Psychodynamic Approaches To Understanding Depression

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

I think we should start with the concept of the psychodynamic approach, what is it in contrast to the classical approach to nosologies and conditions used in psychiatry. Psychiatry, as a science, in the view of Karl Jaspers, the founder of general psychopathology, is based on the so-called phenomenological, or descriptive, approach, the essence of which is “in identifying real, distinguishable phenomena, discovering truths, testing them and demonstrating them clearly. The field of study of psychopathology is everything that belongs to the field of the mental and can be expressed with the help of concepts, which has a constant and, in principle, intelligible meaning. The subject of psychopathology research is the actual, conscious events of mental life. " The goal of the psychiatrist is a detailed description of the symptoms observed in the patient, and further construction on their basis of a syndromological diagnosis. In turn, the task of the psychotherapist, whose work is based on a psychodynamic approach, is to see what lies behind the facade presented by the patient, to understand what lies behind it, going beyond the symptoms and diagnosis. According to Jaspers, “psychotherapy is an attempt to help the patient through mental communication, to penetrate into the last depths of his being and find there a basis from which he could be led on the path of healing. The desire to get the patient out of the state of anxiety is recognized as the self-evident goal of treatment."

Obviously, a logical question arises: why was this topic chosen? First, one cannot fail to note the clearly increasing number of patients with depressive disorders of a different register, both depressions of the neurotic circle and deep psychotic depressive disorders; secondly, in practice, we often encounter a situation when, despite all the applied methods of treatment, namely pharmacotherapy (in particular, the combination of antidepressants with stimulating neuroleptics, benzodiazepines, normotimics, biostimulants, etc.), psychotherapy, PTO etc., the expected effect of therapy is still not observed. Of course, the patient is getting better, but we still do not observe the final reduction of depressive symptoms. It is natural to assume that the understanding of depression is incomplete. Thus, along with the existence of psychodynamic theories of the onset of schizophrenia and affective disorders, there are also theories of the onset of depression. Here you can recall the statement of Freud: "The voice of reason is not loud, but it forces itself to listen … The kingdom of reason is far, but not unattainable far …"

For the first time, the psychodynamic aspects of the depressive state were investigated by Z. Freud and K. Abraham, who linked the occurrence of depression with a situation of loss of an object (mainly the mother). A few words should be said here about the concept of "object". In psychoanalysis, an object can mean a subject, a part of a subject, or another object / part of it, but the object is always meant as a special value. According to J. Heinz, the object is understood as life ambitions / illusions. The object is always associated with attraction or satisfaction of this or that drive, is always affectively colored and has stable signs. As a result, subsequently, under the influence of provoking factors (psychogenic, physiological, environmental, etc.), there is a regression to the early stages of psychosexual development, in this case, to the very stage at which pathological fixation arose, in particular to oral the sadistic stage, when all the infant's drives are concentrated on the mother's breast - this primary and most important object at that stage. One of the most famous sayings of Freud says that 2 basic feelings are found in the mother's breast - love and hunger. The loss of an object, first of all, hits precisely these feelings (from this point of view, both anorexia and bulimia can be considered as a kind of behavioral equivalent or a conversion version of depression)

Let us now try to imagine how a state of depression arises. The lost object is introjected into the Ego, i.e. is identified with it, to some extent, after which the Ego is split into 2 parts - the patient's Ego itself and the part identified with the lost object, as a result, the Ego is fragmented and its energy is lost. In turn, the Super-Ego, reacting to this, increases the pressure on the Ego, i.e. personality, but as a result of the loss of integration and differentiation of the last Ego begins to react to this pressure mostly as the Ego of the lost object, onto which all negative and ambivalent feelings of the patient are projected (and the “broken off” part belonging to his own Ego is impoverished and emptied), this is where the feeling of emptiness that our depressed patients so often complain about. As a result, negative feelings aimed at the lost (perceived as treacherous, disgusting) object concentrate on oneself, which clinically manifests itself in the form of ideas of self-deprecation, guilt, which, at times, reach the level of overvalued, delusional.

Recurrent mood disorders when the question is, "Are you upset about something?" of course known to everyone. These disorders have one or another, usually rational, amenable to analysis and explanation. During such periods, a person feels or demonstrates a decrease in overall energy, some lethargy, immersion in oneself, a certain stuck on some psycho-traumatic topic with an obvious limitation of interest in everyone else, a tendency to retire or discuss this topic with someone close. At the same time, both performance and self-esteem suffer, but we retain the ability to act and interact with others, to understand ourselves and others, including the reasons for our bad mood, according to Freud, this is a common grief.

In contrast, melancholy, i.e. severe depression (equivalently) is a qualitatively different condition, it is a loss of interest in the entire external world, a comprehensive lethargy, inability to perform any activity, combined with a decrease in self-esteem, which is expressed in an endless stream of reproaches and offensive statements about oneself, often outgrowing into a delusional feeling of guilt and the expectation of punishment for their real or fantasy sins = the majestic impoverishment of the I, according to Freud, during grief, “the world becomes poor and empty”, and with melancholy, the self becomes poor and empty. A possible cognitive error of the therapist should be noted here: not painful imagination is the cause of the patient's suffering, and a consequence of those internal (mostly unconscious) processes that devour him I. The melancholic sticks out his shortcomings, but we always see a discrepancy between humiliation and his real personality. Since in such a state the ability to love is lost, reality testing is disturbed, a belief in a distorted reality arises, it is meaningless to convince the patient otherwise, which we often do in such situations. The patient perceives such a reaction from the doctor as a deep misunderstanding of his condition.

It will be important to mention one of the hypotheses of the onset of depression: when the object is lost (or the relationship with it collapsed), but the subject cannot tear off his attachment (libido energy) from it, this energy is directed to his own I, which as a result, as it were, splits, transforms, identifying with the lost object, i.e. the loss of an object is transformed into a loss of I, all energy is concentrated inside, "isolated" from external activity and reality as a whole. But since there is a lot of this energy, it looks for a way out and finds it, transforming into endless mental pain (pain - in its original sound, existing without regard to anything, since matter, energy, etc.

The second hypothesis suggests that powerful aggressive feelings arise, aimed at an object that has not met expectations, but since the latter remains an object of attachment, these feelings are directed not to the object, but again to one's own self, which splits. In turn, the super-ego (the instance of conscience) inflicts a cruel and uncompromising "judgment" over its own I as over this object that did not live up to expectations.

Suffering within the framework of depression is of a "conversion" nature: it is better to be terminally ill, it is better to completely abandon any activity, but only not to show your hostility towards an object that is still infinitely dear. According to Freud, the melancholic complex "behaves like an open wound", ie. it is not protected from external "infections" and is initially painful and any complications, or even just "touching" only aggravate the situation and the possibility of healing this wound, therapy is also a variant of "touch", which should be as delicate as possible and requires preliminary anesthesia with the use of psychotropic drugs.

In the works of K. Abraham, we meet with the fact that depression was understood in the context of the history of libido development, i.e. history of drives. The loss of an object leads to absorption, introjection of the object of love, i.e. a person can all his life is in opposition with an introjected object (and all subsequent significant objects of emotional attachment). Abraham recognized the struggle of conflicting impulses of love and hate at the center of depression. In other words, love does not find a response, and hatred is pushed inward, paralyzes, deprives a person of the ability to rational activity and plunges him into a state of deep self-doubt.

It should be noted that the course of depression, like any other mental illness, and, perhaps, somatic as well, certainly leaves an imprint on the structure of the personal organization, type, level of organization of the patient's personality. If we turn our attention to later studies of the topic of depressive disorders, it is useful to mention the developments of S. Reznik, outlined in the publication On Narcissistic Depression, by which the author means a strong feeling of disappointment and loss of the most important aspect of himself or his pathological ego ideal, his “the illusory world”, this state is experienced as a concrete physical event. In this case, the patient's depressive crying can manifest itself in excessive sweating, "tears" flowing through all the pores of the body, as well as in suicidal fantasies or actions (as a result of the inability to live without these illusory constructions). Illusory reality competes with everyday reality, it can also become a kind of illusory hyperreality in dreams (hyper- and surrealism). In fact, in a dream, normal oneiric hallucinations are perceived as life in a more than real - hyperreal, or more than true world. As the Italian psychiatrist S. de Santi wrote: "a dream can shed light on the material of illusion." The egocentric self considers itself to be the center of the universe and, in delusional excitement, can transform inner and outer reality; in this state, the narcissistic pathological self can transform the nature of everything that becomes an obstacle to its expansive "ideological" movement, delirium is a system of ideas, more or less organized.

Again, as for endogenous depression, obsessive-compulsive disorder, delirium, in the understanding of the supporters of constructive-genetic psychopathology Strauss, Von Gebzattel, Binswanger, it is based on the disorder of the so-called. vital events, which in different diseases only externally manifests itself in different ways. This change in the fundamental event is called “vital inhibition”, “disorder of the process of personality formation”, inhibition of “internal timing”, a moment of stagnation in personal development. So, as a result of the inhibition of the process of becoming, the experience of time becomes the experience of stagnation in time, the future is no longer there, while the past is everything. There is nothing inconclusive, indefinite, unsolved in the world, hence the delirium of insignificance, wretchedness, sinfulness (unlike “psychopathic hypochondriacs,” depressed patients do not ask for consolation and support), and the present inspires fear. The ability to enrich future connections with the outside world serves as a prerequisite for happiness, while the prerequisite for grief is the possibility of losing these relationships. When the experience of the future, under the influence of vital inhibition, comes to naught, a temporary vacuum arises, due to which both happiness and sadness are made impracticable. From the same fundamental disorder - inhibition of the process of personality formation - symptoms of obsessive thinking arise. This inhibition is experienced as something leading to the disintegration of the form, but to the disintegration not immediate, but assuming the image of the disintegrating potential of existing being. Mental life is filled with only negative meanings - such as death, dirt, pictures of poisoning, ugliness. The events underlying the disease are manifested in the patient's mental life in the form of specific interpretations, in the form of a kind of “magical reality” of his world. The goal of compulsive actions is to protect oneself from these meanings and this reality; obsessive actions can be carried out to complete exhaustion and are characterized by their ineffectiveness.

Basic theories of treatment of pre-oedipal patients according to Hayman Spotnitz:

1. In classical analysis we try to establish a positive relationship with the patient, a “working alliance” that the preoedipal patient is unable to form. That. in modern analysis, we do not expect the disturbed patient to be able to cooperate and form positive relationships or remain in therapy without the use of special techniques. We try to focus on the therapeutic situation, with the focus on learning and resolving specific preoedipal resistances that impede the progress of treatment.

2. When working with the pre-oedipal patient, we try to create an atmosphere that will allow the manifestation of aggression.

3. In treating the oedipal patient, we promote the development of an objective transfer that leads to a transfer neurosis. With the preoedipal patient, we form a narcissistic transfer, here the patient's self is the object, but it is projected onto the analyst.

4. In classical analysis, the patient's verbal, often intellectualizing, expressions are important for the development of therapy. But in working with a more disturbed patient, we cannot count on this, therefore it is necessary to work with more primitive forms of verbal communication.

5. In the classical technique, the patient is also responsible for the success of the therapy. In modern analysis, it is the analyst, as a mother for the infant, who is fully responsible for the success or failure of therapy.

6. In the classic version, we try to resolve the resistance from the very beginning. With pre-oedipal patients, we are primarily concerned with strengthening the ego and its defenses. Therefore, before attempting to resolve resistances in a treatment situation, it is necessary to make sure that the defenses are not destroyed. We can join the patient to strengthen his resistance (n / r: the patient "I hate Kiev. I need to move to Lviv" analyst "why to Lviv? Maybe it is better to go to the east, to Donetsk, for example?")

7. In The Problem of Anxiety, Freud formulates five basic resistances that he found operate in the oedipal patient. For the treatment of the preoedipal patient, Spotnitz developed an alternative group of five resistances that apply to these more disturbed individuals, as described in Spotnitz's book Modern Psychoanalysis of the Schizophrenic Patient: A Theory of Technique.

* resistance destroying therapy

* resistance to the status quo

* resistance to progress

* resistance to cooperation

* resistance to the end of treatment

8. In his early works, Freud disapproves of the development of countertransference feelings in the analyst, considering them to be contrary to the principle of the analyst's neutrality and objectivity. In modern analysis, these feelings are an extremely important element in therapy, act as manifestations and keys to many aspects of the dynamics of the treatment process.

TECHNIQUE

one). The main task of the patient in the classical approach is free association, but in modern practice this is avoided as it can lead to fragmentation of the ego and further regression. Instead, the patient is encouraged to say whatever he wants.

2). The main intervention in the classics is interpretation. In work with the preoedipal patient, it is replaced by emotional verbal communication, strong feelings and states are evoked, they are studied and used for progress.

3). The classical analyst resolves resistance by interpretation, the modern one - through the use of alternative forms of verbal communication such as joining, mirroring, reflection.

4). With a neurotic, the analyst usually determines the frequency of sessions; with a pre-elliptical patient, the patient himself plans, with the help of the analyst, a mode of meetings.

five). Orthodox analyst J usually addresses his questions and responses to the patient by formulating ego-oriented interventions. Modern - will use object-oriented interventions.

6). The couch in the classic technique is used only with a high frequency of encounters and with patients whose narcissistic disorders are considered curable; in modern analysis, the couch can be used with all patients.

7). The main goal in treating a preoedipal patient is to help him say "everything." We try not to disagree with the patient's point of view. According to Spotnitz, “It often turns out that the patient's point of view is better than the analyst's. The patient has first-hand information. " Spotnitz bases his system on 2 Freud's statements: "You can only answer the patient that saying everything really means saying everything." And also: "This robot for overcoming resistance is the main function of the analysis." Considering that during the sessions we often appeal to memory, it is appropriate to quote Spotnitz's opinion here: “Modern analysis is a method that helps the patient achieve significant goals in life by telling everything that he knows and does not know about his memory. The analyst's job is to help the patient say everything, using verbal communication to resolve his resistance to saying everything he knows and does not know about his memory."

eight). The classic analyst limits his technique mainly to interpretation.

nine). When working with a deeply regressed patient, the modern analyst will limit his interventions to 4 or 5 object-oriented questions per session in order to limit regression and promote the development of narcissistic transfer.

Spotnitz's concept of narcissistic defense: In the early stages of life, due to the fear that outward expression of anger or hatred towards parents will lead to a loss of relationship with them, the ego develops a series of defenses. Some of these fears may include fear of the omnipotent destruction of the object, resulting in fears of retribution, self-destruction, abandonment, devastating rejection. There may also be a magical fantasy that hatred of a beloved object will destroy the goodness of that object and the child is wasting the opportunity for the love relationship he hopes for.

In normal and neurotic depression, we see that the individual's conflict is related to the self and the external object, while in deep or psychotic depression, the conflict, as Bibring suggests, is intrapsychic and unfolds between the superego and the ego, the self.