Authors: Andrew Solomon
Abraham, responding to “Mourning and Melancholia,” proposed that depression has two phases: the loss of the love-object, and the resuscitation of the love-object through internalization. He describes the disorder as the result of a hereditary factor, a fixation of the libido on that lost breast of the mother, an early injury to self-love because of a real or perceived rejection by the mother, and a pattern of repetition of that primary disappointment. “An attack of melancholic depression is ushered in by a disappointment in love,” he wrote; and the melancholiac becomes “insatiable” for attention.
It is easy enough to apply the insights of Freud and Abraham, albeit in somewhat reductive terms, to one’s own life. At the time of my first breakdown, I was devastated by my mother’s death, and in dreams and visions and writing I most certainly incorporated her into myself. The pain of losing her made me furious. I also regretted all the pain I had ever caused my mother and regretted the complex mixed feelings that persisted in me; full closure in this relationship was forestalled by her death. I believe that internal systems of conflict and self-reproach played a large part in my falling apart—and they centered on my publication of my novel. I regretted the sabotaging privacy that I had developed because my mother so highly prioritized reticence. I decided to publish anyway, and this gave me some feeling of being freed of my demons. But it also made me feel that I was acting in defiance of my mother, and I felt guilty about that. When it came time to read aloud from the book, to declare publicly what I was doing, my self-reproach began to eat into me;
and the more I tried not to think about my mother in this situation, the more the “internalized love-object” of my mother obtruded. A secondary cause of my first breakdown was a disappointment in romantic love; my third breakdown was triggered by the failure of a relationship in which I had invested all my faith and hope. This time there were not so many complicating factors. While friends told me I should be furious, what I felt was despair and self-doubt. I accused myself endlessly as a means of accusing the other. My own attention was fixed on the person whose attention I truly wanted, who was absent, and yet alive within me. My anxiety seemed to follow only too closely the patterns of my childhood and the story of the loss of my mother. Oh, there was no shortage of internalized sadism there!
The great exponents of psychoanalysis have each offered some further refinement on these subjects. Melanie Klein proposed that every child must undergo the sad experience of losing the breast that feeds it. The clarion certainty of that infant wish for milk and the total satisfaction of having it answered are Edenic. Anyone who has ever listened to a baby screaming for nourishment will know that the absence of that milk at the moment when it is desired can result in catastrophic rage. Watching my nephew, born while I was writing this book, in his first month of life, I saw (or projected) struggles and satisfactions that were very much like my own moods and found an approximation of depression settling on him even in the seconds it might take his mother to lift him to her breast. Nor, as I draw close to finishing this book, does he appear pleased about giving up the breast as he is weaned. “In my view,” Klein wrote, “the infantile depressive position is the central position in the child’s development. The normal development of the child and its capacity for love would seem to rest largely on how the ego works through this nodal position.”
The French analysts go one step further. For Jacques Hassoun, who brought the notion of depression to Jacques Lacan’s cryptic deconstruction of the human being, depression was a third passion, as powerful and as urgent as the love or hatred that might trigger it. There was no such thing as autonomy without anxiety for Hassoun. In depression, Hassoun said, we are not properly separated from the other and perceive ourselves to be contiguous with the world. It is the nature of libido to desire the other; and since we cannot perceive a separate other in depression, we have no basis for desire. We are depressed not because we are so far removed from what we want, but because we are merged with it.
Sigmund Freud is the father of psychoanalysis; Emil Kraepelin is the father of psychobiology. Kraepelin separated acquired mental diseases
from hereditary ones. He believed that all mental illness had an internal biochemical basis. He said that some illness was permanent, and some was degenerative. Kraepelin introduced order to the chaotic world of mental illness, maintaining that there were specific, easily defined, discrete diseases, and that each of these had distinctive characteristics and, most importantly, a predictable outcome that could be understood in relation to time. This basic assertion is probably untrue, but it was extremely useful in giving psychiatrists some basis for approaching complaints as they manifested.
Depression he sorted into three categories, allowing a relationship among them. In the mildest, he wrote, “there appears gradually a sort of mental sluggishness; thought becomes difficult; the patients find difficulty in coming to a decision and in expressing themselves. It is hard for them to follow the thought in reading or ordinary conversation. They fail to find the usual interest in their surroundings. The process of association of ideas is remarkably retarded; they have nothing to say; there is a dearth of ideas and a poverty of thought. They appear dull and sluggish, and explain they really feel tired and exhausted. The patient sees only the dark side of life” and so on and so forth. Kraepelin concluded, “This form of depression runs a rather uniform course with few variations. The improvement is gradual. The duration varies from a few months to over a year.” The second form includes poor digestion, skin without luster, numbness of the head, anxious dreams, and so on. “The course of this form shows variations with partial remissions and very gradual improvement. The duration extends from six to eighteen months.” The third form includes “incoherent and dreamlike delusions and hallucinations.” It is frequently a permanent state.
Overall, Kraepelin suggested, “the prognosis is not favorable, considering that only one-third of the cases recover, the remaining two-thirds undergoing mental deterioration.” He prescribed a “rest cure,” “the use of opium or morphine in increasing doses,” and various dietary restrictions. He cataloged depression’s causes: “defective heredity is the most prominent, occurring in from 70 to 80 percent of cases,” he wrote, concluding that “of external causes, beside gestation, alcoholic excesses are perhaps the most prominent; others are mental shock, deprivation, and acute diseases.” There is little room here for such tangled principles as the divided ego or oral fixation on the breast. Kraepelin brought utter clarity to diagnosis, what one of his contemporaries called “a logical and aesthetic necessity.” Comforting though this clarity was, it was often wrong, and in 1920 even Kraepelin had to admit that his assumptions had to be dealt with in limited terms. He began to give way to the increasingly strong wisdom that disease was always complex. The Canadian
physician Sir William Osler summed up a newer way of thinking when he wrote, “Don’t tell me what type of disease the patient has; tell me what type of patient has the disease!”
Adolf Meyer, a Swiss immigrant to the United States, much influenced by American philosophers such as William James and John Dewey, took a pragmatic approach and, impatient with both Kraepelin and Freud, reconciled what had become opposite views of the mind and brain. His principles, once articulated, were so rational that they seem almost commonplace. Of Kraepelin, Meyer was ultimately to say, “To try and explain a hysterical fit or a delusion system out of hypothetical cell alterations which we cannot reach or prove is at the present stage of histophysiology a gratuitous performance.” He characterized the false precision of such science as “neurologizing tautology.” On the other hand, he also felt that the cultic tendencies of psychoanalysis were belabored and foolish; “any attempt at inventing too many new names meets a prompt revenge,” he said, adding, “My common sense does not permit me to subscribe uncritically to whole systems of theories of what the human being must be like and should work like.” Observing that “steering clear of useless puzzles liberates a mass of new energy,” he asked finally, “Why should we have to insist so on the ‘physical disease,’ if it is a mere formula of some vague obstacles, while the functional difficulties give a plain and controllable set of facts to work with?” This is the beginning of psychiatry as a dynamic therapy. Meyer believed that man had infinite adaptive capacities, embodied in the plasticity of thought. He did not believe that each new patient’s experience would lead to absolute definitions and grand insights; he believed that treatment had to work on the basis of understanding this
specific
patient, and he told his pupils that each patient was an “experiment in nature.” Patients might well have hereditary predispositions, but that something was inherited did not mean that it was immutable. Meyer became head of psychiatry at Johns Hopkins, the greatest medical school in America in his time, and trained a whole generation of American psychiatrists; his wife, Mary Brooks Meyer, became the world’s first psychiatric social worker.
Meyer worked with Freud’s idea that infantile experience was destiny, and with Kraepelin’s idea that genetics was destiny, and came up with the idea of behavioral control, which was distinctly American. Meyer’s greatest contribution was that he believed people were capable of change—not only that they could be liberated from misconceptions and medicated away from biological predetermination, but that they could learn to live their lives in a way that would leave them less prone to mental illness. He was very much interested in social environment. This
strange new country, America, where people arrived and reinvented themselves, was thrilling to him, and he introduced an enthusiasm about self-transformation that was half Statue of Liberty and half new frontier. He called the surgeon a “hand-worker” and the physician the “user of physic” and then called the psychiatrist “the user of biography.” Near the end of his life he said, “The goal of medicine is peculiarly the goal of making itself unnecessary: of influencing life so that what is medicine today becomes mere commonsense tomorrow.” This is what Meyer did. Reading his many essays, one finds in them a defining of the human experience that is the medical realization of an ideal whose political exponents were Thomas Jefferson and Abraham Lincoln, and whose artistic champions included Nathaniel Hawthorne and Walt Whitman. It is an ideal of equality and simplicity, in which external embellishment is stripped away to reveal the essential humanity of each individual.
The revelations of psychoanalytic and biochemical truth about depression, mixed with the theory of evolution, left mankind newly isolated and alienated. Meyer’s work with American patients was highly productive, but in Europe his ideas did not find such ready acceptance. Instead, the continent spawned the new desolation-based philosophies of the middle part of this century, especially the existentialist thought of Camus, Sartre, and Beckett. While Camus portrays an absurdity that gives neither reason to continue life nor reason to terminate it, Sartre plunges into a more desperate realm. In his first book about the onset of existential despair, he describes many of the symptoms typical of modern depression. “Something has happened to me,” the hero of
Nausea
says. “I can’t doubt it anymore. It came as an illness does, not like an ordinary certainty, not like anything evident. It came cunningly, little by little; I felt a little strange, a little put out, that’s all. Once established it never moved, it stayed quiet, and I was able to persuade myself that nothing was the matter with me, that it was a false alarm. And now it’s blossoming.” A bit later, he continues, “Now I knew: things are entirely what they appear to be—and behind them, there is nothing. I exist—the world exists—and I know that the world exists. That’s all. It makes no difference to me. It’s strange that everything makes so little difference to me: it frightens me.” And finally: “A pale reflection of myself wavers in my consciousness . . . and suddenly the ‘I’ pales, pales, and fades out.” This is an end to meaning, to one’s meaning anything else. What better way to explain the diminution of the self than to say that the “I” disappears?
Nausea
paints an absolutely cheery picture in comparison with Samuel Beckett’s seminal texts, in which neither work nor anything else can offer even temporary redemption. For Beckett, feeling is anathema. In one of his novels, he writes, “But what matter whether I was born or not, have lived or not, am
dead or merely dying. I shall go on doing as I have always done, not knowing what it is I do, nor who I am, nor where I am, nor if I am.” In another, he describes how, “The tears stream down my cheeks from my unblinking eyes. What makes me weep so? From time to time. There is nothing saddening here. Perhaps it is liquified brain. Past happiness in any case has clean gone from my memory, assuming it was ever there. If I accomplish other natural functions it is unawares.” How much more bleak can one get?
In the middle decades of the twentieth century, two questions troubled the neuroscience of depression. One was whether mood states traveled through the brain in electrical or in chemical impulses. The initial assumption had been that if there were chemical reactions in the brain, they were subsidiary to electrical ones, but no evidence supported this. The second was whether there was a difference between endogenous neurotic depression, which came from within, and exogenous reactive depression, which came from without. Endogenous depressions all seemed to have precipitating external factors; reactive depressions usually followed on a lifetime of troubled reactions to circumstance that suggested an internal predisposition. Various experiments “showed” that one kind of depression was responsive to one kind of treatment, another to another. The idea that all depression involves a gene-environment interaction was not even entertained until the last quarter of the century.
Though this is in part because of the divided nature of modern thought on the matter, it is also because of a much older problem. Patients suffering from depression dislike the idea that they have fallen apart in the face of difficulties someone else might endure. There is a social interest in saying that depression is caused by internal chemical processes that are somehow beyond the control of the afflicted. In the same way that those who lived during the medieval period tended to hide their complaint behind a wall of shame, so did those who lived in the second half of the twentieth century—unless they could claim endogenous depression, something that had descended for no external reason, that was simply the unfolding of a genetic plan on which no regimen of ideas could have the slightest effect. It is in this context that antidepressants are so very popular. Because their function is internal and relatively incomprehensible, they must affect some mechanism that one could never possibly control with the conscious mind. They are as opulent and luxurious as having a chauffeur; you simply sit, relaxed, in the backseat and let someone or something else face the challenges of traffic signs, policemen, bad weather, rules, and detours.