I THEORETICAL EXPLORATION OF THE ORIGINS, MAINTENANCE, AND PSYCHOSOCIAL ASPECTS OF DEPRESSION
One Psychodynamic Interpretations of the Origin of Depression
The following sections explore theoretical explanations of the origins of depression through the lenses of early development and the intergenerational transmission of trauma and loss. Early attachment and the relationship with primary caregivers lay the groundwork for emotion regulation, interpersonal dynamics, and the development of a sense of self, all of which maintain their influence throughout the lifespan. Mirroring and transformative experiences are tools that can lead to the development or failure to develop the capacity for mentalization and reflective functioning, both of which play a major role in depressive states. And finally, in this section, the effects of unmetabolized loss are examined as they pertain to the development of depression in both mother and infant.
DEPRESSIVE ROOTS: ATTACHMENT, MIRRORING, AND TRANSFORMATIVE EXPERIENCES
When I look I am seen, so I exist. I can now afford to look and see.
(Winnicott, 1971, p. 114)
Part of the meaning of being human is that we learn about the world not just through our own explorations of it but by using other people as teachers.
(Fonagy & Target, 2007a, pp. 919-920)
One of the most basic human needs is to be recognized. Beginning in infancy, this need for recognition and connection shapes individuals in ways that will affect them for the duration of their lives. Kaplan (1978) says, “The quality of self an infant achieves in those crucial (first) three years will profoundly affect all of his subsequent existence” (p. 15). Mahler is well known for her work on early infant development in terms of attachment and the process of separation and individuation. In her work with Pine and Bergman (1975), she describes her belief that every human being undergoes a second psychological birth that in the course of healthy, normal development results in the sense of being a whole individual, separate from everyone else. Since the mother-infant relationship is the first and primary relationship, this process can be seen in the ways an infant navigates the feelings of and desire for union with the mother, alongside the slow realization that he1 is separate from her and must pull away from this union in order to develop and preserve an individual sense of self.
Mahler (Mahler, Pine, & Bergman, 1975) and later Kaplan (1978) theorize that initially, an infant is in a state of psychological union with the mother. They believe that an infant does not recognize himself and his mother as separate beings, and there is no distinction between his internal and external world. This provides a sense of security, for it enables the infant to perceive his own internal states as the focal point of his universe. The mother is seen not as a separate being, but as an extension of himself with the sole purpose of alleviating discomfort and meeting basic needs. Slowly this sense of security is tested, as the infant learns to crawl and walk and is drawn away from the mother by curiosity about the environment and a developing sense of individuality. The stability of this bond is tested, as both the infant and the mother turn away from and then return to one other. If the infant develops a secure sense of attachment, this fosters a sense of safety and allows the infant to feel more confident in becoming separate, because he can maintain this security in his mind even when he is not in his mother’s presence. In this sense, the mother serves as a “home base” for the infant to return to after much daring exploration (Kaplan, 1978, p. 12).
Although this theoretical position of infant symbiosis with the mother is much contested by other theoretical positions, the significance of attachment and feelings of security with a primary caregiver should not be overlooked. There are many who believe that human beings are aware of their separateness from the start, and that they are more agentic than a fused state with external objects might suggest. However, the process of learning to navigate interpersonal relationships, and to locate oneself within them, forms a core of subjective experience and contributes greatly to the development of an awareness of one’s self. When this process is interrupted by trauma, early loss, or absence, the results can be devastating.
A state of psychological union—whether it is present at birth or is achieved periodically through interpersonal relationships—is not aligned with the inevitable separateness that occurs between all living beings. We can foster a sense of togetherness through our interactions with other people, and this becomes a core aspect of a life’s work: to build connections so that we can communicate, understand, and be understood. Ultimately, the space between the internal workings of each individual mind cannot be fully bridged, and these connections are therefore a transient, ephemeral phenomenon that requires continued effort to be maintained. As Kaplan says, “Human life begins in illusion” (1978, p. 40). When a mother is devoted to her infant and toward meeting his needs, merely holding him becomes a core metaphorical communication about the nature of the world and its relative responsiveness to the infant’s needs.
In her ordinary way of holding him, a mother gives her baby the impression of a world that will hold him together and make sense of the unformed excitements and appetites raging inside him. The baby then has the illusion that his appetites are congruent with the new world he has just entered. (Kaplan, 1978, p. 40)
According to Kaplan (1978), as adults, if the world at least partially accommodates our needs and we are able to realize our goals and desires, we have the sensation of being held, just like the safety we initially felt in our mother’s arms when our needs were met in infancy. Therefore, this feeling of being held, of being one with the mother, and of being whole can be felt even in her absence, when our daily experiences lead us to believe that our needs are not incompatible with reality, that they will be met, and that our internalized mother will continue to hold us in security and safety. It is our capacity then to carry with us a sense of this oneness with a caring being in our separate, individual adult lives that influences the way we view the world. When the environment is inhospitable to our strivings toward particular goals, when our desires and needs are not met, when we are not recognized, we are left without the feeling of being held, as if we have been dropped or neglected by this internalized mother figure or left to our own devices without the proper resources. We become once again the dependent infant, helpless to create the changes we wish to see in our environment so as to meet our own needs.
This process can also be described in terms of mirroring and mentaliza- tion. Mentalization is the capacity to recognize one’s feelings, thoughts, and actions as reflective of a state of mind as well as the capacity to recognize this in others and to be able to tell the difference between the two. Mentalization allows people to understand the behavior of others, and it is useful in predicting and making sense of social situations. It is therefore a crucial interpersonal skill. It is also tremendously useful in aiding with emotion regulation (Bateman & Fonagy, 2006). Fonagy and Target (2000) describe the capacity for mentalization as a developmental achievement that results from adequate mirroring in early life. They posit that initially infants are unaware that minds are separate. Fonagy and Target (2000) describe infants as assuming that what they think and feel is what everyone else thinks and feels; there is no differentiation and there are no barriers. This theory suggests that the understanding that different states of mind can exist only develops by coming into contact with others who mirror the infant’s experience and simultaneously contrast it with their own. Over time, this enables the infant to separate her internal states from those of the external world. It also creates the possibility of symbolically representing emotional states in a way that makes them abstract concepts rather than synonymous with physical reality. This process is known as symbolization (Fonagy & Target, 2000).
In healthy development, an infant’s mother will reflect her infant’s experience back in a way that shows that she understands it and presents it as manageable. This serves the purpose of metabolizing potentially overwhelming impulses and feelings within the infant and presenting them back in a way that is containing. The infant can then recognize her own internal state by seeing it in another. Conversely, a lack of adequate and accurate mirroring from primary objects results in a developmental impairment in the capacity for self-representation (Fonagy & Target, 2000). Instead of internalizing an integrated sense of her own experience, an infant who is not mirrored instead ends up internalizing her parents’ experiences and defenses as well as their misattuned perceptions of her as an infant and a growing person (Fonagy & Target, 2000, p. 856). She may not learn to distinguish between her own self-states and those of her parents, as she has not been treated by them as a subject with important thoughts, feelings, and perceptions of her own. What the infant takes in is not aligned with her inner world and, thus, feels foreign. She internalizes something distinctly other and therefore cannot access a stable sense of self.
Failure to develop the capacity to mentalize results in what Fonagy and Target call an “undifferentiated mode of representing external and internal experience” (2000, p. 853). The inner world dominates reality, foreclosing all possibility of shared interpersonal space. This creates a schism between self and other that is difficult to bridge, and this has been linked with states of depression.
When infants cannot create such dyadic states the coherence and complexity of their self-representation is dissipated; they move closer to states of disorganization in both the emotional and cognitive domains. Phenomenologically, not causally . . . this state is an aspect of severe depression. It is the infantile loss of contact with the external world of subjectivities that severe depression recreates experientially. The loss of the underlying experience of shared consciousness makes the whole world appear flat, meaningless and isolating. (Fonagy & Target, 2007a, p. 921)
Many who suffer from depression describe a sense of alienation, of separateness in a fundamental way from the rest of humanity (Eigen 1995, 2006; Emery, 2002; Kristeva, 1991; Mairs, 2001). For some of these individuals, the isolation and withdrawal so frequently present in depressive states are evidence of a complete lack of integration due to failures in mirroring in infancy and throughout life. Instead of a unified self, there is disintegration and emptiness, something distinctly Other where an “I” might have otherwise developed. Shabad (2006) describes this experience in terms of shame that is a “primary reaction to the disruption of relational connection” (p. 417). He elaborates,
Chronic shame, caused by a person’s inability to secure a sense of rootedness and belonging to her parents, is characterized by a perpetual feeling of unmoored isolation. Because one is convinced that one is an alien not born of this world, one lives in dread of being exposed and found out for one’s irreconcilable difference, weirdness, or defectiveness, and of thereby being excommunicated forever from the human community. (Shabad, 2006, p. 418)
Whether this process originates as the result of failures in reflective functioning, occurs only sporadically throughout life, or develops over time as the result of feeling isolated within one’s self, there is a lack of social connection in depression that has extremely detrimental effects on the individual, who can then no longer find the bounds of him- or herself in relation to the world and its inhabitants.
Bollas’s (1987) conception of the “unthought known” describes transformative experiences, relationships, and states of being that precede language and therefore conscious thought but, nonetheless, serve the function of altering an individual in a meaningful way. One such example of this is the mother-infant dyad, which Bollas calls “the first human aesthetic” (1987, p. 32). Unable to survive on his own, the infant is entirely dependent on his mother to meet all of his needs and is therefore altered by each interaction. He is fed, bathed, changed, held, soothed (or not), and frustrated according to the mother’s style of parenting and being with him. Bollas (1987) describes these interactions as an “idiom of gesture, gaze and intersubjective utterance” (p. 13) that highly defines the infant’s first experience of being in the world. If the mother is responsive, nurturing, and consistent, the infant will develop a sense of safety, security, and an understanding that his needs will be met. If the mother is inconsistent, neglectful, or misreads the infant’s cues, the infant will likely develop a sense of mistrust, anxiety, and frustration that can lead to further difficulties in life. Bollas says,
The aesthetic experience is an existential recollection of the time when communicating took place primarily through this illusion of deep rapport of subject and object. Being with, as a form of dialogue, enabled the baby’s adequate
processing of his existence prior to his ability to process it through thought.
(1987, p. 32)
Without a stable person to interpret and reflect experience, it becomes more difficult for an infant to eventually learn how to identify and convey internal states. If the mother is unable to accurately perceive the infant’s emotions and to represent them as manageable, the infant will have a difficult time learning to self-soothe. Therefore, the way a mother interacts with her infant, regardless of her style, creates schemas for the infant that represent what existence as both a subject and an object will be like. This is primarily learned from the mother, as she serves as the infant’s first “other self’ (Bollas, 1987, p. 13). In many respects, our understanding of the world and our place in it precedes the development of our capacity to articulate it in words. As Bollas says, “In a sense, we learn the grammar of our being before we grasp the rules of our language” (1987, p. 36).
One potential cause of depression is the result of being misunderstood or misreflected by significant others. If the way a mother (or primary caregiver) interacts with her infant will teach that infant to eventually interact with herself psychologically in similar ways, then feelings that result from misrepresentation or a complete lack of accurate reflection by the mother will become internalized as methods that the infant uses in interacting with and regulating herself. For example, if the infant’s transformative experiences tend to be invalidating, the infant may grow into a person who invalidates herself or who does not trust her instincts and assessments of various interpersonal situations. This can occur when primary objects distort or construct inaccurate meanings from the infant’s subjective existence, or when they project their own needs or desires onto the subject, thus requiring the subject to become an object by conforming to demands of the Other. This can also occur when significant internalized objects completely neglect any attempt at understanding, thereby abandoning the subject’s attempts to articulate itself. This very process can serve as an impediment to the individual’s capacity to make meaning of personal experience based on the demands and perceptions of the other.
Just like in failures of mentalization due to deficient mirroring early in life, if a person’s initial environment or first human aesthetic continues to be incongruent with his actual subjective experience of it, or if it does not remain stable and consistent enough so that he can acclimate himself to it and communicate his needs, this lack of stable symbolic representation may manifest itself in the diffuse, meaninglessness characteristic of depression. As the person cannot define his experience or himself in terms of the Other because they are distortions, he experiences a loss of self. This can result in the individual’s attempts at representation feeling foreign because they are too entrenched in the language of the Other, which is often accompanied by a misinterpretation or an inaccurate reading of his own experience. Sometimes only by gaining the recognition of the Other through a completely new language is a person able to symbolize again (Clare, 2004). This forms the core of psychodynamic and psychoanalytic therapeutic work, as patient and therapist work together to find alternative methods of symbolizing unformulated experience through metaphor, fantasy, and the co-constituted language that evolves within the dialogue of the therapeutic relationship.