events has an importance in the genesis of depression; I believe it is important for CAT to bear this in mind.
The influence of life events
For our purpose we are interested in the study of life events, i.e. to examine the associations between depressive disorders and certain types of event in a person’s life. Ostensibly, it seems reasonable to assume that people who have been subject to adverse situations such as an unhappy relationship, disputes at work, economic disadvantage, unsatisfactory housing or more recently asylum seeking etc are more predisposed towards developing depressive features than other people; indeed, outpatient teams often seem besieged by such cases. Finlay-Jones and Brown (1981) have summarized the evidence for the clinical significance of ‘recent stressors’; they conclude that life events are especially related to the onset of mild and moderate depression. Brown & Harris (1977) describe vulnerability factors amongst women that increase the likelihood of depressive incidence; these include, firstly, current social indicators, primarily: not working outside the home, lack of a close confiding relationship and having three or more children under the age of 15 at home; secondly, past events, which increase vulnerability notably, loss by death or separation of the depressed person’s mother before the age of 11 yrs. Past vulnerability factors can perhaps be considered as a psychological or intra-psychic factor. A later study (Brown and Harris, 1993) found that adversity in childhood such as physical, emotional or sexual abuse increased the likelihood of depression developing in adulthood; major loss in adulthood with lack of social support also is correlated with depression. It is known (see Gotlib and Hammen, 1996) that depressed persons are more likely to have a smaller and restricted circle of social support than their non-depressed counterparts. Paykel and Cooper (1992) found that poor social support and integration are predictors of depression. Harris (2001) notes that since the 1980’s self- deprecation and social withdrawal have been seen as essential almost to the development of depression, he suggests that low self-esteem and lack of social support generally exist for a person prior to the clinical onset of depression.
Importance has been given to events involving loss of people or of cherished ideas due to adverse experiences, Harris (2001) reports that recently such events have been mapped according to the emotional impact and meaning for the person, he notes that experiences of ‘humiliation or entrapment’ have been identified as particularly prominent prior to the onset of depression. Events not involving humiliation or shame (e.g. no-fault unemployment) lead to much lower and less severe levels of depression. One can see a correlation between someone suffering from low self-esteem and a recent stressor of humiliation or provoked shame. Put simply a Brown and Harris sociological model of depression might read: -
Low self-esteem resulting from past history + Humiliation in the present
= Risk of depressive onset.
Harris further suggests that people with learned low self-esteem vulnerability their-selves are often causal in producing their own humiliating experience, this idea is of course central to a range of psychotherapeutic and in particular CAT thinking: i.e. the circular procedural relationship between emotional, cognitive, behavioural and environmental events. So ‘the lack of any supportive relationship which might protect against onset issues not always from the hostile networks into which life has currently thrust them [i.e. the depressed] but sometimes from their own attachment styles which have led them to avoid intimacy or to alienate potentially supportive figures by their needs for enmeshment’. In sociological terms, people become alienated from society, rather than integrated into it. As Karp (1996) has suggested, alienation of this kind may be a result of a biopsychosocial feedback loop: depressed affect, leads to separation from others, which leads to more intense depression, and so on around the loop. The work of Brown and Harris etc has been influential but not always replicated, it is also true (see Gotlib and Hammen, 1996) that the majority of persons who experience significant life stressors do no go on to develop clinical depression - yet overall there appears to be a six to nine times increased risk of clinical depression following aversive life events in persons possessing the right precipitating features.
The psychology and emotionality of depression
Emotion can be defined as follows: - ‘a strong mental or instinctive feeling such as love or fear, emotional intensity or sensibility’ (OED, 9th edition). Although useful this definition leaves much of importance unsaid. Greenburg and Safran (1987) state “Few practicing clinicians would deny that their patients emotional experiences in therapy play a pivotal role in the process of psychotherapy change’; certainly this is so in my own clinical practice and is a basic tenet of CAT theory. Emotion could be said to be at the very core of psychotherapy, as the later discussion of individual cases will show. In the following review we shall attempt to relate psychological theorising together with an appreciation of the role of the emotions implicated in depression.
Motivation and emotion are closely related, for example anger is frequently an emotional motivant of aggressive behaviour. Emotion can activate and direct behaviour in a similar way to purely biological motives - e.g. hunger and tiredness respectively motivate nourishment and rest. Emotions may be positively goal directed in that certain activities we follow will bring us pleasure, or emotions may be negatively directed, e.g. avoidance of a fearful situation. Since the time of Darwin (1872) and before some emotions have been considered ‘basic’, Power and Dalgleish (1997) consider fear, sadness, anger, disgust and happiness to represent the basic emotions, others might wish to include ‘surprise’. ‘Complex’ or socially and culturally derived emotions such as jealousy, despair, disdain etc can be thought of as a combination of two or more of the basic emotions (i.e. nostalgia as an admixture of happiness and sadness) or as an emotion(s) combined with an intellectual/cognitive/social/cultural component (e.g. disdain could involve disgust in the presence of an intellectual disagreement of someone’s opinion), in any event complex social emotions are seen as deriving from the basic emotions. Some emotions are regarded as primitive - almost ‘visceral’, anger and territorial protection for example have been related to the limbic system of the central nervous system, a characteristic and neuro-structure shared by our reptilian evolutionary ancestors. Other emotions e.g. complex cultural and social emotions such as love and pity assume an ethical dimension, yet others have a group character, shame and guilt as will be seen are perhaps the classic examples.
Power and Dalgleish (1997) comment that it would be useful to re-list psychiatric disorders in terms of their main emotional dysfunction. This would be a difficult task with regard to depression as so many factors are involved. In terms of basic emotional subsystems: sadness, anger, fear and disgust are all implicated as are a range of complex social emotions such as despair, hopelessness, humiliation and shame. The range of factors to be noted under the psychological discussion such as loss and mourning and sociological factors such as interrelational difficulties, social withdrawal, loss of self-esteem and significant ongoing life adversity etc relate and contribute to depression and must also be written into the account.
Behavioural and cognitive approaches
Behavioural approaches to depression were popular until the early 1980’s after which they were overtaken by cognitive perspectives. Behavioural theorists said little about the impact or meaning of the emotions in depression and saw them as drive mechanisms implicated in the processes of positive and negative conditioning. Following in the tradition of Watson and Skinner, Ferster (1973) saw depression as the consequence of inadequate or insufficient positive reinforcement leading to insufficient positively conditioned behaviour. Other theorists saw depression as a behavioural deficit, e.g. a lack of assertiveness or self-esteem that resulted from a lack of positive reinforcement. Some of these ideas have remained in other approaches, e.g. CBT and CAT homework setting.
A number of related but differing cognitive psychology theories of depression have been suggested. Seligman (1975) proposed a learned helplessness theory, depression is seen as the product of a history of faulty learning regarding personal locus of control, when one is subjected to negative events seen as outside of one’s control - hopelessness, passivity and depression result. Ellis (1962) proposed a Rational Emotive (Behavioural) Therapy, in which dysfunctional emotion or lowered affect is seen as the result of an irrational belief system.
Aaron Beck (Beck et al 1979) has proposed, perhaps, the most accepted cognitive theory. Beck suggests that lowered affect is secondary to dysfunctional cognition. Three major features of cognition are believed to perpetuate the disorder. First, the ‘cognitive triad’; this consists of negative cognitions concerning oneself (e.g. “I am undesirable, worthless and inadequate”), the world (e.g. the world is defeating and overly demanding), and the future (e.g. “I am always bound to fail and to suffer”). Secondly, faulty thinking or cognitive errors, which maintain the cognitive triad of which a number of errors have been identified, e.g. all-or-nothing thinking, overgeneralization, mind reading, personalisation and discounting the positive etc. In time thinking errors become so practiced they gain an automated quality, these are termed ‘automatic negative thoughts’. People are usually only partially aware of their automatic thoughts; however they exert a great influence over how they view the world and accordingly behave. Thirdly, schemas; these are hypothetical cognitive structures that influence the screening, coding and organization of environmental information. Negative schemas are learned from early unfortunate interactions with the environment, especially with significant others. Sometimes early experience can shape maladaptive attitudes and beliefs in the child. Dysfunctional schemas (e.g. “I must do everything perfectly or else I’m a failure”) can predispose people to distort events in a characteristic fashion that leads to depression. It is thought that dysfunctional schemas and beliefs can lie ‘hidden, dormant’ and unacknowledged for a number of years until a series of events ‘re-awaken’ the schematic beliefs which then activate the cognitive triad.
Cognitive theory often sees emotion as an event that occurs after perception and appraisal, to some extent emotions are considered an unwanted an epiphenomena. So cognition precedes affect, a model could be written thus:
Event ---- Perception ---- Cognitive appraisal ---- Emotion ---- Action.
A popular book that perhaps epitomises this approach to emotion and emotional disorders is ‘Mind over Mood’ (Padesky, C., and Greenburger, D, 1995).
Criticism has been made of this approach i.e. how little an attempt is made to view emotion as an integrated aspect of the evolved biological system. Information processing models have heavily influences cognitive theory and use the computer as a metaphor for mind; people are implicitly viewed as information processors that are disconnected from the environment, i.e. as decontextualised beings who disturb their-selves only by their thoughts. Gilbert (2000) views this ‘purely cognitive view’ as theoretically flawed, not supported by the evidence and politically dubious - certainly this simple view seems to ignore much of the sociological evidence previously discussed.
Having reviewed the ‘basic’ cognitive approach we should realise that, like any other, cognitive theory is continually refined and redefined. Developments have occurred within cognitive theory regarding the role of the emotions. Working from an academic psychology perspective and using an information processing model Power and Dalgleish (1997) describe a theory of the emotions akin to Aristotelian functionalism; i.e. they look at the functional role of the emotions, so for example anger has the function of motivating an individual to violent retaliatory behaviour. Emotions are ‘conceptualised in terms of the functions they perform in the individual’s psychology’; the psyche is conceived as a functional goal directed system. Power and Dalgleish define emotional ‘states’ as comprising: - (1) an event (external or internal to the person), (2) an interpretation of the event, (3) an appraisal of the situation, (4) physiological change, (5) a propensity for action, and (6) conscious awareness. Often certain actions and behaviours will follow. Power and Dalgleish also allow for the existence of unacknowledged or ‘unconscious’ emotion - e.g. suppressed or denied anger. It is the interpretation and appraisal of an event which produces one emotion as opposed to another, thus if one appraises the removal of an object as a welcome event one is happy whereas if one views the removal of the object as a theft one is angry. Interestingly this representation reminds us of Ryle’s (1990) early cognitive-analytic ‘procedural sequence model’, although the sequence of the elements differ.
Evolutionary approaches regard emotions as not just ‘feelings’ which exist inside of us but as a form of information about the self in interaction with the environment; therefore, emotion, perception and action are inextricably linked (See Safran and Segal, 1987 for an evolutionary and integrative psychological account). Evolutionary psychology (see Stevens and Price, 2000) views the human mind as a product of evolution; it is concerned with identifying the problems that our ancestors faced and the adaptations that evolved to solve these problems. Emotional systems, which are adaptive, survive through processes of natural selection whilst maladaptive systems are selected out of existence; we do however need to note that not all emotional experience and expression is adaptive, if it were there would be little need for psychotherapy!
Evolutionary theorists see emotional systems as relatively independent systems of mental events and action potentials, or as the tendency of our brains to function as a set of semi-autonomous subsystems, almost as if a number of different and competing systems have the potential to operate and the emotional appraisal of a percepitant decides which system to use - metaphorically emotional appraisal ‘decides’ which record from the duke-box to play. Emotional states, processes and systems which have proved adaptive to hominid and human emergence have been selected-in, whilst presumably non-adaptive systems have been selected out of the evolutionary process. Of course this begs the question: How is it that depressive behaviour continues despite the fact that it seems to work against biologically adaptive behaviour? We do not have enough space to enter into this question in detail; however, Beck (1985) postulates that depression does have an adaptive function. Historically when supplies of food were low, or when access to powerful figures may have been limited (e.g. in times of tribal conflict) ‘depression’ may have acted as a type of hibernation behaviour to either conserve body energy levels or else to keep quiet and hidden. Hagen (2002) proposes a bargaining model of depression; following an aversive life event the depressed person undergoes something akin to ‘a labour strike’. When powerful others are benefiting from an individual’s efforts, but the individual them-self is not benefiting they can, by reducing their productivity, put their value to others at risk in order to compel their consent and assistance in renegotiating the social contract. Each view suggests that depression, similar to a phobic response, at times has a useful function but often exists out of kilter with the existing social setup and takes on an exaggerated form out of alignment with current need.
Psychoanalytic theory tends to assume that emotions are affects attached to ideas and that their presence indicates a disturbance in psychic equilibrium (Rycroft, 1995). An affect is usually thought of as ‘good or bad’ but does not have the differentiated quality of an emotion. Early psychoanalytic thought linked affect and cognition to somatic process through the notion of instinctual psychic energy. Freud believed that human beings could only be understood as creatures of biological evolution driven by non-social instinctual forces; it was felt that if one accepted the irrational nature of instinctual forces then one could accommodate to the environment through such processes as ‘sublimation’. Affect was seen in terms of the hydraulic concept of energy accepted at the time; emotions operate under pressure of instinctual impulses which are driven to discharge to preserve the homeostasis of the system - that is the organisms need to maintain a quantity of psychic energy at a constant level. Excessive psychic energy is discharged in the form of emotion, the development of emotional life was conceptualised as an interaction between instinctual and environmental forces. Psychic energy was said to provide the driving force behind emotion and to shape its particular character in life. In this scheme emotions and memory are strongly linked. For Freud unconscious emotions are different to unconscious ideas; unconscious ideas exist as actual structures whereas unconscious affect represents the potential for conscious emotion, which was prevented from developing, (Freud, 1915).
This ‘instinctual drive model’ of the emotions can be criticised (in similar vein to criticism of early cognitive theory) on the grounds of its monadic emphasis; the self and incumbent emotions are seen as a wrapped up biological package sufficient and self-maintaining unto itself - with interaction with the later environment and other people occurring almost as an afterthought. Psychoanalysis has made little use of the distinction between basic emotions and complex social emotions and tends as a result to interpret simple emotions as manifestations of complex ones. There is also a tendency to assume that complex emotions are present at birth e.g. Klein (1935) attributes envy to the newborn infant.
For psychodynamic theory, loss and the resultant emotion of sadness together with redirected anger are regarded as the chief components of depression. Abraham’s psychoanalytic theory (1911) maintained a depressed individual redirects his feelings of hostility, anger and rage towards a ‘lost’ person and channels them inwardly against the self. This account was expanded by Freud (1917), who also introduced an early ‘Object Relations’ element into depression - here loss can be real, imagined or symbolic. Typically lost ‘objects’ reflect individuals who are significant but regarded ambivalently, i.e. love concurrent with anger, early in a child’s life. The lost object is often the mother and particularly is lost during the oral phase of development. In order to make the loss of the mother-object bearable the child learns to internalise a representation of the lost object. Loss is heralded as a vulnerability factor that may lead to depression in adulthood if the individual is confronted with a significant loss of role or status later on. Freud compared the experience of grief and mourning to that of depression and melancholia but emphasised in depression the importance of loss of self-esteem, self-denigration, feelings of worthlessness etc. Freud hypothesised that the denigration of the self is not actually towards the self per se, but that there is an identification of the self with the lost object; thus anger and disappointment that previously had been directed towards a lost object are now internalised leading to a loss of self-esteem and a tendency to engage in self criticism - as if ‘the shadow of the object falls upon the ego’ (Freud, 1917). Pedder (1982) argues that later in his career Freud would not have considered that internalization of the lost object only occurs in depression; Pedder argues internalisation is common in grief and indeed is an important stage at the end of psychotherapy, though, it must be remembered that in 1917 Freud wrote in the infancy of Object-Relations theory.
Klein (1934) argued that a predisposition to depression was not due to early loss per se, but rather to the quality of the mother and child relationship in the first year of life. Depression is more likely to develop as the result of failure of the child to overcome ambivalence towards its love objects - excessive fears and anxieties and low levels of self-esteem lead to risk of depression later in life. Pedder suggests the child needs to develop ‘good object constancy’, which he hypothesises occurs around the age of 9-10 yrs before the good object can be used as an antidote to depression; prior to this and particularly with greater amounts of splitting used as a psychic defence, object constancy is not so available and therefore a vulnerability to depression exists. One could note this seems to parallel more recent cognitive investigation that suggests a depressed individual does not have greater amounts of negative cognitions that the non-depressed, rather there is a lack of positive cognition to counterbalance the negative for a depressed person (for a discussion appertaining to this point see Gilbert, 2000).
Building on Klein’s work Jacobson (1971) used an Object-Relations perspective to hypothesise that fusion of the individual’s self and object-representations early in childhood result in the self-condemnation and reproach typical of depression. Anger and hostility are directed at the lost object and its internal representation, but through the process of fusion the internal representation of the object and self become indistinguishable. Consequently the anger and hostility initially directed towards the lost object are experienced as self-condemnation and self-hate. Kohut (1977) notes the importance of idealisation in early childhood. With normal caring parenting a child’s behaviour is idealised; in effect the parents act as a mirror in which the child can see him or herself as good and loved (or bad etc), these idealisations are internalised – resulting in good self-objects. The person who experiences good self-objects is seen as psychologically healthy.
Attempting to sum up the various contributors Pedder comments that the predisposition to depression arises in childhood from early disappointments in the child’s relationships with its parents. Good enough infant care promotes the establishment of good internal objects and lays the foundations for self-esteem. Also, manageable amounts of disappointment or disillusionment are prophylactic in immunising the child against much larger disappointment, anxiety and frustration that occurs later in life.
Blatt (1998) comments that Freud attempted to devise a unified theory of depression instead of recognising that two mechanisms operate separately; namely, depression caused by object loss at an early stage of development and depression caused by harsh super-ego development. From a current analytic perspective Blatt, drawing on varying current psychoanalytic accounts, differentiates between an early object loss depression focused primarily on interpersonal issues such as dependency, helplessness and feelings of loss and abandonment - which he terms “anaclitic” or dependent depression; and depression derived from a harsh punitive super-ego focused primarily on self-criticism and criticism of others and concerns about self-worth, feelings of failure and guilt which he terms “introjective” or self critical depression. Similarly Bowlby (1988) discussed different mechanisms of depression in: firstly, anxiously attached individuals who seek interpersonal contact and are excessively dependent on others; and secondly, compulsively self-reliant individuals who avoid intimacy and contact with others. Cognitive theorists have proposed a similar type of depressive classification: i.e. socially dependent or sociotropic personality types who fear the loss of a close partner, and autonomous personality types who fear loss of status and a fall in social hierarchy.
The role of shame and guilt in symptom formation
We noted earlier that disgust could be considered one of the basic five emotions. Power and Dalgleish (1997) argue that when disgust comes to be applied to the self then the foundation for many emotional related disorders, including depression, are laid. Bibring’s (1953) classic ego-psychoanalytic reanalysis of depression argues that depression may be derived from the primary emotions of sadness and disgust as opposed to Freud’s construction of sadness and anger. Similar to Freud, self-condemnation and guilt are directed towards the self but they are seen as deriving from the emotion of disgust as opposed to anger. Low self-esteem and feelings of humiliation may also be seen as deriving from disgust directed towards the self, such that aspects of the self are seen as bad and need to be eliminated or rejected from the self.
Over the last few years there has been an enormous growth of interest in shame. Gilbert (2000) regards shame as one of the most powerful and potentially problematic issues in psychotherapy because it involves concealing experiences or being unable to process shameful information. Shame and guilt belong to the group of self-conscious emotions (e.g. Lewis, 1993) in that each requires an internal evaluation of the self against a set of culturally defined rules and standards in which the self is adjudged to have failed. Guilt relates to some standard to which we fall short and often concerns a particular action; for shame it is the ‘self’ that is at fault, one believes oneself to be totally useless ‘bad’ lacking in value etc. Shame is about the total person. Shame is manifest physically by a dropping of the head and a contraction and withdrawal of the body. Object Relations theory highlights the primacy of relationship and sees shame as an experience of being alienated or cut off from others, threat or damage to social bonds is an important context of shame. With shame comes a loss of self–esteem and feelings of powerlessness and humiliation which, as we have seen, are a major component of sociological descriptions of depression. Guilt is more associated with an attempt to put right what was made wrong, i.e. an act of reparation.
The recent focus on shame in psychopathology breaks with the traditional psychoanalytic focus on guilt. Freud came to see guilt as a failure of standard judged by a harsh superego and ICD-10 argues for guilt as a key component of depression. However recent theoreticians (see Gilbert, 1992) argue that shame is a key component of depression in the sense that shame arises from a combination of disgust, anxiety (fear) and anger directed towards the self. With shame it is the self rather than an act carried out by the self (as in guilt) that becomes an object of that disgust and anger; so shame has an internal directed nature, whilst guilt an external focus towards the behaviour directed to another.
Shame is implicated in social dominance hierarchies in which submission and defeat versus dominance and triumph are a consequence of an individual being shamed by a critical other. Shame and guilt are primarily social and cultural emotions that develop from early social interactions and are re-activated in socio-cultural settings; however, early experiences are internalised and later involve the relationship between the self and oneself. Typically shame and guilt are often considered to be ‘harmful’ emotions but we should remember that both aid the development of the self. The experience of shame provides a navigation to the child for acceptable and unacceptable behaviour and provides important feedback about how behaviour and the self are viewed by significant others, this in turn aids the development of the self further. Shame therefore has a crucial role in socialisation because the child wants to follow cultural standards and cares about the opinions of others, to quote from a standard work on Transactional Analysis: - ‘The capacity to feel shame is built into human beings, and it has a civilising effect in adapting a child to his family and culture’ (English, 1975), in order to remain connected one needs to understand and follow the cultural rules of society.
On a cautionary note it may be wise to remember Maslow’s (1975) remark ‘If the only tool you have is a hammer, you tend to see every problem as a nail’. Resnick (1977) disagrees with any phenomena or concept that begins to approach a universal explanatory scheme; although it is wise to note the importance of the role of shame and guilt in the causation and maintenance of depression we should not forget the impact of other factors and emotional states as noted earlier.
Psychosocial and cultural approaches to the emotions
Averill (1980) asks for a psychosocial perspective of the emotions; he claims that a social level of analysis is necessary for a complete understanding. Complex ‘social’ emotions are viewed as social constructions that provide transitory social roles; a role is viewed as a socially prescribed set of responses for a given situation. These roles, which are similar to the reciprocal roles of CAT, are viewed as culturally arranged responses designed to resolve conflicts in the social system. Different emotional roles fit into the overall arrangement of social interaction. Averill conceptualises emotions as responses governed by cognitive structures that guide the appraisal of environmental information and the person’s response. Averill is primarily interested in the cultural rules that govern emotional expression. Emotional behaviour and experience are determined by the meaning and requirements of the emotional role as that person interprets. Once people understand the meaning of their emotional roles they monitor their own behaviour and experience in light of this understanding. Averill draws close to the contributions of Vygotsky (1978). Vygotsky felt that individuals’ personalities are not self generated but are shaped and maintained through their social interactions with others. In this view complex social emotions can be seen as a facet of cultural interaction – there is a rejection of the monadic view of selfhood, self and emotion are cultural constructs in league with inherited characteristics.
Towards a theoretical synthesis?
Ryle (2002) taking a lead from Vygotsky and current evolutionary psychology maintains that CAT is based upon ‘a clearly defined and radically social concept of the self’. During individual development personally and socially meaningful interactions with others are internalised to form mental structures and capabilities. Ryle (1990) considers primary emotional responses to be processed rapidly, unconsciously, and by a partially separate affective processing or appraisal system which scans the environment for events of personal or social significance. This model does not see emotion as an ‘end point’ of information processing, which can be managed by therapeutic technique, but integrates emotion into the heart of human experience and sees it as (in league with other cognitive and appraisal systems) a driver of human action, perception and memory; so a study of emotion becomes essential to understanding human experience and interpersonal behaviour. The integrated view proposed by Safran and Segal (1996), amongst others, also offers a more satisfactory account in which existing knowledge from many sources including: cognitive, evolutionary and psychoanalytic, puts emotion at the forefront of human experience and emphasizes its organizing role in the experience of reality, sense of self, and orientation toward others. We may note however that even amongst cognitive theorists a differing attitude is developing towards the role of the emotions in psychological dysfunction (see Mahoney 1984).
A Cognitive Analytic Therapy perspective of depression
Emotional states and reciprocal roles etc
So what is the link between emotional causation, the differing theories of depression, and CAT theory and practice? We could argue that the idea of an emotional state as a semi-autonomous subsystem is similar, in part, to CAT’s notion of Reciprocal Roles and the self-state. A Reciprocal Role (RR) refers to how we relate-to and experience others. RR’s can be considered as a concept derived, in particular, from Ronald Fairbairn’s Objects-Relations theory and modified into a more cognitive or accessible hands-on model. Ryle describes a RR thus:
A stable pattern of interaction originating in relationships with caretakers in early life, determining current patterns of relationship with others and self-management. Playing a role always implies another, or the internalised voice of another, whose reciprocation is sought or experienced. (Ryle, 2002)
We can note that ‘self management’ refers to a particular type of RR acted within oneself or to oneself. It is important to note that ‘Role’ as explained here implies action linked to memory, meaning, cognition and affect/emotion etc. By way of example if someone criticises us we can feel and take on the role of being criticised, or in turn we can be critical and they take on the role of the criticised, within this process memories of earlier criticism will be evoked and the current situation charged with meaning which in turn will charge and direct our actions. As noted RR’s can also be directed by the self towards the self, so for instance we can learn to be critical of ourselves and in turn feel criticised, as if by an internal critic - early role relationships with others have now become internalised and can self-maintain. A Reciprocal Role procedure ‘contains’ an emotional state which ‘colours’ the way an individual perceives other people, the world and their-selves in relation to the world; the emotion also impacts upon the way a person relates to and behaves towards the world, their-selves and to other people.
One way of looking at a ‘self-state’ refers to the way in which people can become locked into a type or ‘state of mind’ which is relatively self-enduring and un-open to other ways of thinking, feeling and behaving and un-open to contradictory information from the environment or from other people; thus a person reciprocating to an-other in a state of anger can only see the person, their-self and the world in general as influenced by their rage, an ‘unreasonable’ state of mind results, e.g. the saying “I saw red”. A RR self-state represents a relatively autonomous emotional, perceiving, appraising, thinking and behaving sub-system of operation upon the world and the self. Usually most of us move transitionally from one RR to another with relative ease, so for example we can commence by being polite to someone, move to curiosity, intrigue, passion, annoyance, understanding and back to politeness etc in a matter of minutes. If particular emotions are strongly aroused, e.g. fear or shame, we can find ourselves set in a particular frame of mind for a considerable time seemingly immune to attempts to alter our mood. I consider depression to be a particular type of depressive self-state in which a limited number of RRP’s (with emotions, set cognitions etc) predominate to the relative exclusion of others. Depressive RRP’s can be longstanding and seem impervious to change attempts from either the self or from others’ attempts. A self-state represents a partial (or in some cases almost complete) shutting off from interaction with other people, problematic RR procedures have a psychosocial feedback quality to them, traditionally in CAT parlance this is termed a trap, once commenced depression has a self-maintaining feedback quality.
A cognitive analytic model
As noted earlier Freud’s quest for a single route to depression is impracticable, the ICD-10 account also appears unsatisfactory though it never professed to be more than a general description. Earlier we differentiated between two main types of depression, the ‘dependent’ or object-loss depression and the ‘self-critical’ depression. Linking together our understanding of emotional functioning with psychological interaction and informed by social process we should be able to explicate a general CAT description of the two depressions.
Two proposed CAT models of Dependent depression (DD) and self-critical depression (SCD) are proposed. Both are presented in a form similar to a sequential diagrammatic formulation. One point to note for those unfamiliar with CAT Sequential diagrammatic re-formulations (SDR’s) is that an SDR does not attempt to depict what occurs in the mind-body-environment continuum, instead the SDR isolates various mental and environmental occurrences in a manner which shows these events in sequential relationship and in a circular feedback fashion; we may note here the similarity to Karp’s (1996) biopsychosocial feedback loop or Brown and Harris’s self maintaining depression model. There is no automated or laid-down means of producing an SDR although many stick to general principles; yet even a basic SDR can vary considerably dependent upon the practitioner, the main focus has always been on producing SDR’s which are illuminative and useful for the practitioner and intended recipient.
Templates act as guidance rather than certainty in an actual world, please note the models relate to the period of depressive dysfunction and are not representative of premorbid functioning, though they seek to outline the early psychological and social vulnerability of the individual. Both models are suggested as general accounts and as relatively distinct from each other, that is we are interested in drawing out the differences and looking at two routes to vulnerability.
The DD is characterised by feelings of loneliness, helplessness and weakness, these individuals have an intense and chronic fear of being abandoned and left unprotected, see diagram 1. These ‘anxiously attached’ patients have a deep longing to be loved nurtured and protected and often show excessive dependency and clinging behaviour. Clinically and metaphorically these patients often have an ‘emptiness’, as though we would wish to fill them with ‘good’ from ourselves; but no matter how hard we struggle we fail to nurture and sustain these individuals, like trying to fill a sieve with water. Because there has been little internalisation of the good qualities from others, caused by early object-loss, others are valued primarily for the immediate care, comfort and satisfaction they provide, but little real relationship results. Clinically these patients can be draining and exasperating. Attempts to assist guided self-discovery or increase self-efficacy are met by protestations of inability to cope or ‘disinclination’ to help their-selves. This counter-transference, once recognised, provides a clue to the nature of the patient’s inner psychology and helps enable one to accept the nature of the RRP being enacted in the room. Once recognised it is far easier to challenge or work with this procedure.
Early in life the child experiences a significant loss - loss can be real (i.e. separation from a caretaker) or symbolic, e.g. a parent who is emotionally absent. One could predict (as did Bowlby) that the more traumatic the abandonment (e.g. in the absence of other mitigating circumstances such as an older supportive sibling or other relative or carer) the greater the risk of severe dysfunction. Abandonment and loss experiences are internalised, ‘stored’ as part of the RRP and cognitive and emotional content of the psyche. In order to accommodate to the emotional pain of the RR the child will devise (probably unconsciously) certain life aims and procedures to adapt to the pain. In the face of loss and abandonment, the child using a psychic inner adaptation, develops an idealised version of the lost object. One can see primary splitting in operation, due to a lack of object constancy the internalised object is split into ‘abandoning, loss, emptiness’ versus an unrealistic ‘fantasy protector, nurturer, comforter etc’. Dysfunctional RRP’s are thereby commenced and perhaps are analogous to analytic unconscious defence mechanisms or the ‘Life Scripts’ of Eric Berne’s Transactional Analysis.
To some extent how the child feels and perceives him or herself is socially and culturally determined. As noted earlier mind, complex emotion and how we process emotion and experience is at least in part culturally constructed and determined, other basic emotional systems and coping abilities appear to be evolutionarily and biologically hard-wired. The emotional pain ‘contained’ in the RR can be seen as a type of ‘battery of energy’ driving the RR procedures onwards. Initially dysfunctional RRP’s may be mild or embryonic and unapparent to the self or close others. Similar to cognitive and analytic models, the RRP’s of Cognitive Analytic theory await later development before they become truly problematic.
This early disadvantage constitutes a vulnerability to depression. It is at this stage that the sociological impact of significant life events, as discussed earlier, become apparent; an event or circumstance may occur which metaphorically replicates the early experience: perhaps the person is abandoned by a partner or left to cope on their own in life etc. This leads to a re-experience of abandonment, aloneness etc in which the person perceives him or herself to be helpless and weak. Once ‘awakened’ the depressive RR self-state assumes a relatively stable systemic and self-maintaining structure.
Depletion of ‘psychic energy’ can be interpreted in many ways ranging from a loss of focus on what previously was important in life, to a turning inwards upon the self and withdrawal from exterior life, to a neurotransmitter disruption caused by an overabundance of the stress hormone cortisol etc. Nonetheless, the person experiences panic, fear and anxiety and desperately seeks to be helped protected and loved by others. At this stage a number of events can occur, if no ‘protector’ is actually or symbolically available (this is not shown on the diagram as such) then the person re-experiences even greater loss and abandonment and so ‘loops around’ the diagram becoming increasingly desperate and depressed.
Sometimes people are available to help; however, dependency, clinging and a ‘whining’ need to be protected from a harsh world can cause even the most patient of carers to withdraw. In any event, no helper can ever provide enough to repair the nurturing-need within the depressive and eventually all fail - leaving the depressive to realise that once again they’re on their own. Sometimes in an attempt to escape from the harsh world the depressive will take to alcohol, drugs or other escapist behaviour; fugue and trancelike states are sometimes noted Some people sit for hours in a car when due at work etc, others are found lost miles away from home and out of synchronisation with their usual memories or coping abilities. The point we are trying to draw is that a wide range of individualised behaviour is possible at this point dependent upon the individual nature of the person and the degree of depression experienced. By self-or-other agency the sufferer finds them self isolated, withdrawn and socially redundant, this experience leads back to and confirms the original belief of being alone in the world, unloved and abandoned.
An abandoned child will develop a range of beliefs to account for their abandonment, sometimes these beliefs are only partially recognised but may include ideas of being evil, tainted, unlovable, unwanted etc; the depressive develops shame, guilt, self-loathing etc. An idealization defence may be used intra-psychically or the adult may try to undo their abandonment by finding a perfect protector, or by trying to prove to their-selves and others that really they can be loveable and worthy etc. An internal struggle may ensue, although having found an ‘idealised protector’ the depressive still believes they were originally abandoned because they were and remain unlovable, unworthy and evil. Perhaps the protector needs protecting from the e
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