Seeing the Wood from the Trees

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist,
Dublin, Ireland.

A client, who shall remain anonymous, said some things in the course of a session once that have stayed with me a long time. This particular client was suffering from a severe form of depression. What does that look like in reality? Well, it includes an inability to consider anything good about themselves, an inability to motivate themselves, a profound sadness and regret at who they are and what their lives have turned out to be, an absence of any hope for the future, and a harsh sense of judgement of themselves and their abilities.
It is depression and that is the diagnosis you would expect from a psychiatrist or a psychologist, which is valid in its own right. Psychoanalytic psychotherapists use the word too, in fact the theme for the 16th Annual Congress of the Association for Psychoanalysis and Psychotherapy in Ireland (APPI) next November is ‘Depression and Melancholia in Modern Times’. But where we differ is that this word depression is a starting point, rather than an end in itself. It is the place we begin a search, if you like, rather than the place where we settle down to consider the nature of the symptoms.
As I have said before, depression is a broad diagnostic label, one of many that give us the impression of understanding the issues involved when in fact they are only a very general guide. Description is not the same thing as understanding.
Taking the client I mentioned above, the things this client said in that session I referred to were that they (I use the plural to ensure confidentiality) were completely stuck on three ideas that had an almost persecutory quality.
One was the idea that the future would turn out bad. Something that had happened in their life was going to come back and haunt them in the form of unforgiveness from other people. There was some degree of reality in this, given the nature of this client’s background.
Secondly, this client was unable to stop thinking about a former lover, one that had since moved on to another relationship. The client felt extreme regret at having ‘lost’ this person through their own choice and now wanted this partner back even though the likelihood of that happening remained very slim.
And thirdly, as a result of this threat from others in the future, different options were constantly being considered to escape this threat. But the client experienced a deep depression around any of these options. In short, no matter where this client pictured themselves in the future, it was going to be awful.
The upshot of all this was a person who was deeply depressed about their situation and who was on the strongest depression medication available which, while keeping them from experiencing extreme pain, was far from blocking out all negative feeling.
The resonances I spoke of in this case were that this client was, while on the face of it anxious and depressed about the possibility of real things either happening or not happening in their life, the psychical reality was they were completely stuck. The ideation, or rather the process of idea formation, was almost exclusively centered around three identifiable issues, each with a modicum of real possibility about them. The tendency and indeed the temptation would be to work on the rationality behind these ideas and consider whether they might or might not happen while, along the way, work out options or strategies that might stave off the more unpleasant outcomes from taking place.
And yet that would be to ignore an essential point. It was not the content of the ideas themselves that was the source of distress for this client, even though at one level that was the case. It was more to do with the fixedness of the ideas; the fact that they could not escape thinking these ideas, despite the strong medication; that they could not escape the frightening and paralysing effect that these ideas had on them.
This form of thinking was, when we examined it more closely, quite similar to a style of thinking that this client had put into operation in many other areas of their life, both past and present. The gripping on to notions, and the worrying about them to an extreme degree, was part of a complicated internal defence strategy that they had learned over many, many years.
The issue was not what they needed to do about these ideas in themselves but what they needed to do about this kind of thinking. It sounds a bit like a behavioural approach to therapy doesn’t it? Simply teach the person to think in a different way. But it is not as simple as this either.
This kind of thinking is not simply un-learned and another more positive type inserted in its place. This style of thinking is, at a hidden level, designed to blot out many other aspects of the person’s life. It is, quite literally, a screen behind which the realities of their existence are kept concealed. So it is not a question of re-learning anything. It is, rather, a question of patiently and carefully dismantling a very sophisticated form of defence system in order to allow for a consideration of the fullest aspects of the life it seeks to conceal.
Now we are firmly back in the realm of psychoanalytic psychotherapy. A place where one takes one’s time and proceeds with the sense of caution and respect necessary to do a delicate job well. Unveiling things that have remained veiled for a great many years needs patience and care. It also needs a robust theoretical framework which allows for it to be recognised for what it is in the first place.