Theory of Depression

Biopsychosocial

Michael Peters was a 50 year old Caucasian resident at the Ed Thompson Veteran's Center, a substance abuse residential rehabilitation facility for Veterans. Michael attended group sessions but didn't contribute to discussions or interact with anyone. He was very quiet and isolated a lot. Michael grew up in Bushwick, Brooklyn. He was the son of a substance abusing mother who had six children with six different men. His childhood was riddled with severe neglect and trauma. It became apparent to neighbors that Michael's mother was unable to take care of the kids, so Michael and two of his siblings were taken in by a friend of the family. He was a single man living alone and he was a father to Michael, the only stable figure in his life. He died when Michael was twelve years old. Michael was forced to go back to living with his mother, and that's when the abuse happened. A man in the neighborhood sexually abused Michael for three years; he would take him to a bar first and get him drunk. In treatment, without the use of alcohol to numb emotional pain, Michael was experiencing intense feelings of guilt and self-criticism. He was very self-critical of things he had done in the past: He was involved in a relationship which produced a child. He abandoned his son out of fear that he would do the same thing to his son that was done to him; that he would touch him the same way that he was touched.

At the age of 19 Michael joined the military in search of a better life. He watched a man collapse and die in basic training. He snapped and was discharged without any grief counseling. After that his drinking and drug use escalated. Michael was married for thirteen years and raised three children. Although at the present he is estranged from his family. His drinking caused him to spiral downward; he was sleeping on friends couches, essentially homeless. He knew he couldn't go on this way and came for treatment.

It was not easy to engage Michael in therapy at first. His tendency to isolate all his life makes him uncomfortable talking to people one “on- one. His low self-esteem and sense of inferiority were magnified by his perception of me being in a higher socio-economic class than him and being more educated. Michael grew up in poverty and had no educational aspirations. The neighborhood in Brooklyn where he lived did not espouse values of education and goal achievement. His mother was not a good role model for him. This added to his fear and anxiety at the beginning of our relationship.

In actuality, we are all very similar. In my own life journey I have also experienced verbal and emotional abuse by my father. In my search for ways of healing I was very fortunate to have found a talented therapist who practiced psychodynamic psychotherapy. He helped me access my anger and express it in a productive way. I was enraged when I realized as an adult, how crazy my father was, and that I had believed everything that he said about me as a child. I had to work so much harder than most people to be a functioning human being in life. This anger was an integral part in my healing trajectory, it helped me find my voice and reclaim my personhood. I have also learned to allow and encourage my kids to express their anger towards me, and not suppress it. The open communication and expression of anger has helped in our relationship.

I was interested in exploring the anger turned inward hypothesis of the psychodynamic theory of depression (Freud 1917). I wanted to find out if this theory has ever been empirically studied and tested. Does unresolved anger really cause depression? Anger has always been looked at as a negative symptom; I wanted to learn how unconscious anger can be surfaced and used constructively as a tool in the healing process of child sexual abuse (CSA) survivors.

Proof of Theory

Scott and Day (1996), studied abuse-related symptoms in survivors of childhood sexual trauma and they found that anger is one of the most prevalent emotional after-effects of childhood sexual abuse. Not surprisingly, Murphy et al. (1988) found that survivors of CSA had substantially more problems dealing with anger than non-abused controls. Interestingly, they also discovered that the correlation of CSA in women with re-victimization was directly mediated by self-blame. This shows that victimized women believe that they do not deserve to be in a loving relationship.

Other studies that I came across tested whether anger directed towards the self is connected with depression: Brody et al. (1999) found more suppressed anger and hostility in individuals recovering from depression than in healthy controls, accompanied by a fear that expressing anger would destroy relationships. Becker & Lesiak (1977) found that the severity of depression directly correlated with repressed anger, guilt, irritability and suspicion in clinic outpatients, but not with outwardly expressed anger. And finally, Kiefer and Wolfersdorf (1998) found that, compared with healthy controls, depressed in-patients had higher levels of inhibited aggression and repressed anger and hostility, but did not express aggression.

Besides depression, repressed anger has also been associated with eating disorders, substance abuse, sleep disorders, anxiety, physical problems such as ulcers, the jaw joint disease and suicide (Blume, 1990). Michael has been suffering from deep and unbearable pain his entire life since the CSA. He told me that he attempted suicide several times in his life, once he tried to hang himself, and the belt snapped. He used alcohol to self-medicate, but it comes with many other problems. Researchers who studied anger experience and symptom formation have also identified extreme guilt and self- tormenting behavior as indicators of repressed anger (Blume, 1990). Michael feels very guilty about abandoning his son and has been tormenting himself his whole life. He has a very low self-esteem. I once asked him, What would you do to this man who abused you if you could find him today? He responded: I would kill him, because I know that he did it to other kids too. For these reasons, I believe Michael would benefit from exploring his repressed anger, reattributing it to the perpetrator and advancing personal growth and power.

Psychoanalytic Model of Depression

Since the beginning of psychoanalytic theorizing, many theorists believed that anger plays a big role in depression (Busch, 2009). I will mention a few of the important theories. The first to contemplate depression as self-directed anger was Karl Abraham (1911). He noticed that depressed patients had a predisposition towards hatred based on their temperament or early life experience. He believed that this excessive anger triggers guilt and anxiety, becomes repressed and projected onto others. As a result, the patient believes that people hate them and they are inferior, which in turn lowers their self-esteem and leads to depression. Subsequently, in 1924, Abraham added to this theory that individuals with depression endure anger and low self-esteem as a result of a traumatic rejection either in childhood or later in life (Busch, 2009). In Freud's (1917) perspective, depression comes from a fantasized or real loss of a person for whom the patient has ambivalent feelings. The patient internalizes an aspect of that person in order to deal with the loss. As a result, the anger directed at that person now becomes directed at the self, identified with that individual. This leads to self-criticism and depression (Busch, 2009).

More recently, Dr. Frederick Busch, a Professor at Columbia University Center for Psychoanalytic Training and Research (Busch et al, 2016) together with Dr. Mary Rudden (Rudden et al, 2003) developed their own psychodynamic model of depression based on theory, research and their clinical experience. They posit that individuals who are prone to depression are very sensitive to rejection or loss; called Narcissistic Vulnerability. This sensitivity develops early in life when a child experiences rejection, disappointment and powerlessness by parents or caregivers, which they perceive as proof of inferiority, unlovability and damage. This sensitivity becomes an integral part of their personality and identity as they grow up, shaping their psychological functioning. All failures, rejections or losses in life are viewed as additional proof of inferiority and damage. Besides feelings of unlovability and inferiority in childhood, rejection and disappointment trigger angry feelings at the perpetrator of these painful experiences. In turn, this anger triggers guilt and activates defense mechanisms intended to shield the needed adult. That is how the anger becomes self-directed, further lowering self-esteem. This completes a full circle of Narcissistic Vulnerability and anger.

The second layer to this theory is another vicious cycle, in which low self-esteem causes a person to compensate for their perceived defects by idealization of the self and others. We idealize our parents and find excuses for their shortcomings. However, these idealized expectations always lead to disappointments and devaluation of the self which further lowers self-esteem.

Defense Mechanisms in Depression

Depressed individuals attempt to manage anger unconsciously and protect the people they care about from angry feelings and fantasies by employing defense mechanisms. However, these defense mechanisms backfire and often exacerbate depression. Defense mechanisms associated with depression are: denial, passive aggression, displacement, reaction formation, projection and identification (Bloch, 1993).

Denial keeps anger and hostility out of consciousness. This intensifies depression because anger becomes directed towards the self and is not used effectively to solve relationship problems. In projection, anger directed at others is denied and reversed as if the anger is being expressed by others directed towards the self. This leads to increased rejection and further lowering in self-esteem. In passive aggression, anger is expressed indirectly by avoiding doing what is expected by others. This causes others to become angry at the individual and worsens relationship problems. In reaction formation, anger is denied and replaced by over-compliance and attempts to help others. However, intrapsychic and interpersonal problems underlying the anger remain unaddressed and this fuels the rage even more. In identification, the person identifies and takes on the image of their abuser or aggressor who has made them feel disempowered. This is why some kids who were abused grow up to be abusers. It gives them feelings of power and being in control but it also makes them feel guilty. Sometimes anger can also be externalized through displacement, usually at subordinates like children. It's easy to yell at children or physically punish them but they become hostile to the parent (Bush, 2016).

Adding to all of this is dissociation. Dissociation is a defense mechanism employed by victims of trauma and sexual abuse, to protect them from the psychological effects of trauma. It unconsciously changes the cognitive framework of a person's reality (Braun, 1998).

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