11

Depressive and
Manic Personalities

In this chapter I discuss people with character patterns shaped by depressive dynamics. I also address briefly the psychologies of those whose personalities are characterized by the denial of depression; that is, those who have been called manic, hypomanic, and cyclothymic. Whereas people in the latter diagnostic groups approach life with strategies antithetical to those used unconsciously by depressive people, the basic organizing themes, expectations, wishes, fears, conflicts, and unconscious explanatory constructs of depressive and manic people are similar. Many people experience alternating manic and depressive states of mind; those with psychotic-level conditions used to be described as having a “manic–depressive” illness, a term that implied delusion and suicidality. Yet many people who never become psychotic or suicidal undergo marked cycles of mania and dysthymia. Currently, they tend to be diagnosed as bipolar.

Individuals who are mainly depressive, those who are mainly manic, and those who swing from one pole to the other all exist at every point on the severity continuum. Although Kernberg (1975) considers hypomanic personality disorder to be a definitionally borderline condition because it reflects the primitive defense of denial, this observation applies only to instances when a person’s character is problematic enough to be seen as a personality disorder rather than just a personality type. I have known people with core hypomanic dynamics whose denial exists alongside too integrated an identity and too keen a self-observing capacity to be considered borderline.

DEPRESSIVE PERSONALITIES

A serious impediment to our collective understanding of depressive psychology arose when the formulators of DSM-III elected to put all depressive and manic conditions under the heading of Mood Disorders (see Frances & Cooper, 1981; Kernberg, 1984). With this decision, they privileged the affective aspects of dysthymic states over the imaginal, cognitive, behavioral, and sensory components that are equally important in the phenomenology of depression. They also dispensed with the clinically and empirically long-established diagnosis of depressive personality disorder and diverted us from attending to the internal processes that characterize depressive people even when they are not in a clinically depressed state. I was recently told that every member of the work group who made this call had some connection with a drug company. I do not think they were corrupt people, but such involvements raise the question of unconscious influence on putatively “scientific” decisions. Pharmaceutical companies generally prefer to construe mental suffering in terms of discrete disorders rather than as longstanding personality patterns that are notoriously unresponsive to pharmacology.

A clinical depression is pretty unmistakable. Many of us have had the bad luck to have suffered the unremitting sadness, lack of energy, anhedonia (inability to enjoy ordinary pleasures), and vegetative disturbances (problems in eating, sleeping, and self-regulating) that characterize the disorder. Freud (1917a) was the first writer to compare and contrast depressive (“melancholic”) conditions with normal mourning; he observed that the significant difference between the two states is that in ordinary grief, the external world is experienced as diminished in some important way (e.g., it has lost a valuable person), whereas in depression, what feels lost or damaged is a part of the self. Grief tends to come in waves; between the episodes of acute pain when one is reminded of a loss, one can function almost normally, whereas depression is relentless and deadening. The mourning process ends in slow recovery of mood, whereas depression can go on and on.

In some ways, then, depression is the opposite of mourning; people who grieve normally tend not to get depressed, even though they can be overwhelmingly sad during the period that follows bereavement or loss. The cognitive, affective, imaginal, and sensory processes that are so striking in a clinical depression operate in a subtle, chronic, organizing, self-perpetuating way in the psyches of those of us with depressive personalities (Laughlin, 1956, 1967). Given the intended audience of this book, the phrase “those of us” may be apposite, since it appears that a substantial proportion of psychotherapists are characterologically depressive (Hyde, 2009). We empathize with sadness, we understand wounds to self-esteem, we seek closeness and resist loss, and we ascribe our therapeutic successes to our patients’ efforts and our failures to our personal limitations.

Greenson (1967), commenting on the connection between a depressive sensibility and the qualities of successful therapists, went so far as to argue that analysts who have not suffered a serious depression may be handicapped in their work as healers. Greenson might reasonably have considered himself an exemplar of someone at the healthy end of the depressive continuum, along with more visibly anguished historical figures like Abraham Lincoln. At the highly disturbed end of the spectrum one finds the delusional and ruthlessly self-hating mental patients who, until the discovery of antidepressive medicines, could absorb years of a devoted therapist’s efforts and still believe uncritically that the best way to save the world is to destroy the self.

Since writing the first edition of this book I have become more familiar with Sidney Blatt’s work (Blatt, 2004, 2008; Blatt & Bers, 1993) on subtypes within the depressive spectrum. In brief, Blatt has studied the different internal experiences and different therapeutic needs of people who formulate their depressive state as “I’m not good enough, I’m flawed, I’m self-indulgent, I’m evil” (the “introjective” version) versus those whose subjective world feels like “I’m empty, I’m hungry, I’m lonely, I need a connection” (the “anaclitic” version, from the Greek word for “to lean on”). In the 1994 edition, this chapter assumed a more introjective version of depressive psychology; I think I implicitly construed the more anaclitic version as a dependent personality style or disorder. In this rewriting I have tried to accommodate both subtypes, especially in the section on therapy.

When he examined those polarities beyond the depressive realm, Blatt (2008) renamed them as “self-definition” and “self-in-relationship” inclinations. We all have both self-definitional and relational needs, and one aspect of overall mental health is surely having some balance between the two. But just as people with narcissistic personalities, despite both devaluing others and craving their attention, tilt toward either the more arrogant (self-definition) or depleted (self-in-relationship) pole, depressive people tend to lean more one way than the other. Members of the Personality Task Force for the Psychodynamic Diagnostic Manual (PDM Task Force, 2006) discovered that where there is longstanding clinical lore about personality subtypes, those subtypes map nicely onto Blatt’s polarity. His differentiation will come up again in later chapters.

DRIVE, AFFECT, AND TEMPERAMENT IN DEPRESSION

That one can inherit a vulnerability to depression has long been suggested by studies of family histories, twins, and adoptees (Rice et al., 1987; Wender et al., 1986). Depression clearly runs in families, although no one can yet confidently evaluate the extent to which the transmission of depressive tendencies is genetically determined versus the extent to which depressed parents behave in ways that set up their children for dysthymic reactions. Research with other mammals has identified patterns of reaction to early maternal loss or rejection that look identical to depression in humans (Panksepp, 2001). That a prototype for loss and its accompanying affect, cognition, and bodily experience could be set down in one’s youngest days, could then permanently affect one’s brain function, and could then be reenacted with one’s children because of how one’s brain got structured suggests that what may look simply genetic may be more complex.

Freud (1917a) speculated, and Abraham (1924) subsequently elaborated, that an important precursor to depressive states is the experience of premature loss. In line with the classical theory that people who are either overindulged or deprived become fixated at the infantile stage when this happened, depressive individuals were initially understood as having been weaned too soon or too abruptly, or as having suffered some other early frustration that overwhelmed their capacities to adapt (see Fenichel, 1945). The “oral” qualities of people with depressive characters influenced this construction; it was noted that depressive people were often overweight, that they usually liked eating, smoking, drinking, talking, kissing, and other oral gratifications, and that they tended to describe their emotional experience in analogies about food and hunger. The idea that depressive people are orally fixated has not completely disappeared, probably more because of the intuitive appeal of such a formulation than because of its theoretical status. When one of my supervisors commented that I see everybody as hungry, thus confronting my tendency to project my depressive issues on all my clients, I was able to start discriminating between those who needed to be emotionally fed and those who needed to be asked why they had not learned to cook.

An early psychodynamic way of describing a depressive process, and one that has been thoroughly popularized, illustrates the application of drive theory to specific clinical problems. Freud (1917a) noted that people in depressed states aim negative affect away from others and toward the self, hating themselves out of all proportion to their actual shortcomings. At a time when psychological motivation was translated into libido and aggression, this phenomenon was described as “sadism (aggression) against the self” or as “anger turned inward.” Because of its clinical promise, this formulation was embraced eagerly by Freud’s colleagues, who began trying to help their patients to identify things that had angered them so that the pathological process could be reversed. It fell to later theorists to explain why a person would have learned to turn angry reactions against the self and what functions would be served by maintaining such a pattern.

The aggression-inward model is consistent with observations that depressive people seldom feel spontaneous or unconflicted anger on their own behalf. Instead, especially if their version of depressive personality is more introjective, they feel guilt. Not the denied, defensively reinterpreted guilt of the paranoid person, but a partly conscious, ego-syntonic, pervasive sense of culpability. Author William Goldman once quipped to an interviewer, “When I’m accused of a crime I didn’t commit, I wonder why I have forgotten it.” Depressive people are agonizingly aware of every sin they have committed, every kindness they have neglected to extend, every selfish inclination that has crossed their minds.

Sadness, the dominant feeling in anaclitic depressives, is the other major affect of people with a depressive psychology. Evil and injustice distress them but rarely produce in them the indignant anger of the paranoid, the moralization of the obsessive, the undoing of the compulsive, or the anxiety of the hysterical person. The sorrow of someone who is clinically depressed is so palpable and arresting that in the public mind—and evidently now in the professional mind as well—the terms “sadness” and “depression” have become virtually synonymous (Horowitz & Wakefield, 2007). Since many people who are free of dysthymic symptoms have depressive personalities, and since grief and depression are in at least one respect mutually exclusive conditions, this equation is misleading; yet even a psychologically robust, high-spirited person with a depressive character will convey to a perceptive listener the hint of an inner melancholy.

Monica McGoldrick’s (2005) brilliant depiction of the Irish, a group famous for having a song in the heart and a tear in the eye, captures the ambience of a whole ethnic subculture with a depressive soul. Unless they are so disturbed that they cannot function normally, most depressive people are easy to like and admire. Because they aim hatred and criticism inward rather than outward, they are usually generous, sensitive, and compassionate to a fault. Because they give others the benefit of any doubt, and strive to preserve relationships at any cost, they are natural appreciators of therapy. In a later section I discuss how to prevent these appealing qualities from working to their detriment.

DEFENSIVE AND ADAPTIVE PROCESSES IN DEPRESSION

The most powerful and organizing defense used by introjectively depressive people is, not surprisingly, introjection. Clinically, it is the most important operation to understand in order to reduce their suffering and modify their depressive tendencies. As psychoanalytic clinical theory developed, simpler energic concepts (aggression-in vs. aggression-out) yielded to reflections on the internalization processes that Freud had begun to describe in “Mourning and Melancholia” (1917a) and that Abraham (1911) had noted as the depressive person’s “identification with the lost love object.” As analysts began emphasizing the importance of incorporative processes in depression (Bibring, 1953; Blatt, 1974; Jacobson, 1971; Klein, 1940; Rado, 1928), they added immeasurably to our therapeutic power in the face of depressive misery.

In working with introjectively depressive patients, one can practically hear the internalized object speaking. When a client says something like, “It must be because I’m selfish,” a therapist can ask, “Who’s saying that?” and be told, “My mother” (or father, or grandparent, or older sibling, or whoever is the introjected critic). Often the therapist feels as if he or she is talking to a ghost, and as if therapy, to be effective, will have to include an exorcism. As this example shows, the kind of introjection that characterizes depressive people is the unconscious internalization of the more hateful qualities of an old love object. That person’s positive attributes are generally remembered fondly, whereas negative ones are felt as part of the self (Klein, 1940).

As I noted in Chapter 2, the internalized object does not have to be a person who in reality was hostile, critical, or negligent (though this is often the case, and it encumbers therapy with extra challenges) for the patient to have experienced the object that way and internalized such images. A young boy who feels deserted by a father who deeply loves him—perhaps he suddenly had to work two jobs to make ends meet or was deployed to a war zone or was hospitalized for a serious illness—will feel hostility over his abandonment but will also yearn for him and feel self-rebuke for not having appreciated him sufficiently when he was around. Children project their reactions onto love objects who desert them, imagining that they left feeling angry or hurt. Then such images of a malevolent or injured abandoner, because they are too painful to bear and because they interfere with hopes for a loving reunion, are driven out of awareness and felt as a bad part of the self.

A child may thus emerge from experiences of traumatic or premature loss with an idealization of the lost object and a relegation of all negative affect into his or her sense of self. These well-known depressive dynamics create a pervasive feeling that one is bad, has driven away a needed and benevolent person, and must work very hard to prevent one’s badness from provoking future desertions. The reader can see that this formulation is not inconsistent with the older anger-inward model; in fact, it accounts for why someone could get into the habit of handling hostile feelings in precisely this way. If one emerges from painful separations believing that it is one’s badness that drove the beloved objects away, one may try very hard to feel nothing but positive affects toward those who are loved. The resistance of depressive people toward acknowledging ordinary and natural hostility and criticism is comprehensible in this context, as is the upsetting and much-remarked phenomenon of the person who stays with an inconsiderate or abusive partner, believing that if only he or she were somehow good enough, the partner’s mistreatment would stop.

Turning against the self (A. Freud, 1936; Laughlin, 1967), a related defense mechanism in introjectively depressive people, is a less archaic outcome of these dynamics. Introjection as a concept covers the more total experience of feeling incomplete without the object and taking that object into one’s sense of self in order to feel whole, even if that means taking into one’s self-representation the sense of badness that comes from painful experiences with the object. Turning against the self gains a reduction in anxiety, especially separation anxiety (if one believes it is one’s anger and criticism that ensure abandonment, one feels safer directing it against the self), and also maintains a sense of power (if the badness inheres in me, I can change this disturbing situation).

Children are existentially dependent. If those on whom they must depend are unreliable or badly intentioned, they have a choice between accepting that reality or denying it. If they accept it, they may generalize that life is empty, meaningless, and uninfluenceable, and they are left with a chronic sense of incompleteness, emptiness, longing, futility, and existential despair. This is the anaclitic version of depressive suffering. If instead they deny that those they must depend upon are untrustworthy (because they cannot bear living in fear), they may decide that the source of their unhappiness lies within themselves, thereby preserving hope that self-improvement can alter their circumstances. If only they can become good enough, can rise above the selfish, destructive person they know themselves to be, life will get better (Fairbairn, 1943). This is the introjective dyanmic. Clinical experience attests resoundingly to the human propensity to prefer the most irrational guilt to an admission of impotence. The introjective depressive person feels bad but powerful in that badness, whereas the anaclitically depressed person feels victimized, powerless, and passive.

Idealization is the other defense important to note in depressive patients. Because their self-esteem has been damaged by the effects of their experiences (either by feeling chronically empty or feeling secretly bad), the admiration with which they view others is correspondingly increased. Self-perpetuating cycles of holding others in excessively high regard, then feeling diminished in comparison, then seeking idealized objects to compensate for the diminution, feeling inferior to those objects, and so on, are typical for depressive people. This idealization differs from that of narcissistic people in that it constellates around moral concerns rather than status and power.

RELATIONAL PATTERNS IN DEPRESSIVE PSYCHOLOGY

The above section on ego processes suggests some important themes in the object relations of depressive patients. First, there is the role of early and/or repeated loss. The striking affective correspondences between depression and mourning have prompted theorists at least as far back as Freud to look for the origins of dysthymic dynamics in painful, premature experiences of separation from a love object. And such experiences are usually easy to find in the histories of depressive clients. Early loss is not always concrete, observable, and empirically verifiable (e.g., death of a parent); it may be more internal and psychological, as in the case of a child who yields to pressure to renounce dependent behaviors before he or she is emotionally ready to do so.

Erna Furman’s (1982) deceptively modest essay “Mothers Have to Be There to Be Left” explores this second kind of loss. In a respectful but trenchant critique of classical ideas about the mother’s responsibility to wean infants when they are ready to accept the loss of a need-gratifying object, Furman stressed that unless they are hurried, children wean themselves. The striving for independence is as primary and powerful as the wish to depend; separation is naturally sought by youngsters who are confident of the availability of the parent if they need to regress and “refuel” (Mahler, 1972a, 1972b). Furman’s recasting of the separation process in terms of the child’s natural movement forward challenges a persistent Western notion (reflected in older psychoanalytic thinking and in many popular books on child rearing) that parents must titrate frustrations because left to themselves, youngsters will prefer regressive satisfactions.

According to Furman (1982), it is ordinarily the mother, not the baby, who feels keenly the loss of a gratifying instinctual satisfaction at weaning—and by analogy at other times of separation. Along with her pleasure and pride in her child’s growing autonomy, she suffers some pangs of grief. Normal children appreciate these pangs; they expect their parents to shed a tear on the first day of school, at the first prom, at graduation. The separation–individuation process eventuates in depressive dynamics, Furman believed, only when the mother’s pain about her child’s growth is so great that she either clings and induces guilt (“I’ll be so lonely without you”) or pushes the child away defensively (“Why can’t you play by yourself?!”). Children in the former situation are left feeling that normal wishes to be aggressive and independent are hurtful; in the latter, they learn to hate their natural dependent needs. Either way, an important part of the self is experienced as bad.

Not just early loss but conditions that make it difficult for the child to understand realistically what happened, and to grieve normally, may engender depressive tendencies. One such condition is developmental. Two-year-olds are simply too young to fathom fully that people die, and why they die, and are incapable of appreciating complex interpersonal motives such as “Daddy loves you, but he is moving out because he and Mommy don’t get along.” The world of the 2-year-old is still magical and categorical. At the height of conceiving things in gross categories of good and bad, the toddler whose parent disappears may generate assumptions about badness that are impossible to counteract, even with reasonable educative comments. A major loss in the separation–individuation phase virtually guarantees some depressive dynamics.

Other circumstances include family members’ neglect of their children’s needs when they are beset by difficulties and their ignorance of the degree to which children require explanations that counteract their self-referential and moralistic interpretations. Judith Wallerstein’s long-term research on the outcome of divorce (Wallerstein & Blakeslee, 1989; Wallerstein & Lewis, 2004) has demonstrated that along with lack of abandonment by the noncustodial parent, the best predictor of a nondepressive adaptation to parental divorce is the child’s having been given an age-appropriate, accurate explanation of what went wrong in the marriage.

Another circumstance that encourages depressive tendencies is a family atmosphere in which mourning is discouraged. When parents and other caregivers model the denial of grief, or insist (e.g., after an acrimonious divorce) that the child join in a family myth that everyone is better off without the lost object, or need the child to reassure them that he or she is not in pain, mourning can go underground and eventually take the form of the belief that there is something wrong in the self. Sometimes children feel intense, unspoken pressures from an emotionally overburdened parent to protect the adult from further grief, as if acknowledging sorrow were equivalent to falling apart. The child naturally concludes that grief is dangerous and that needs for comfort are destructive.

Sometimes in a family system the prevailing morality is that mourning and other forms of self-care and self-comfort are “selfish” or “self-indulgent,” or “just feeling sorry for yourself,” as if such activities were prima facie contemptible. Guilt induction of this sort, and associated admonishments to a stricken child to stop whining and get over it, instill both a need to hide any vulnerable aspects of the self and, out of identification with the critical parent, an eventual hatred of those aspects of oneself. Many of my depressive patients were called names whenever they could not control their natural regressive reactions to family difficulties; as adults, they abused themselves psychologically in parallel ways whenever they were upset.

The combination of emotional or actual abandonment with parental criticism is particularly likely to create depressive dynamics. A patient of mine lost her mother to cancer when she was 11 and was left with a father who repeatedly complained that her unhappiness was aggravating his ulcer and hastening his death. Another client was called a sniveling baby by her mother when she cried because, at age 4, she was being shipped away to overnight camp for several weeks. A depressive man I worked with whose mother was severely depressed and unavailable emotionally during his early years was told that he was selfish and insensitive for wanting her time, and that he should be grateful she was not sending him to an orphanage. In such instances it is easy to see that angry reactions to emotional abuse by the parent would have felt too dangerous to the child, who already feared rejection.

Some depressive patients I have worked with appear to have been the most emotionally astute person in their family of origin. Their reactivity to upsetting situations that other family members handled by denial got them branded “hypersensitive” or “overreactive,” labels they continued to carry internally and to connect with their general sense of inferiority. Alice Miller (1975) described how families can unwittingly exploit the emotional talent of a particular child, with the result that he or she eventually feels valued only for serving a particular family function. If the child is also scorned and pathologized for the possession of emotional gifts, depressive dynamics will be even stronger than if he or she is simply used as a kind of family therapist.

Finally, a powerful causative factor in depressive dynamics is significant depression in a parent, especially in a child’s earliest years. A seriously depressed mother with no one to help out will give a baby only the most custodial kind of care, no matter how sincerely she wishes to help it start life on the best possible footing. The more we learn about infants, the more we know about how critical their earliest experience is in establishing their basic attitudes and expectations (Beebe et al., 2010; Cassidy & Shaver, 2010; M. Lewis & Haviland-Jones, 2004; D. N. Stern, 2000). Children are deeply bothered by a parent’s depression; they feel guilty for making normal demands, and they come to believe that their needs drain and exhaust others. In general, the earlier their dependence on someone who is deeply depressed, the greater is their emotional privation.

Numerous different pathways can thus lead to a depressive accommodation. Both loving and hateful families can breed depressive dynamics out of infinitely varied combinations of loss and insufficient psychological processing of that loss. In a society where adults fail to make enough time to listen sensitively to the concerns of children, where people move their residence routinely, where family breakups are common, and where painful emotions can be ignored because drugs will counteract them, it is not surprising that our rates of youthful depression and suicide have skyrocketed, that counterdepressive compulsions like prescription drug abuse, obesity, and gambling are on the rise, that we are seeing an explosion of popular movements in which the “lost child” or the “child within” is rediscovered, and that self-help groups that reduce feelings of isolation and fault are widely sought. Human beings seem not to have been designed to handle as much instability in their relationships as contemporary life provides.

THE DEPRESSIVE SELF

People with introjective depressive psychologies believe that at bottom they are bad. They lament their greed, their selfishness, their competition, their vanity, their pride, their anger, their envy, their lust. They consider all these normal aspects of experience to be perverse and dangerous. They worry that they are inherently destructive. These anxieties can take a more or less oral tone (“I’m afraid my hunger will destroy others”), or an anal-level one (“My defiance and sadism are dangerous”), or a more oedipal dimension (“My wishes to compete for and win love are evil”).

Depressive people have made sense out of their experiences of unmourned losses by the belief that it was something in them that drove the object away. The fact that they felt rejected has been converted into the unconscious conviction that they deserved rejection, that their faults provoked it, and that future rejection is inevitable if anyone comes to know them intimately. They try very hard to be “good,” but they fear being exposed as sinful and discarded as unworthy. One of my patients became convinced at one point that I would refuse to see her again after hearing about her childhood death wishes toward a younger sibling. She, like many sophisticated psychotherapy clients today, knew at the conscious level that such wishes are an expectable part of the psychology of the displaced child, yet in her deeper experience she was still awaiting condemnation.

The guilt of the introjectively depressive person is at times unfathomable. Some guilt is simply part of the human condition, and is appropriate to our complex and not entirely benign natures, but depressive guilt has a certain magnificent conceit. In someone with a psychotic depression it can emerge as the conviction that some disaster was caused by one’s sinfulness—police departments are accustomed to delusional depressives calling up to claim responsibility for highly publicized crimes they could not possibly have committed—but even in expansive, high-functioning adults with a depressive character structure similar ideas will emerge in psychotherapy. “Bad things happen to me because I deserve them” may be a consistent underlying theme. Introjective depressive clients may even have a paradoxical kind of self-esteem based on the grandiose idea that “No one is as bad as I am.”

Because of their readiness to believe the worst about themselves, they can be very thin-skinned. Criticism may devastate them; in any message that includes mention of their shortcomings they tend to hear only that part of the communication. When criticism is intended constructively, as in an evaluation at work, they may feel so exposed and wounded that they miss or minimize any complimentary facets of the report. When they are subject to genuinely mean-spirited attacks, they are incapable of seeing beyond any grains of truth in the content to the fact that no one deserves to be treated abusively, no matter how legitimate are the persecutor’s complaints.

Introjectively depressive people often handle their unconscious dynamics by helping others, by philanthropic activity, or by contributions to social progress that have the effect of counteracting their guilt. It is one of the great ironies of life that it is the most realistically benevolent people who seem most vulnerable to feelings of moral inferiority. Many individuals with depressive personalities are able to maintain a stable sense of self-esteem and avoid depressive episodes by doing good. In researching characterological altruism (McWilliams, 1984), I found that the only times my charitable subjects had experienced depression were when circumstances had made it temporarily impossible for them to carry on their humanitarian activities.

Psychotherapists, as previously noted, often have significant introjective dynamics. They seek opportunities to help others so that their unconscious anxieties about their destructiveness will be kept at bay. Since it is hard to help people psychologically, at least as fast as we would all wish, and since we cannot avoid inflicting temporary pain on patients in the service of their growth or when we simply make a mistake, feelings of exaggerated responsibility and disproportionate self-criticism are common in beginning therapists. Supervisors can confirm how often such dynamics get in the way of their trainees’ learning of their craft. One of my depressive patients, a therapist, responded to any setback with a client, especially if it provoked negative feelings in her, with a search for her own role in the problem—to such a degree that she ignored opportunities to learn about the ordinary vicissitudes of working with that particular kind of patient. The fact that therapy is a two-person process, where intersubjectivity is a given, was converted by her into a quest for self-purification and a terror that she was somehow basically unsuited to helping people.

Parenthetically, I think training to be a therapist tends to create depression even if one lacks powerful introjective and anaclitic dynamics. In the program where I teach, I have noticed that most students go through a depressive period some time around their second year. Graduate training can be a breeding ground for dysthymic reactions, since one has the worst of both adult and child roles (one is expected to be responsible, autonomous, and original, but one has no power; one is dependent on one’s “elders” in the field, yet with no accompanying protection and comfort). Training in therapy additionally confronts people with the fact that learning an art is very different from mastering a content area. Students who come to our program as stars in their prior roles find the transition to self-exposure and critical feedback on their work to be emotionally jarring.

So far I have talked mostly about the introjectively depressive self. Anaclitically depressive individuals experience themselves not so much as actively bad; they see themselves as chronically inadequate and longing, but destined to a life of disappointment. They are more likely to suffer shame (because no one wants them) than to react with guilt that they get love they feel they do not deserve. They may view their yearning for closeness without self-hatred but still see it as futile. They may try to talk the therapist into sharing their view that “life sucks and then you die,” because anything better than that is not in their future, and they would feel unbearable envy if they were to imagine other possibilities. One of my patients told me she couldn’t stand my tendency to frame issues as problems to be solved; the closest she had come in her history to feeling connected with friends and relatives was via a “misery loves company” bemoaning of how fate had treated them. Any effort to change what was fated threatened the sweetness of their mutual lamentation.

Women seem more at risk of depressive solutions to emotional problems than men. In the 1970s and 1980s, feminist theorists (e.g., Chodorow, 1978, 1989; Gilligan, 1982; J. B. Miller, 1984; Surrey, 1985) accounted for this phenomenon by reference to the fact that in most families, the primary caregiver is female. Male children consequently attain a sense of gender identity from being different from the mother, and females derive it from identification with her. An outcome of this imbalance in early parenting is that men use introjection less, as their masculinity is confirmed by separation rather than by fusion, and women use it more, because their sense of femaleness comes from connection. When feeling internally empty, men may be more likely to use denial and to behave counterdependently than to experience themselves anaclitically as needy and longing.

TRANSFERENCE AND COUNTERTRANSFERENCE
WITH DEPRESSIVE PATIENTS

Depressive clients are often easy to love. They attach quickly, ascribe benevolence to the therapist’s aims even when fearing criticism, are moved by empathic responsiveness, work hard to be “good” in the patient role, and appreciate bits of insight as if they were morsels of life-sustaining food. They tend to idealize the clinician (as morally good, in contrast to their subjective badness, or as filling their internal emptiness), but not in the emotionally unconnected way typical of more narcissistically structured patients. Depressive people are highly respectful of the therapist’s status as a separate, real, and caring human being, and they try hard not to be burdensome.

At the same time, introjectively depressive people project on to the therapist their internal critics, voices that have variously been conceptualized in the psychoanalytic literature as a harsh, sadistic, or primitive superego (Abraham, 1924; Freud, 1917a; Klein, 1940; Rado, 1928; Schneider, 1950). It can be startling to see a patient writhe in miserable anticipation of disapproval when confessing some minor crime of thought. Depressive clients are subject to the chronic belief that the therapist’s concern and respect would vanish if he or she really knew them. This belief can persist over months and years, even in the face of their having volunteered every negative thing they can think of about themselves, and having encountered only steadfast acceptance.

Anaclitically depressive individuals are more likely to feel initially comfortable in treatment. Blatt (2004) found that their pleasure in having a therapist’s warm, noncritical attention had immediate positive effects, including reduction of their depressive symptoms. This makes intuitive sense: If my internal experience of depression is that I am desperate for a warm attachment, and I get one from a therapist, I may feel better immediately. Anaclitically depressive people are more likely to develop a benign idealization and to assume that a therapist is taking care of them. Difficulties in the transference and countertransference tend not to arise until the therapist begins confronting the client about making real-world changes.

As introjectively depressive patients progress in therapy, they project their hostile attitudes less and experience them more directly as anger and criticism toward the therapist. At this point in treatment, their negativity may take the form of comments that they do not really expect to be helped and that nothing the therapist is doing is making a difference. It is important to tolerate this phase without taking their criticisms too personally, and to console oneself that in the process, they are getting out from under all the self-directed complaining that was previously keeping them unhappy. As anaclitically oriented clients progress, they tend to get critical, too, because they have to confront the painful fact that even though they now have a warm connection, there are things they have to work on. I have noticed that the more their complaints are welcomed, the more likely they are afterward to take positions on their own behalf outside the treatment room.

State-of-the-art psychopharmacology now enables us to work with depressive people at all levels of disturbance and to analyze depressive dynamics even in psychotic clients. Before the discovery of the antidepressive properties of lithium and other chemicals, many patients with borderline and psychotic structure were so firmly convinced of their badness, so sure of the therapist’s inevitable hatred of them, or so despairing of real devotion, that they could not tolerate the pain of attachment. Sometimes they would commit suicide after years of treatment because they could not bear to start feeling hope and thereby risk another devastating disappointment.

Healthier introjective clients tend to be easy to work with because their convictions about their basic flaws are mostly unconscious and are ego alien when brought into awareness. People who are more troubled may need medication to reduce the intensity of their depressive feelings and convictions. The ruthless, implacable states of self-loathing by which borderline and psychotic depressive people can be possessed are infrequent in medicated patients. It is as if their depressive dynamics have been made chemically ego dystonic. The shadows of self-hatred that remain after they are established on an appropriate medication can then be addressed as one would analyze pathological introjects with neurotic-level depressive people.

Healthier anaclitic clients are also easy to work with, though their underlying passivity can be irritating. At borderline and psychotic levels, they can be very difficult because their sense that the therapist should simply fix things for them can be deeply ego syntonic, and the experience of being medicated reinforces their sense that help has to come from outside because their internal resources are completely inadequate.

Countertransference with depressive individuals runs the gamut from benign affection to omnipotent rescue fantasies, depending upon the severity of the depressive issues. Such reactions constitute a complementary countertransference (Racker, 1968); the therapeutic fantasy is that one can be God, or the “Good Mother,” or the sensitive, accepting parent that the client never had. These longings can be understood as a response to the patient’s unconscious belief that the cure for depressive dynamics is unconditional love and total understanding. (There is a lot of truth in this idea, but as I will spell out shortly, it is also dangerously incomplete.)

There is also a concordant countertransference familiar to therapists of depressive patients: One can feel incompetent, blundering, damaging, “not good enough” (the introjective elements) or hopeless, incompetent, demoralized, and futile (the anaclitic elements). Depressive attitudes are contagious. I first became aware of this when I was working in a mental health center and (naively) scheduled four severely depressed people in a row. By the time I came shambling to the office coffee pot after the fourth session, the clinic secretaries were offering me chicken soup and a shoulder to cry on. One can easily conclude during work with depressive people that one is simply an inadequate therapist. These feelings can be mitigated if one is fortunate enough to have plentiful sources of emotional gratification in one’s personal life (see Fromm-Reichmann, 1950; McWilliams, 2004). They also tend to diminish over one’s professional lifetime as it becomes incontrovertible that one has succeeded in helping even relentlessly depressive patients.

THERAPEUTIC IMPLICATIONS OF THE DIAGNOSIS
OF DEPRESSIVE PERSONALITY

The most important condition of therapy with a depressed or depressively organized person is an atmosphere of acceptance, respect, and compassionate efforts to understand. Most writings about therapy—whether they express a general humanistic stance, a psychodynamic orientation, or a cognitive-behavioral preference—emphasize a style of relatedness that is particularly adapted to the treatment of depressive clients. Although a basic tenet of this book is that this generic attitude is insufficient to the task of therapy for some diagnostic groups (e.g., psychopathic and paranoid), I want to stress how critical it is to helping depressive people. Because they have radar for the slightest verification of their fears of criticism and/or rejection, a therapist working with depressive patients must take special pains to be nonjudgmental and emotionally constant.

With introjectively depressive clients, addressing undercurrent presumptions about inevitable rejection, including understanding counteractive efforts to be “good” in order to forestall it, constitutes much of the work. Blatt and Zuroff (2005) discovered, in an analysis of data collected for an ambitious National Institute of Mental Health (NIMH) study of major depression, that improvement in the introjective patients was centrally related to the therapist’s addressing the patient’s presumed internal beliefs about badness and its role in any losses they had had. Whether the clinician came at the topic from a cognitive perspective (as in Beck’s [e.g., 1995] focus on “irrational cognitions”) or from a psychodynamic one (as in the control–mastery emphasis on “pathogenic beliefs”), the critical issue was to expose and challenge the person’s implicit thoughts.

For higher-functioning introjective patients, the famous analytic couch is useful because it brings such themes quickly into focus. A woman I treated (who had no overt depressive symptoms but whose character was depressively organized) was an expert at reading my expressions. When we worked face to face, she so rapidly disconfirmed expectations that I was critical and rejecting that she was not even aware she had had such apprehensions. Neither was I; she was so skilled at this monitoring that my usual mindfulness of someone’s searching gaze was not aroused. When her decision to use the couch deprived her of eye contact, she was amazed to find herself suddenly hesitant to talk about certain topics because of the conviction that I would not approve of her. When the couch is not an option, there are ways of sitting and talking that minimize opportunities for visual search so that clients can get in touch with how chronic and automatic is their vigilance.

In the case of anaclitic patients, Blatt and Zuroff (2005) found that they got better quite quickly in therapy almost no matter what they talked about with their therapists. Not surprisingly, given that their experience of depression centered on the need to attach, as soon as they felt safely connected with a caring person, their symptoms diminished. The bad news with this group was that when the relatively brief therapy covered by the NIMH study ended, they became symptomatic again. This finding suggests that therapy with anaclitically depressed clients may have to be long term or at least open ended in order to avoid recreating a situation in which they make an attachment and then lose it prematurely under circumstances beyond their control. It takes time to internalize the therapist’s presence as a reliable positive inner voice.

Since short therapies are often presented by insurance companies or clinics as the treatment of choice, patients whose only option is brief treatment may conclude that they are sicker than they thought. The assumption that “this obviously works for other patients but not for a bottomless pit like me” will undermine self-esteem even if the therapy temporarily improves the person’s mood. In working with depressive clients under conditions that force termination, it is especially important to predict preemptively the patient’s expectable interpretation of the meaning of the loss. Treatments that are arbitrarily limited to a certain number of sessions may provide welcome comfort during a painful episode of clinical depression, but the time-limited experience may be ultimately assimilated unconsciously by the depressive person as another relationship that was traumatically cut short—further evidence that the patient is a failure in maintaining attachments.

Effective therapy with either anaclitic or introjective depressive patients in the borderline and psychotic ranges may require a particularly long period of building a safe alliance with a real, visible, emotionally responsive person. Their presumptions of their unlovability and terrors of rejection are so profound and ego syntonic that without the freedom to scrutinize the therapist’s face and invalidate their worst fears, they are apt to be too anxious to talk freely. The therapist may have to log a great deal of time demonstrating acceptance before even the conscious expectations of rejection in a depressive client can become open to scrutiny and eventual invalidation.

It is critical with depressive patients of both types to explore and interpret their reactions to separation, even to the separation of brief silence from the therapist. (Long silences should be avoided; they arouse the feelings of being uninteresting, valueless, adrift, hopeless.) Depressive people are deeply sensitive to abandonment and are unhappy being alone. More important, they may experience loss—usually unconsciously, but especially those introjectively depressive people with psychotic tendencies, sometimes consciously—as evidence of their badness or inadequacy. “You must be going away because you’re disgusted with me,” or “You’re leaving to escape my insatiable hunger,” or “You’re taking off to punish me for my sinfulness” are all variants on the depressive theme of basic unlovability. Hence it is critical not only to be attuned to how bothersome ordinary losses are to a depressive patient—this will come up naturally in anticipation of the therapist’s vacations or when the therapist cancels a session—but also to how the client interprets them.

While basic nonjudgmental acceptance is a necessary condition of therapy with a depressive person, it is not a sufficient one, especially with introjective individuals. I have noted in beginning therapists treating depressive clients a tendency to avoid taking vacations or imposing cancellations that are not rescheduled out of a wish to spare the patient unnecessary pain. Most of us in the field probably started out being neurotically flexible and generous in an effort to protect our depressive patients from suffering. But what depressive people really need is not uninterrupted care. What they need is the experience that the therapist returns after a separation. They need to know that their anger at being abandoned did not destroy the relationship and that their hunger did not permanently alienate the therapist. One cannot learn these lessons without enduring a loss in the first place.

On being encouraged to get in touch with negative feelings, depressive patients may protest that they cannot take the risk of noticing hostility toward the therapist: “How can I get angry at someone I need so much?” It is important not to join in this elliptical thinking. (Unfortunately, because their dynamics are similar to those of the patient, therapists with depressive sensibilities may regard such remarks as making perfect sense.) One can point out that the question contains the unexamined assumption that anger drives people apart. It may come as a revelation to depressive individuals that the freedom to admit negative feelings increases intimacy, unlike being false or out of touch. Anger interferes with normal dependency only if the person one is depending upon has pathological reactions to it—a circumstance that defines the childhood experience of many depressive clients but not the possibilities for adult relationships.

Therapists often find that their efforts to improve their depressive patients’ self-esteem are either ignored or received paradoxically. Supportive comments to a person immersed in self-loathing may provoke increased depression, via the internal transformation: “Anyone who really knew me could not possibly say such positive things. I must have duped this therapist into thinking I am okay. I’m bad for misleading such a nice person. And I can’t trust support from this direction because this therapist is easily fooled.” Hammer (1990) is fond of quoting Groucho Marx here, who used to insist that he would not be interested in joining any club that would have him for a member.

If support backfires, as it almost always will, especially with introjective clients, what can one do to improve the self-esteem of a depressive person? The ego psychologists had a useful prescription: Don’t support the ego; attack the superego. If a man is berating himself for the crime of envying a friend’s success, and the therapist responds that envy is a normal emotion, and that especially since the patient did not act it out, he might congratulate himself rather than running himself down, the patient may respond with silent skepticism. But if the therapist says, “So what’s so terrible about that?” or teases him for trying to be purer than God, or tells him good-naturedly to “Join the human race!” the patient may be able to take the message in. When interpretations are put in a critical tone, they are more easily tolerated by depressive people (“If she’s criticizing me, there must be some truth in what she says, since I know I’m bad in some way”), even when what is being criticized is a critical introject.

Another aspect of sensitive treatment of depressive patients is the therapist’s willingness to appreciate, as achievements, behaviors that would signify resistance in other clients. For example, many therapy patients express their negative reactions to treatment by canceling sessions or failing to bring a check. Depressive people work so hard to be good that they are usually exemplary in the patient role—so much so that their compliant behavior may be legitimately considered part of their pathology. One can make small dents in a depressive mentality by interpreting a client’s cancellation or temporary nonpayment as a triumph over the fear that the therapist will retaliate at the slightest sign of opposition. One is tempted with excessively cooperative patients just to relax and appreciate one’s luck, but if a depressive person never behaves in adversarial or selfish ways in treatment, the therapist should bring that pattern up as worthy of investigation.

Overall, therapists of characterologically depressive patients must accept and even welcome the client’s removing their halo. It is nice to be idealized, but it is not in the patient’s best interest. Therapists in the earliest days of the psychoanalytic movement knew that it signified progress when a depressed patient became critical or angry or disappointed with the clinician; while they understood this more or less hydraulically (angry energy turned outward instead of inward), contemporary analysts appreciate it from the standpoint of self-valuation. Depressive patients need eventually to leave the “one-down” position and to see the therapist as an ordinary, flawed human being. Retaining idealization inherently retains an inferior self-image.

Finally, where circumstances permit, it is more important with depressive patients than with others to leave decisions about termination up to them. It is also advisable to leave an open door for further treatment and to analyze ahead of time any inhibitions the client may have about asking for help in the future (one often hears that coming back for a psychological “tune-up” would be admitting defeat, or that the therapist might be disappointed with a less than complete “cure”). Since the causes of a depressive sensibility so frequently include irreversible separations—which forced the growing child to cut all ties and suppress all regressive longings, instead of feeling secure in the availability of an understanding parent—the termination phase with depressive patients must be handled with special care and flexibility.

DIFFERENTIAL DIAGNOSIS

The two dispositions most commonly confused with depressive psychology are narcissism (the depleted version) and masochism. It is my impression that misdiagnoses are more often made in the direction of construing as depressive someone who is more basically either narcissistic or masochistic than in the direction of misunderstanding an essentially depressive person as either of the others. The tendency of therapists to misread a narcissistic or masochistic patient as depressive seems to me attributable to two factors. First, depressively inclined therapists may project their own dynamics onto people whose core internal story is different. Second, people with either narcissistic or masochistic personality structure frequently have symptoms of clinical depression, especially dysthymic mood. Either misreading can have unfortunate clinical consequences.

Depressive versus Narcissistic Personality

In Chapter 8 I described people with depressed–depleted forms of narcissistic personality. There is some overlap between people with this psychology and people with the anaclitic version of depressed dynamics. As there are no clean boundaries in personality differences, many of us have both tendencies. The more narcissistic person is subjectively less hungry, however, less valuing of relationship, and defends more against shame than the anaclitically depressive person, who may also express feelings of emptiness, meaninglessness, and existential despair. The subjective sense of emptiness of the anaclitic depressive is not the same thing as the therapist’s inference of an actual emptiness at the core of the self in narcissistic clients. Narcissistically depressed people tend to have self-object transferences, whereas those with depressive character have object transferences. Countertransference with the former tends to be vague, irritated, affectively shallow; with the latter it is much clearer, warmer, and more powerful, usually involving rescue fantasies.

Explicitly sympathetic, encouraging reactions can be comforting to a narcissistically organized person, but to whatever extent a depressive person has introjective dynamics, they may be demoralizing. Because self-attack is not central to the narcissistic dynamism, attacking the presumed superego—even in gentle ways such as commenting on possible self-reproach—will not likely help a person whose basic structure is narcissistic. Interpretations that redefine affective experience in the direction of anger rather than more passive emotional responses will similarly fizzle with narcissistic patients because anger is not a core affect state for them. Such interpretive efforts may, however, relieve and even energize introjective clients, whose responsiveness can make the old anger-in-versus-anger-out formulations look uncannily apt.

Interpretive reconstructions that emphasize critical parents and injurious separations will generally fall on deaf ears with narcissistic clients, no matter how depressed they are, because rejection and trauma are not the main internal narrative in narcissistic dynamics. But they may be gratefully received by depressive patients as an alternative to their longstanding habit of attributing all their pain to their personal shortcomings. With a narcissistic person, attempts to work “in the transference” may be shrugged off, belittled, or absorbed into an overall idealization, but a depressive patient will appreciate the traditional approach and make good use of it.

The difference between introjectively depressive and narcissistically depressed individuals, even though their observable symptoms may be the same, comes down to the metaphorical understanding of narcissistic clients as pathologically empty and depressive ones as pathologically filled with hostile introjects. Therapy must be tailored to these contrasting subjective worlds.

Depressive versus Masochistic Personality

Depressive and self-defeating (masochistic) patterns are closely connected, since both orientations may be adaptations to unconscious guilt. They coexist so frequently, in fact, that Kernberg (e.g., 1984), in acknowledgment of Laughlin’s (1967) seminal observations, considers the “depressive–masochistic personality” to be one of three common neurotic-level kinds of character organization. In spite of their frequent coexistence and synergism, I prefer to differentiate carefully between depressive and masochistic psychologies. An organizing principle of this text has been to attend to those differences among people that have an established conceptual status in the psychoanalytic tradition and that have significant implications for psychotherapy technique. In Chapter 12 I explore the differences between predominantly depressive and predominantly masochistic personalities and elaborate on the implications of those differences for treatment.

HYPOMANIC (CYCLOTHYMIC) PERSONALITIES

Mania is the flip side of depression. People with hypomanic personalities have a fundamentally depressive organization, counteracted by the defense of denial. Because most people with manic tendencies suffer from episodes in which their denial fails and their depression surfaces, the term “cyclothymic” has sometimes been used to describe their psychology. In the second edition of the DSM (DSM-II; American Psychiatric Association, 1968), both depressive and cyclothymic personality disorders were accepted diagnoses.

Hypomania is not a state that simply contrasts with depression; point for point, it is a mirror image of it. The hypomanic individual is elated, energetic, self-promoting, witty, and grandiose. Akhtar (1992) describes the individual with hypomanic personality disorder as follows:

The individual with hypomanic personality is overtly cheerful, highly social, given to idealization of others, work-addicted, flirtatious, and articulate, while covertly guilty about aggression toward others, incapable of being alone, defective in empathy, unable to love, corruptible, and lacking a systematic approach in his cognitive style. (p. 193)

Many individuals with characterological hypomania, however, have more mild versions than the personality disorder Akhtar is describing, and are able to love and to behave with integrity.

People in a manic state or with a manic personality are famous for grand schemes, racing thoughts, and extended freedom from ordinary physical requirements, such as food and sleep. They seem constantly “up”—until exhaustion eventually sets in. Because the person experiencing mania literally cannot slow down, drugs like alcohol, barbiturates, and opiates that depress the central nervous system may be highly attractive. Many comics and humorists appear to have hypomanic personalities; their relentless wit can sometimes be quite wearing. Sometimes the dysthymic side of a very funny person is more visible, as with Mark Twain, Ambrose Bierce, Lenny Bruce, or Robin Williams, all of whom suffered serious depressive episodes.

DRIVE, AFFECT, AND TEMPERAMENT IN MANIA

People with hypomanic psychologies are notable for high energy, excitement, mobility, distractibility, and sociability. They are often great entertainers, storytellers, punsters, mimics—treasures to their friends, who nevertheless sometimes complain that because they turn all serious remarks into occasions for humor, they are hard to get close to emotionally. When negative affect appears in people with manic and hypomanic psychologies, it tends to manifest itself not as sorrow and disappointment, but as anger, sometimes in the form of episodes of sudden, uncontrolled rage.

Like their counterparts in the depressive realm, they have struck psychoanalytic observers as organized along oral lines (Fenichel, 1945): They may talk nonstop, drink recklessly, bite their nails, chew gum, smoke, gnaw on the insides of their mouth. Especially at the disturbed end of the manic continuum, many are overweight. Their perpetual motion suggests considerable anxiety, despite their often markedly elevated mood. The delight they display and, by contagion, bestow, has a somewhat fragile, undependable quality; their acquaintances often harbor worries about their stability. Whereas exhilaration is a familiar condition for hypomanic individuals, a calm serenity or a Lacanian juissance may be completely outside their experience (Akiskal, 1984).

DEFENSIVE AND ADAPTIVE PROCESSES IN MANIA

The core defenses of manic and hypomanic people are denial and acting out. Denial is conspicuous in their tendency to ignore (or to transform into humor) events that would distress or alarm others. Acting out often takes the form of flight: They run from situations that might threaten them with loss. They may escape painful affects by sexualization, intoxication, provocation, and even acts that appear psychopathic, such as theft; hence, some analysts have questioned the stability of the reality principle in manic clients (Katan, 1953). Manic people also devalue, a process isomorphic with the depressive tendency to idealize, especially when they contemplate making loving attachments that they fear will disappoint.

For a manic person, anything that distracts is preferable to emotional suffering. Those with severe personality disorders and those in a temporarily psychotic state may also use the defense of omnipotent control; they may feel invulnerable, immortal, convinced of the assured success of some grandiose scheme. Acts of impulsive exhibitionism, rape (usually of a spouse or intimate), and authoritarian control are not unknown during a manic psychotic break.

RELATIONAL PATTERNS IN MANIC PSYCHOLOGY

In the histories of hypomanic people, perhaps even more strikingly than in those of depressive individuals, one finds a pattern of repeated traumatic separations with no opportunity for the child to process them emotionally. Deaths of important people who went unmourned, divorces and separations that no one addressed, and family relocations for which there was no preparation litter their childhoods. One hypomanic man I worked with had moved 26 times during his first 10 years; more than once he arrived home after school to find the moving van in the driveway.

Criticism and abuse, emotional and sometimes physical, are also common in the backgrounds of manic and hypomanic individuals. I have already discussed this combination of traumatic separation and emotional neglect and mistreatment as it applies to depressive outcomes; it may be that in the histories of manic people the losses were more extreme, or that attention to their emotional significance by the child’s caregivers was even scarcer than it is in the backgrounds of depressive people. Otherwise it is hard to explain the need for a defense as extreme as denial.

THE MANIC SELF

One of my hypomanic patients described herself as a spinning top. She was keenly aware of her need to keep moving lest she feel something painful. People with a hypomanic pattern are frightened of attachment, because to care about someone means that losing that person will be devastating. The manic continuum from psychotic to neurotic structure loads more heavily in the borderline and psychotic areas because of the primitivity of the processes involved; a consequence of this is that many hypomanic and cyclothymic people are at risk of the subjective experience of self-disintegration that self psychologists refer to as fragmentation. It is as if they fear that if they do not keep moving, they will fall apart. Often they come to therapy right after a depressive experience of profound self-fragmentation, when their manic defenses failed.

Self-esteem in hypomanic people may be maintained, somewhat tenuously, by a combination of success at avoiding pain and elation at captivating others. Some individuals with manic defenses are masterful at attaching other people to themselves emotionally without reciprocating an investment of comparable depth. Because they are often brilliant and witty, their friends and colleagues—especially those holding the common but fallacious belief that intelligence and severe psychopathology are mutually exclusive—can be nonplussed to learn of their psychological vulnerabilities. Suicide attempts and flagrantly psychotic behavior can suddenly invade a manic fortress if some loss becomes too painful to deny.

TRANSFERENCE AND COUNTERTRANSFERENCE
WITH MANIC PATIENTS

Manic clients can be winsome, insightful, and fascinating. They also tend to be confusing and exhausting. Once while working with a hypomanic young woman, I became aware of the fantasy that my head was in a clothes dryer, the kind in the laundromat that whirl garments in full view but too fast to track. Sometimes in an initial interview one is aware of a nagging feeling that with such a turbulent history, the patient should be showing more emotionality in recounting it. At other times one is aware of somehow not being able to put all the pieces together.

Perhaps the most dangerous countertransference tendency in therapists working with hypomanic people is underestimating the degree of suffering and potential disorganization that lies beneath their engaging presentation. What may appear to be a congenial observing ego and a reliable working alliance may be manic denial and defensive charm. More than one therapist has been shocked by the results of projective testing with an appealing hypomanic client; the Rorschach often picks up a level of psychopathology that no one on the intake team suspected.

THERAPEUTIC IMPLICATIONS OF THE DIAGNOSIS
OF HYPOMANIC PERSONALITY

One’s primary concern with a hypomanic patient must be the prevention of flight. Unless the therapist discusses this in an early session, interpreting the person’s defensive need to escape from meaningful attachments (which will be evident from the history) and contracting with the client to remain for a certain period after feeling the impulse to bolt, there will be no therapy because there will be no patient. One can do this as follows:

“I notice that every important relationship in your life has been disrupted abruptly, usually at your initiative. There’s no reason why that won’t also happen in this relationship—especially because in therapy so many painful things get stirred up. When life gets painful, your pattern is to flee. I want you to make a deal with me up front that no matter how reasonable it seems, if you suddenly decide to break off your therapy at any point, you’ll come back for at least six more sessions [or any other number that seems reasonable or can be negotiated], so that we can understand in depth your decision to go and have a chance to process the ending in an emotionally appropriate way.”

This may be the first time the patient has been confronted with the fact that there is an emotionally appropriate way to end relationships; that is, one has to deal with grief and other expectable feelings that surround endings. A constant focus on the denial of grief and negative emotions in general should inform the therapy work. Most analysts (e.g., Kernberg, 1975) have considered the prognosis for hypomanic patients to be guarded at best, even when the therapist takes every precaution to prevent flight, because of these clients’ extreme difficulties tolerating grief. Sometimes more manifestly “sick” manic patients are easier to help, because the degree of their psychological discomfort supports their motivation to stay in treatment.

With more disturbed manic patients, as with more seriously ill depressive ones, psychotropic medicine has been a godsend. Current psychiatric sophistication makes it possible to adjust type and dosage of medication to the specific needs of the patient; the days when lithium was the only effective drug for mania are long gone. I have found it important, however, to be sure that the prescribing physician takes a careful, individualized approach to each patient; clients with manic tendencies are as variable as anyone else and often have idiosyncratic physical sensitivities, addictions, and allergies. A dependable relationship with their physician as well as their psychotherapist, and a mutually supportive relationship between these practitioners, supports their recovery. Contrary to some conventional wisdom, psychotherapy is valuable and effective with manic patients; without it, they fail to work through their experiences of ungrieved loss and to learn how to love with less fear. They also stop taking their medicine.

Healthier hypomanic people tend to come to therapy later in life, when their energies and drives have lessened, and when they can see clearly in retrospect how fragmented and unsatisfying their histories are. They sometimes come for individual help after a long stint of work on an addiction in a 12-step program, when their self-destructiveness has lessened and they want to make sense of their life. Like narcissistic clients of the grandiose type, with whom they share some defensive patterns, older hypomanic people are sometimes easier to help than their younger counterparts (Kernberg, 1984). But they still need to contract against premature flight. The dearth of literature on the psychotherapeutic treatment of hypomanic personalities may reflect the fact that many therapists learn the hard way that they should have made such an agreement.

Some considerations applicable to the treatment of paranoid patients also apply to hypomanic ones. Frequently one must “go under” a defense; for example, aggressively confronting denial and naming what is denied rather than inviting the patient to explore this intrinsically rigid, inflexible defense. The therapist must be strong and devoted. He or she should interpret upward, educating the hypomanic person about normal negative affect and its lack of catastrophic effects.

Because of manic terrors of grief and self-fragmentation, therapy must move slowly. The clinician who demonstrates deliberateness offers a spinning client a different model of how to live in the world of feelings. Treatment should also be conducted in an especially forthright tone. In their efforts to avoid psychic pain, most hypomanic people have learned to say whatever works. Emotional authenticity may be a struggle for them. The therapist must therefore inquire periodically whether they are telling the truth, as opposed to explaining away, entertaining, or temporizing. Like paranoid people, hypomanic clients need a therapist who is active and incisive, and who is notably lacking in cant, hypocrisy, and self-deception.

DIFFERENTIAL DIAGNOSIS

I noted the main obstacle to identification of hypomanic clients in the section on transference and countertransference: Therapists may misperceive these initially appealing people as having more mature defenses, more ego strength, and better identity integration than they do, a mistake that may alienate a sensitive hypomanic person after only one interview. Manically organized clients outside the psychotic range are most commonly diagnosed as hysterical, narcissistic, or compulsive, or as having attention-deficit disorder (ADD). Those with psychotic symptoms are most frequently misunderstood as schizophrenic.

Hypomanic versus Hysterical Personality

Because of their charm, their seeming capacity to engage warmly, and their apparent insightfulness, hypomanic clients, especially women, can be misunderstood as hysterical. This error risks losing the patient quickly, since the therapeutic style that helps people with hysterical organization may make the hypomanic person feel insufficiently “held” and only superficially understood. The unconscious conviction that anyone who seems to like them has been duped exists in manically structured people just as in introjectively depressive ones; it will issue in devaluation of and flight from the therapist unless addressed directly in ways that would be contraindicated with a hysterically structured patient. Evidence of abruptly ended relationships with people of both sexes, a history of traumatic and unmourned losses, and absence of the hysterical person’s concern with gender and power are some of the areas that differentiate hypomanic from hysterical people.

Hypomanic versus Narcissistic Personality

Because grandiosity is a central feature of manic functioning, it is easy to misconstrue a hypomanic or cyclothymic person as the more grandiose kind of narcissistic patient—again, in remarkable parallel to confusions between depressive patients and the depressed–depleted type of narcissistic person. A good history should highlight the disparity; narcissistically structured people lack the turbulent, driven, catastrophically fragmented backgrounds of most hypomanic clients.

The intrapsychic difference is between inner emptiness in the narcissistic person and the presence of savagely negative introjects—managed by denial—in the hypomanic one. Although an arrogant narcissistic person can be difficult to treat, and resists attachment in many ways, the threat of immediate flight is less severe. Misconstruing a hypomanic individual as narcissistic can thus cost one a patient. The two groups have an affinity, however, in that both become more accessible therapeutically when older; moreover, analysts who understand grandiose narcissism in introjective terms (e.g., Kernberg, 1975) advocate a similar approach to each type of client.

Hypomanic versus Compulsive Personality

The driven qualities of the hypomanic person invite comparison with characterological compulsivity. Both compulsive and hypomanic people are ambitious and demanding, and on this basis, they have sometimes been compared (Akiskal, 1984; Cohen, Baker, Cohen, Fromm-Reichmann, & Weigart, 1954). Their similarities are mostly superficial, however. Akhtar (1992), contrasting the hypomanic person with the compulsive client (whom he construes, following Kernberg (1984), as being by definition at the neurotic level of personality organization), summarizes:

Unlike the hypomanic, the compulsive individual is capable of deep object relations, mature love, concern, genuine guilt, mourning, and sadness. . . . The compulsive is capable of lasting intimacy but is modest and socially hesitant. The hypomanic, on the contrary, is pompous, loves company, and rapidly develops rapport with others only to lose interest in them soon afterward. The compulsive loves details, which the hypomanic casually disregards. The compulsive is tied down by morality and follows all rules, while the hypomanic, like the “perverse character” (Chasseguet-Smirgel, 1985), cuts corners, defies prohibitions, and mocks conventional authority. (pp. 196–197)

Thus, as is the case with the distinction between hypomania and hysteria, it is critical to notice the difference between the internal meaning and the manifest content of behavior.

Mania versus Schizophrenia

A person in a manic psychotic condition can look very much like a schizophrenic in an acute hebephrenic episode. This differential is important for medication purposes. Popular impressions aside, the fact that someone is overtly psychotic does not equate to his or her being schizophrenic. To determine the nature of a person’s disorganization, especially with younger patients having an initial psychotic break, it is important to take a good history (from the client’s family if the client is too delusional to talk), to assess underlying flatness of affect and to evaluate the capacity to abstract. The conditions we sometimes call “schizoaffective” comprise psychotic-level reactions that have both manic–depressive and schizophrenic features and consequently require especially sensitive pharmacological treatment.

Mania versus Attention-Deficit Disorder

In recent years there has been a lot of attention to adult ADD and attention-deficit/hyperactivity disorder (ADHD). I assume that this trend reflects the fact that contemporary life presents us with countless competing stimuli, reinforcing any tendencies we have toward distractedness, and that this diagnostic tendency has arisen because we now have so many medications that reduce distractibility. The characterologically manic person is highly distractible and can be easily assumed to be suffering from ADD. But internal themes of loss, longing, and self-hatred, countered by the defense of denial, can discriminate a personality tendency from the symptomatic difficulties of people with adult ADD. Of course, it is possible to have a hypomanic personality and also have an attention-deficit problem; physicians medicating in this situation should be particularly careful not to prescribe a drug with known risks of triggering a manic state.

SUMMARY

In this chapter I have discussed patients who are organized characterologically along depressive lines, whatever their experience with the disorders of mood that we define as clinical depression. I followed Blatt (2004, 2008) in differentiating between the anaclitic or longing version of depressive personality and the introjective or self-attacking version. In terms of drive, emotion, and temperament, I emphasized orality, unconscious guilt, and exaggerated sorrow or joy, depending on whether the patient is depressively or manically inclined. I covered the ego processes of introjection, turning against the self, and idealization in predominantly depressive structure, and denial, acting out, and devaluation in predominantly manic organization. I framed object relations in terms of traumatic loss, inadequate mourning, and parental depression, criticism, abuse, and misunderstanding. I characterized introjective depressive images of self as irredeemably bad and anaclitic images as insatiably hungry. In the sections on transference and countertransference, I noted the appealing qualities of depressive and manic people, and the associated rescue wishes and potential demoralization of the therapist who cannot rescue fast enough.

As for treatment style, in addition to a sustained empathic attitude, I recommended the vigorous interpretation of explanatory constructs, persistent exploration of reactions to separation, attacks on the superego, and in manic patients, flight-prevention contracts and a persistent demand for honest self-expression. Diagnostically, I distinguished depressive clients from narcissistically and masochistically oriented patients; I differentiated hypomanic and manic clients from hysterical, narcissistic, compulsive, and schizophrenic people and from those with ADD and ADHD.

SUGGESTIONS FOR FURTHER READING

Laughlin’s (1967) chapter on the depressive personality is excellent, though hard to find these days. Gaylin’s (1983) anthology on depression contains a fine summary of psychoanalytic thinking on depression. The only recent essay I know of on the hypomanic personality is in Akhtar’s Broken Structures (1992). Again, Fenichel (1945) is worth reading on both depressive and manic conditions for those who are not put off by his somewhat arcane terminology. Although they do not describe so much the personality attributes as the clinical phenomenon of major depression or bipolar illness, I think the best window into the subjective experience of the person with depressive and/or manic psychology can be found in memoirs. Those of William Styron, Kay Redfield Jamison, and Andrew Sullivan are particularly compelling.

At the end of Chapter 9, I mentioned two DVDs that the American Psychological Association plans to release in 2011 and suggested watching the session I had had with a man whose psychology I saw as schizoid (Beck, Greenberg, & McWilliams, in press-b). The woman who volunteered to be the patient in the other demonstration video (Beck, Greenberg, & McWilliams, in press-a) seemed to me to have some hypomanic dynamics. Chi Chi was sensitive and funny and talented, and she related with immediate warmth. She and I had unexpectedly bonded before the filming, when I had a meltdown about my professionally done makeup (I looked in the mirror and saw Cruella de Ville).

Chi Chi complained of a pattern of dropping or sabotaging things, including relationships, whenever she got emotionally invested. The daughter of a diplomat, she had been uprooted again and again during her childhood, and her critical mother had tolerated no grief or yearning for lost connection. When I asked why she had volunteered to be filmed, she told me she had been the patient in several Master Clinician videos, that she liked being on stage. I wondered if her fear to attach deeply had left her trying to address her underlying depressive tendencies by getting therapy in bits and pieces, unconsciously replicating the dislocations of her history. During the second session with her, I speculated about her fear of intimate connection and, despite her expressed discomfort with exploratory therapies, tried to talk her into considering long-term work with a carefully chosen therapist. She seemed dubious, and in a follow-up interview she said that she had not felt safe with me—perhaps because I was trying to demonstrate a psychoanalytic idea rather than staying in her comfort zone. So I feel some pain about this DVD, but readers who would like to view me trying to be of help to a client with hypomanic defenses may find it illuminating.