Attacks on Value: a Ne* A??roaclt to Defression R U S S E LM L EARES
Russell Meares expresses grave concem ovef the eJfect o{ the cuneht biolqgical reductionisrn governing the management of intractable depression. Suc-ttreductionism leads to a failure to consider appropriate psychological treatment and a persistence with, or escalation of, polypharmaceutical and electrical treatments when they are having no ameliorative effect. Meares
,Trh.
World Health Organisation I has predicted that depressionis likelp in a few years time, to impose a greater burden than any other illness upon the world community. This is so despite the enormous amount of money spent on anti-depressant medication. Since this medication has a demonstrable effect, the problem must lie in the burden imposed by those depressiveillnessesthat are resistant to medication. Something ofthe nature ofthe problem is illustrated by a study from Holland, the NEMISIS project. I In the NEMISIS study a population of over 7,000 people were studied in order to discover the onset
of major depressiveepisodesand to chart their course. It was found that half of depressiveillnessesrecovered in three months, two thirds have recoveredin six months, while three quarters recoveredin a year. After two years,however, one fifth ofdepressive illnesseshad not resolved.The people in this group form a large pool which, we might suppose,are the major contribution to the burden ofillness. The predictors of those who form this pool did not include severity of depression.Although those with severedepressionwere more at risk than those with mild depression, the diference was not great. More significant was a history of recurrent
. vol T2No 3. MAY2006 PSYCHOTHERAPY IN AUSTRALIA
depression.Those with recurrent depressionwere neady three times more likely than those without this history to suffer intractable depression. Even more important was the coexistenceof dysthymia, a condition frequently associatedwith the disruption of personality development. More than half the people with morbid dysthymia remained depressedat the end oftwo years. The NEMISIS team tracked the outcome of three systemsof car€-mental health system, no care and primary care. The results were somewhat surprising. There was little difference between care in the mental health system and no care. On the
'l'.., other hand, treatment in primary care stream had an outcome that was twice as good as those of the other two streams. No explanation was available for this finding but it is tempting to speculatethat the effect ofthe relationship with the therapist was an important element in the enhanced therapeutic efect achievedby the primary carersDespite the importance of intractable depression, there exists, in the world literature, no accepted means of psychological treatment for this group ofpeople. The only acceptedmeasurersare electrical and pharmacological. In this chapter, a psychological approach to the problem of intractable depressionis put forward. The argument depends upon the senseofvalue which attaches to the core ofa personal being. I belive that memories of attacks upon this fundamental experience conribute, in a significant number of cases,to intractability or recurrence ofdepressive illness. A discussionof this idea will include a re-visitation of Freud's classic paper,Mourning and Melancbolia, which has become the basis of a large amount of psychological work in this spehereof depression.
activated by the pain of humiliation.3 Robert Hobson and I remarked upon the pathogenic significance ofinvalidating responsesin a paper entided'The PersecutoryTlteraVist' published in 1977-aAttacks upon value may be obvious in such emotional
abuseas ridicule, rnockery and general disparagement,but they are also a part of sexual abuseand some kinds of physical abuse.However, attacks upon value may be much less obvious than such assaults.Apparently small slights and hurts, inflicted day after
. , , Attacksu?onwaluenay bemuclt Iessoboious. . . smallslightsandhurts,
inflixeddoy&tr da!,builda system of anconscious traumaticmemurythot mrght influencetheshapeof a wholelife.
Value For each ofus there are series of images, memories, imaginings and other experiencesthat are often barely conscious,but which lie at the core ofpersonal being. They are felt as intensely personal and valued.2 William Jameslikened this areaof 'sanctuary'and experience to a spoke, repeatedly, of a feeling of 'rtarmth and intimary'associatedwith it. Experiences from this private domain are those that are shared in intimate relatedness.They are the'coins of intimacy'. Revelation ofaspects ofthis core of psychic life, which is chargedwith positive emotion, involves a risk. An inappropriate responsefrom the other is likely to inflict upon the individual a senseof harm which is experienced in away which is analogousto a physical attack. Indeed, a recent study suggeststhe same area in the brain that is activated byphysical pain is also lllustration: Savina Hopkins
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daY,build a system ofunconscious traumaticmemory which might rnnuencethe shape of a whole life. lhis background atmosphere pervades the individuals' whole existence. in a waYof which he or she is generally unaware.Much of the *otk i.t psychotherapy is concerned with the enectsofthis noxious background. In lyview, it is often overlooked in cases ot unrelenting depression.
Mourningand Metancholia
fieud's Mourning and Melancbolia s . rs.considered by some authorities to be *ot, significant work. The paper ,ltt was,written against the background ot the First Wodd War when he encounteredthe consequencesof warrnducedpsycholoeical iraumata. This tuelled, in my viJ a shift in Freudt
which*", .rr.r,,.r"llymade
ilhltg ct-early evident in his famous revision ot 1926.6 war produced a large number of"The illnesseswe now cail p&ttraumatic stressdisorder and related conditions. rvrany influential Germanic ph1'sicians believed that these illnesses were frctitious and that the Datients were malingerers. Freud thought otherwise. ne testified to this effect at a posr-war comrnission, conducted in Vienna. which investigated the cruel treatment, consistingof electrical shocks, meted out by the medical profession to those with war ...rror.r.'Fr.ud believed that these people, as a consequenceof trauma, had suffered a disturbance of the central nervous system function and that they should be treated in this way.7 The influence of Freud's encountering'war neuroses'on his attemPt to formulate a psychogenetic theory ofsevere deoressionis evident in a letter to Errr.ri Jorresdated r'€bruary 18th 1919. ,Thecaseof the war neuroses is a caseof internat narcissistic coni/ict tuithin- tbe ego som.eaobat analogousto the meJanism of melancbolu'.8 Freud iad come to understand the ^ tundamental pathogenic significance or trauma. This is evident in the letter written to Jones. He wrote: Anxiety ts a Protection against sbock.Nous the condition of thelraumatic neurosisseems to be that ihe soul bad no time to rccur to
two different intellectual universes. tltis frotection and is taken by tbe trauma The tone of Moarning and unprefared'. Freud was saying that is uncharacteristically the individual Melancholia anxiety arisesto protect if he is making his way as which humble, kind ofanxiety against another ' ofwhich he is a formulation towards which there is overwhelming and in no claim Freud makes dear. not vet is a senseof annihilation or imminent his of argument. for ih" universality annihilation. As a consequence,- . 'ax must begin by naktng He wrote avoidancemechanisms are triggered, an admission,as a atarning against of which repression,in the Freudian any over-estimation of the value of system, is the most important. This (p.2a! He found it our conclusions'. new understanding gave rise to Freud's his unlikely that proposal would be later distinction between signal and 'Inhibitions, relevant to all forms of depressionso primary anxiety rnade in thatlrroe shall, tberefore,from tbe outset Symftomsand Anxiety'-6In this drop all claim to general validityfor our conception, trauma is a state in which (p-243) eonclusions.' primary anxiety is evoked. A key passageia Mourning and It seemsnot unlikely, at least Melancholia is the following: to me, that Freud's encountering the pathogenic significance of 'Let us dwellfor a tnoneflt on the sie'Il) psychological trauma led to a series disorderafords afiiclt tbe melancbolic's ofncw ideas that appear from 1915 of the constitationof tbe humanego.Wc onwards. His ideas have puzzled seeboroin him oney'art ofthe egosett a number of observerssince they itself over tlte other,judges it eritical$, seem out of kilter with his previous and, asit vtere,turtesit asits object.Our theoretical system. There is a tendency susficiontbat thecriticalagencyt:hich is amongst psychoanalytical theorists lteresplit offiom tlteegomightalsoshocJ) to dismiss them. For example, of ix indelendencein other circamttances these later writings Oliver ZmgwllJ 'Freud uill be confirmed by everyfurther displayd an admittedly wrote, (p.247) obseruation.' speculatioeturn of nind, and although someof his ideasare ofgreat interest, tbcir This observationconcerning empiical foundations becamedecidedly 'the critical agency'is central to my ueakei.e Of the 1926 revision the argument. In this passageego can influential psychoanalystsSandler & be seenas a generalword for self Joffe wrote, as late as 1969, that the 'l{t or psyche.It wasnt until the 1930s us zaithfurtberfroblems work had that Freud eventually distinguished of conceptualintegration zobichbaoe not between ego and selfr2, ego being asyet beenfaced'.lo essentiallya neurophysiologically Among Freud's ne$r conceptions - part of what has been called basedmechanism,mediating between 'the outer and inner worlds. The term turning point of the 1920s' 11 'split ofl is to be understood in p.97 were'tbe compulsionto re?eat', 'tbe terms ofJanett dissociatedparts needfor punishment','the death of the personaliry (p.132) u I am sadoinstinct','primaql masocbism','tbe 'reversal into supposingthat the critical agency is masocbisticoscillation'. a:nd equivalent to Janet's'subconscious the opposite'.These notions can all be fixed idea'an unconsciouscomplex of understood in terms of trauma theory. traumatic experiencethat in the case Akhough his colleagueswere puzzled, of depressioninvolves devaluation, Freud was convinced that he was 'breakingradically netts ground'. (p.97)11 disparagementand other forms of belittlement which are sequestered.It Mourning and Melaneholiawas is'split-off, from the rest of psychic one of the first fruits of Freud's shift life. in thinking. It must have been an Having made this important extremely difficult work to write since observation,Freud strikes difficulty. it is unlike his previous theory based He attempts to fit it in to his previous on the consequencesof unacceptable theories involving drive. FIe begins to drives. To read this paper written in 'Introductory develop an argument that the critical Lectures',written 1915 and agency,rather than being related to about the same time. is to enter into
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exogenous,traumatic impacts, has an endogenousorigin. He develops a theory which relates hostility in the individual to the genesisof depression. He begins to move beyond the data. 'the zoomanubo loudly He remarks pities her busbandfor being tied to such an incafable zuifeas berself is really accusingher busband of being incapable, in wbateoer senseshetnay rnean thk'.(p.2aB) There is no reason to suppose
loss. fhe other, which was the most common, was an increasein the number of arguments the patient had had with his or her spouse.fn the first caseforsakennessis overtl in the second it is covert. With the rise in antagonism between partners there arisesalso a senseofdistancing or alienation. In the fight, not only is one emotionally damaged but also in a situation of loss. Now hatred may arise. Freud saw it as a basis of
. . , treotmentresistantor intractable depression tltat is beyondthereacltof antidefressantmedication,na! beunderpinnedby traumatic rnemorieswhicb canbecltaracterized
as'attacksonealue'.TreAtment should tbereforeinwolwea systematicattempt to alter
thenoxiousfficts of this traumaticsystern. that the object ofthe criticism is not the woman herself, Observations of the minutiae of the therapeutic conversation suggestjust the opposite. The person being devalued is indeed the patient. Those giving descriptions of the experience of devaluation are not infrequently able to describe something beyond self accusation. It is the sensethat this criticism has a voice which is rather like that of a parent. In this way using Freud's beautiful language 'tbeshadou of tbe objutfell ulon tbe ego,and the latter could henceforthbejudged fu a special agenc!, as tboagh it toerean object,tbe object'.(p.249 The notion of forsaken 'forsakenness'is not developed by Freud, but it is essential. Loss, or forsakennessis found frequently in a seriesoflife events studies to proceed, and presumably, to trigger a depression.However, one ofthe earliestand best ofthese studies coming from Gene Paykel working at Kings College London, showed something else.t3Paykel and his colleaguesfound two common antecedentsof depression.One was
melancholia. The individual now harbours both love and hate for the same person. Ambivalence, so Freud believed, is at the bottom of melancholia. Hewrote tustas mourning impels tbe egoto gioe uf tbe objectfu declaring tbe objectto be dead and ffiring the egotbe inducementof continuing to live, sodoeseacbsingle struggle of ambivalenceloosenthefxation oftbe libido to the objectby disparaging it, denigrating it and even, as it ztsere, killing;t'. (p.257) This is an odd view of mourning. Indeed, it seemsthat at this point in his argument Freud's doubts begin to rise. His essaynow peters out, somewhat inconclusively. Freud's formulation, when looked at in a logical way, leads to an impassesince by killing the object, the individual is constantly repeating the loss. Consequently, the depressioncan never end. Freud seemsto seethe difficulty 'it ispossiblefor tbeprocessin tbe anconseious to cofiteto an end, eitber after tbefury hasspent itself or after the objecthas beenabandonedas valueless. Wecannot tell ulticb of tbesetuo
2ossibilities is tbc moreregular or more usaal one in binging melancboliato an end, nor wbat infuence tbis termination has on tbelfaturecourseoftbe case.Tbe egona! enjoy in tbis tbe satisfaction of knotoing itself astbe better of tbe tauo,as superior to tbe olTect'.(p.257) Tiiumph is an unusual, we might even say pathological, responseto the death of the attachment figure or the loved one. Despite its tentative tone and unsatisfactory ending, this essay has been extremely influential. It is widely held by those influenced by the psychoanalytical point of view that ambivalence is the basis of depression. Unconscious rage and hatred is sensedas having harmed, perhaps irreparably, the inner representationof the other, the internal object. Evidence concerning the child's magical belief of the power ofwishes gives some support to the theory. However, there is no evidencethat a therapeutic approach basedon this theory and upon an interpretive style directed at repressed hostility is effective in overcoming depression. A new theory is required. Such a nelv theory can be derived from Freud's observation concerning the split-offpart of the psychic system which involves what he called the critical agent.
Pathogenic Effect of the Gritical Agency Freud's tritical agency'can be seen as equivalent, as previously remarked, to a traumatic memory systemwhich is largely unconscious. Unconscious,in this sensemeans that those episodes in which the individual had been, in various ways, made to feel stupid, incompetent, ugly and in other ways worthless, are largely absentfrom the conscious senseof oneself as lacking in value. It is not that these episodes are repressed,but rather that the memories are stored in the system which is beyond the reach ofordinary consciousness.In Janet's terminology, the system is dissociated, having a certain amount of independence', to use Freud's term. ft operates automatically beyond voluntary control. Although the episodesin which disparagementand humiliation occurred are not part of immediate
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and current experience, the selF Mourning as a Model for evaluationswhich arose during these the Integration of Trauma repeatedettacks upon value persist and The main implication of the can be spoken of, A number ofrecent argument so far is that treatment studies suggestthat those vulnerable resistant or intractable depression that to depressionmay be affected by such is beyond the reach ofanti-depressant negative selFevaluations. medication, may be underpinned by In one study,20 treatment resistant traumatic memories which can be 'attacks depressiveswere compared with characterized as on value'. 20 people who were responsive to Treatment should therefore involve a treatment.la The treatment resistant systematic attempt to alter the noxious subjects'rEorted signllcantly greater effects of this traumatic system. koels of cbildbood emotional abuse, Although such measuresas exposure and experiencedcurrent da1-to-day are often recommended in the seguelaeof childltood emotional abuse'. treatment of trauma following single Another study from Sterling County events, they are not usually effective in concerned 489 subjects who were casesofintractable depressionthat is interviewed and then followed up in determined by cumulative traumata. order to examine associationsbetween What is required is a treatment of the findings of this interviewwith larger scopethat includes not only an subseguentdepression.l5'Feeling approach to negative self attributes, worthless' at first interviewwas highly but the noxious nature of the traumatic predictive of subsequent depression. system itself, which is operating In this paper, reference was made as an independent, automatic and 'parasitic' of two other studies in which the life-form hovering on the same findings were made. In a third edgesofconsciousness,ready, as it recent study Kendler and colleagues were, to move in to the field of thought also found that loss, humiliation, and obliterate the more healthy entrapment and danger are predictive consciousnessof self. Janet wrote: of onsets of major depression and 'Ihe generalized anxiety-16The study sample pozuerof suchideasde?endsu?on of 7322 adult twins were blindly tbeir isolation. Theygrou, tbey install related on dimensions of humiliation, themselaesin thefeld of thougbt like entrapment, loss and danger. The a Parasite,and the subjecteannotcbeck authors remarked that' bumiliating their deoelopmentby any efort on bis eaentsthat directly deoalue an individual part, becausetbey are ignored, beeause in a corerole'were linked strongly they exist by themselaesin a second to risk for depressiveepisodes. Loss feld of thougbtdetacbedfromthefrst'. (p.600) D and humiliation combined were the most pathogenic events. An example of such a situation is other-initiated Janet consideredthat a most separation. These findings replicated important aspectof treating this earlier studies from London showing malignant debilitating system is loss, humiliation and entrapment to alter the form of consciousness among women developing depression.lT that is the vehicle of the negative A further study, published last year, selfattributes into another form supported the hypothesis that loss of consciousnessthat more closely and humiliation are particularly resemblesthe healthy consciousness relevant in the provocation ofonset of personal being. In this way, it of depression.lsIt might be supposed can mingle with other forms of that a significant proportion of these consciousness and become'liquidated', findings can be explained in terms of to use his word. This processof traumatic memory systemsconcerning liquidation dependsupon the devaluation. These symptoms can traumatic systemsof ideas and feelings be triggered by the circumstancesof taking its place in the story of an current existence,so leading to the individual life. An individual must 'knozu onset of clinical depression. bota to associate tbe bappening u:itb tbe otber eaentsin bis life, bozu to ?at it in itsplace in tbat hfr history 66
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uhich eacboneof us is2erpenally building up andfor ubicb eachof as is an essentialelementof bispersrnality'.Le (p.662) Janet'ssuggestion leadsto the possibility that mourning, a universal set ofexperiences and behaviours following loss, might be a model of the liquidation or integration of trauma. Indeed, this might be implied in Freudt classicessayin which melancholia is seenasif it were something like the processof mourning gone wrong. The original traumata were experiencedas blows. The derision, the belittling, the derogation, or whatever it was, was felt like a hit. The triggering of the traumatic memory has a similar effect. There is a sharp and instantaneousfeeling of distress ofvarious kinds. This instant is not connected to the rest oflife. It is an interruption in going on being. The sudden death of a friend or family member is felt in a similar way. The news brings an inrush of devastation. Recurring memory of the event evokes the stab ofgrief. Mourning is the means of dealing with an event that is part of human life. It is a universal practice that has many different variations across cultures. However. there are certain customs and behaviour that are common to many rituals of mourning. They might act as a guide to dealing with trauma in general. Hobson's description of bereavementshowsthe resemblance between this event and other forms of trauma.(p.219)20 There is, first of all, shock. The individual might be as if stunned, and affiicted, for a time, with a senseof unreality. This is followed by a period of disorganization in which 'there is commonlyan interzaeaoingof thenes uith fve charaeteristics:bodily distrus, preoccupationu:itb tbe image of deceased, bostilereactions,guilt and lossof usualpatterns of feelings, conduct'.Finally, and slowly, there is reorganization. The individual reenters the world of others with his or her life shapedanew. The traumata underpinning depressionare not as obviously severe as those ofbereavement. They consist of the repeatedhurts and slights which individuallv are innocuous but that
leave their scarswhen accumulated over months and years. They are an effect of the pervasive atmospherein which the subject grew up. Although each'attack upon value'is small, the consequenceofits repetition is great, shaping an individual life. Atthough seemingly different to bereavement, an approach to the traumatic memory system built up, asJanet put it, from 'a succession of slightforgotten sbocks', 'from actual eoentstbat recur eoery da1f, (p.275)'t has similarities to aspeits of mourning. The similarity is more obvious when the more severeforms of traumata, are involved. The 'slight forgotten shocks',and the more severetraumata. such as sexual abuse, are both likely to play a part in the developmental background ofthose who suffer borderline personality disorder. These two categoriesof trauma are hidden in different ways. In the former case,the subject is unaware of the way in which his or her life is being undermined; in the latter, the hiddeness is typically conscious.The traumatised person has a phobia of the memory and, as a consequence,does not reveal it for fear of re-living the experience.One woman, for example, waited 30 years before she could tell her husband of a rape which occurred before their marriage and that affected her whole life. Another woman who had been sexually abusedby her father was unable to reveal this 'pathogenic secret' to those who treated her for repeated severedepression,which required hospitalisation, and which recurred over 30 years.What she eventually revealed was not'recovered memory', but memory that had persistently tormented her. Whatever the kind of trauma, the memory of the event or the eventshas to be changed, as Pierre Janet made clear in his description of 'liquidation of trauma'. It must be transformed from a sudden. almost instantaneousdistress which slices into, and has no connection with the experiencesofordinary living, into an experiencewhich can be integrated into the larger consciousnessof sel{, including its past of memories and its future perspectives. 'Memory', saidJanet, 'is an action; essentially,it is the action of telling a
story'.(p.661)t'Th. activity of this kind atmosphere,or mood, that memories of memory comes with the emergence can be played around'within a state of dualistic consciousness.However, of mind that is associativeand unlike memory does not usually come all at the linear mode of mental activity, or once, but in bits and pieces,haltingly. brain-state, in which the traumatic As the story is told in its different material is imbedded. Although the forms, it is linked up to the rest of life. trauma is an omnipresent theme, it is The important story of a life is not told not confronted relentlessly.Rather, the as events recounted for legal evidence, subject comes and goes, interspersed but rather in the way the child tells it, with such apparently smaller matters engagedin symbolic play. as the events ofdaily life, health, and Certain of the rituals of mourning so forth. Something of the style is portay something of the pathway evident in Keats last 1etter.23In this towards integration. In these customs letter Keats told a friend that he is the loss ofthe dead person is linked up dying and that he had loved him. not only to the world of self, but also The way he does it is tonversational', 'apparently to the world of others. meandcring througb topics The ritual plays out, in an overt and sacbas symptoms,incidents in thepast, even exaggeratedform, the stat€ of the friends or tbe bealtb ofotbers. Bit by bereaved.The senseofisolation ofthe bit tlte zaorkis done.'Keatshaving bereavedis ritualised in prohibitions quietly completed the task of farewell that set this person apart, cut offfrom concludesby making clear what had many aspectsof usual living. Then, been his task. 'I canscarcelybid you at the funeral ceremony itsel{, grief good-byeeoen in a letter. I aluays made is highlighted by behaviours such an aanbuardbou.2a as mourners gashing their bodies, Something more, however, needs weeping and wailing in a prolonged to be added to the model of mourning and orgaoized way, so as to represent as epitomized by the wake, at least the experienceofthe bereaved,to lay it in the usual caseofthe consequences 'attacks out before their eyes and ears.22 of upon value', in which the The character ofthe occasionthen memories are, in part, 'unconscious'. changes to become celebratory. Play Evidence of the repeated humiliation and pleasurereplace the manifestations suffered by the patient frequently is ofgrief, The person is drawn into missing from the standard psychiatric activities such as feasting, singing, history since the patient considers and dancing. In this wap the subject is that his/her childhood was 'normal'. brought back into the fold ofhis or her Alternatively, the pain of these social environment. A famous example memories is avoided by keeping is provided by the funeral procession them secret. Skilled listening and ofjazz bands going through the streets responding are required. Evidence of New Odeans. Another example appearsin the minutiae of the of this cusrom is the Irish wake. in therapeutic conversation of the system which over a long period of drinking that is persistently undermining the and talking, the mourners, sometimes senseofthe worth ofpersonal being. laughing or crying, tell stories about Identification of,, and appropriate the dead person. They themselvesmay elaboration of these, at times, be participants in these stories. These barely discernable moments, shown tales are an aspectofthe 'recital'of for example in shifts of mood or which Janet spoke. apparently inconsequential remarks, The model of mourning as it is a main aspectof the'liquidation concerns 'attacks upon value'is beyond process'.(Some exarnplesof these the scopeof this paper. However, the minutiae are given in the casesof main elements of the wake convey Jane'and'Olivia', in Intimary and something of the process.First oi Alienation).2i What emergesin these all, the senseof being with others conversationalepisodesbecomespart who understand one's state, who are of an evolving'narrative of self'. 'fellows', and with whom one feels Finally, it is necessaryto state safe,is an essentialprior condition for the main imperative driving the 'liquidation' the of trauma. It is in this authorship ofthis paper. It is a grave PSYCHOIHERAPY . vol 12No 3 . MAy 2006 lN AUSTRAUA
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concern over the effect ofthe current biological reductionism governing the management of intractable depression.This leads to a failure to consider appropriate psychological treatment and a persistencewith, or escalation of, poly-pharmaceutical and electrical treatments when they are having no ameliorative effect. Pilot studies at Westmead Hospital specifically focusing upon the effects of unconscioustraumatic memories relating to disparagement, devaluation and humiliation suggestthat such an approach has the potential to provide a very significant benefit to patients who are disabled by intractable depression despite high levels of medication.
FOOTNOTES 1. Spijker,J., De Graaf, R, Bijt, R, Beekman, A., Ormel, J. & Nolen, W. Duration of Major Depressive Episodes in the General Population: Results lor the Netherlands Mentat Health Survey fncidence Study. Bntrbh Journal of Psychiatry 181; pp. 2OB-19,2OO2. 2. Meares, R. The Secret, psychiatry 39: pp. 258-65. 1976. 3. Eisenberg,N., Lieberman, M-, Williams, K.D. Does Rejection Hurt? An fMRl Study of Social Exclusion.Science, 3O2: pp. 29092.2003. 4. Meares, R., & Hobson. R.F.The Persecutory Therapist. British Journal of Medical Psychology 50: pp. 349-59. 1977. 5. Freud, S. Mourning and Melancholia. Standard Edition 14: pp. 299-SB. 191S. 6. Freud, S. Inhibitions, Symptoms and Anxiety. Standard Edition 20 : pp. Z7-17.1. 1926. 7. Jones, E. Sigmund Freud: Life and Work. Vol llt. London: Hogarth, p. 28. 19S7 8. Jones, E. Sigmund Freud: Life and Work. Vol //. London: Hogarth, p.285. 1955. 9. Zangwill, O. Sigmund Freud. In Companion to the Mind ed. R.L. Gregory; Oxford: Oxford Un iversitv P r e s s ,p . 2 6 9 . 1 9 8 7 .
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10. Sandler,J., & Joffe, W. Psychoanalytic Psychology & Learning Theory in lhe Role of Learning in Psychotherapy, ed. R. Porter: Ciba Symposium, London, Churchill. 1969.
17.Brown,G., Harris,T.,& Hepworth, C. Loss,Humiliation& Entrapment amongWomenDevelopingDepression: A Patientand Non-PatientComparison. PsychologicalMedicine25: pp.7-21.1995.
11. Laplanche, J., & Pontalis,J. B. The Language of Psychoanalysls. Trans. D. Nicholson-Smith, New York: Norton. 1973.
18.Farmer,A., & McGriffin,P.Humiliation, Lossand OtherTypesof Life Eventsand Difficulties:A Cornparisonof Depressed Subjects,HealthyCohortsandTheir Siblings.Psychologicat Medicine33: pp. '1169-75.2003.
12. Strachey, J. Editoriat Note. Sfandard Edition. 19: 8. '1961. 13. Paykel,E., Myers, J., Kienelt, M. Klerman, G., Lindenthal,J & Pepper, M. Life events and depression. A controlled study. Archives of General Psychiatry.21: pp. 753-760. 1969. 14. Kaplan, M., & Klinetob, N. Chitdhood Emotional Trauma and Chronic postTraumatic Stress Disorder in Adult Out-Patients with Treatment Resistant Depression. Journal of Nervous and Mental Disease188: pp. 596-600.2000. 15. Murphy, J., Nierenberg,A., Monson, R., Laird, N., Sobol, A., Leighton,A., Kendler, K. Self Disparagement as a feature and forerunner of depression: findings from the Stirling County Study. Comprehensive Psychiatry 43:, pp.13-21- 2OO2. 16. Kendler,K., Hettema, J., Butera, F., Gardner, C., Prescott, C. Life Event Dimensions of Loss, Humiliation, Entrapment, and Danger in the Prediction of Onsets of Major Depression and Generafized Anxiety. Archives of Genera! Psychiatry 6O: pp. 789-96. 2003.
19.Janet, P.PsychologicalHealing,Vot. t. London:GeorgeAlten& Unwin.1925. 20. Hobson,R.F.Formsof FeelingLondon: Tavistock.1985. 21.Janet,P. Principlesof Psychotherapy. London:GeorgeAllen& Unwin.1924. 22. Fison,L., & Howitt,A. FuneralCustoms in Australia.ln eds.M. Mead& N. Callas PrimitiveHeritageLondon:Gollancz1959, pp.545-46.1880. 23. Meares,R. On SayingGoodbyeBefore Death.Joumal of the AmericanMedical Association246:pp. 1227-29.19BO 24. Keats,J. The Lettersof John Keats 1814-1821 ed. H. RotlinsVots1 & 2. CambridgeMA: HarvardUniversityPress. 1958. 25. Meares,R. lntirncy & Alienation: Memory Trauma& PersonatBeing. London:Routledge. 2000.
AUTHOR NOTES RUssELt MEARES M.D.is Emeriu.rsProfessor of fuchintry at the university of sydney and Dircctor of the Joirn centres of Mentar Health Excellenceon theWesmread campus. He was founding president of theAustralian and Nerry ZeafandAssociation of Psychodrerapy.l-le is the author of rhe M*ophor ofplq, Second ftition (2005) *a nti^uy' ind Afienqtlm(2000).
ACKNOWLEDGMENT This paperwasfirst publishedin Ttresetfin conversotiofih,. nl', Editedby Russell Mearesand PaulineNolanandpublishedbyANZAp Books,2OO4. Comments:
[email protected]
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