THE DARK SUN OF MELANCHOLIA
Recently I read a long letter from a psychiatrist detailing his treatment of a very depressed artist, a woman whose chronic misery influenced her photography. She was very successful in her work, which showed a genius for capturing in pictures excruciating moments of human tragedy. The doctor told her she should try antidepressant medication, because, as he put it, “Depression is a disease that is treatable, and it makes no sense to suffer unnecessarily.” She was worried though that taking pills would somehow affect her art. The psychiatrist reassured her that she would have even more energy to bring to her photography and that there was no danger at all. So she agreed and embarked upon a course of medication to relieve her very gloomy moods. After a period of weeks, the intensity of the depression from which she suffered did indeed begin to recede. But she also noticed that she had lost interest in photographing tragedy, and that she wanted to take pictures of people in joyful scenes instead. A problem arose because the new photographs were technically of the highest quality, but no one cared about viewing or purchasing images of happiness. So her career as an artist fell apart. The patient became very upset, thinking that the medication had indeed destroyed the basis for her art. So she stopped the medication, and, after a period, her misery rolled in once again. Now she was able to resume her career as a photographer of tragedy, but she also had again begun to suffer quite severely. Finally, after many back and forth moments, she resumed the antidepressant medications, accepting the fact that her passion for her art was changing irrevocably. The psychiatrist, in his letter, raised the question as to whether this treatment should be called a success. The patient’s pain had lessened, but her career as a photographer of the dark moments of human existence had been brought to an end. Suffering was substantially relieved, but at the expense of a very creative artist’s lifework. The doctor did not say what his patient had done as an alternative, but I think she found some other way of supporting herself, and frowned less.
So I decided to make a call to my old friend, the great psychiatrist Dr. E, just to see if he had any interesting thoughts relevant to this matter. I showed him the letter from the doctor who gave his antidepressants to the photographer. What follows is a transcript of our conversation
G.A. Hey old friend, I wanted to talk to you a little about the topic of depression and the story of the photographer who sought help. Tell me your reactions to the letter from the psychiatrist.
Dr. E. Typical, stupid, unconscionable. An artist is silenced, perhaps destroyed. It is to the credit of the doctor who wrote about this so-called treatment that he at least questions its result. But it is also to his discredit, because he has silenced an artist, whose work, like that of all artists, had a truth to tell, a reality to disclose, a communication to complete. The patient is perhaps smiling more, but my question about all that is: So what? Who said a person should smile more and frown less? Who determined that less suffering is to be recommended over more suffering? I do not believe God informed us of that principle of life. What if there is good reason for that suffering? What if there are situations in the photographer’s world that are the sources of her sense of the tragic, her resonance with human despair? What if her pictures of the dark moments of life carried central truths of her personal history and family background? We will never know, because her doctor in his infinite wisdom “treated” her depression. I would not call this a success. I would not call it a treatment. I would call it an injury of undetermined scope and magnitude.
G.A. Talk to me more about depression in general. Do you get depressed sometimes?
Dr. E.: I get depressed a lot. As far as I am concerned, in this world, much of the time anyway, depression is the only mood that makes sense. Have I told you my definitive theory of depression? It is caused by the depressing things that happen to us. Among a great many other things, it depresses me that depression itself has been turned by psychiatry and psychology into a disease process, something the drug companies tell us is “treatable.” Depression will never be treatable, and the reason is that it is built into the human condition itself. Human life has very depressing things within it, and to encounter these things is to be depressed by them. The idea that one can or should “treat” depression is totally insane; but what else is new? Sometimes I have the depressing thought that insanity rules the world.
G.A. I guess I can understand your idea, but what about people who become so depressed they cannot function, they try to kill themselves, they cannot even get out of bed. Are you saying there is no treatment for them?
Dr. E.: There is no medical treatment - that is for sure. I am not saying there is no help for a person in the grip of something that causes depression. There is help: namely the help that is given by the support and understanding that person may be lucky enough to encounter from others who care about whatever it is that has happened.
G.A.: What kind of help is it then that can be given when something truly depressing has occurred? Tell me your thoughts about trying to offer assistance to someone who has had something devastating happen.
Dr. E.: The topic of helping people in depression is immensely complicated. It is never a matter of medical treatment, but always one of finding the human response that might make a difference to someone. Some situations precipitating depression are so terrible that it is difficult to imagine any response that could be of help. Like one’s child’s suicide, an event that it would hard to match in terms of its devastating power. The idea of “treating” the resulting depression is an insult to one’s intelligence. If your son or daughter commits suicide, you should be depressed, terribly, terribly depressed.
G.A. So what happens to such a person?
Dr. E.: I read about a case recently of a woman whose son killed himself, and who became so depressed in the aftermath of the death that, among other things, she sought psychiatric help. Her doctor prescribed antidepressants for her depression, thinking that anything he could offer to relieve her suffering would be for the best. As a result of taking the drug, her pain did abate somewhat. She felt all her feelings less intensely at this point. So-called antidepressants ought to be renamed: they are anti-intense-feelings drugs, not specific to depressive affect. But giving antidepressants to a person whose boy has killed himself is itself completely crazy. There is no treatment for such a person.
G.A. Dr. E., if someone whose child had committed suicide came to you, I don’t believe you would tell them there is no help for them. You would do everything in your power to help that person.
Dr. E. Yes, everything in my power. The problem is that nothing in such a case would be within my power, because the only thing conceivable that would help the person feel better would be the undoing of the child’s suicide, the reversal of reality itself. Inasmuch as I am not God, I could offer little or nothing to such a person.
G.A. How in the world can you be sure you could offer nothing?
Dr.E. Maybe I am not being fair to every situation that might arise here. Before saying to someone there is no help I would inquire as to the circumstances of the death. If the boy ended his life because he had just received a diagnosis of incurable cancer, that might be different. In the case I encountered recently that was not the story. What happened is that the son, at the time 35 years old, had been chronically addicted to a variety of drugs and alcohol. He had never been able to make a career for himself, and had survived because his mother gave him money for food and rent. He had tried a variety of rehabilitation programs, Alcoholics Anonymous, and even psychotherapy, but to no avail. He kept falling back into the addictive pattern and relying on his mother’s money. She had a lot of it, being married to the boy’s stepfather, a multimillionaire. After a number of years of his continuing addiction, and of his mother’s ever-present financial support, the stepfather decided that he and his wife, the boy’s mother, were “enabling” the addiction and resulting self-destruction of the young man. So he prevailed upon his wife to adopt a policy of “TOUGH LOVE.” The boy was told that at a date certain, two months hence, the dispensations from his mother would irrevocably cease. The boy responded by thanking his mother for all the help she had been able to provide over the years, and then hanged himself. The death was a direct reaction to the cutoff of the support. The mother and her husband tried to tell each other that they had done all that was possible, that the boy had elected to destroy himself, first with drugs, and then with a noose. It was for the best, they said, and at least now they could know their son was at peace. But as the weeks and months passed, a feeling of emptiness and despair began to envelop the mother, finally becoming so painful that she sought a psychiatric consultation Her doctor gave her drugs immediately to ameliorate her suffering, and in consequence her pain did diminish fairly quickly. But she was now in a more-or-less numbed state, which is what antidepressants do to you, and should one consider the chemical numbing of this mother’s agony a meaningful treatment of her depression? It is appalling. As I was saying, depression is not treatable, and that is because it is a reaction to the depressing things that happen.
G.A. Well, Dr. E., what would you do for this woman? If she came to you seeking help, I cannot believe you would turn her away.
Dr. E. I would not turn her away. I would listen to her story, and I would ask her how she was understanding her son’s death. I would ask her about the sources of his original addiction. Addictions do not arise out of nothing; they appear when someone becomes dependent on a substance or activity that is an antidote to painful affect states of one kind or another. I would ask this mother what those states were, and what caused them. I would ask her why she let herself be persuaded by her husband to cut her son off. I would want to know how she felt toward her husband now that his firm advice had turned out to have fatal results. I would ask her if she herself felt she was responsible for her son’s death. I would not promise her that she would feel better as a result of any treatment I could provide, but I would make myself available if she decided she wanted to try to make some new sense of the tragedy that had occurred in her family. I would know that any effort to do that might well intensify her pain, rather than relieve it.
G.A. So what finally happened to this woman?
Dr. E. I don’t know. My experience has been that parents in such a situation most often do very poorly, and that is because a catastrophe of unimaginable scope has occurred. Maybe she came down with cancer and died. Or perhaps she just wasted away. Maybe she tried to start a movement against the dangers of drug addiction, and burned herself out doing so. The ‘guilt of the survivor’ a parent experiences in this situation is beyond description, and its consequences are never pretty. I would not want to say a parent could not find a pathway for a creative response to a child’s suicide – people always turn out to be capable of something we cannot anticipate. But most often the only thing that comes in the wake of such an event is devastation for all concerned.
G.A. Your discussion is itself depressing Dr. E., and it hard for me to believe that you think there is no help for people in depression.
Dr. E.: I did not say there is no help. I said there is no treatment. Help is another matter altogether. If a person is depressed, he or she may jump off the George Washington Bridge. If I position myself beneath the railing and catch the jumper, I have helped that person survive, at least for a little while. But that is not a treatment for the depression, which is occurring because everything has gone black. There is no treatment for depression, because depression is not a disease.
G.A. But what about people who become terribly depressed – lethargy, sleep disturbance, loss of appetite, falling self-esteem, suicidality, the whole bit – but who have had nothing happen to them that has been depressing? They used to call this ‘endogenous depression.’
Dr. E.: Endogenous depression is a myth, a psychiatric fantasy - not a reality. Every depression is caused by something depressing that has happened, with no exceptions. Sometimes though people don’t know what it is, or don’t want to know what is causing them to feel so bad. It is a paradox that human beings will plummet into deadly moods and all the while be avoiding or unable to look at what it is that has brought them there. Naive observers examine someone’s life and see none of the standard precipitants in the advent of depression – loss, disappointment, failure - and then - crudely, stupidly - draw the conclusion that it has arisen “from within,” endogenously, by which they usually mean from within the neurochemical environment of the person’s brain. Strangely enough, the patient will often cling to such an explanation, because the depression was actually experienced as “coming from nowhere,” as having no connection to the person’s present or past circumstances. What that means though is that the depression has been somehow stripped of its context – of depressing things happening – and the first step in helping such a person will be to restore the gloom that has enveloped him or her to its formative setting, its human context. There will be a story there, perhaps never before told, and one has to discover that story. Chemically numbing someone’s painful mood states would be the opposite of what would make sense in most instances.
G.A. Are you suggesting that the whole field of the use of medication in treating – or helping – people in depression makes no sense? Even that it operates against the real help a person might otherwise need to find?
Dr. E. Pretty much yes, although I do not want to go on record as being against the use of drugs. We live in a drug culture, it is human to use drugs of all different kinds, and I personally love them. But with regard to the use of medications in the so-called psychiatric treatment of the experience of depression, I haven’t seen a lot to encourage me that it even works. There are, in unusual circumstances though, occasions where antidepressants in particular do assist a person.
G.A. Tell me of such a case.
Dr. E. I have a colleague in my profession, actually a professor like you, G. A., and he is subject to recurring depressive episodes. He has found that betting on the horses at racetracks helps him lift himself out of otherwise extremely dark moods. So the excitement of the gambling operates to neutralize his depressive suffering. Recently he came to me and said, “Hey E., did you know that prozac is a miracle drug? It works from a distance!” I asked him what he meant. He said that he had been very depressed recently, because his wife would not let him go to the horse races. If he went nevertheless, she would greet him at the door when he came home and try to hit him with a frying pan. She felt he was squandering their young children’s college funds and she was outraged by his gambling. As a result he had nothing to help him lift his terrible moods, and his depressions grew darker and darker. But then his wife, who was herself terribly distressed, began to take prozac, at the urging of her family physician. Once the drug was in her system, my colleague reported, she lightened up about his gambling and was less worried about the family’s future financial obligations, and when he would return from a day at the races now she would even greet him at the door with a martini, and perhaps a kiss. In turn, his depressions began to lift. He said, “My wife takes the prozac, and I feel better! It’s a miracle, and it works from a distance. What a great drug.”
G.A. But you saying there is no role of neurochemistry in a person’s moods?
Dr, E. I don’t want to get into that right now. Suffice it to say that every mood we have, every experience that occurs, positive or negative, is associated with its own distinctive neurophysiology. No exceptions there either, because everything is biological. I want to avoid the topic though, because any discussion of it immediately descends into dualism, and I have no interest in going there. Depression comes about from depressing things that occur.
G.A. I don’t mean to be difficult Dr. E., but a few days ago I was talking to a medical person, and he was describing the depressions that may ensue as a result of steroids. He was telling in particular about the danger of suicidal depression and suicide itself in young people who take these drugs. According to him, the depressions are caused by the drugs, and he gave his understanding of the underlying neurochemistry.
Dr. E. I told you I didn’t want to get into all that. I have looked at a number of cases of young people on so-called steroids, which constitute a vastly extensive range of compounds, and they are generally trying to improve their physical prowess and enhance their chances of fulfilling athletic dreams. The drive to do such things obviously will often be associated with a background of depressive feelings. Sometimes, it is true, they crash suddenly, and maybe even kill themselves. But the acts of suicide come from their feelings that they have been defeated in their great self-improvement project, from a sense that they are worthless failures - and not just from the drugs themselves. People want to find a material cause for the experience of depression, and if such a thing could be found, perhaps we could banish it from human existence altogether. That is a utopian dream that will never be realized. Depression comes from depressing things that happen, and that is the beginning, the middle, and the end. So just stop with the chemistry and physiology please. It is really not very interesting.
G.A. Okay. But getting down to specific situations, what is it that makes someone prone to depression, what leads to recurring bouts of this experience? What goes on with people who think terrible thoughts about themselves, feel worthless, can’t get themselves to function, and no matter what happens, continue ever onward with darkness. What is your view of Freud’s linking depression and mourning in this connection? And how can an understanding of whatever it is that goes on lead us to a pathway of giving help?
Dr. E. Here are the thoughts that come to mind. Something is behind the individual’s terrible feelings. Something has occurred that has been taken as an indicator, not to be disputed, that the person is utterly without value, if not actively evil and destructive. There are a lot of things that leave a person in such a place. If we can find out what it is, generally that will be a clue as to what, if anything, could perhaps be of help to the person. If the depression arises along the pathway described by Freud in his famous essay “Mourning and melancholia,” something that in my experience is rare in the genesis of this subjective state, the help to be offered will occur within an exploring of the loss the person has experienced, the ambivalence that has colored the relationship to the lost one, the preservation of the lost object within the identification that sets in, the dark side of that identification in the person having incorporated the negative attributes of the lost one - what Freud speaks of as ‘the shadow of the object falling on the ego.’ The depression in such a case is really an arrested grief reaction, and the person’s journey lies in the realm of the completion of the mourning process. Of course this will also involve a long and hard look at the factors that interfered with the working through of the grief in the first place, something that Freud gave little consideration to. That is a whole complex topic in itself.
Dr. A.: I am interested in that complex topic, so tell me some things about it.
Dr. E.: Do you have a few years? One would need that long to even begin to address the endlessly involved question of mourning and the conditions that may operate to complicate it.
Dr. A.: I have all the time you and I have left on this earth, Dr. E., so give me what you can for now.
Dr. E.: Well, I will just say the first few things that come to mind. Let us start by returning again to Freud and the discussion of melancholia in his famous article. The single most interesting idea in the paper is contained in Freud’s little statement about “the shadow of the object falling on the ego.” Freud wanted to see the self-recriminations in depression as an attack against an object that has been turned back upon oneself, so that the reactive fury in the face of abandonment by someone is deflected away from that person, and his/her disappointing, even enraging qualities become somehow transported into the “I,” the ego, the experienced selfhood of the patient. He had this idea as an extension of the well-known phenomena of identification occurring in the process of mourning, where features of the lost object suddenly reappear as features of the mourning person him- or herself. An additional source of his thinking here is the theme of his own life, rooted in his childhood, one of blaming himself for the deprivations and abandonment shocks that occurred in his relationship to his own mother. Actually I don’t think the self-hatred, self-criticism, and self-condemnation of people in the grip of melancholia come primarily from the source Freud identified. I cannot say I have seen very many cases of severe depression that closely fit the schema outlined in “Mourning and melanchlolia,” and please know I have looked into the lives of so many depressed people that if one lined them up I think the line might reach all the way to the moon.
G.A. So what more about all that?
Dr. E. There is definitely something important in Freud’s emphasis on identification processes in mourning. He highlights something one sees all the time. In prolonged grief reactions, an identificatory reaction is almost always present, and an understanding of this helps to explain things that otherwise seem to come from nowhere. For example, a colleague of mine lost his beloved young wife, and as the months and years passed afterward, his depression deepened. Finally, after perhaps 5 years of suffering, he described a sense of having lost all his feelings, an experience of numbness and deadness. He went to a psychiatrist, who upon hearing these symptoms described, pronounced the diagnosis: Clinical Depression. The doctor wanted to prescribe antidepressant medications in the face of this unfortunate turn in his condition. But my colleague checked with me just before embarking on the drug therapy, and I gently suggested the possibility that his clinical depression, with its accompanying symptoms of numbness and deadness, might actually be an identification with his deceased wife, a projection of himself into the state of feeling nothing and being nothing that he imagined as her death-state. He was, as I was picturing it there, being with her in death, closing the gap that separated him from her. As I suggested this interpretation, he began to cry. The so-called clinical depression itself lifted a little as the sadness rolled in. It is so important to understand this sort of thing.
G.A.: Tell me some more about ‘this sort of thing.’
Dr. E.: Another story that comes to mind is that of a young woman who had suffered the tragedy of the loss of her 4 year-old daughter. She had been wrapped up in this child’s life because of congenital heart problems, and gave herself to her child without limit. Her own emotional life became entangled with the child’s physical survival, and when the daughter died, time froze and life stopped. The mother, two years later, had a very simple, elegant dream that captured her situation. In the dream, there was a rushing river with the water being very clear. She somehow saw herself – the mother – in the river, lying on the bottom, as the river flowed over her, with her unmoving eyes staring straight upward. The dream symbolized how time had ceased for her, as it had ceased for her child. She was identified with the girl, in death, and within that experience felt a deadness, a coldness, a frozen immobility, even as the waters of time passed over her.
G.A.: Tell me what happened to this person.
Dr. E.: She needed 10 years to begin to pick up a life that she could participate in. In the interim, she became very attached to me, almost overwhelmingly so, because a deep part of her had never experienced emotional holding and understanding, and had in fact been emotionally killed when she was still a child herself. This was a complicating factor in the situation, that in protectively loving her daughter, she had found, vicariously, the possibility of her own emotional resurrection. With the tragedy of the child’s death, she herself died once again. Her need to be brought out of the emotional lifelessness of her early years eventually passed over on to the relationship between her and me, and she and I suffered terribly with this need for a very long time. It all worked out though.
G.A.: Give me some further thoughts on depression and loss.
Dr. E.: As I said earlier, most very severe depressions, including especially the ones where self-hatred is so prominent, do not arise out of the sequence described by Freud.
He thought that the self-recriminations, the self-attacks were secondary to a loss of the object, and ultimately represented a turning of a rage reaction back upon the self. Severe depressions do often involve a rageful attitude toward oneself, but the source of this does not lie in an experience of loss. In a certain way, Freud’s formula for melancholia is an inversion of the dominant pathway toward this human experience. The loss that is involved is a loss of the self, and the depression is tied in with an effort to protect against the danger of loss of the object.
G.A. You have to explain that. .
Dr.E. The story runs as follows. The person who becomes subject to so-called melancholia, including self-hatred as one of its most prominent features, has been entangled with a parent whose emotional availability is conditional on the child’s compliance with an agenda as to who that child should be, how he or she should behave, even what the child should think and feel. The identity of the boy or girl borrows its cohesion from the parent’s vision rather than establishing it on an independent basis of the child’s autonomy and agency. Such an event includes a jettisoning of the child’s own authentic possibilities, an act of profound self-rejection and self-abandonment. In that way, what my good friend Donald Winnicott called the child’s true self becomes lost in space, perhaps forgotten, driven away as an offending presence. I learned much about this sort of thing from my even better friend, Bernard Brandchaft. The tie to the parent is protected by the swallowing of the parental agenda . The power behind this structure of experience coming into being is an infinite threat, felt at the core of the child’s being. There are only two choices: complying with the parental pressure and preserving the bond, or destroying the tie and plummeting forever into isolation and chaos.
G.A. But how does this turn into depression. What further development in such a story results in melancholia?
Dr. E. It usually happens because of the chickens.
G.A. The chickens?
Dr. E. Yes, the chickens -meaning by this that they – the chickens – have an irreducible, ineradicable tendency to come home to roost. And when they do, watch out! A person cannot abandon himself or herself without paying a price, and there is great suffering that appears when that price suddenly has to be paid. Maybe a man, reacting to events great or small, begins to realize that his life has been surrendered long ago, that he has thrown himself into an identity that was never his own, that his whole situation on this planet was authored by others rather than chosen by him. Perhaps this life then suddenly becomes an unbearable burden, a torturing prison camp, a trap from which no escape is possible. He knows nothing is right for him, but he has no basis for doing anything different. If he tries to alter his life conditions, ancient barriers reassert themselves, early childhood anxieties about desertion reappear, and in any case he has no inner basis for any lasting change in his situation. Or perhaps a woman, responding to some shock that occurs, awakens to the realization that her whole life course, possibly even including marriage and family, was set up for her by the various people she credited as authorities. Maybe she has followed in her mother’s footsteps in this regard, resigning herself to filling out preexisting roles and responsibilities and without ever letting herself consider what she might authentically desire. Such situations are paralyzing and depressing beyond description. The problem in such instances is that the parental agenda, one in which there is no space for the child’s authentic initiative, has gotten under the child’s skin, has become a feature of how the child relates to himself or herself. Once this transpires, the child’s identity, rather than forming out of spontaneous desire and its vicissitudes in the course of life events, is instead imported from without, drawn from a stock of externally defined, prepackaged images, perhaps those that constitute the parents’ dreams for themselves, dreams that repair and undo histories of parental trauma. In this way the child’s life becomes enslaved to the process of repairing injuries belonging to the personal worlds of those that lived before, and, paradoxically, self-defeatingly, tragically, those original injuries are thereby passed on to the next generation.
G.A. What about situations though in depression where a person comes to believe he or she is actively evil, a demon, a murderer, the world’s worst sinner, someone who deserves to suffer and die? And so often this occurs in lives that, to the outside observer anyway, don’t show much in the way of dramatic crimes committed by or against the child. I am not sure the story about lost authenticity can illuminate such things.
Dr. E. The history in such instances does usually go back to an enmeshment scenario with parental agendas, as I described. An added twist lies in the child’s specific experience of his or her impact on the parents, in those moments during which autonomous strivings and genuine feelings are expressed, however sporadically and tentatively, that disrupt the parent-child system and induce catastrophic anxiety and unbearable suffering in the parent. Sometimes these feelings include reactions of pain and of furious anger. The child sees the destruction visited upon those on whom he or she depends, and the violence they experience with the emergence of their child’s individuality appears as something limitless and devastating. This means that the annihilation of the parent-child bond eventuates not only in the child’s isolation and falling into chaos, but also what feels like the torture and murder of the parent. Sometimes family events conspire with and magnify all these feelings – a parent dies, commits suicide, grows ill. I knew a young girl once who described the choices presented to her by her situation: she could be a live monster – psychologically, spiritually alive, expressing her spontaneous initiative and feelings – or a dead princess – her father’s little sweetheart, compliantly harmonizing with his need for her sexual intimacy and adoration. When she deviated from the role he required of her, for instance by angrily complaining about his intrusions, his own emotional state would alternate between terrifying rage and even more frightening suicidal depression. When she made herself pleasing to him, surrendering herself to his gentle attentions, he stabilized and was even elated. Along this pathway arises the notion that one is ineradicably evil. Freud saw a person’s idea of being evil as an inward turning deflection of an accusation against a faithless object that has committed the crime of abandonment. I am saying a more common origin is the child’s sense that he or she is in danger of heartlessly abandoning and destroying the object. You can see what is meant then in saying Freud’s schema is a kind of inversion of the more common scenario. But whatever the specific sequence, depression, as I have been telling you, always comes from the depressing things that happen. The sun that shines in this territory of the human soul is a dark one, and it rises when bad things occur.
G.A. Keep going, Dr. E. Don’t ever stop.
Dr. E. What is it you want from me, G.A.? Do you want me to tell you everything that I know, everything that I have thought about, everything that I have guessed in regards to the topic of depression?
G.A. Yes, the whole deal, all of it, the totality of everything you know, hope to know, don’t know, will never know, and that no one can know.
Dr. E. You will have to come back some other time. You are a bit of a pest.
So I decided to make a call to my old friend, the great psychiatrist Dr. E, just to see if he had any interesting thoughts relevant to this matter. I showed him the letter from the doctor who gave his antidepressants to the photographer. What follows is a transcript of our conversation
G.A. Hey old friend, I wanted to talk to you a little about the topic of depression and the story of the photographer who sought help. Tell me your reactions to the letter from the psychiatrist.
Dr. E. Typical, stupid, unconscionable. An artist is silenced, perhaps destroyed. It is to the credit of the doctor who wrote about this so-called treatment that he at least questions its result. But it is also to his discredit, because he has silenced an artist, whose work, like that of all artists, had a truth to tell, a reality to disclose, a communication to complete. The patient is perhaps smiling more, but my question about all that is: So what? Who said a person should smile more and frown less? Who determined that less suffering is to be recommended over more suffering? I do not believe God informed us of that principle of life. What if there is good reason for that suffering? What if there are situations in the photographer’s world that are the sources of her sense of the tragic, her resonance with human despair? What if her pictures of the dark moments of life carried central truths of her personal history and family background? We will never know, because her doctor in his infinite wisdom “treated” her depression. I would not call this a success. I would not call it a treatment. I would call it an injury of undetermined scope and magnitude.
G.A. Talk to me more about depression in general. Do you get depressed sometimes?
Dr. E.: I get depressed a lot. As far as I am concerned, in this world, much of the time anyway, depression is the only mood that makes sense. Have I told you my definitive theory of depression? It is caused by the depressing things that happen to us. Among a great many other things, it depresses me that depression itself has been turned by psychiatry and psychology into a disease process, something the drug companies tell us is “treatable.” Depression will never be treatable, and the reason is that it is built into the human condition itself. Human life has very depressing things within it, and to encounter these things is to be depressed by them. The idea that one can or should “treat” depression is totally insane; but what else is new? Sometimes I have the depressing thought that insanity rules the world.
G.A. I guess I can understand your idea, but what about people who become so depressed they cannot function, they try to kill themselves, they cannot even get out of bed. Are you saying there is no treatment for them?
Dr. E.: There is no medical treatment - that is for sure. I am not saying there is no help for a person in the grip of something that causes depression. There is help: namely the help that is given by the support and understanding that person may be lucky enough to encounter from others who care about whatever it is that has happened.
G.A.: What kind of help is it then that can be given when something truly depressing has occurred? Tell me your thoughts about trying to offer assistance to someone who has had something devastating happen.
Dr. E.: The topic of helping people in depression is immensely complicated. It is never a matter of medical treatment, but always one of finding the human response that might make a difference to someone. Some situations precipitating depression are so terrible that it is difficult to imagine any response that could be of help. Like one’s child’s suicide, an event that it would hard to match in terms of its devastating power. The idea of “treating” the resulting depression is an insult to one’s intelligence. If your son or daughter commits suicide, you should be depressed, terribly, terribly depressed.
G.A. So what happens to such a person?
Dr. E.: I read about a case recently of a woman whose son killed himself, and who became so depressed in the aftermath of the death that, among other things, she sought psychiatric help. Her doctor prescribed antidepressants for her depression, thinking that anything he could offer to relieve her suffering would be for the best. As a result of taking the drug, her pain did abate somewhat. She felt all her feelings less intensely at this point. So-called antidepressants ought to be renamed: they are anti-intense-feelings drugs, not specific to depressive affect. But giving antidepressants to a person whose boy has killed himself is itself completely crazy. There is no treatment for such a person.
G.A. Dr. E., if someone whose child had committed suicide came to you, I don’t believe you would tell them there is no help for them. You would do everything in your power to help that person.
Dr. E. Yes, everything in my power. The problem is that nothing in such a case would be within my power, because the only thing conceivable that would help the person feel better would be the undoing of the child’s suicide, the reversal of reality itself. Inasmuch as I am not God, I could offer little or nothing to such a person.
G.A. How in the world can you be sure you could offer nothing?
Dr.E. Maybe I am not being fair to every situation that might arise here. Before saying to someone there is no help I would inquire as to the circumstances of the death. If the boy ended his life because he had just received a diagnosis of incurable cancer, that might be different. In the case I encountered recently that was not the story. What happened is that the son, at the time 35 years old, had been chronically addicted to a variety of drugs and alcohol. He had never been able to make a career for himself, and had survived because his mother gave him money for food and rent. He had tried a variety of rehabilitation programs, Alcoholics Anonymous, and even psychotherapy, but to no avail. He kept falling back into the addictive pattern and relying on his mother’s money. She had a lot of it, being married to the boy’s stepfather, a multimillionaire. After a number of years of his continuing addiction, and of his mother’s ever-present financial support, the stepfather decided that he and his wife, the boy’s mother, were “enabling” the addiction and resulting self-destruction of the young man. So he prevailed upon his wife to adopt a policy of “TOUGH LOVE.” The boy was told that at a date certain, two months hence, the dispensations from his mother would irrevocably cease. The boy responded by thanking his mother for all the help she had been able to provide over the years, and then hanged himself. The death was a direct reaction to the cutoff of the support. The mother and her husband tried to tell each other that they had done all that was possible, that the boy had elected to destroy himself, first with drugs, and then with a noose. It was for the best, they said, and at least now they could know their son was at peace. But as the weeks and months passed, a feeling of emptiness and despair began to envelop the mother, finally becoming so painful that she sought a psychiatric consultation Her doctor gave her drugs immediately to ameliorate her suffering, and in consequence her pain did diminish fairly quickly. But she was now in a more-or-less numbed state, which is what antidepressants do to you, and should one consider the chemical numbing of this mother’s agony a meaningful treatment of her depression? It is appalling. As I was saying, depression is not treatable, and that is because it is a reaction to the depressing things that happen.
G.A. Well, Dr. E., what would you do for this woman? If she came to you seeking help, I cannot believe you would turn her away.
Dr. E. I would not turn her away. I would listen to her story, and I would ask her how she was understanding her son’s death. I would ask her about the sources of his original addiction. Addictions do not arise out of nothing; they appear when someone becomes dependent on a substance or activity that is an antidote to painful affect states of one kind or another. I would ask this mother what those states were, and what caused them. I would ask her why she let herself be persuaded by her husband to cut her son off. I would want to know how she felt toward her husband now that his firm advice had turned out to have fatal results. I would ask her if she herself felt she was responsible for her son’s death. I would not promise her that she would feel better as a result of any treatment I could provide, but I would make myself available if she decided she wanted to try to make some new sense of the tragedy that had occurred in her family. I would know that any effort to do that might well intensify her pain, rather than relieve it.
G.A. So what finally happened to this woman?
Dr. E. I don’t know. My experience has been that parents in such a situation most often do very poorly, and that is because a catastrophe of unimaginable scope has occurred. Maybe she came down with cancer and died. Or perhaps she just wasted away. Maybe she tried to start a movement against the dangers of drug addiction, and burned herself out doing so. The ‘guilt of the survivor’ a parent experiences in this situation is beyond description, and its consequences are never pretty. I would not want to say a parent could not find a pathway for a creative response to a child’s suicide – people always turn out to be capable of something we cannot anticipate. But most often the only thing that comes in the wake of such an event is devastation for all concerned.
G.A. Your discussion is itself depressing Dr. E., and it hard for me to believe that you think there is no help for people in depression.
Dr. E.: I did not say there is no help. I said there is no treatment. Help is another matter altogether. If a person is depressed, he or she may jump off the George Washington Bridge. If I position myself beneath the railing and catch the jumper, I have helped that person survive, at least for a little while. But that is not a treatment for the depression, which is occurring because everything has gone black. There is no treatment for depression, because depression is not a disease.
G.A. But what about people who become terribly depressed – lethargy, sleep disturbance, loss of appetite, falling self-esteem, suicidality, the whole bit – but who have had nothing happen to them that has been depressing? They used to call this ‘endogenous depression.’
Dr. E.: Endogenous depression is a myth, a psychiatric fantasy - not a reality. Every depression is caused by something depressing that has happened, with no exceptions. Sometimes though people don’t know what it is, or don’t want to know what is causing them to feel so bad. It is a paradox that human beings will plummet into deadly moods and all the while be avoiding or unable to look at what it is that has brought them there. Naive observers examine someone’s life and see none of the standard precipitants in the advent of depression – loss, disappointment, failure - and then - crudely, stupidly - draw the conclusion that it has arisen “from within,” endogenously, by which they usually mean from within the neurochemical environment of the person’s brain. Strangely enough, the patient will often cling to such an explanation, because the depression was actually experienced as “coming from nowhere,” as having no connection to the person’s present or past circumstances. What that means though is that the depression has been somehow stripped of its context – of depressing things happening – and the first step in helping such a person will be to restore the gloom that has enveloped him or her to its formative setting, its human context. There will be a story there, perhaps never before told, and one has to discover that story. Chemically numbing someone’s painful mood states would be the opposite of what would make sense in most instances.
G.A. Are you suggesting that the whole field of the use of medication in treating – or helping – people in depression makes no sense? Even that it operates against the real help a person might otherwise need to find?
Dr. E. Pretty much yes, although I do not want to go on record as being against the use of drugs. We live in a drug culture, it is human to use drugs of all different kinds, and I personally love them. But with regard to the use of medications in the so-called psychiatric treatment of the experience of depression, I haven’t seen a lot to encourage me that it even works. There are, in unusual circumstances though, occasions where antidepressants in particular do assist a person.
G.A. Tell me of such a case.
Dr. E. I have a colleague in my profession, actually a professor like you, G. A., and he is subject to recurring depressive episodes. He has found that betting on the horses at racetracks helps him lift himself out of otherwise extremely dark moods. So the excitement of the gambling operates to neutralize his depressive suffering. Recently he came to me and said, “Hey E., did you know that prozac is a miracle drug? It works from a distance!” I asked him what he meant. He said that he had been very depressed recently, because his wife would not let him go to the horse races. If he went nevertheless, she would greet him at the door when he came home and try to hit him with a frying pan. She felt he was squandering their young children’s college funds and she was outraged by his gambling. As a result he had nothing to help him lift his terrible moods, and his depressions grew darker and darker. But then his wife, who was herself terribly distressed, began to take prozac, at the urging of her family physician. Once the drug was in her system, my colleague reported, she lightened up about his gambling and was less worried about the family’s future financial obligations, and when he would return from a day at the races now she would even greet him at the door with a martini, and perhaps a kiss. In turn, his depressions began to lift. He said, “My wife takes the prozac, and I feel better! It’s a miracle, and it works from a distance. What a great drug.”
G.A. But you saying there is no role of neurochemistry in a person’s moods?
Dr, E. I don’t want to get into that right now. Suffice it to say that every mood we have, every experience that occurs, positive or negative, is associated with its own distinctive neurophysiology. No exceptions there either, because everything is biological. I want to avoid the topic though, because any discussion of it immediately descends into dualism, and I have no interest in going there. Depression comes about from depressing things that occur.
G.A. I don’t mean to be difficult Dr. E., but a few days ago I was talking to a medical person, and he was describing the depressions that may ensue as a result of steroids. He was telling in particular about the danger of suicidal depression and suicide itself in young people who take these drugs. According to him, the depressions are caused by the drugs, and he gave his understanding of the underlying neurochemistry.
Dr. E. I told you I didn’t want to get into all that. I have looked at a number of cases of young people on so-called steroids, which constitute a vastly extensive range of compounds, and they are generally trying to improve their physical prowess and enhance their chances of fulfilling athletic dreams. The drive to do such things obviously will often be associated with a background of depressive feelings. Sometimes, it is true, they crash suddenly, and maybe even kill themselves. But the acts of suicide come from their feelings that they have been defeated in their great self-improvement project, from a sense that they are worthless failures - and not just from the drugs themselves. People want to find a material cause for the experience of depression, and if such a thing could be found, perhaps we could banish it from human existence altogether. That is a utopian dream that will never be realized. Depression comes from depressing things that happen, and that is the beginning, the middle, and the end. So just stop with the chemistry and physiology please. It is really not very interesting.
G.A. Okay. But getting down to specific situations, what is it that makes someone prone to depression, what leads to recurring bouts of this experience? What goes on with people who think terrible thoughts about themselves, feel worthless, can’t get themselves to function, and no matter what happens, continue ever onward with darkness. What is your view of Freud’s linking depression and mourning in this connection? And how can an understanding of whatever it is that goes on lead us to a pathway of giving help?
Dr. E. Here are the thoughts that come to mind. Something is behind the individual’s terrible feelings. Something has occurred that has been taken as an indicator, not to be disputed, that the person is utterly without value, if not actively evil and destructive. There are a lot of things that leave a person in such a place. If we can find out what it is, generally that will be a clue as to what, if anything, could perhaps be of help to the person. If the depression arises along the pathway described by Freud in his famous essay “Mourning and melancholia,” something that in my experience is rare in the genesis of this subjective state, the help to be offered will occur within an exploring of the loss the person has experienced, the ambivalence that has colored the relationship to the lost one, the preservation of the lost object within the identification that sets in, the dark side of that identification in the person having incorporated the negative attributes of the lost one - what Freud speaks of as ‘the shadow of the object falling on the ego.’ The depression in such a case is really an arrested grief reaction, and the person’s journey lies in the realm of the completion of the mourning process. Of course this will also involve a long and hard look at the factors that interfered with the working through of the grief in the first place, something that Freud gave little consideration to. That is a whole complex topic in itself.
Dr. A.: I am interested in that complex topic, so tell me some things about it.
Dr. E.: Do you have a few years? One would need that long to even begin to address the endlessly involved question of mourning and the conditions that may operate to complicate it.
Dr. A.: I have all the time you and I have left on this earth, Dr. E., so give me what you can for now.
Dr. E.: Well, I will just say the first few things that come to mind. Let us start by returning again to Freud and the discussion of melancholia in his famous article. The single most interesting idea in the paper is contained in Freud’s little statement about “the shadow of the object falling on the ego.” Freud wanted to see the self-recriminations in depression as an attack against an object that has been turned back upon oneself, so that the reactive fury in the face of abandonment by someone is deflected away from that person, and his/her disappointing, even enraging qualities become somehow transported into the “I,” the ego, the experienced selfhood of the patient. He had this idea as an extension of the well-known phenomena of identification occurring in the process of mourning, where features of the lost object suddenly reappear as features of the mourning person him- or herself. An additional source of his thinking here is the theme of his own life, rooted in his childhood, one of blaming himself for the deprivations and abandonment shocks that occurred in his relationship to his own mother. Actually I don’t think the self-hatred, self-criticism, and self-condemnation of people in the grip of melancholia come primarily from the source Freud identified. I cannot say I have seen very many cases of severe depression that closely fit the schema outlined in “Mourning and melanchlolia,” and please know I have looked into the lives of so many depressed people that if one lined them up I think the line might reach all the way to the moon.
G.A. So what more about all that?
Dr. E. There is definitely something important in Freud’s emphasis on identification processes in mourning. He highlights something one sees all the time. In prolonged grief reactions, an identificatory reaction is almost always present, and an understanding of this helps to explain things that otherwise seem to come from nowhere. For example, a colleague of mine lost his beloved young wife, and as the months and years passed afterward, his depression deepened. Finally, after perhaps 5 years of suffering, he described a sense of having lost all his feelings, an experience of numbness and deadness. He went to a psychiatrist, who upon hearing these symptoms described, pronounced the diagnosis: Clinical Depression. The doctor wanted to prescribe antidepressant medications in the face of this unfortunate turn in his condition. But my colleague checked with me just before embarking on the drug therapy, and I gently suggested the possibility that his clinical depression, with its accompanying symptoms of numbness and deadness, might actually be an identification with his deceased wife, a projection of himself into the state of feeling nothing and being nothing that he imagined as her death-state. He was, as I was picturing it there, being with her in death, closing the gap that separated him from her. As I suggested this interpretation, he began to cry. The so-called clinical depression itself lifted a little as the sadness rolled in. It is so important to understand this sort of thing.
G.A.: Tell me some more about ‘this sort of thing.’
Dr. E.: Another story that comes to mind is that of a young woman who had suffered the tragedy of the loss of her 4 year-old daughter. She had been wrapped up in this child’s life because of congenital heart problems, and gave herself to her child without limit. Her own emotional life became entangled with the child’s physical survival, and when the daughter died, time froze and life stopped. The mother, two years later, had a very simple, elegant dream that captured her situation. In the dream, there was a rushing river with the water being very clear. She somehow saw herself – the mother – in the river, lying on the bottom, as the river flowed over her, with her unmoving eyes staring straight upward. The dream symbolized how time had ceased for her, as it had ceased for her child. She was identified with the girl, in death, and within that experience felt a deadness, a coldness, a frozen immobility, even as the waters of time passed over her.
G.A.: Tell me what happened to this person.
Dr. E.: She needed 10 years to begin to pick up a life that she could participate in. In the interim, she became very attached to me, almost overwhelmingly so, because a deep part of her had never experienced emotional holding and understanding, and had in fact been emotionally killed when she was still a child herself. This was a complicating factor in the situation, that in protectively loving her daughter, she had found, vicariously, the possibility of her own emotional resurrection. With the tragedy of the child’s death, she herself died once again. Her need to be brought out of the emotional lifelessness of her early years eventually passed over on to the relationship between her and me, and she and I suffered terribly with this need for a very long time. It all worked out though.
G.A.: Give me some further thoughts on depression and loss.
Dr. E.: As I said earlier, most very severe depressions, including especially the ones where self-hatred is so prominent, do not arise out of the sequence described by Freud.
He thought that the self-recriminations, the self-attacks were secondary to a loss of the object, and ultimately represented a turning of a rage reaction back upon the self. Severe depressions do often involve a rageful attitude toward oneself, but the source of this does not lie in an experience of loss. In a certain way, Freud’s formula for melancholia is an inversion of the dominant pathway toward this human experience. The loss that is involved is a loss of the self, and the depression is tied in with an effort to protect against the danger of loss of the object.
G.A. You have to explain that. .
Dr.E. The story runs as follows. The person who becomes subject to so-called melancholia, including self-hatred as one of its most prominent features, has been entangled with a parent whose emotional availability is conditional on the child’s compliance with an agenda as to who that child should be, how he or she should behave, even what the child should think and feel. The identity of the boy or girl borrows its cohesion from the parent’s vision rather than establishing it on an independent basis of the child’s autonomy and agency. Such an event includes a jettisoning of the child’s own authentic possibilities, an act of profound self-rejection and self-abandonment. In that way, what my good friend Donald Winnicott called the child’s true self becomes lost in space, perhaps forgotten, driven away as an offending presence. I learned much about this sort of thing from my even better friend, Bernard Brandchaft. The tie to the parent is protected by the swallowing of the parental agenda . The power behind this structure of experience coming into being is an infinite threat, felt at the core of the child’s being. There are only two choices: complying with the parental pressure and preserving the bond, or destroying the tie and plummeting forever into isolation and chaos.
G.A. But how does this turn into depression. What further development in such a story results in melancholia?
Dr. E. It usually happens because of the chickens.
G.A. The chickens?
Dr. E. Yes, the chickens -meaning by this that they – the chickens – have an irreducible, ineradicable tendency to come home to roost. And when they do, watch out! A person cannot abandon himself or herself without paying a price, and there is great suffering that appears when that price suddenly has to be paid. Maybe a man, reacting to events great or small, begins to realize that his life has been surrendered long ago, that he has thrown himself into an identity that was never his own, that his whole situation on this planet was authored by others rather than chosen by him. Perhaps this life then suddenly becomes an unbearable burden, a torturing prison camp, a trap from which no escape is possible. He knows nothing is right for him, but he has no basis for doing anything different. If he tries to alter his life conditions, ancient barriers reassert themselves, early childhood anxieties about desertion reappear, and in any case he has no inner basis for any lasting change in his situation. Or perhaps a woman, responding to some shock that occurs, awakens to the realization that her whole life course, possibly even including marriage and family, was set up for her by the various people she credited as authorities. Maybe she has followed in her mother’s footsteps in this regard, resigning herself to filling out preexisting roles and responsibilities and without ever letting herself consider what she might authentically desire. Such situations are paralyzing and depressing beyond description. The problem in such instances is that the parental agenda, one in which there is no space for the child’s authentic initiative, has gotten under the child’s skin, has become a feature of how the child relates to himself or herself. Once this transpires, the child’s identity, rather than forming out of spontaneous desire and its vicissitudes in the course of life events, is instead imported from without, drawn from a stock of externally defined, prepackaged images, perhaps those that constitute the parents’ dreams for themselves, dreams that repair and undo histories of parental trauma. In this way the child’s life becomes enslaved to the process of repairing injuries belonging to the personal worlds of those that lived before, and, paradoxically, self-defeatingly, tragically, those original injuries are thereby passed on to the next generation.
G.A. What about situations though in depression where a person comes to believe he or she is actively evil, a demon, a murderer, the world’s worst sinner, someone who deserves to suffer and die? And so often this occurs in lives that, to the outside observer anyway, don’t show much in the way of dramatic crimes committed by or against the child. I am not sure the story about lost authenticity can illuminate such things.
Dr. E. The history in such instances does usually go back to an enmeshment scenario with parental agendas, as I described. An added twist lies in the child’s specific experience of his or her impact on the parents, in those moments during which autonomous strivings and genuine feelings are expressed, however sporadically and tentatively, that disrupt the parent-child system and induce catastrophic anxiety and unbearable suffering in the parent. Sometimes these feelings include reactions of pain and of furious anger. The child sees the destruction visited upon those on whom he or she depends, and the violence they experience with the emergence of their child’s individuality appears as something limitless and devastating. This means that the annihilation of the parent-child bond eventuates not only in the child’s isolation and falling into chaos, but also what feels like the torture and murder of the parent. Sometimes family events conspire with and magnify all these feelings – a parent dies, commits suicide, grows ill. I knew a young girl once who described the choices presented to her by her situation: she could be a live monster – psychologically, spiritually alive, expressing her spontaneous initiative and feelings – or a dead princess – her father’s little sweetheart, compliantly harmonizing with his need for her sexual intimacy and adoration. When she deviated from the role he required of her, for instance by angrily complaining about his intrusions, his own emotional state would alternate between terrifying rage and even more frightening suicidal depression. When she made herself pleasing to him, surrendering herself to his gentle attentions, he stabilized and was even elated. Along this pathway arises the notion that one is ineradicably evil. Freud saw a person’s idea of being evil as an inward turning deflection of an accusation against a faithless object that has committed the crime of abandonment. I am saying a more common origin is the child’s sense that he or she is in danger of heartlessly abandoning and destroying the object. You can see what is meant then in saying Freud’s schema is a kind of inversion of the more common scenario. But whatever the specific sequence, depression, as I have been telling you, always comes from the depressing things that happen. The sun that shines in this territory of the human soul is a dark one, and it rises when bad things occur.
G.A. Keep going, Dr. E. Don’t ever stop.
Dr. E. What is it you want from me, G.A.? Do you want me to tell you everything that I know, everything that I have thought about, everything that I have guessed in regards to the topic of depression?
G.A. Yes, the whole deal, all of it, the totality of everything you know, hope to know, don’t know, will never know, and that no one can know.
Dr. E. You will have to come back some other time. You are a bit of a pest.