Ray Maloney
A Cognitive Analytic Perspective of Depression
The aim of this paper is to consider depression and lowered mood within a Cognitive Analytic Therapy (CAT) context; initially depression will be contextualised in terms (briefly) of a bio-medical, sociological, emotional, evolutionary and psychological background. The CAT literature has discussed models for conditions as diverse as borderline and narcissistic personality disorder (see Ryle A, and Kerr I, 2002), deliberate self-harm (Cowmeadow, 1994), treatment non-compliant diabetes (Fosbury et al, 1997), substance misuse (Leighton, 1995) and sexual abuse (Pollock, 1996). Yet, surprisingly little, apart from an article by Ryle (1991) and a few paragraphs in their introduction to CAT (Ryle and Kerr, 2002) has been written on a CAT perspective of depression. We shall attempt to construct a CAT model, or template, for depression together with an analysis on the role of the emotions. Two different ‘types’ or causal routes to depression will be considered together with an appreciation of the difficulties encountered whilst working with depressed individuals. Some suggestions for working with these difficulties will be considered.
It seems that the bio-medical model purports to offer a precisely defined and delineated set of observations reported by an impartial, unbiased ‘scientific’ observer; contrarily much of the psychotherapeutic literature offers an ‘insiders lived-in’ experience of the suffering of depression. Probably we are being unfair by describing one approach as ‘impartial science’ and another as ‘lived-in experience’ as both aspects are found in each approach; nevertheless, I have attempted to use these two styles of enquiry, with the first part of the paper having a ‘scientific practitioner’ style and the second having more an ‘insider’ therapeutic feel.
Even a cursory examination of the writing on depression show that no two writers seem to agree, even basic ‘facts’ are disputed: for example Brown and Harris (1993) suggest that low self-esteem is positively correlated with incidence of depression; disobligingly, Alladin and Heap (1991) contend “there is no evidence that low-self esteem is more common in people who develop depression than those who do not’. I suspect Anadin and Heap’s analysis of the evidence is overly reductive and pedantic; but the point to draw is that the literature on depression can seem confused, even contradictory. Perhaps any approach one takes to depression is at least in part a personally based construction. The best we can hope for is an account that fits with the available ‘evidence’, our own clinical experience and the lived experience of life and mood. The aim of considering differing traditions and styles is not to ‘compare and contrast’ or decide ‘who is right’; rather a range of perspectives will be considered to see what each contributes to an understanding of depression as a total entity.
Prevalence
Most people experience low mood at some stage. Clinical depression is so common that Seligman (1975) described it as the ‘common cold of psychiatry’ and perhaps depression is present, as a subsidiary difficulty in the majority of psychiatric conditions. It has been estimated that 3-4% of the population suffers from significant or clinical depression and between 13-20% suffer significant levels of depressive symptoms or dysthymia at any point in time. More than 12% of this total will require professional treatment. Depression accounts for up to 75 % of psychiatric hospitalisations (see Boyd and Weissman, 1982 for an epidemiological review). Prevalence rates amongst the various socio-economic, age related, gender and ethnic groups is a tortuous area too complex to enter into detail, but we may note that the rate of depression among women in Western industrialised countries is approximately twice the rate of men. For women depression is most common between 35-45 yrs of age whilst with men incidence increases with age. Depression is more prevalent amongst divorced or separated persons and within socio-economic classes 1, 2 and 5.
Diagnostics
As a diagnosis depression is probably over-popular amongst clinicians (Ryle, 1991), perhaps this is due to the availability of reliable pharmacological agents and psychological treatments. The role of ‘simple’ measuring tools such as the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983), the Beck Depression Inventory (Beck et al 1961) and the Hamilton Rating Scale (Hamilton, 1967) have also shaped the idea of depression being a ‘clinically testable’ and tangible condition.’ Depression’ can be considered a broad-sweep diagnostic label covering a range of conditions and symptoms and deriving from a range of ‘biopsychosocial’ causes (Harris, 2001); including: genetic predisposition, personality factors, familial history of depression or alcoholism, disturbed neurotransmitter functioning, physical or infectious illness, early life experience such as parental loss or neglect, significant current life events, a critical or hostile spouse or lack of a close confiding relationship, lack of adequate social support, socio economic deprivation and long term lack of self-esteem (Ostler et al, 2001). We do need to remember that given enough stress or trauma just about anyone has the potential to develop depression irrespective of his or her personal history or protective factors. Depression can be seen as part of the mainstream of human experience as opposed to some discrete psychiatric domain.
Depression or even ‘clinical’ depression as a diagnostic category represents another tortuous and confusing area. Goldberg et al (1987) in an otherwise humourless review comments ‘there has been a long controversy about the best way to classify depressive illnesses, and the non-psychiatrist is well advised to ignore it’, however, one could argue this is too important an area to ignore. No general agreement about the best way to classify depression exists, (Gelder et al, 1995). However, distinctions have been drawn between bipolar (i.e. bipolar-affective disorder) and unipolar depression, between endogenous melancholic (i.e. bio-medically caused) and reactive (or neurotic) depression. Related classifications include ‘dysthymia’ which can be seen as a milder form of depression not amounting to true ‘clinically significant’ depression; psychotic depression, which can amount to a qualitatively severe form of depression including hallucinatory and delusional elements. We should note also: agitated depression (i.e. symptoms of agitation concurrent with low mood); depressive stupor and retarded depression (i.e. psychomotor retardation is especially prominent); and masked depression. Often persons who present with an anxiety disorder (specific or general) will complain of lowered mood, which they then define as depression. Lastly we should not forget the adjustment disorders including Post Traumatic Stress Disorder (PTSD) and grief or bereavement reactions, milder depression often tapers off into feelings of sadness and unhappiness over some loss or trauma within the person’s life and can be considered a ‘normal’ phenomenon - albeit very distressing to the person concerned.
For the purpose of this article we are referring, in the main, to unipolar-depression, namely: depressive episode (F32. ICD 10: WHO, 1992), recurrent depressive episode (F33), dysthymia (F34.1) and mixed depressive and anxiety disorder (F41.2). However, as we shall see later, even the idea of a single type of unipolar-depression is open to question and we shall consider two different psychosocial routes to depression. A discussion of complex depression, for example depression complicated by personality disorder, will not be entered into here as this subject has been extensively covered in the writings of Ryle and other commentators whilst the more common condition of unipolar depression has remained largely unexplored.
Symptoms and signs
Depression can be classified in terms of mild, moderate or severe intensity. For diagnostic purposes the person is required to have reduced mood for at least two weeks. At least two symptoms, usually a complex mix, will be found, although some symptoms will be more prominent than others. Depression can be classified with or without biological symptoms, which include: early morning wakening, diurnal variation of mood, appetite and weight disturbance, anhedonia, decreased libido and psychomotor disturbance. Often thought of as a condition of 6 months duration 50% of sufferers still satisfy criteria for depression a year later (NICE, clinical guidelines 2003), there is also a marked tendency for depression, particularly if untreated, to reoccur; 50% of people following a first episode will have at least one more episode, with significant numbers suffering symptoms of depression for many years (NICE 2003). Up to 15% of depressive sufferers take their own lives by suicide.
The following symptoms and signs are based upon the ICD-10 general criteria for a depressive episode:
1. Lowering of mood, little variation on a day-by-day basis and unresponsive to external life circumstances.
2. Reduction of energy and decrease in activity, marked tiredness after minimum effort.
3. Reduced capacity for enjoyment, loss of interest is common in usually enjoyable activities.
4. Reduced concentration.
5. Disturbed sleep, possibly waking several hours before ‘usual’ waking time.
6. Disturbed appetite - decreased or increased.
7. Confidence and self-esteem are significantly lowered.
8. Ideas of guilt, self-reproach or worthlessness, deserving of punishment.
9. Hopelessness or a bleak view of the future.
10. Ideas and or acts of self harm or suicide
11. Diurnal variation of mood, often worst in the morning.
12. Anxiety, agitation, irritability, hypochondrias.
Perhaps hinted at, but often left out of the descriptive account, is the commonly held observation that depression ‘is not a feeling, but an absence of feeling. That is, depression is different from feeling sadness, loneliness, or disappointment. Rather, it is the experience [of] blankness, hollowness, or nullity.’ (Scheff, 2000), see also Ryle and Kerr (2002). Scheff argues there is ‘near consensus’ that the blunting of affect results from a suppression of feeling; so depression is a defence against emotional pain. It seems reasonable to suggest that ‘normal’ feelings of sadness and grief at one pole of human experience slowly merge into feelings of blankness and loss of affect as the depressive episode becomes increasingly severe. As noted under 2. above individuals who experience depression often appear lacking in energy feeling exhausted after minimum effort. Psychic energy also is low with disturbance of memory, concentration etc If a friend or a therapist offers a ‘helpful’ suggestion it is as though the person ‘can’t be bothered to help them-self’, or as if there is a lack of energy, (of libido in the psyche) which is necessary to fuel mental and emotional life. The psychoanalytic metaphor of energy attachment (libidinal cathexis) can prove useful here.
The ICD-10 description of depression is useful for identifying who is depressed and who is not, who needs medication and perhaps who is in need or suitable for therapy etc. However, variations in the symptomatic presentation of individuals can be enormous – a patient could have any number of combinations of between 2-12 symptoms! More significant, the description does not account for who is vulnerable to depressive onset, or the cause and course of depression; neither does the account seek to identify common or different causal pathways to depression. From the perspective of a Cognitive Analytic, or other psychotherapist, the intricacies of classification concerning this heterogeneous group of related disorders are perhaps of less interest than the nature of need of the person in distress; however, we do have an interest in the diverse elements that lead to depressive onset and a concern into which factors are ameliorable to intervention.
The biopsychosocial mix of depression
It seems that no single factor can adequately explain the occurrence of depression. Although lip service is paid to the multi-causality of depression, ‘the full-scale integration of perspectives implied by such homage is still slow to come about’ (Harris, 2001). Whichever theory has gained prominence none in its own right has proved convincing as a singleton theory. Most observers (see NICE, 2003) now believe a range of biopsychosocial elements increase an individual’s vulnerability to depression although how this mix configures in an individual’s pathology is difficult to ascertain in practice (Harris, 2002). Nuechterlein and Dawson (1984) advocate a stress-vulnerability model for mental disorder in which vulnerability factors interact with current social circumstances and stressful life events act as a trigger for a depressive episode – we take a similar stance in this paper. Although we do not have the space to enter into detail here we might agree that for a total treatment of depression to be effective effort needs to be divided amongst the disciplines of bio-medicine, social interventions, psychology, cultural, political and economic policy. We are interested in the depressed person as a whole: vulnerability, stress, triggers etc.
Biomedical treatment of depression
Treatment options
Antidepressant medication is the treatment of choice. Over the last 10 - 15 years SSRI’s (specific serotonin reuptake inhibitors) and related agents have become the most popular although the older tricyclic antidepressants and even on occasion MAOI’s (mono-amine oxidase inhibiters) are used. Occasionally benzodiazepines are used for brief periods to treat patients with depression and concurrent agitation or anxiety, with more complicated agitation or when symptoms verge into psychosis a major tranquilliser or antipsychotic may be tried. Patients with recalcitrant or episodic depression are sometimes prescribed prophylactic mood stabilizers such as lithium salts or other anti-epileptic preparations, in more extreme cases or when depression is considered to be ‘treatment resistant’ ECT (electro convulsive therapy) is considered. I base the above on a number of years of experience in various psychiatric establishments.
According to Ryle (1991) in deciding whether to use antidepressant medication both the current symptom pattern and the patient’s history must be taken into account, the more marked the symptomatic picture (particularly somatic symptoms) the more likely the need for medication; indeed, the severely depressed patient is unlikely to engage with other therapeutic modalities until the antidepressant has, to some extent, been able to stabilise and lift the patient’s mood. NICE (2003) guidelines suggest that antidepressant medication is not appropriate for milder cases of depression and that the patient be given choice of other treatment modalities. Based on my own experience, many psychiatric establishments take the view that the depressed should be given antidepressant treatment in the initial stages of management; if the patient does not show significant improvement within say six months then psychotherapy or other treatment options are considered. I am unsure as to how universal this view is but suspect widespread use. Often patients will profit from combined medication and psychotherapy.
Various biochemical explanations have been used to theorise how life stress and difficulty can be translated into the neurochemical changes that characterise depressive illness, Gelder et al (1996) suggest there may be a deficiency in neurotransmitters such as noradrenalin, dopamine and serotonin in certain areas of the brain involved in regulating reactions to stress and in altering behaviours commonly noted in depression. Another theory implicates abnormality in the functioning of the brain systems that regulate hormonal secretion and other important biological activity. Also noted is a disturbance of nerve cell function owing to an alteration in the distribution of certain positively charged ions (such as potassium and sodium) across the nerve cell membrane, which leads to a state of unstable hyper-excitability across the central nervous system (see Stern and Mendels, 1980).
Although there is some support for these hypotheses, often based upon the neurochemical effects of the antidepressants, they do not account for all the symptoms noted in depression; to what extent neurochemical changes represent a correlation as opposed to a causal factor in depressed mood currently remains unclear.
Sociological aspects of depression
According to Safran and Segal (1996) one of the more enduring criticisms levelled at psychological models has been the scant attention paid to environmental stressors faced by depressed persons, theorists then wonder why psychological interventions aimed at these psychological symptoms fail to assist. Harris (2001) comments that increasingly over the last decade there has been a ‘rapprochement’ between researchers investigating inner psychological cause and those investigating the outer social world. However, according to Gotlib and Hammen (1996) sociological perspectives have not attained the status of a cohesive model in the same way that psychological or bio-medical theories have. It seems that although CAT pays homage to the impact of the social and cultural life of an individual it remains essentially a dialogic theory as opposed to a systemic account. Dialogic refers to two individuals in relationship but does not take account of the wider social systems within which all operate. As we shall see the importance of systemic social events has an importance in the genesis of depression; I believe it is important for CAT to bear this in mind.
For our purpose we are interested in the study of life events, i.e. to examine the associations between depressive disorders and certain types of event in a person’s life. Ostensibly, it seems reasonable to assume that people who have been subject to adverse situations such as an unhappy relationship, disputes at work, economic disadvantage, unsatisfactory housing or more recently asylum seeking etc are more predisposed towards developing depressive features than other people; indeed, outpatient teams often seem besieged by such cases. Finlay-Jones and Brown (1981) have summarized the evidence for the clinical significance of ‘recent stressors’; they conclude that life events are especially related to the onset of mild and moderate depression. Brown & Harris (1977) describe vulnerability factors amongst women that increase the likelihood of depressive incidence; these include, firstly, current social indicators, primarily: not working outside the home, lack of a close confiding relationship and having three or more children under the age of 15 at home; secondly, past events, which increase vulnerability notably, loss by death or separation of the depressed person’s mother before the age of 11 yrs. Past vulnerability factors can perhaps be considered as a psychological or intra-psychic factor. A later study (Brown and Harris, 1993) found that adversity in childhood such as physical, emotional or sexual abuse increased the likelihood of depression developing in adulthood; major loss in adulthood with lack of social support also is correlated with depression. It is known (see Gotlib and Hammen, 1996) that depressed persons are more likely to have a smaller and restricted circle of social support than their non-depressed counterparts. Paykel and Cooper (1992) found that poor social support and integration are predictors of depression. Harris (2001) notes that since the 1980’s self- deprecation and social withdrawal have been seen as essential almost to the development of depression, he suggests that low self-esteem and lack of social support generally exist for a person prior to the clinical onset of depression.
Importance has been given to events involving loss of people or of cherished ideas due to adverse experiences, Harris (2001) reports that recently such events have been mapped according to the emotional impact and meaning for the person, he notes that experiences of ‘humiliation or entrapment’ have been identified as particularly prominent prior to the onset of depression. Events not involving humiliation or shame (e.g. no-fault unemployment) lead to much lower and less severe levels of depression. One can see a correlation between someone suffering from low self-esteem and a recent stressor of humiliation or provoked shame. Put simply a Brown and Harris sociological model of depression might read: -
Low self-esteem resulting from past history + Humiliation in the present
= Risk of depressive onset.
Harris further suggests that people with learned low self-esteem vulnerability their-selves are often causal in producing their own humiliating experience, this idea is of course central to a range of psychotherapeutic and in particular CAT thinking: i.e. the circular procedural relationship between emotional, cognitive, behavioural and environmental events. So ‘the lack of any supportive relationship which might protect against onset issues not always from the hostile networks into which life has currently thrust them [i.e. the depressed] but sometimes from their own attachment styles which have led them to avoid intimacy or to alienate potentially supportive figures by their needs for enmeshment’. In sociological terms, people become alienated from society, rather than integrated into it. As Karp (1996) has suggested, alienation of this kind may be a result of a biopsychosocial feedback loop: depressed affect, leads to separation from others, which leads to more intense depression, and so on around the loop. The work of Brown and Harris etc has been influential but not always replicated, it is also true (see Gotlib and Hammen, 1996) that the majority of persons who experience significant life stressors do no go on to develop clinical depression - yet overall there appears to be a six to nine times increased risk of clinical depression following aversive life events in persons possessing the right precipitating features.
The psychology and emotionality of depression
Emotion can be defined as follows: - ‘a strong mental or instinctive feeling such as love or fear, emotional intensity or sensibility’ (OED, 9th edition). Although useful this definition leaves much of importance unsaid. Greenburg and Safran (1987) state “Few practicing clinicians would deny that their patients emotional experiences in therapy play a pivotal role in the process of psychotherapy change’; certainly this is so in my own clinical practice and is a basic tenet of CAT theory. Emotion could be said to be at the very core of psychotherapy, as the later discussion of individual cases will show. In the following review we shall attempt to relate psychological theorising together with an appreciation of the role of the emotions implicated in depression.
Motivation and emotion are closely related, for example anger is frequently an emotional motivant of aggressive behaviour. Emotion can activate and direct behaviour in a similar way to purely biological motives - e.g. hunger and tiredness respectively motivate nourishment and rest. Emotions may be positively goal directed in that certain activities we follow will bring us pleasure, or emotions may be negatively directed, e.g. avoidance of a fearful situation. Since the time of Darwin (1872) and before some emotions have been considered ‘basic’, Power and Dalgleish (1997) consider fear, sadness, anger, disgust and happiness to represent the basic emotions, others might wish to include ‘surprise’. ‘Complex’ or socially and culturally derived emotions such as jealousy, despair, disdain etc can be thought of as a combination of two or more of the basic emotions (i.e. nostalgia as an admixture of happiness and sadness) or as an emotion(s) combined with an intellectual/cognitive/social/cultural component (e.g. disdain could involve disgust in the presence of an intellectual disagreement of someone’s opinion), in any event complex social emotions are seen as deriving from the basic emotions. Some emotions are regarded as primitive - almost ‘visceral’, anger and territorial protection for example have been related to the limbic system of the central nervous system, a characteristic and neuro-structure shared by our reptilian evolutionary ancestors. Other emotions e.g. complex cultural and social emotions such as love and pity assume an ethical dimension, yet others have a group character, shame and guilt as will be seen are perhaps the classic examples.
Power and Dalgleish (1997) comment that it would be useful to re-list psychiatric disorders in terms of their main emotional dysfunction. This would be a difficult task with regard to depression as so many factors are involved. In terms of basic emotional subsystems: sadness, anger, fear and disgust are all implicated as are a range of complex social emotions such as despair, hopelessness, humiliation and shame. The range of factors to be noted under the psychological discussion such as loss and mourning and sociological factors such as interrelational difficulties, social withdrawal, loss of self-esteem and significant ongoing life adversity etc relate and contribute to depression and must also be written into the account.
Behavioural and cognitive approaches
Behavioural approaches to depression were popular until the early 1980’s after which they were overtaken by cognitive perspectives. Behavioural theorists said little about the impact or meaning of the emotions in depression and saw them as drive mechanisms implicated in the processes of positive and negative conditioning. Following in the tradition of Watson and Skinner, Ferster (1973) saw depression as the consequence of inadequate or insufficient positive reinforcement leading to insufficient positively conditioned behaviour. Other theorists saw depression as a behavioural deficit, e.g. a lack of assertiveness or self-esteem that resulted from a lack of positive reinforcement. Some of these ideas have remained in other approaches, e.g. CBT and CAT homework setting.
A number of related but differing cognitive psychology theories of depression have been suggested. Seligman (1975) proposed a learned helplessness theory, depression is seen as the product of a history of faulty learning regarding personal locus of control, when one is subjected to negative events seen as outside of one’s control - hopelessness, passivity and depression result. Ellis (1962) proposed a Rational Emotive (Behavioural) Therapy, in which dysfunctional emotion or lowered affect is seen as the result of an irrational belief system.
Aaron Beck (Beck et al 1979) has proposed, perhaps, the most accepted cognitive theory. Beck suggests that lowered affect is secondary to dysfunctional cognition. Three major features of cognition are believed to perpetuate the disorder. First, the ‘cognitive triad’; this consists of negative cognitions concerning oneself (e.g. “I am undesirable, worthless and inadequate”), the world (e.g. the world is defeating and overly demanding), and the future (e.g. “I am always bound to fail and to suffer”). Secondly, faulty thinking or cognitive errors, which maintain the cognitive triad of which a number of errors have been identified, e.g. all-or-nothing thinking, overgeneralization, mind reading, personalisation and discounting the positive etc. In time thinking errors become so practiced they gain an automated quality, these are termed ‘automatic negative thoughts’. People are usually only partially aware of their automatic thoughts; however they exert a great influence over how they view the world and accordingly behave. Thirdly, schemas; these are hypothetical cognitive structures that influence the screening, coding and organization of environmental information. Negative schemas are learned from early unfortunate interactions with the environment, especially with significant others. Sometimes early experience can shape maladaptive attitudes and beliefs in the child. Dysfunctional schemas (e.g. “I must do everything perfectly or else I’m a failure”) can predispose people to distort events in a characteristic fashion that leads to depression. It is thought that dysfunctional schemas and beliefs can lie ‘hidden, dormant’ and unacknowledged for a number of years until a series of events ‘re-awaken’ the schematic beliefs which then activate the cognitive triad.
Cognitive theory often sees emotion as an event that occurs after perception and appraisal, to some extent emotions are considered an unwanted an epiphenomena. So cognition precedes affect, a model could be written thus:
Event ---- Perception ---- Cognitive appraisal ---- Emotion ---- Action.
A popular book that perhaps epitomises this approach to emotion and emotional disorders is ‘Mind over Mood’ (Padesky, C., and Greenburger, D, 1995).
Criticism has been made of this approach i.e. how little an attempt is made to view emotion as an integrated aspect of the evolved biological system. Information processing models have heavily influences cognitive theory and use the computer as a metaphor for mind; people are implicitly viewed as information processors that are disconnected from the environment, i.e. as decontextualised beings who disturb their-selves only by their thoughts. Gilbert (2000) views this ‘purely cognitive view’ as theoretically flawed, not supported by the evidence and politically dubious - certainly this simple view seems to ignore much of the sociological evidence previously discussed.
Having reviewed the ‘basic’ cognitive approach we should realise that, like any other, cognitive theory is continually refined and redefined. Developments have occurred within cognitive theory regarding the role of the emotions. Working from an academic psychology perspective and using an information processing model Power and Dalgleish (1997) describe a theory of the emotions akin to Aristotelian functionalism; i.e. they look at the functional role of the emotions, so for example anger has the function of motivating an individual to violent retaliatory behaviour. Emotions are ‘conceptualised in terms of the functions they perform in the individual’s psychology’; the psyche is conceived as a functional goal directed system. Power and Dalgleish define emotional ‘states’ as comprising: - (1) an event (external or internal to the person), (2) an interpretation of the event, (3) an appraisal of the situation, (4) physiological change, (5) a propensity for action, and (6) conscious awareness. Often certain actions and behaviours will follow. Power and Dalgleish also allow for the existence of unacknowledged or ‘unconscious’ emotion - e.g. suppressed or denied anger. It is the interpretation and appraisal of an event which produces one emotion as opposed to another, thus if one appraises the removal of an object as a welcome event one is happy whereas if one views the removal of the object as a theft one is angry. Interestingly this representation reminds us of Ryle’s (1990) early cognitive-analytic ‘procedural sequence model’, although the sequence of the elements differ.
Evolutionary approaches
Evolutionary approaches regard emotions as not just ‘feelings’ which exist inside of us but as a form of information about the self in interaction with the environment; therefore, emotion, perception and action are inextricably linked (See Safran and Segal, 1987 for an evolutionary and integrative psychological account). Evolutionary psychology (see Stevens and Price, 2000) views the human mind as a product of evolution; it is concerned with identifying the problems that our ancestors faced and the adaptations that evolved to solve these problems. Emotional systems, which are adaptive, survive through processes of natural selection whilst maladaptive systems are selected out of existence; we do however need to note that not all emotional experience and expression is adaptive, if it were there would be little need for psychotherapy!
Evolutionary theorists see emotional systems as relatively independent systems of mental events and action potentials, or as the tendency of our brains to function as a set of semi-autonomous subsystems, almost as if a number of different and competing systems have the potential to operate and the emotional appraisal of a percepitant decides which system to use - metaphorically emotional appraisal ‘decides’ which record from the duke-box to play. Emotional states, processes and systems which have proved adaptive to hominid and human emergence have been selected-in, whilst presumably non-adaptive systems have been selected out of the evolutionary process. Of course this begs the question: How is it that depressive behaviour continues despite the fact that it seems to work against biologically adaptive behaviour? We do not have enough space to enter into this question in detail; however, Beck (1985) postulates that depression does have an adaptive function. Historically when supplies of food were low, or when access to powerful figures may have been limited (e.g. in times of tribal conflict) ‘depression’ may have acted as a type of hibernation behaviour to either conserve body energy levels or else to keep quiet and hidden. Hagen (2002) proposes a bargaining model of depression; following an aversive life event the depressed person undergoes something akin to ‘a labour strike’. When powerful others are benefiting from an individual’s efforts, but the individual them-self is not benefiting they can, by reducing their productivity, put their value to others at risk in order to compel their consent and assistance in renegotiating the social contract. Each view suggests that depression, similar to a phobic response, at times has a useful function but often exists out of kilter with the existing social setup and takes on an exaggerated form out of alignment with current need.
Psychoanalytic approaches
Psychoanalytic theory tends to assume that emotions are affects attached to ideas and that their presence indicates a disturbance in psychic equilibrium (Rycroft, 1995). An affect is usually thought of as ‘good or bad’ but does not have the differentiated quality of an emotion. Early psychoanalytic thought linked affect and cognition to somatic process through the notion of instinctual psychic energy. Freud believed that human beings could only be understood as creatures of biological evolution driven by non-social instinctual forces; it was felt that if one accepted the irrational nature of instinctual forces then one could accommodate to the environment through such processes as ‘sublimation’. Affect was seen in terms of the hydraulic concept of energy accepted at the time; emotions operate under pressure of instinctual impulses which are driven to discharge to preserve the homeostasis of the system - that is the organisms need to maintain a quantity of psychic energy at a constant level. Excessive psychic energy is discharged in the form of emotion, the development of emotional life was conceptualised as an interaction between instinctual and environmental forces. Psychic energy was said to provide the driving force behind emotion and to shape its particular character in life. In this scheme emotions and memory are strongly linked. For Freud unconscious emotions are different to unconscious ideas; unconscious ideas exist as actual structures whereas unconscious affect represents the potential for conscious emotion, which was prevented from developing, (Freud, 1915).
This ‘instinctual drive model’ of the emotions can be criticised (in similar vein to criticism of early cognitive theory) on the grounds of its monadic emphasis; the self and incumbent emotions are seen as a wrapped up biological package sufficient and self-maintaining unto itself - with interaction with the later environment and other people occurring almost as an afterthought. Psychoanalysis has made little use of the distinction between basic emotions and complex social emotions and tends as a result to interpret simple emotions as manifestations of complex ones. There is also a tendency to assume that complex emotions are present at birth e.g. Klein (1935) attributes envy to the newborn infant.
For psychodynamic theory, loss and the resultant emotion of sadness together with redirected anger are regarded as the chief components of depression. Abraham’s psychoanalytic theory (1911) maintained a depressed individual redirects his feelings of hostility, anger and rage towards a ‘lost’ person and channels them inwardly against the self. This account was expanded by Freud (1917), who also introduced an early ‘Object Relations’ element into depression - here loss can be real, imagined or symbolic. Typically lost ‘objects’ reflect individuals who are significant but regarded ambivalently, i.e. love concurrent with anger, early in a child’s life. The lost object is often the mother and particularly is lost during the oral phase of development. In order to make the loss of the mother-object bearable the child learns to internalise a representation of the lost object. Loss is heralded as a vulnerability factor that may lead to depression in adulthood if the individual is confronted with a significant loss of role or status later on. Freud compared the experience of grief and mourning to that of depression and melancholia but emphasised in depression the importance of loss of self-esteem, self-denigration, feelings of worthlessness etc. Freud hypothesised that the denigration of the self is not actually towards the self per se, but that there is an identification of the self with the lost object; thus anger and disappointment that previously had been directed towards a lost object are now internalised leading to a loss of self-esteem and a tendency to engage in self criticism - as if ‘the shadow of the object falls upon the ego’ (Freud, 1917). Pedder (1982) argues that later in his career Freud would not have considered that internalization of the lost object only occurs in depression; Pedder argues internalisation is common in grief and indeed is an important stage at the end of psychotherapy, though, it must be remembered that in 1917 Freud wrote in the infancy of Object-Relations theory.
Klein (1934) argued that a predisposition to depression was not due to early loss per se, but rather to the quality of the mother and child relationship in the first year of life. Depression is more likely to develop as the result of failure of the child to overcome ambivalence towards its love objects - excessive fears and anxieties and low levels of self-esteem lead to risk of depression later in life. Pedder suggests the child needs to develop ‘good object constancy’, which he hypothesises occurs around the age of 9-10 yrs before the good object can be used as an antidote to depression; prior to this and particularly with greater amounts of splitting used as a psychic defence, object constancy is not so available and therefore a vulnerability to depression exists. One could note this seems to parallel more recent cognitive investigation that suggests a depressed individual does not have greater amounts of negative cognitions that the non-depressed, rather there is a lack of positive cognition to counterbalance the negative for a depressed person (for a discussion appertaining to this point see Gilbert, 2000).
Building on Klein’s work Jacobson (1971) used an Object-Relations perspective to hypothesise that fusion of the individual’s self and object-representations early in childhood result in the self-condemnation and reproach typical of depression. Anger and hostility are directed at the lost object and its internal representation, but through the process of fusion the internal representation of the object and self become indistinguishable. Consequently the anger and hostility initially directed towards the lost object are experienced as self-condemnation and self-hate. Kohut (1977) notes the importance of idealisation in early childhood. With normal caring parenting a child’s behaviour is idealised; in effect the parents act as a mirror in which the child can see him or herself as good and loved (or bad etc), these idealisations are internalised – resulting in good self-objects. The person who experiences good self-objects is seen as psychologically healthy.
Attempting to sum up the various contributors Pedder comments that the predisposition to depression arises in childhood from early disappointments in the child’s relationships with its parents. Good enough infant care promotes the establishment of good internal objects and lays the foundations for self-esteem. Also, manageable amounts of disappointment or disillusionment are prophylactic in immunising the child against much larger disappointment, anxiety and frustration that occurs later in life.
Blatt (1998) comments that Freud attempted to devise a unified theory of depression instead of recognising that two mechanisms operate separately; namely, depression caused by object loss at an early stage of development and depression caused by harsh super-ego development. From a current analytic perspective Blatt, drawing on varying current psychoanalytic accounts, differentiates between an early object loss depression focused primarily on interpersonal issues such as dependency, helplessness and feelings of loss and abandonment - which he terms “anaclitic” or dependent depression; and depression derived from a harsh punitive super-ego focused primarily on self-criticism and criticism of others and concerns about self-worth, feelings of failure and guilt which he terms “introjective” or self critical depression. Similarly Bowlby (1988) discussed different mechanisms of depression in: firstly, anxiously attached individuals who seek interpersonal contact and are excessively dependent on others; and secondly, compulsively self-reliant individuals who avoid intimacy and contact with others. Cognitive theorists have proposed a similar type of depressive classification: i.e. socially dependent or sociotropic personality types who fear the loss of a close partner, and autonomous personality types who fear loss of status and a fall in social hierarchy.
The role of shame and guilt in symptom formation
We noted earlier that disgust could be considered one of the basic five emotions. Power and Dalgleish (1997) argue that when disgust comes to be applied to the self then the foundation for many emotional related disorders, including depression, are laid. Bibring’s (1953) classic ego-psychoanalytic reanalysis of depression argues that depression may be derived from the primary emotions of sadness and disgust as opposed to Freud’s construction of sadness and anger. Similar to Freud, self-condemnation and guilt are directed towards the self but they are seen as deriving from the emotion of disgust as opposed to anger. Low self-esteem and feelings of humiliation may also be seen as deriving from disgust directed towards the self, such that aspects of the self are seen as bad and need to be eliminated or rejected from the self.
Over the last few years there has been an enormous growth of interest in shame. Gilbert (2000) regards shame as one of the most powerful and potentially problematic issues in psychotherapy because it involves concealing experiences or being unable to process shameful information. Shame and guilt belong to the group of self-conscious emotions (e.g. Lewis, 1993) in that each requires an internal evaluation of the self against a set of culturally defined rules and standards in which the self is adjudged to have failed. Guilt relates to some standard to which we fall short and often concerns a particular action; for shame it is the ‘self’ that is at fault, one believes oneself to be totally useless ‘bad’ lacking in value etc. Shame is about the total person. Shame is manifest physically by a dropping of the head and a contraction and withdrawal of the body. Object Relations theory highlights the primacy of relationship and sees shame as an experience of being alienated or cut off from others, threat or damage to social bonds is an important context of shame. With shame comes a loss of self–esteem and feelings of powerlessness and humiliation which, as we have seen, are a major component of sociological descriptions of depression. Guilt is more associated with an attempt to put right what was made wrong, i.e. an act of reparation.
The recent focus on shame in psychopathology breaks with the traditional psychoanalytic focus on guilt. Freud came to see guilt as a failure of standard judged by a harsh superego and ICD-10 argues for guilt as a key component of depression. However recent theoreticians (see Gilbert, 1992) argue that shame is a key component of depression in the sense that shame arises from a combination of disgust, anxiety (fear) and anger directed towards the self. With shame it is the self rather than an act carried out by the self (as in guilt) that becomes an object of that disgust and anger; so shame has an internal directed nature, whilst guilt an external focus towards the behaviour directed to another.
Shame is implicated in social dominance hierarchies in which submission and defeat versus dominance and triumph are a consequence of an individual being shamed by a critical other. Shame and guilt are primarily social and cultural emotions that develop from early social interactions and are re-activated in socio-cultural settings; however, early experiences are internalised and later involve the relationship between the self and oneself. Typically shame and guilt are often considered to be ‘harmful’ emotions but we should remember that both aid the development of the self. The experience of shame provides a navigation to the child for acceptable and unacceptable behaviour and provides important feedback about how behaviour and the self are viewed by significant others, this in turn aids the development of the self further. Shame therefore has a crucial role in socialisation because the child wants to follow cultural standards and cares about the opinions of others, to quote from a standard work on Transactional Analysis: - ‘The capacity to feel shame is built into human beings, and it has a civilising effect in adapting a child to his family and culture’ (English, 1975), in order to remain connected one needs to understand and follow the cultural rules of society.
On a cautionary note it may be wise to remember Maslow’s (1975) remark ‘If the only tool you have is a hammer, you tend to see every problem as a nail’. Resnick (1977) disagrees with any phenomena or concept that begins to approach a universal explanatory scheme; although it is wise to note the importance of the role of shame and guilt in the causation and maintenance of depression we should not forget the impact of other factors and emotional states as noted earlier.
Psychosocial and cultural approaches to the emotions
Averill (1980) asks for a psychosocial perspective of the emotions; he claims that a social level of analysis is necessary for a complete understanding. Complex ‘social’ emotions are viewed as social constructions that provide transitory social roles; a role is viewed as a socially prescribed set of responses for a given situation. These roles, which are similar to the reciprocal roles of CAT, are viewed as culturally arranged responses designed to resolve conflicts in the social system. Different emotional roles fit into the overall arrangement of social interaction. Averill conceptualises emotions as responses governed by cognitive structures that guide the appraisal of environmental information and the person’s response. Averill is primarily interested in the cultural rules that govern emotional expression. Emotional behaviour and experience are determined by the meaning and requirements of the emotional role as that person interprets. Once people understand the meaning of their emotional roles they monitor their own behaviour and experience in light of this understanding. Averill draws close to the contributions of Vygotsky (1978). Vygotsky felt that individuals’ personalities are not self generated but are shaped and maintained through their social interactions with others. In this view complex social emotions can be seen as a facet of cultural interaction – there is a rejection of the monadic view of selfhood, self and emotion are cultural constructs in league with inherited characteristics.
Towards a theoretical synthesis?
Ryle (2002) taking a lead from Vygotsky and current evolutionary psychology maintains that CAT is based upon ‘a clearly defined and radically social concept of the self’. During individual development personally and socially meaningful interactions with others are internalised to form mental structures and capabilities. Ryle (1990) considers primary emotional responses to be processed rapidly, unconsciously, and by a partially separate affective processing or appraisal system which scans the environment for events of personal or social significance. This model does not see emotion as an ‘end point’ of information processing, which can be managed by therapeutic technique, but integrates emotion into the heart of human experience and sees it as (in league with other cognitive and appraisal systems) a driver of human action, perception and memory; so a study of emotion becomes essential to understanding human experience and interpersonal behaviour. The integrated view proposed by Safran and Segal (1996), amongst others, also offers a more satisfactory account in which existing knowledge from many sources including: cognitive, evolutionary and psychoanalytic, puts emotion at the forefront of human experience and emphasizes its organizing role in the experience of reality, sense of self, and orientation toward others. We may note however that even amongst cognitive theorists a differing attitude is developing towards the role of the emotions in psychological dysfunction (see Mahoney 1984).
A Cognitive Analytic Therapy perspective of depression
Emotional states and reciprocal roles etc
So what is the link between emotional causation, the differing theories of depression, and CAT theory and practice? We could argue that the idea of an emotional state as a semi-autonomous subsystem is similar, in part, to CAT’s notion of Reciprocal Roles and the self-state. A Reciprocal Role (RR) refers to how we relate-to and experience others. RR’s can be considered as a concept derived, in particular, from Ronald Fairbairn’s Objects-Relations theory and modified into a more cognitive or accessible hands-on model. Ryle describes a RR thus:
A stable pattern of interaction originating in relationships with caretakers in early life, determining current patterns of relationship with others and self-management. Playing a role always implies another, or the internalised voice of another, whose reciprocation is sought or experienced. (Ryle, 2002)
We can note that ‘self management’ refers to a particular type of RR acted within oneself or to oneself. It is important to note that ‘Role’ as explained here implies action linked to memory, meaning, cognition and affect/emotion etc. By way of example if someone criticises us we can feel and take on the role of being criticised, or in turn we can be critical and they take on the role of the criticised, within this process memories of earlier criticism will be evoked and the current situation charged with meaning which in turn will charge and direct our actions. As noted RR’s can also be directed by the self towards the self, so for instance we can learn to be critical of ourselves and in turn feel criticised, as if by an internal critic - early role relationships with others have now become internalised and can self-maintain. A Reciprocal Role procedure ‘contains’ an emotional state which ‘colours’ the way an individual perceives other people, the world and their-selves in relation to the world; the emotion also impacts upon the way a person relates to and behaves towards the world, their-selves and to other people.
One way of looking at a ‘self-state’ refers to the way in which people can become locked into a type or ‘state of mind’ which is relatively self-enduring and un-open to other ways of thinking, feeling and behaving and un-open to contradictory information from the environment or from other people; thus a person reciprocating to an-other in a state of anger can only see the person, their-self and the world in general as influenced by their rage, an ‘unreasonable’ state of mind results, e.g. the saying “I saw red”. A RR self-state represents a relatively autonomous emotional, perceiving, appraising, thinking and behaving sub-system of operation upon the world and the self. Usually most of us move transitionally from one RR to another with relative ease, so for example we can commence by being polite to someone, move to curiosity, intrigue, passion, annoyance, understanding and back to politeness etc in a matter of minutes. If particular emotions are strongly aroused, e.g. fear or shame, we can find ourselves set in a particular frame of mind for a considerable time seemingly immune to attempts to alter our mood. I consider depression to be a particular type of depressive self-state in which a limited number of RRP’s (with emotions, set cognitions etc) predominate to the relative exclusion of others. Depressive RRP’s can be longstanding and seem impervious to change attempts from either the self or from others’ attempts. A self-state represents a partial (or in some cases almost complete) shutting off from interaction with other people, problematic RR procedures have a psychosocial feedback quality to them, traditionally in CAT parlance this is termed a trap, once commenced depression has a self-maintaining feedback quality.
A cognitive analytic model
As noted earlier Freud’s quest for a single route to depression is impracticable, the ICD-10 account also appears unsatisfactory though it never professed to be more than a general description. Earlier we differentiated between two main types of depression, the ‘dependent’ or object-loss depression and the ‘self-critical’ depression. Linking together our understanding of emotional functioning with psychological interaction and informed by social process we should be able to explicate a general CAT description of the two depressions.
Two proposed CAT models of Dependent depression (DD) and self-critical depression (SCD) are proposed. Both are presented in a form similar to a sequential diagrammatic formulation. One point to note for those unfamiliar with CAT Sequential diagrammatic re-formulations (SDR’s) is that an SDR does not attempt to depict what occurs in the mind-body-environment continuum, instead the SDR isolates various mental and environmental occurrences in a manner which shows these events in sequential relationship and in a circular feedback fashion; we may note here the similarity to Karp’s (1996) biopsychosocial feedback loop or Brown and Harris’s self maintaining depression model. There is no automated or laid-down means of producing an SDR although many stick to general principles; yet even a basic SDR can vary considerably dependent upon the practitioner, the main focus has always been on producing SDR’s which are illuminative and useful for the practitioner and intended recipient.
Templates act as guidance rather than certainty in an actual world, please note the models relate to the period of depressive dysfunction and are not representative of premorbid functioning, though they seek to outline the early psychological and social vulnerability of the individual. Both models are suggested as general accounts and as relatively distinct from each other, that is we are interested in drawing out the differences and looking at two routes to vulnerability.
Dependent depression
The DD is characterised by feelings of loneliness, helplessness and weakness, these individuals have an intense and chronic fear of being abandoned and left unprotected, see diagram 1. These ‘anxiously attached’ patients have a deep longing to be loved nurtured and protected and often show excessive dependency and clinging behaviour. Clinically and metaphorically these patients often have an ‘emptiness’, as though we would wish to fill them with ‘good’ from ourselves; but no matter how hard we struggle we fail to nurture and sustain these individuals, like trying to fill a sieve with water. Because there has been little internalisation of the good qualities from others, caused by early object-loss, others are valued primarily for the immediate care, comfort and satisfaction they provide, but little real relationship results. Clinically these patients can be draining and exasperating. Attempts to assist guided self-discovery or increase self-efficacy are met by protestations of inability to cope or ‘disinclination’ to help their-selves. This counter-transference, once recognised, provides a clue to the nature of the patient’s inner psychology and helps enable one to accept the nature of the RRP being enacted in the room. Once recognised it is far easier to challenge or work with this procedure.
Diagram I
Early in life the child experiences a significant loss - loss can be real (i.e. separation from a caretaker) or symbolic, e.g. a parent who is emotionally absent. One could predict (as did Bowlby) that the more traumatic the abandonment (e.g. in the absence of other mitigating circumstances such as an older supportive sibling or other relative or carer) the greater the risk of severe dysfunction. Abandonment and loss experiences are internalised, ‘stored’ as part of the RRP and cognitive and emotional content of the psyche. In order to accommodate to the emotional pain of the RR the child will devise (probably unconsciously) certain life aims and procedures to adapt to the pain. In the face of loss and abandonment, the child using a psychic inner adaptation, develops an idealised version of the lost object. One can see primary splitting in operation, due to a lack of object constancy the internalised object is split into ‘abandoning, loss, emptiness’ versus an unrealistic ‘fantasy protector, nurturer, comforter etc’. Dysfunctional RRP’s are thereby commenced and perhaps are analogous to analytic unconscious defence mechanisms or the ‘Life Scripts’ of Eric Berne’s Transactional Analysis.
To some extent how the child feels and perceives him or herself is socially and culturally determined. As noted earlier mind, complex emotion and how we process emotion and experience is at least in part culturally constructed and determined, other basic emotional systems and coping abilities appear to be evolutionarily and biologically hard-wired. The emotional pain ‘contained’ in the RR can be seen as a type of ‘battery of energy’ driving the RR procedures onwards. Initially dysfunctional RRP’s may be mild or embryonic and unapparent to the self or close others. Similar to cognitive and analytic models, the RRP’s of Cognitive Analytic theory await later development before they become truly problematic.
This early disadvantage constitutes a vulnerability to depression. It is at this stage that the sociological impact of significant life events, as discussed earlier, become apparent; an event or circumstance may occur which metaphorically replicates the early experience: perhaps the person is abandoned by a partner or left to cope on their own in life etc. This leads to a re-experience of abandonment, aloneness etc in which the person perceives him or herself to be helpless and weak. Once ‘awakened’ the depressive RR self-state assumes a relatively stable systemic and self-maintaining structure.
Depletion of ‘psychic energy’ can be interpreted in many ways ranging from a loss of focus on what previously was important in life, to a turning inwards upon the self and withdrawal from exterior life, to a neurotransmitter disruption caused by an overabundance of the stress hormone cortisol etc. Nonetheless, the person experiences panic, fear and anxiety and desperately seeks to be helped protected and loved by others. At this stage a number of events can occur, if no ‘protector’ is actually or symbolically available (this is not shown on the diagram as such) then the person re-experiences even greater loss and abandonment and so ‘loops around’ the diagram becoming increasingly desperate and depressed.
Sometimes people are available to help; however, dependency, clinging and a ‘whining’ need to be protected from a harsh world can cause even the most patient of carers to withdraw. In any event, no helper can ever provide enough to repair the nurturing-need within the depressive and eventually all fail - leaving the depressive to realise that once again they’re on their own. Sometimes in an attempt to escape from the harsh world the depressive will take to alcohol, drugs or other escapist behaviour; fugue and trancelike states are sometimes noted Some people sit for hours in a car when due at work etc, others are found lost miles away from home and out of synchronisation with their usual memories or coping abilities. The point we are trying to draw is that a wide range of individualised behaviour is possible at this point dependent upon the individual nature of the person and the degree of depression experienced. By self-or-other agency the sufferer finds them self isolated, withdrawn and socially redundant, this experience leads back to and confirms the original belief of being alone in the world, unloved and abandoned.
An abandoned child will develop a range of beliefs to account for their abandonment, sometimes these beliefs are only partially recognised but may include ideas of being evil, tainted, unlovable, unwanted etc; the depressive develops shame, guilt, self-loathing etc. An idealization defence may be used intra-psychically or the adult may try to undo their abandonment by finding a perfect protector, or by trying to prove to their-selves and others that really they can be loveable and worthy etc. An internal struggle may ensue, although having found an ‘idealised protector’ the depressive still believes they were originally abandoned because they were and remain unlovable, unworthy and evil. Perhaps the protector needs protecting from the evil depressive sufferer, one way is to absent oneself from the carer, suicide may seem an option and can be seen as the ultimate justification of the belief systems inherent in this disorder, suicide can be justified (by the depressive) as being in the best interest of the carer. A milder option is to seek absence via other withdrawal mechanisms, mental health workers often happen across depressed individuals (often depressed women) who wish to be taken away from their partners and children because “they’ll be better off without me”. In summary the depressive may either drive others away, thus fulfilling the original emotional belief system; or they may absent their-selves from others using the belief system as a justification for their actions.
Self-critical depression
Although shame and self-criticism has been noted in DD the overriding feeling is one of emptiness, abandonment and clinging. It is with the self-critical depressive (SCD) that internalised disgust of the self merges with anger and self-and-other criticism becomes so prominent. The SCD feels unworthy, guilty and inferior – these individuals engage in harsh self-scrutiny and have a chronic fear of criticism and of losing the approval of significant others. They strive for excessive achievement and perfection, are often highly competitive and make great demands upon their-selves and upon others; superficially they may achieve a great deal, but with little lasting satisfaction - internal self-sabotage will make certain of that! Because of intense competitiveness the SCD can be critical and attacking towards others. Through overcompensation they strive to achieve and maintain approval and recognition see, diagram 2, a tendency to perfectionism is often noted. Clinically these patients often have a flavour of hostility and suppressed (though not always suppressed) anger and suspicion. Often the SCD will ‘attack’, perhaps for having being kept so long on a waiting list or the receptionist was rude or the appointment time did not suit etc. Frequently, anger is disguised or undisclosed but one may feel a sullen ‘smouldering’ just beneath the surface. A therapist can feel unwilling to engage the SCD Diagram 2
and on assessment can relate a host of reasons why the SCD are not suitable to be seen by the department and certainly not by oneself as a CAT therapist! Sometimes this countertransferential urge to punish, or discovery of the patients inner anger may take longer in therapy to manifest, however, it provides an important clue to the SCD’s psychological inner world and often hints at the nature of the therapeutic work to follow.
A proposed CAT model of SCD envisages an early caretaker as harsh and critical towards the child. Loving attachment is sought as is approval and recognition, this is met by put-downs and perhaps ridicule and humiliation; as a result the child feels anger, rage even at being treated so harshly when all he or she desires is love. Being small and ineffective it is difficult to direct this rage towards the criticising caretaker, all that may result is even harsher criticism or punishment, instead the anger is directed against the true offender – the self, after all maybe the caretaker is right and the child/self is unworthy. A basic tenet of Object-Relations theory is all humans seek relationship and warm attachment with an-other, initially with the prime caretaker. Instead of the love the child so desperately seeks, harsh criticism is given; having failed to live up to expectations and win respect the child strives increasingly harder to provide what is requested, this is encouraged by the caretaker with exhortations to strive yet harder. Reciprocally the child may produce more (feels driven) but usually to no, or limited, effect. The child introjects harsh criticism from an-other into an inner-self which becomes self-critical; a compensatory RR of ‘striving to driven’ arises as a defence or adaptation against the criticism: the criticised child is guilty of failing and therefore not deserving of love from others, the striving child is given some recognition and regard and after all is following the advise of the parent which may seem like a route to love and attachment, although this hope is often forlorn.
The above can be seen as the childhood precipitant of vulnerability towards depression. Reciprocally we have a person inclined towards criticism of their-selves and criticism of other people together with inner demands to try still harder and external exhortations from others to strive yet harder. A great deal may be achieved by these RRP’s but often little satisfaction is gained at what has been achieved or the effort spent achieving it is continually criticised and undermined; or once achieved the person does not deserve the gains as ultimately they are no good and not deserving of love and recognition. Similar procedures are used against others perhaps with equally harsh criticism. Depression rears when a series of setbacks or an adverse significant life event occurs: perhaps a partner leaves as a result of continuing criticism or serious arguments occur with the other person attacking back – leading later to self-criticism. Maybe children are exhorted to further efforts, fail and leave the household in disgust at the continual criticism; in any event it becomes apparent that the early ‘life script’ of the patient has failed. Greater efforts lead to continued failure and the patient may find them self socially isolated and redundant; or perhaps being continually driven results in an exhaustion of energy (psychic and physical) with resultant ‘shut down’ and a withdrawal into the self. The SCD can find the ‘main game plan’ of their life in tatters, as a result life has no purpose and all meaning is lost.
At this stage a wide range of behaviour is possible similar in many respects to the DD. As mentioned the SCD does not feel so ‘empty’ as the DD although often a ‘hollowness’ is noted; one notes instead an anger towards life, others and them-selves for everything going so wrong. Self or narcissistic wounding is often noted, perhaps with drunken binges etc to block out the realities of life, or serious suicide attempts as a means to punish the self or others for the pathetic weakness and failure. The broken line on the diagram is an attempt to show that as the depression deepens the ‘strive harder’ RRP no longer functions as a defence for the patient (itself a reason for self criticism), the patient can become locked into a self-state of perpetual criticism, shame, humiliation and anger, it is often at this stage that ‘shutdown’ and depletion of psychic and physical energy occurs, together with a feeling of apathy and hopelessness regarding the self, others and the future.
Discussion
The two models share certain features in common. Both contain elements of angry behaviour and of guilt or shame, both can alienate others leading to social isolation, social redundancy and loss of energy within the psyche. Yet there is a different ‘feel’ to each. The SCD has an aggressive (to other or self) energy, with unworthiness, inferiority, failure and guilt prominent; whilst the DD centres on longing and loss, loneliness, helplessness and shame. The DD often has a great fear of hurting other’s feelings and at times can appear obsequious in order to maintain the dependency; conversely the SCD is not averse to the emotional attacking of others in an attempt to shore up their own weak ego at the expense of the other - even though they are profoundly vulnerable to criticism from others. However, there is no reason to suppose that an individuals’ depression is not sometimes an amalgam of both routes, therefore an individual could undergo early object-loss (say the death of a mother) and then suffer a childhood of a critical father whereby interactions are later internalised into punitive self criticism. I would hypothesise that the DD is somewhat more represented in women and the SCD is more represented in men, this would fit with the tendency of males to indulge in more aggressive acts of self-harm whilst depressed and for women to be more dependent in their behavioural pattern (see Gelder et al, 1996).
The two models of depression are based on an individual’s RR’s, problematic adaptive procedures and fundamental character structure, as well as significant life and cultural experiences that initiate and help maintain the depressive features. One should note from a psychosocial perspective that the importance of events and experiences lies not so much in the events but in the individual’s perception of that event and of the meaning ascribed to the experience. ‘Truth and meaning’ from a constructionist viewpoint are both cultural and social constructs; what one person construes as harsh criticism another will see as helpful comment, what elicits depression in one will leave another untouched.
Readers conversant with the CAT literature may note a certain similarity between the two models of depression and with depictions of borderline and narcissistic personality disorder. The DD shares an idealisation RR with the borderline personality disorder and abandonment is often also a feature with borderlines; however, abusiveness per se is not so highly represented in DD as it is with the borderline and there is less harsh self-state mood shifting from one RRP to another. The mood of the DD tends to be continually low whilst borderlines may self-state shift from high excitability, to destructive and uncontrollable emotional despair, to cutting off from emotion - as opposed to the blanking-off of emotions of the DD. A therapist is able to engage positively and honestly with the DD whilst the therapeutic position is less clear with the borderline. The SCD shares elements of striving and self-criticism with the narcissistic personality disordered patient; self-wounding is also a shared feature. Similar to DD one is able to engage in an honest therapeutic relationship with the SCD whilst with the narcissist one can engage in an admiring-to-admired transference and counter-transference, which can make therapeutic engagement problematic, here narcissism is used as a defence against depression. In general, with personality disorder, the disorder ‘gets in the way’ of therapeutic work, almost as if the patient ‘doesn’t want to get better’ (though deep down they do); with depression one can engage with the sufferer to assist with their mood dysfunction and unwanted social situation.
We could question whether DD and SCD are impacted upon differently by shame and guilt, or is this an argument mainly of semantics? It seems this is an area in need of further exploration and analysis. Nevertheless, we might conjecture that SCD is more influenced by guilt and DD by shame. The SCD attacked by criticism attempts to make good their ‘shortfall’ by striving and ever more vigorous attempts to make-good, i.e. an act of reparation commensurate with their guilty wrongdoing. The DD cannot hope to make good their ‘shortfall’, they are basically unlovable, feel ashamed and direct this emotion of anger and disgust towards the self – i.e. they experience shame from which there is no escape.
CAT models of depression applied to case studies
This paper presents an attempt to suggest a CAT perspective of depression, hopefully taking into account a range of thought, research and suggestion from other approaches. At this stage it may be useful to consider the two models with regard to a small number of cases I have worked with. Possibly it would seem more satisfactory to present and discuss cases from other practitioners, one difficulty though is reliance upon other practitioners isolating the same factors in which we are interested, and also completing SDR’s in a manner consistent with our approach. But, as mentioned our task is initially to suggest a model which if considered valuable, other practitioners are at liberty to use modify and extend. To guard against total subjectivity the cases I have chosen to present are all cases previously and independently diagnosed as having a unipolar depressive illness, the SDR’s I depict were all formulated and produced before this paper was proposed or undertaken and have been included unaltered. The names of all people mentioned have been altered to protect confidentiality.
Dana H. - dependent depression
Dana was a female patient seen for sixteen CAT sessions plus a follow up. Her SDR is represented in diagram 3. Dana was referred by her GP and CPN following a period of over three year’s of intermittent depression, anxiety as a co-morbid feature was prominent with frequent panic attacks. An anxiety management class (conducted along CBT lines) was attended by Dana and felt to be useful although little improvement in Diagram 3
mood was noted. Dana has been prescribed an SSRI antidepressant together with occasional use of diazepam; she maintained little benefit had occurred.
Early in life Dana was ‘abandoned symbolically’ by her mother who suffered from post-natal depression, reports suggest her depressed mother showed little emotion or regard towards Dana, although in a practical sense she looked after her. This pattern persisted throughout childhood; Danna’s father ‘abandoned’ her and his wife by joining the merchant navy and remaining absent for long periods. The soon-after birth of a rival sister, who seemingly was doted upon by mother, increased the feeling of abandonment and isolation. Dana remembered her mother, in particular, being judgemental and at times harshly punishing; but the overriding feel was one of emotional distance. In later years both parents remained aloof. At school and on home visits Dana was exposed to the love and warmth experienced by her friend from their parents; unsurprisingly she remembered wishing and fantasising about being in an ideal domestic situation herself - of being able to move in with a friend and receive love and attention. This compensatory idealisation offered a refuge against reality and an adaptatory cut-off from difficult emotional experiences which were hard to manage.
As an adult Dana was continually fearful of being abandoned and left, unseen and unheard. Although married with two children, at the age of 33yrs Dana still indulged in rich fantasy in which people would love, admire and rescue her. Grudgingly she admitted this fantasy kept difficult emotions at bay but prevented her from dealing with her difficulties and from ‘repairing’ her life. Intense fear of being alone and abandoned lead to two major life difficulties. First, with fear of aloneness, anxiety and panic attacks occurred. An image used to describe this situation (produced by Dana) was of being left alone to cope in a black hole and struggling violently to get out and be reached by others. The image seemed to fit with Dana’s description of a panic attack, it seemed as though anxiety was at the very core of her personality.
Secondly, as problematic for Dana was her history of entering into a series of disastrous relationships with men, where the relationship was actual or quasi sexual and with women where the degree of emotional intensity reached a peak ending in mental exhaustion. After fourteen years of marriage Dana’s husband was becoming exasperated by a series of near-miss affairs with men or of women remaining in the house until the early hours of the morning. Predictably relationships always went wrong with either Dana rejecting the person when her needs were not met (e.g. a man who wanted sex but not emotional reciprocation) or the person rejecting her.
Predictably, the main difficulty throughout therapy was the tendency for Dana to become emotionally attached and dependent upon the therapist, to fantasise upon the therapeutic relationship but to avoid working on the real issue of abandonment. An attempt to refocus the therapy, mid way through, was itself seen as an emotional abandonment by the therapist with Dana ‘clinging-on’ with increasing desperation, e.g. “why are you being so official, why cant we just talk as friends?”. One had the sense of never being able to provide enough to satisfy her emotional need. Remaining boundaried felt to Dana like a rejection of her self.
The SDR reformulated for Dana shows Dana’s DD. Other problematic procedures could have been drawn but I decided to concentrate on the most prominent issue. A judging/critical to judged/criticised RR was also in operation, thus showing an element reminiscent of SCD, and indeed Dana could be self or other critical but the overriding theme was of fear of abandonment. Fantasy life and “fantasy” relationships staved off depression for many years but eventually broke down following a miscarriage in which neither her mother or her husband were felt to be emotionally supportive and told her to ‘get on with life’. A supportive friendship with a man at work ended when he wanted to provide sex rather than support after the miscarriage. Once depression set it was difficult to resolve even after three years had elapsed since the miscarriage; we can see that depressive maladaptive procedures had the self-maintaining quality of a depressive self-state; Dana’s reciprocal procedures were un-open to adaptation via non-depressive role interactions with other people.
We can see a merger between the psychological predisposition to depression, that is early object-loss and the failure to develop good object constancy, as seen in the lack of a positive relationship with either parent and the adult sociological stressors of loss via miscarriage in the context of perceived lack of emotional support from husband and mother together with a humiliating rejection from a man, with whom she craved comfort, but who only offered unwanted sex.
The self-critical depression of Carol S
Carol presented with a diagnosis of depression (see diagram 4 for a depiction of her SCD) and a request for psychotherapy from her psychiatrist. Carol had taken large amounts of antidepressants for over two years and had been a longstanding member of an open ended assertiveness group for nine months. Despite these interventions Carol remained low. Initially Carol found it hard to proceduralise her difficulties yet hinted at not being able to manage her emotions ‘I feel like a little girl’; and not being assertive with others. Carol’s assessment suggested an insecure but over-attached relationship with her highly critical mother.
Carol spent her early years being criticised and intimidated by her cold and unloving mother who ‘always got her own way’. Carol’s father received much the same treatment but took to drink and would scream back (in vein) at his wife when intoxicated. Frightened by the anger Carol learnt to isolate herself in her room and indulged in fantasies of escape by reading adventure novels concerning escape from the Germans in WWII etc.
As an adult Carol had two main relationships, partner one was ‘weak’ like father; a male child resulted from the relationship. Partner two bullied like mother. Finding no pleasure in relationship Carol retreated into a friendless self-isolating existence, fairly devoid of emotional comfort, meaning or adult contact apart from regular interference by her mother. Carol contented herself with daily gym training, wearing headphones to avoid contact with people; she obtained a part time job as a van driver delivering spare parts, again little contact with people was needed. Apart from her parents Carol had one friend, Diagram 4
A woman who made no demands and offered little, the pair met at a CMHT out patient appointment.
Carol’s isolated, emotionless life continued until once again people intruded. Carol lived in a flat above a shop, when the tenancy changed to an ‘Alldays’ supermarket Carol heard ‘the shop girls’ shouting, screaming, having fun and listening to the radio. Carol complained to the supermarket manger, environmental health (re the noise), her landlord, the police and the council - all to no effect. At this time even her 13 yr old son was beginning to see her behaviour as ‘peculiar’. Carol felt that everyone had ‘let her down again’ which confirmed her solution of self imposed isolation but also lead to a depressive episode of over two years duration. Carol rehoused herself and thus the social aggravation was resolved but the depressive episode continued.
Once commenced Carol’s depressive self-state had a quality of bitterness and anger towards other people and towards herself for being a failure. For Carol a diagnosis of depression ‘proved’ she was a failure and a weak useless person. Guilt, shame and internal criticism were particularly prominent. During therapy the impact of Carol’s self and other criticism were apparent, it was as if one could feel the anger emanating; Carol, although polite and self-effacing was quick to take offence if I ‘made a mistake’, e.g. in session two I forgot to return her psychotherapy form.
From the SDR (diagram 4) we can see the harsh parental criticism RR which now had internalised; the striving RR (of the basic SCD model) is represented in the demanding box, ‘Intruding’ can be seen as the method by which Carol’s mother criticised her, this eventually internalised into self and other criticism. Interestingly, the anger shown by Carol’s mother towards her own husband also ‘manifested’ in Carol as an anger towards ‘weak’ and loud, noisy people. The fantasy box represents the original idea Carol had of her own wants and needs. Carol recognised that she took her anger and frustration out on herself but was unable to see that she ‘attacked’ others and upset people who then were unwilling to help. Carol’s belief was that she was the victim of a cruel hard world and she needed to act by being more assertive and shouting back. Owing to the time limit and due to the restricted nature of her ability to emotionally understand the problematic psychodynamics I decided to work, in the main, on elements of open and ‘honest’ communication with others. Carol became more open and assertive concerning her own needs and considered therapy to have been a success; however, important elements of her life are missing from the SDR, which represent a strategic decision on how to describe what seemed important to Carol and on which issues to proceed. However, I recognised that much work remained undone by the close of therapy.
This case shows a merging of psychological vulnerability resulting from early childhood criticism together with adult stressors (shop girls making a nuisance and no-one assisting her) which instigated a depression. One can see the interplay between psychological and sociological factors and how, to some extent, Carol with learned low self esteem set in motion her own humiliating experiences via a psychosocial feedback loop a la Karp (1996). Once commenced the SCD had a self maintaining quality, Carol’s attacking attitude towards others drove people away, once isolated there was no one to assist Carol and she found herself unable to cope with life on her own, this was used as evidence to ‘attack’ others for not helping and herself for being ‘too week’ to cope by herself, a classic example of a CAT trap.
Aims of CAT
Hopefully these case examples give an insight into some of the issues encountered whilst working with depressed people. We have considered reasonably ‘pure type’ cases in order to test the fit of our models with real life patients. Hopefully we can see the qualitative difference between the dependency due to abandonment and early object-loss of Dana and the self-criticism and inner rage of Carol, which had been internalised from the child-mother-father relationship. However, there is an inherent danger when working with models of depression. Patients are often referred to psychotherapy by GP’s or other health professionals with a range of depressive and biological symptoms. One could conclude that the ‘job’ of the therapist is somehow to allay the problematic syptomatology. This aim runs counter to much psychotherapeutic and CAT thinking which concentrates upon the perceived difficulties and life concerns of the patient, a negotiated attempt is made to look at the dynamics behind the symptom picture and resolve inner conflict together with the life and social difficulties experienced and self-constructed by the individual. A model of depression with a ‘paint by numbers’ approach would ill fit with CAT’s stated aims However, our objective has been to differentiate and describe depression as a totality and to place it within a CAT theoretical context, this should enable us to better understand the problem area and hopefully provide a tool to use as appropriate and assist patients in a more thorough and knowledgeable manner.
Working with dependent depression
With the basic framework in place we shall further turn our attention to exploring some of the difficulties encountered while working with the depressed. Initially let us consider an additional case to draw some of the difficulties encountered whilst working with DD and consider how to work with these concerns in clinical practice.
Ego-strength in depression
Dave a 48yr old married man was referred with depression and concurrent anxiety by his GP, initially assessed by a consultant in psychiatry, who increased his medication, it was felt after six months of treatment that insufficient progress had been made and assistance was sought from psychological services. At assessment Dave was found to be considerably depressed and suffered from a range of biological symptoms commensurate with ICD-10 pointers. Dave complained of general lethargy, diurnal variation of mood, inability to concentrate and loss of libido with inability to achieve erection - all of which were having a deleterious effect upon his marriage. A mild mannered and previously sociable man Dave presented as a clinging, helpless and somewhat ‘pathetic’ individual; life appeared to have lost all meaning and hopelessness pervaded his view of the future, one attempt at suicide had occurred and the risk of future attempts remained.
Due to the longstanding, interpersonal and childhood related nature of his depression it was felt CAT would be a suitable intervention; however, despite six months of antidepressant medication Dave’s mood remained consistently low and the risk of suicide remained high. Given the demanding and exploratory nature of CAT it was felt this approach might prove over-taxing - Dave just lacked the ego-strength to engage with the therapeutic task.
Preliminary groupwork
One can see a difficulty commonly encountered when working with the depressed, but perhaps particularly with DD; namely a lack of energy or of ego-strength to engage with therapy. Ryle’s 1990 book Cognitive-Analytic Therapy: Active Participation in Change presumed that engaging a person by a joint reformulation of their history and current situation would ensure their participation in therapy. But for many depressed persons this is not so; antidepressant medication may help but sometimes remains insufficient to significantly lift their mood. Dave was referred to a Depression Management Group which was co-facilitated by another staff member and myself. The group continued for some twelve sessions and was managed along broad-based CBT lines but included material from other approaches and was fairly practical in nature. Fourteen participants who had been significantly depressed for over six months and were on medication took part in the group, all participants were screened for severity of depression by scrutinising clinical records and by administering a batch of rating schedules (e.g. BDI, HAD and Effect-on-life scoring).
The Depression Group made a considerable impact on alleviating the depression levels of the members. Yet, several of the members went on to have further psychological treatment: either CAT or other approaches. The group did not appear to alter underlying psychopathology yet seemed to bring people to the point where psychotherapy could be influential. On reassessment Dave presented with much the same content but now was open to change. Dave commented that being in a group of fellow sufferers had much helped, listening to others’ experience he felt less alone and less ashamed of himself, this allowed him to slowly contribute to group process and look at the nature of his own difficulties without so much guilt. Many members described the group as a ‘weekly haven’. Often as group facilitators we were ‘ridiculed’ for not being depressed and therefore unable to understand the experience of the depressed; whatever the truth of this assertion it appeared that being in a group with other depressed persons was far less shaming than being with the non-depressed – this encouraged a self-to-other opening. Differing perspectives are available as to why the group assisted, but one could note that interaction between group members occurred in a boundaried, structured and safe manner. We could conjecture that a type of forced role-reciprocation occurred. We have noted previously that depression can be seen as a self-maintaining self-state, outside of true role-reciprocation with others, forced role-reciprocation perhaps begins to reverse this process, the depressive self-state begins to dissolve.
Following successful completion of the group Dave underwent a successful CAT, as though the group had developed his ‘ripeness’ and willingness to work with therapy. In total three of the group members underwent CAT, two others benefited from CBT and one other from personal counselling. Many psychiatric services are unable to offer Group initiative prior to individual therapy, this is unfortunate as many patients ‘drop-out’ from the waiting list or are later found to be difficult in individual therapy. Without entering into a discourse on group theory one could argue that the nature or content of the group are of less importance than that of the group offering boundaried and structured interaction between group members.
Group work can be seen as one method of strengthening the weakened psyche and social world of the DD, but often the helplessness, hopelessness and ‘apathy’ of the DD patient is forbidding. If we consider the three patients who underwent a group prior to individual CAT work we can see they received a total of thirty-two sessions (group assessment – 1, group sessions – 12, group follow-up – 1, reassessment – 1, CAT – 16, CAT follow-up – 1, total = 32). The traditional number of CAT sessions envisaged for a ‘neurotic’ presentation is sixteen. Yet, debatably sixteen is insufficient for the slower moving DD. Self-state dissolution can be a slow process; also one may be involved with helping reinvigorate a patient’s social system. Arguably twenty-four sessions, or longer, may be necessary to effect change of a necessary standard. Given that a longer than usual time may be necessary to therapeutically assist the depressed one has to consider whether the increased time is invested directly into more CAT sessions or whether other ego-strengthening preliminary CAT work would prove more beneficial.
Ego-strengthening methodologies
What other methods are there to assist the weakened self of the depressed other than group work or longer CAT’s? One method to increase the self-efficacy and moral of the depressed may be to offer, say, six weeks of preliminary ego-strengthening work, hopefully this should also assist with depressive symptom control as a first step. Cognitive therapists often do an amount of preliminary behavioural work (see Beck et al, 1979) prior to consideration of automatic thinking and dysfunctional assumptions etc. Methods include keeping activity diaries, task centred homework (e.g. exposure routines) or information gathering tasks. The range or content of the tasks or preliminary work one might use is enormous and limited only by the imagination; e.g. art work, relaxation for the anxious, referral to other groups etc. One other approach to consider is the Cognitive-Humanist therapy of Motivational Interviewing (MI) of Miller and Rollnick (1991).
Originally conceived as a therapy for addictive behaviour MI can be seen as an approach to assist people ‘trapped by ambivalence’ between change or homeostasis, MI is seen as strengthening the motivation for change. Miller and Rollnick see motivation not as much as a personality problem but more as ‘a state of readiness or eagerness to change …. That can be influenced’. CAT, alongside psychodynamic and cognitive therapy, concentrates on the psychopathological, CAT can be seen as a problem solving therapy, often this is useful but for the depressed an exploration of the problematic can seem like one more attack upon a vulnerable self consumed by loneliness and shame. To take a patient to the causal genesis of their depression via the reformulation process can on occasion worsen the depressive episode, hence the exhortation to check for preliminary ego-strength before considering a therapy. MI concentrates instead upon the existing (even if meagre) strengths in the personality and reinforces movements towards adaptation. The patient is helped move through a cycle of pre-contemplation of change, to contemplation, to determination and action. The emphasis of MI on the adaptive, versus the problematic focus of CAT, perhaps places MI at one level of a continuum and CAT at the other. Nevertheless, it may be that the two approaches could work well together in treating depression; MI to encourage motivation and CAT to effect ‘active participation in change’ once the participant is more motivated or strengthened to undergo the change process. My understanding is that CAT and MI have indeed been linked together in such areas as addictions and eating disorders, although no research or data is currently available in terms of the relative successfulness of combining the two.
The therapeutic relationship
DD individuals, as mentioned, frequently seek and reciprocate the care and concern of their therapist; often they complain of somatic difficulties or intolerable anxiety as seen in the cases of Dave and Dana. Predictably (see diagram 1.) patients often idealise their therapist, particularly after the relationship is cemented via the reformulation process. Kohut (1977) views idealisation as a necessary development. A patient will move through the process, initially, of seeing in the therapist a ‘return’ of the lost fantasy object to later, a normal person good and ill combined. The therapeutic task lies in fusing the idealised object (fantasy protector in diagram 1.) with the abandoning object (and all the bad this entails). In effect this represents the usual developmental task of combining split part-objects: so the world is neither bad nor good but a combination of both.
Combination is clinically a difficult task. Dave’s ‘empty clinging’ idealisation took the form of attempting favours and asking if we could meet for a drink after work etc; however, by the close of therapy he was more able to control and understand his dependency seeking requests. Dana’s clinging was more problematic; either we were in idealised fusion, which had erotic undertones or I was seen as rejecting and abandoning which filled her with dread of ceasing to exist and caused her to cling ever tighter and complain bitterly: “how can you be so cruel when all I want is to be a friend to you”. Towards the end of her therapy Dana felt she understood herself better but never managed to tolerate her wish for co-dependent fusion with an-other.
The psychoanalytic notion of ‘regression’ is useful here. Regression refers to reversion to an earlier mode of functioning - such as infantile idealisation of an-other (see Rycroft, 1995). With depression the more deeply depressed the patient becomes the more childlike their behaviour can appears to others, Freud considered regression a necessary condition of successful therapy. From a CAT perspective regression can be seen as elementary procedural functioning - as acquired in childhood. The more regressed a DD becomes the greater the degree of childlike dependency and problematic procedural in-session enactments shown: towards the therapist. Although sometimes problematic, regressed behaviour provides clues about the parenting style the patient received as a child, and the role positioning played by the child; this provides an opportunity for exploration, challenge and procedural revision by the patient.
For the CAT therapist the task is to provide care without dependency and insight without abandonment or rejection. Kohution therapists attempt to re-parent or re-nurture their patients; the CAT approach, similar to CBT or Transactional Analysis, is to enlist the co-operation of the ‘adult’ in the personality. Enlisting the adult entails the patient assuming a degree of control over his or her emotional life, belief systems and actions, all within the context of renewed understanding; i.e. being able to see how past events lead to the development of current difficulties. With understanding the patient develops a degree of choice. Prior to therapy Dave acted out the problem procedure:
I feel abandoned and lonely, I need others, I will do what ever they want me to, and then they will rescue me.
Unfortunately rather than acceptance people rejected Dave for his annoying ‘puppy dog’ like behaviour. Once Dave had his problem procedure described he was more able to recognise its occurrence in life and in therapy, and take steps to correct and adapt his behaviour and tolerate his emotional distress. Toleration of emotional distress was achieved essentially through trial and error in which Dave ‘discovered’ that though feeling distressed nothing awful actually occurred to him.
As a therapy CAT operates across the spectrum of the emotional, cognitive and action systems. Under the auspices of an idealising relationship the therapist can encourage the patient to undergo ‘homework’ tasks (as described in the previous section), emotional trials or cognitive investigations etc. The suggestion is that the idealising relationship can be used to motivate and invigorate a reluctant patient. Developmentally this process is similar to the Vygotskian notion of the ‘zone of proximal development’ which is seen as the gap between what a child can do on his or her own and what the child can do with assistance and encouragement from his or her parent/teacher. In the context of an idealising relationship a patient should be able to move further that he or she could on his own. By the close of therapy the aim is for the DD to realise that separateness is not abandonment or rejection, that being an independent person is a positive experience of more benefit than fantasies of pure care. Thus the patient has moved from a position of idealising or seeking fused dependency with the therapist to a position of ‘realness’ where the world is less ‘fantastic’ and more a place in which one can live and experience real relatedness.
Working with self-critical depression
Inevitably many of the issues relating to one type of depression cross over into the other. The Depression Group referred to earlier dealt with SCD patients as well as DD Even though each type of patient used the group differently the rating scores suggested that each benefited. One could suggest that group work, lengthier CAT’s and preliminary CAT work as identified would benefit each. In this section we shall concentrate on the difficulties in the therapeutic relationship encountered whilst working with the SCD.
Difficulties in the therapeutic relationship
We noted earlier that the SCD shares certain features with narcissistic personality disorder; the SCD is unlikely to exhibit the same over-inflated ego; however, a grim self-satisfied manner is sometimes noted. With failure of the striving RRP (see diagram 2.) to produce results the SCD finds their primary defence mechanism redundant and lapses into internal criticism with feelings of guilt and shame. Hostility towards others and the therapist may barely be concealed and has a tendency to ‘leak’; the SCD is sometimes quarrelsome and difficult to help. Part of the difficulty is that any attempt to elucidate the nature of the depressive difficulty or to formulate a problematic procedure is seen by the SCD as an attempted criticism, countertransferentially it seems as if the patient considers “I came here to be helped, not have my problems rammed down my throat, if that’s the best you can do, I’d best look elsewhere”. Sometimes it is difficult to like the SCD, as will be seen in the following case example, and perhaps particularly if the patient criticises the therapy. Yet, by understanding the nature of their reciprocal role relationships one can feels great sympathy for the DD - if one can intuit the distress beneath the harsh exterior and reach through to the wounded person inside.
Sharon F was a forty-three year old single woman who took a major overdose following a relationship failure. Her partner of six weeks duration has recently buried his daughter who died from cancer. Sharon felt he should be showing her more attention as she was experiencing difficult relations at work, following an argument she took an overdose and drove to the seaside to die, a passer-by found her in a coma and an ambulance was called. A ten-day hospitalisation followed after which she was referred for psychotherapy. On assessment Sharon complained that throughout her life men had failed her, as had her sister and father. Employers failed to recognise her worth or provide adequately reward despite several years of service. Following the recent relationship breakdown Sharon re-experienced a total loss of hope, felt desperate and decided life had no meaning and that the one person she loved (her son) would be better off without her. Sharon detailed a lifelong history of episodic depression triggered by relationship failure; this was her third attempt on her life and perhaps the fifth depressive episode. An attempt to reformulate her difficulties into problem areas or aims based upon her reportage was met by rebuttal; it was difficult to warm or sympathise towards Sharon who finally asked “If I were ill like the people in [psychiatric] hospital, would I be taken seriously and treated different?”
The nature of the self-critical condition counters the therapy and sours the therapeutic relationship; Carol (see previous case example) tended to see descriptions of in-session problem procedural re-enactments as an attack upon her self, though over time she learnt to tolerate the emotional arousal. Sharon attended three sessions before deciding she no longer needed therapy; a future depressive episode is predicted.
Countertransference felt emotion affords an insight into the psychology of the SCD in the room. As our previous discussion on the role of the emotions suggested the emotional appraisal system of the SCD scans interpersonal interaction for elements of personal significance which then are mediated through an internal relationship with a criticising object, the patient ‘discovers’ criticism, will criticise him or herself and possibly retaliate in a critical manner to an-other. If an ‘argument’ occurs the patient feels him or herself on familiar territory and the original schema is systemically evidenced - thus satisfying the self fulfilling prophesy belief system.
Working with SCD it may be wise to vary CAT technique, ‘active participation in change’ (Ryle, 1990) may need delaying. Ego strengthening methods as described may be useful but with a self-and-other critical attitude and without such an idealised relationship the therapist may need to tread wary; perhaps forgoing detailed problem description and spending extra time cementing the therapeutic alliance. Again an MI, or similar approach, can be used but eventually the CAT aim is to connect to the frightened person beneath the self-other criticism, to reach through to the driving core emotional experience of vulnerability and ‘unloved-ness’ inside. The reformulation process of allowing the person to describe their ‘story’ and retelling the story in sympathetic manner through the uncritical eyes of an-other (i.e. the therapist) is particularly useful perhaps with the caveat to allow the patient to move at his or her own pace as opposed to a ‘universal’ rule to reformulate after four or five sessions. One could predict for SCD patients that without such an approach therapy is unlikely to be successful. In partial support, Blatt (1998) reviewing an analytic research programme comments ‘Harsh, critical, judgemental super-ego introjects and negative representations of self and others in these introjective patients appear to limit markedly the effectiveness of all … brief treatments’, interestingly the brief treatments referred to consisted of sixteen sessions. However, Blatt suggests that with longer therapies SCD patients have more potential to substantially improve than the DD patient.
Working with shame and guilt
As mentioned, shame represents an attack by the self upon the self; a number of emotional subsystems are involved together with affect laden self-critical and destructive cognitions. Rhetorically, shamed patients are ashamed of their-selves and feel guilty of their actions. There is an inclination to draw inwards, to cover-up shameful experiences and hide behind a façade; and despite an attempt to reach the vulnerable person inside shame acts as an internal saboteur disrupting therapeutic intention, the therapeutic relationship and aims towards self-growth. Shame can result in important experiences remaining undisclosed, sexual abuse is an obvious example. The major therapeutic traditions comment upon this difficulty: Freud wrote of a punitive super-ego, Gestalt therapy comments upon ‘top-dog and under-dog’ components of the psyche, Transactional Analysis upon dysfunctional parental to child transactions and behavioural and cognitive approaches refer to self-punishment etc. CAT takes a similar, albeit less inspiring, approach in terms of the RR relationship: Critical – Criticised, Abusing - Abused etc.
Sally J was an early case (1999) of SCD I worked with, (see diagram 5), as a child she had suffered continuous harsh criticism from her punitive mother. Criticism continued up to the time Sally commenced therapy. During childhood criticism came together with severe punishment, any attempt to develop self-independency or find a voice for herself literally was ‘beaten out of her’. By the time she reached her 50’s Sally had become a morose self–effacing individual. Interestingly, Sally showed no anger towards her mother, only continued terror which often resulted in PTSD like visual flashbacks. During supervision we hypothesised that her anger and shame were turned inwards against herself, she experienced shame and guilt but was entirely unable to experience or recognise feelings of anger, at least initially. It was as if the rage had been beaten down to the depths of her psyche where it remained poisoning herself against her-self. I would Diagram 5
like to include elements from a letter I wrote to Sally (a CAT ‘goodbye’ shared letter) as I feel this summarise what occurred in therapy and is pertinent to many of the issues under consideration:
“Initially the difficulties we considered were centred around the sense of guilt and shame that often seems to accompany you, how hard you find it to say "yes" to yourself; also, we were concerned with the difficulties you have feeling so responsible for other people and especially "letting go" of Karen.[Sally's disabled daughter} In order to help meet these aims we focused on three patterns, which are connected with these aims.
Early on, we spent time looking at how early relationships and circumstances helped shape your world and the way you relate to your environment and to other people. We looked at how the way your mother treated you (often abusing and blaming you) have lead to a common feeling of shame and guilt over many of your actions and also in your dealings with people. The way you were brought up to be responsible and care for other people has perhaps made it hard for you to be able to say "yes" to yourself, find a voice for yourself and also encourage you to how you feel over responsible for other people, especially Karen, to this very day.
I feel that as you related your story to me and we looked at relationships, past and present, more and more you began to see how your history has helped shape you and influences the way you deal with people, and events, in the present. With this understanding you yourself suggested a number of ways out of your difficulties. You began to recognise your right to be heard, your right to your own space, time and enjoyment. I feel you began to find the strength inside yourself to say "yes" to yourself and to look for your share of "good things”
I noticed that as the weeks went by the relationship in the room between us seemed to develop. Initially I felt you may almost have felt as if you were with "an important person", perhaps someone who could make things better if you "did as you were told", however as time went by I feel you began to trust yourself more and also myself more so that a more "real" trusting relationship developed, you certainly became much less nervous of me when an event went wrong - such as your being unavoidably late, it seems that you eventually felt you could be more honest without feeling so guilty.
I do understand that you may feel as though you would have liked to achieve more from therapy than you eventually did and that this may seem disappointing. Towards the end of therapy Karen returned home; it may have seemed that you were back to square one with no time for yourself and husband, again having to say "yes" to everyone but yourself, you also told me that you felt you were being blamed by everyone for the decision that you made and how once again you were feeling guilty; however, even here you began to recognise that the main person who blame you now is - "you yourself”
Sometimes life seemed to be so difficult for you that there were times when you were not sure if you could even finish your therapy; however, I would like to congratulate you on being so brave and managing to see things through to the end.” (RM November 1999)
A number of ‘techniques’ can be employed to assist against self-sabotage; hinted at earlier is the desirability of allowing the patient to move at their own speed and divulge content when they are ready, this is shown with Sally who took up to eight weeks for the relationship to develop sufficiently for her to trust me and tell her story.
Another approach is by use of hypothesising. This method is similar to the Rogerian counselling technique of reflecting the feeling tone of the content back to the client and by careful use of language one ‘guesses’ at what lies behind the perceived distress; an attempt to proceed likewise with Sally is shown in writing in the penultimate paragraph of the letter; usually this is a verbal strategy but can be used to good effect in writing or diagrammatically. The therapist gives the patient permission to disclose shameful detail in the context of a soundly based therapeutic relationship. The process of written reformulation and sequentially diagrammed reformulation can be especially powerful here as embarrassing and shame-ridden content is placed in the context of total life experience, also shameful self-objects are exteriorised onto paper as if away from the self, this can help the disclosure feel less painful.
Although techniques (as discussed) and perhaps homework tasks etc are useful, arguably the greatest assist will derive from the therapeutic relationship. If shameful experiences are disclosed or if a countertransferential invite to the therapist to criticise or feel disgust is experienced it will be important to avoid a collusive and harmful reciprocation. Some therapies use devises such as an ‘inner friend’, or anchoring of positive resources a la hypnotherapeutic technique (see Alladin and Heap, 1991). With CAT procedural in-session enactments will be analyzed and the positive transference and relationship act as a future template for relating to others. Hopefully the positive and enhancing relationship is introjected by the patient for relating self-to-self and self to an-other. Over time the dynamics of the therapeutic relationship internalize and achieve positive self-object constancy. Good object constancy acts as a future prophylaxis against depressive onset. CAT makes use of a number of shared letters and tools which are given to the patient, therefore acting as transitional objects, a developmental stage towards achieving good self-object constancy.
Final observations and conclusion
In this paper we have attempted to formulate a CAT approach to depression. We have considered depression in terms of its medical and biological components: the impact of life events upon the person, both early life events which are seen as impacting upon constitutional and cultural factors to develop a ‘psychological vulnerability’ to depressive onset; and later ‘sociological’ factors and life events which are hypothesized as triggering a depressive episode in an already vulnerable person. A review was undertaken of psychological approaches to the emotions and to depression.
Traditional psychological models (Cognitive and Psychoanalytic) seem not to deal adequately with an understanding of the nature and role of the emotions in depression. An attempt was made to trace the development of the role of the emotions in order to more fully understand and account for the experience of depression. Emotions can be seen as part of our evolutionary inheritance, a series of semi-independent subsystems, which appraise the environment for personal meaning and give ‘drive’ to our actions, e.g. we will hit harder if we are angry and run faster if frightened! This view places emotions both at the centre of human experience and of mood - including the occurrence of depression. CAT seems to have taken a similar view of human nature, RRP’s encompass cognitive and emotional appraisal and experience systems, which lead to action potential, i.e. a series of mental, environmental, and behavioral events, which occur in a feedback self-maintaining, loop system (originally referred to as the Procedural Sequence Model, see Ryle, 1991). Of course we should be careful not to overemphasize the notion of self-maintaining systems as CAT disavows a monadic concept of human existence, CAT is inherently a social construction model; we live in dialogic relationship to other people, the socio-cultural environment and even towards ourselves, depression can be conceived as a perverse state in which the person is out of sync with the social environment and is relatively not reciprocating to others.
Together with the CAT construct of RRP’s we looked at the concept of the self-state. Unfortunately perhaps people use the term differently, but for our purpose we can view a self-state as a relatively autonomous subsystem of mind (self-self, self-other interaction) in which the person is relatively ‘closed off’ from interaction and information input-output from others. Therefore a depressive episode, once fully underway, can be seen as a complex depressive self-state, comprising a limited number of emotional and cognitive (RRP’s) sub-systems. The depressive self-state is ‘caused’ by the factors as outlined above (i.e. psychosocial and cultural experiences in admixture with constitutional factors) but once commenced is relatively impervious to the ordinary interactions of others. Also, it is as if once a particular self-state is cemented, other self-states are unavailable to the person, so if one is depressed then non-depressive states (i.e. joy, curiosity etc) are relatively closed-off; technically non-depressive states may not be self-states as they may involve full and beneficial interaction with others, e.g. Helping–Helped. The idea of the mind and of consciousness being composed of a ‘series of selves’, or of subsystems which exist relatively autonomously and independently of each other, is of course a well constructed historical theory reaching back perhaps to the early days of Buddhism, with its disavowal of a central-self, but currently undergoing development and investigation (see Blackmore, 2003).
Taking a lead from current psychoanalytic theory we detailed two separate routes to depression whilst remembering that often they share similar concerns and issues. From these models a CAT defined SDR approach was acquired and developed. Case studies were used to see if the models hold in practice. This approach was used to develop a deepening of a CAT understanding of depression as opposed to a prescription for every depressed patient; nevertheless a number of issues for discussion were drawn. It seemed as if a standard CAT therapeutic approach might not be best practice for the depressed as a first intervention; instead we advised pre-CAT input, e.g. group work, focus on symptom work, Motivational Interviewing etc, and the necessity of longer CAT’s. Possible differences in CAT technique and approaches to the two types of depression were considered.
A number of questions arise from this suggestive paper. It seems to me that the concept of the self-state and its role in mental disturbance is ripe for further consideration and development. With regards to depression it would be interesting to see if other CAT observers pick out similar patterning and differences when reviewing their patient population. Also, it would be interesting to review the SDR’s of patients who show similar RRP’s to the depressed but who are not yet depressed, are these patients showing a future vulnerability to depression, or are other protective factors in existence or are the models as described in need of further revision and definition? Wherever future developments may lead it seems CAT provides an extremely robust tool to describe and define mental illness and dysfunctional states and provide a means to consider the interpersonal, the intrapsychic and the social environment each in conjunction with each other.
References: -
Abraham, K. (1927). Notes on the psychoanalytical investigation and treatment of manic-depressive insanity and allied conditions. In E. Jones (Ed.), Selected papers of Karl Abraham, M.D. London: Hogarth Press. (Original work published 1911)
Alladin, A. and Heap, M. (1991). Hypnosis and Depression. Ch4 in Hypnotherapy a handbook. (eds) Heap, M. and Dryden W. Open University Press.
Averill, J.R. (1980) On the paucity of positive emotions. Referred to in: Greenburg, L.S. and Safran, J. D. (1987) Emotion in psychotherapy The Guilford Press.
Beck, A.T. ,Ward C.H., Mendelson, M., Mock, J. and Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry. 4, 561-71.
Beck, A. T., Rush, A.J., Shaw, B.F., and Emery, G. (1979) Cognitive theory of depression. Guilford Press.
Beck, A.T. (1985) Anxiety disorders and phobia. Guilford Press.
Bell (1999) The spectrum of problems in patients with eating disorders: an analysis of 30 patients treated with CAT. CAT Papers Collection, vol 2. 1999
Bibring, E. (1953) The mechanism of depression. In Greenacre, P. (Eds.) Affective disorders: psychoanalytic contribution to their study. NY: International Universities Press.
Blackmore, S. (2003) Consciousness: an introduction. Hodder, Arnold, H & S.
Blatt, S.J. (1998) Contribution of psychoanalysis to the understanding and treatment of depression. Journal of the American Psychoanalytic Association. Paper 4, 46(3)
Bowlby, J. (1988) A secure base: Clinical applications of attachment theory. Routledge. Mentioned in Blatt, S.J. (1998) Contribution of psychoanalysis to the understanding and treatment of depression. Journal of the American Psychoanalytic Association. Paper 4, 46(3)
Boyd, J.H. and Weissman, M.M. (1982) Epidemiology. In Handbook of affective disorders, (ed. E.S. Paykel, pp. 109-25. Churchill Livingstone, Edinburgh.
Brown, G.W., Harris, T., and Copeland, J.R. (1977) Depression and loss. The British Journal of Psychiatry. 130, 1-18.
Brown, G.W., Harris, T. and Eales, M.J. (1993) Aetiology of anxiety and depressive disorders in an inner city population. Psychological medicine 23, 155-65.
Cowmeadow, P (1994) Deliberate self-harm and cognitive analytic therapy. CAT Papers Collection, vol 2. 1999
Darwin, C. (1872) The Expression of the Emotions in Man and Animals . Paul Ekman (Editor). Oxford University Press. 1998
Ellis, A. (1962) Reason and Emotion in psychotherapy. Lyle Stewart
English, F (1975) Transactional Analysis Journal
Ferster, C. (1973). A Functional analysis of depression. American Psychologist, 28, 857-70.
Finlay – Jones, R., and Brown, G.W., (1981) Types of stressful life event and the onset of anxiety and depressive disorders. Psychological Medicine. 11, 803 – 16
Fosbury et al (1997). A trial of CAT in poorly controlled type 1 diabetes patients. CAT Papers Collection, vol 2. 1999.
Freud, S. (1915) The Unconscious. Standard edition, Volume 14. Hogarth Press
Freud, S. (1917) Mourning and Melancholia. Standard edition. Volume 14. Hogarth Press.
Gelder, M., Gath, D., Mayou, R. and Cowen P. (1995). Oxford Textbook of psychiatry. Third edition. (1996) Oxford university press.
Gilbert, P. (1992) Depression: The evolution of Powerlessness. Hove, Lawrence, Erlbaum.
Gilbert, P. (2000) Counselling for depression. Counselling in practice. 2nd edition, Sage Publications
Gotlib, I.H., and Hammen, C.L., (1996) Psychological aspects of depression: towards a cognitive-interpersonal integration. John Wiley and sons limited. P141.
Goldberg, D., Benjamin, S., and Creed, F. (1987). Psychiatry in medical practice. Routledge, London and New York. P183.
Greenburg, L.S. and Safran, J. D. (1987) Emotion in psychotherapy The Guilford Press.
Hagen, E H. (2002) The bargaining model of depression, in Hammerstein, Peter, Eds. The genetic and cultural evolution of cooperation. MIT Press.
Hamilton, M. (1967) ‘Development of a rating scale for primary depressive illness’. British Journal of Social and Clinical Psychology. 6, 278-296
Harris, T. (2001) ‘Recent developments in understanding the psychosocial aspects of depression’ British Medical Bulletin 57:17-32.
ICD-10. 1992. Pocket guide to the classification of mental and behavioural disorders. World health organization, Geneva. Churchill Livingstone. 1995.
Karp, D. (1996) Speaking of Sadness. New York: Oxford University Press. Referenced in: Scheff, T.J., (2000). ‘Social Components in Depression’ Shame and Community.
Klein, M. (1934) A contribution to the psychogenesis of manic-depressive states. In Contributions to psycho-analysis. 1921-1945. Hogarth press
Kohut, H (1977) The restoration of the self. International Universities Press.
Lewis (1993), quoted in: Power, M.J. and Dalgleish, T. (1997) Cognition and emotion: From order to disorder. Psychology press.
Mahoney, M.J. (1984) Integrating affect and action: A comment. Cognitive therapy and research, 8, 585-589. Noted in, Greenburg, L.S. and Safran, J. D. (1987) Emotion in psychotherapy The Guilford Press.
Maslow, A. (1975) Pearls of wisdom. Harper and Row
Miller, WR. And Rollnick, S. (1991) Motivational interviewing. Preparing people to change addictive behaviour. The Guilford Press.
Nuechterlein, K.H., and Dawson, M.E., ‘A heuristic vulnerability/stress model of schizophrenic episodes.’ (1984). Schizophrenia Bulletin. 10, 300-312
NICE (2003). Depression: the management of depression in primary and secondary care. 2nd draft (2003).National Institute for Clinical Excellence .
Ostler, K., Thompson, C., Kinmonth, A.L.C., Peveler, R.C., Stevens, L., Stevens, A. (2001). ‘Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care.’ British Journal of Psychiatry. 178, 12-17.
Padesky, C. and Greenburg, D. (1995) Mind over mood: Cognitive Treatment Therapy Manual for Clients. Guilford Press.
Paykel, E.S. and Cooper, Z. (1992) Life events and social stress. Quotted in: Gelder, M., Gath, D., Mayou, R. and Cowen P. (1995). Oxford Textbook of psychiatry. Third edition. (1996) Oxford university press. P 217
Pedder, J.R. (1982) Failure to mourn and melancholia. British Journal of Psychiatry. 141, 329-337.
Pollock (1996) Clinical issues in the CAT of sexually abused women who commit violent offences. CAT Papers Collection, vol 2. 1999
Power, M.J. and Dalgleish, T. (1997) Cognition and emotion: From order to disorder. Psychology press.
Resnick, W. (1997) The recursive loop of shame: an alternative Gestalt Therapy viewpoint. Gestalt review, Vol 1, no 3.
Rycroft, C (1995) A critical dictionary of psychoanalysis. (second edition) Penguin Books.
Ryle, A. (1990) Cognitive-analytic therapy: active participation in change. John Wiley and sons.
Ryle, A. (1991). Depression. In, Textbook of psychotherapy in psychiatric practice. Jeremy Holmes (Ed). Churchill, Livingstone, UK Limited.
Ryle, A., and Kerr, I., (2002) Introducing cognitive Analytic therapy, principles and practice. John Wiley and sons ltd. P 149.
Safran, J. and Segal, Z. (1996) Interpersonal process in cognitive therapy. Jason Aronson inc.
Seligman, M.E.P. (1975). Helplessness. Freeman, San Francisco.
Scheff, T.J., (2000). ‘Social Components in Depression’ Shame and Community.
Stevens, A. and Price, J. (2000) Evolutionary psychiatry: a new beginning. Routledge
Stern, S.L., and Mendels. J. (1980) Affective disorders, in Kazdin, A.E., Bellack, A.S., and Hersen, M. (eds) New perspectives in abnormal psychology. Oxford University Press.
Vygotsky, L.S. (1978) Mind in society; the development of higher psychological processes. Harvard University Press
Young, J. (2003) Schema therapy: A practitioner’s guide. Guilford Press.
Zigmond, A. S., and Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica. 67, 361-370.