Friday, 5 August 2016

anger, depression and masochism - a postcript on Beck and ISTDP

Beck abandoned the psychoanalytic approach to depression because he found no evidence of self-hate in his depressed patients. To recap, he thought the psychoanalytic theory had it that depressed patients were depressed because they literally turned their anger back in on themselves. But his patients did not seem to evince such self-directed aggression. For this reason he abandoned the whole idea of depression being unconsciously motivated.

It's clear today that that was an enormous and unwarranted leap. First off Beck completely ignores the mainstay of psychoanalytic theorising about depression - depression as the result of avoided sadness over loss rather than mismanaged anger over slights. But leaving that aside, Beck's theory also entirely misses the two other most obvious dynamic explanations of unconsciously motivated self-depletion:

1. I provide myself with a lowered sense of self-worth relative to the worth I ascribe to you to preserve my good impression of you (rather than allow myself to be angry in a way which might challenge our relationship) and thereby maintain a relationship I depend on (and might, should I lose it, find too painful to mourn). 2. I rehearse a dismal auto-depleting vision of my situation and future and selfhood (Beck's triad) so that I can't be knocked by a fate worse than auto-depletion - namely, depletion by a world outside my control.

I don't mean to deny that we do sometimes also meet, in clinical practice, with something more masochistic (somewhat a la Beck's original-then-abandoned psychodynamic 'masochism theory' of depression) - namely ferocious attacks by the super-ego on the ego. But it would be an obvious stretch to have this cover most of the non-psychotic depression we see about us. So why did Beck miss 1. & 2. above?

Of course, I just don't know; I'd be interested to know what he himself would say today. But my best guess is that his psychoanalytic theorising and practice was simply far too constrained by the mid-century American ego-psychology he was trained in. Such a psychology takes rather literally various concepts like 'libido', 'ego' and 'aggression' as distinct psychological energies roaming around in search of an object. In such a framework we can easily imagine anger as a quantity of 'emotional energy' which, when denied its own natural object, must instead be turned somewhere else (e.g. against the self). Leave aside the arcane metapsychology, however, and what we instead arrive at are a range of more humanly tractable issues to do with how we manage our object relations. Thus I shame myself in my imagination to avoid being shamed by you when, as I fear it, you reject me. Anger might not come on the scene, or avoidance of it may not leave it stewing somewhere, seeking another object, but instead be achieved through a revaluation of one's worth and relationships which completely removes it (and part of oneself) from the table.

The notion that suppressed anger is at the root of much psychopathology is still remarkably common - e.g. in today's ISTDP. Speaking for myself, I no longer buy it as a general theory. Sure, if I recover my self-esteem then I may well feel anger towards those of my objects who I've let take me for granted or use or abuse me. And that might make it look as if the anger was there all along but just in a hidden suppressed ('unconscious') form. But isn't more than the (angry) form of the recovery needed to justify the ascription of unconscious anger in the as-yet-un-recovered patient?

At any rate, what I propose is needed by the patient is not so much a call to de-repress anger, but rather a call to overcome their fear. For what, it seems to me, the various forms of depression all involve is a failure of nerve. Thus I deplete myself to avoid suffering the knocks of fate. I devalue myself to pre-empt your abusive wrath. I avoid the pain of mourning and the call that mourning itself makes to us to now make a life of our own. In all such cases I keep my equilibrium under my own control, rather than face myself and my relationships in a clean and clear fashion. The real task of recovery, I propose, is heeding not a psychological call to emotion but a moral call to courage. Courage to face fate rather than pre-empt it. Courage to place oneself in the hands of the other. Courage to say not 'I will it' but, instead, 'bring it on', 'inshallah'.