Vol 1, No. 11, October, 1988
Carolyn Reichelt has
identified two characteristics of the relation between depression and R which I think can be
very confusing. First, what is depression in systems terms? Is it an agent of change or an agent of homeostasis? I will come back to this. Second, the
criticism which maintains the depressed mood is often directed against the depression itself.
Criticism of the depressive symptoms. A recent patient in my clinic had a disagreement
with her husband because she had taken a part time job. He was against it,
partly because it undermined his status as the sole provider for the family,
and partly because it gave her opportunities for meeting other men. However, it was
difficult for him to put these points across in rational argument. Instead,
he made a general attack on her, criticising her intelligence, her
appearance and her parents. She became mildly depressed, and her ability to
run the house was impaired, but she hung
on to the job which was "the only thing that kept me sane". Then the husband switched
his attack to her household management, finding fault with everything. These attacks were more effective; she had known the
previous attacks were unjustified, so
that even if they were painful they did not
really get to her. However, she knew that the attacks on her household
management were justified because she was too depressed to do her work up to its former high
standard. So, knowing she was in the wrong, she was more vulnerable to the
criticism and she became more depressed. She became too depressed to go to work
and she gave up her job.
Carolyn Reichelt mentions a husband getting angry at a wife's complaints of
depression. In the case above the husband got angry because his house wasn't cleaned
properly. In a previous ASCAP I mentioned the husband who was angry at his wife's tearfulness
("you'd feel better if you didn't cry all the time"). Some husbands
get angry at lack of sexual response, others at weight loss or gain. Wives get
angry with the depressed husband who does't do
jobs around the house, or leaves them half done.
To criticise
someone for being depressed is an effective strategy for producing change. First of all the
victim cannot fight back, because she knows the accusation is true.
Secondly, the more depressed she gets, the more there is to criticise, which
makes her even more depressed, and so on,
in escalating fashion, until an end-point is reached. In the above case, the end-point came
when she gave up her job, which is what her husband wanted in the first place. He had got his own
way. She had played (subconciously) a yielding strategy in the form of
depression - a strategy for not getting
her own way. The end-point may not be so tangible as giving in over a specific issue, such
as my patient who gave up her job, it
may just be a reversal of dominance, or the loss of equality by one
spouse.
But once the
snowball of depression has started down the hill, your correspondent asks, what is to stop
it? In many cases, once the end-point is reached, the
other spouse stops sending catathetic signals. In the case of my patient, the husband became much
more "understanding" when she had
given up the job and he realised that she was "ill", and
needed to be off work for medical
reasons. Sometimes, though, R goes on falling until it gets to levels unimaginable by those who have
never been depressed, and in doing so
allows others to achieve biological goals which otherwise would have been denied to them. Another patient
realised that her husband was
having an affair with the baby sitter. This made her depressed,
and she was
unable to object when her husband brought the baby sitter to live in their house, telling her that being depressed
she needed more help with the children. She believed that she was so worthless
that she did not deserve
a man of her own. Some patients believe that they do not deserve
to live, others
that their children would be better off without them. Such beliefs indicate very low R.
Both
these women might have "played" an escalating rather than a yielding strategy. If
they had experienced elevation of mood rather than depression, they would have had the
courage and the energy to fight back and
make their husbands feel in the wrong and depressed. Or, less likely, they would have
been able to maintain symmetrical relationships with their husbands, standing up for their rights but
not putting their husbands down. Of course, neither would have had any choice
over whether she became elated or depressed. The switch mechanism is
probably in the corpus striatum, what MacLean calls the "reptilian
brain", well below the level of any brain
mechanisms which subserve "choice".
The
amplifying, positive feedback situation outlined above, in which criticism of the depression leads to
more depression which leads to more
criticism, etc., is only one of many similar processes seen with depression. It might be helpful to list some
of these.
Positive feedback loops in depression
1. At the intrapsychic level.
Depressed people have a depressing view of events,
which is in turn
depressing. They selectively recall unfavourable events from the
past. The classical psychiatric view is that the depression comes first and the depressive
perspective on life is secondary. Cognitive therapists such as Beck say that the depressing view
comes first and the depressed mood is
secondary. In systems terms the direction of causation is irrelevant.
Recently there
has been interest in changes in causal attribution during depression (Brewin,
1985). Depressed people may attribute aversive life
events to internal, stable, global causes, and
this leads to more depression. Internal
attribution has replaced non-contingency in the theory of learned helplessness - which
makes sense as we know that a lot of
depressives have too much contingency, as when they feel personally responsible for disasters they read about in
the newspapers. What could be
more depressing than feeling responsible for, say, the IRA?
Finally, if
aversive life events cause depression, what about getting depressed about having an attack of
depression?
2. In the mind-body
subsystem.
At the vegetative level depression is usually associated with
loss of sleep and
reduction of food intake, both of which have been identified as causes of depression. In some 'atypical' depressions
there is hyperphagia (excessive eating)
and this may lead to obesity which gives a negative self-image and thus increases depression.
There is often constipation
which gives rise to a negative chain of reasoning; for instance, ideas that the body is not working properly or that
the gut contents are rotting and
invading the system with the foul products of putrefaction, or even that the
bowels are totally seized up, turned to concrete and will never open again.
At the musculo-skeletal level depression may be associated
with loss of poise
and disorders of both posture and gait (Sloman, 1980) of which the
subjective experience may be depressing and which
may lead to negative feedback from
others. There are also aches and pains, which are not only depressing in themselves but they also
may give rise to ideas of serious
malfunction and disease. A tension headache is often interpreted as evidence of tumour of the brain, the intercostal pain due to breathing irregularity is put down to heart
disease; the epigastric
discomfort known as "butterflies in
the tummy" is attributed to stomach cancer.
Likewise
other symptoms are given a gloomy interpretation which leads to further pessimism and anxiety; the palpitations of anxiety, for instance, may be experienced as acute heart
disease presaging imminent death.
3. At the executive
level.
The loss of energy associated with depression leads to
failure to carry out tasks and thus to
the accumulation of dirty dishes, unanswered letters and unemptied
dustbins; so that increasing quantities
of rubbish and other evidence of
incompetence and failure surround the depressed person and cannot but have a further depressing effect.
Moreover, neglect of self- care leads to a deterioration of skin, hair and
clothes so that to look in
the mirror is a depressing experience.
4. At the social
level.
Depression leads to isolation which for most people is
depressing. If there
was just avoidance of people who make one feel bad, such as enemies, the depression might serve a homeostatic
function in this respect; but, on the contrary, the depressed person avoids
friends and relatives who would, if they
were permitted, cheer him up.
Klerman
(1974)investigated the "communication of
distress" function of depression,
postulating that it served as a cry for help which mobilised social resources. However, after studying a
group of 40 depressed women
and a matched control group he came to the conclusion that the
depression
had alienated the women not only from
friends and relatives but even from
their husbands and children.
5. At the
therapeutic level.
The depressed person tries to get himself out of the
trough, but these
efforts are more likely to make things worse rather than better.
The only drug
generally available to him is alcohol, and while in some depressed patients this numbs the pain of the
depression for a while, he is soon left
with not only the pain but also the hangover. The same applies to other drugs of the
sedative/hypnotic group. Samuel Johnston recognised the dangers of alcohol for the depressed
person, saying "Melancholy should be
combated by all means except by alcohol."
Many
depressed patients make extraordinary efforts to cure themselves, even without the
added stimulus from friends to "Pull yourself together" or to "Snap out of it." These efforts fail, and this failure enhances
the depression.
Homeostatic aspects of depression
In view of the above considerations we might expect
every depressed patient to be
accelerating towards disaster, but in practice the majority of depressed patients, certainly most of those
seen in the out-patient clinic, seem to
be very chronic and appear to the clinician to be "stuck" rather than in a state of change. This may be an
illusion due to the very
variable time scale of the accelerating process (which may take
anything from minutes to years), but in
many cases it seems to be the depression
itself which is preventing the change from occurring. A man is depressed in his job,
but he lacks the intitiative to apply for another
job; he is nervous about the interview situation, and he
dreads the rejection of being turned
down. As with a job, so with a marriage. One of the commonest presentations
in my out-patient clinic is the woman who is married to an uncaring tyrant; her life is one of drudgery and service to a
man who will give her no pleasure and
denies her the opportunity of seeking pleasure
elsewhere. These women are "stuck" in their awful marriages,
and the depression
makes it impossible for them to leave. They lack the energy and initiative to set up on their own,
they lack the interest to look for an
alternative partner and the depression makes them unattractive to any
man who might come along.
As it was said
of Hamlet, depression is the agent by which unfavourable circumstances take away one's capacity
to deal effectively with those
circumstances. In these cases, it is acting as an agent of homeostasis.
Is there really a paradox?
Can depression be both an agent of change and an agent
of homeostasis? I pondered over this apparent paradox
for many years. Adopting the systemic approach had got over the difficulty
about cause and effect, but gave one
this even greater difficulty about change and homeostasis. Were there different
categories of depression, some causing change and others homeostasis? This is what I thought at one stage (Price,
1974). A more likely
explanation was that depression is causing change at one logical level but homeostasis at a higher level (as,
for instance, a change in sweating may
mediate homeostasis of temperature). I now favour a third possibility. But before giving my own
solution, I think it would be fair to
Carolyn Reichelt to let her work it out for herself,
assuming, that is, that she agrees with
me that there is a problem.
Brewin, C.R. (1985) Depression and causal
attributions: what is their relation? Psychological Bulletin 98, 297-309.
Brewin, C.R. (1988) Cognitive Foundations
of Clinical Psychology. Hove:
and Mental Diseases, 159, 172-181.
Klerman, G.L., 1974, Depression and adaptation. In The
Psychology of
Depression. R.J.Friedman and M.M.Katz (Eds.).
MacLean, P.D., 1985, Evolutionary
psychiatry and the triune brain. Psychological Medicine 15:219-221.
Price, J.S., 1972, Genetic and phylogenetic
aspects of mood variation. International Journal of Mental Health, 1,
124-144.
Sloman, L. et al. (1982) Gait patterns of depressed
patients and normal
subjects. Americal Jornal of Psychiatry, 139, 94-97.
My solution (Nov '88)
What changes,
or does not change, is who gets their own way. The depressed person does not get his own
way. If he formerly got his own way, then depression is an agent of change.
If he formerly did not get his own way, then he continues to not get his
own way and the depression is an agent
of homeostasis.
In order to be
clear about it, one has to distinguish between change and homeostasis in the relationship (with
whoever the depressed person has been in
conflict with) and change, or staying the same, in secondary matters, such as getting or losing a job, or staying
together or getting divorced. The function of depression concerns change and
homeostasis in the
relationship. It is not concerned with whether or not there
shall be secondary
change, it is concerned with whether or not there is a change in who decides whether or not there shall be
change.
In my patient
who lost her job depression was an agent of change, not because she stopped work, but because
stopping work represented a change from
getting her own way about working to not getting her own way about working. In my patient whose husband brought
the baby sitter into the
house, depression was an agent of homeostasis, in that she
remained married in spite of what would
have been an intolerable situation to most women. She had never got her own
way, and the depression enabled her to put up with even more humiliation than usual.
She could not leave, because her husband did not want her to, and
leaving would have meant getting her own
way.
Other forms of
change are secondary to the power issue, and may go either way. If the dominant partner wants
change, such as a move of house, there is change, and the depressed partner
goes along with it. If the dominant partner wants to stay where he is,
there is no change, and the depressed partner
goes along with that.
In summary,
depression is an agent of passivity, and the depressed person either becomes passive (change) or
remains passive (homeostasis), putting
up with the direction of the partner without either fighting back
or leaving.
March 1989
Postscript to comment on CRR's
first contribution
On rereading the above I see that I have not answered CRR's comments;
they triggered a related but
separate concern of mine, and I went off on my own hobby horse. CRR makes the point that
sometimes, in a complementary
relationship where there is already an RHP gap, the system
operates in "runaway" fashion
rather than homeostatically. She gives two examples.
In one case
the husband reacts to his wife's submissive signal as though it was a catathetic
signal; it makes him angry and he
attacks her so that she gets more
depressed, becomes even more submissive, angers him even more, etc., etc. In this case, the wider the
gap, the more catathetic is the signalling of the higher-ranking
partner, which is the opposite of what
the theory predicts.
I think what
may be happening here is that the husband is so identified with his wife that he interprets her
own attack on herself as an attack on
himself. Her statement to the effect that "I, your wife, am
worthless" is the
equivalent of saying "We are a worthless couple" or "You are a
bad husband" or, to the extent that
he sees his wife as a possession, her self- denigration is the equivalent of
someone saying "Your car is a heap of
junk".
The wife can
get round this by remembering that the submissive signal is a signal of unfavourable relative RHP
and can be signalled in any of three
ways. It can be a comment on her own low RHP,
as above. Or it can be a
comment on his high RHP such as "You are wonderful". Or
it can be a comment
on the RHP gap such as "You are more competent than me". These latter two ways
of expressing submission are less likely to be
misinterpreted as catathetic signals.
The second
example is a husband who is angry with his wife and giving her catathetic signals
in an attempt to widen the RHP gap (by lowering her RHP), but in doing so he
falls short of his image of himself as the ideal husband who is courteous to his wife and
so he loses RHP. The more he tries to widen the gap by lowering her
RHP with catathetic signals, the more he lowers his own RHP by deviating from
his ideal self. If the
transaction lowers his RHP more than hers they are in a runaway
situation and one end-point could be a
reversal of dominance. Paul Gilbert has pointed out to me that this situation
often happens with mothers who scream at
their children - the loss of self-respect on the part of the mother is often greater than the subduing effect on the
children. It may end up with
mothers who are subordinate to their children.
In the second
example the runaway can lead to a change in dominance because the situation to be explained
is paradoxical loss of RHP by the
dominant partner so that change is possible. In the first example, however, change is
not possible because the situation is one in which the wife continues to be put down and she is
already subordinate. Where does it end? In CRR's example
the wife learns not to express self-denigration. No doubt there are other
possible outcomes, such as suicide or hospitalisation.
The first
example is an instance of "incomplete yielding" described by Sloman, Gardner
and Price (unpublished paper). In order for yielding to be completed, at least four stages must
occur:
1. The yielder must yield. To do this he must stop
sending catathetic
signals to the winner, and react to the winner's catathetic
signals not with catathetic
signals but with escape or submission (anathetic
signals). Also he must signal low RHP.
Also he must give whatever yielding signals are appropriate to his culture. Also
he must give up whatever the fight was about. This last requirement may
be particularly difficult, because he may not be able to provide the goods,
for instance if he is required to
provide love, or something else over which he does not have control. In one case of mine a
depressed wife was required by the husband to give up visits that were required by her mother, to
whom she was even more subordinate than
to her husband.
2. The winner must recognise the yielding signals and
accept them as
sufficient. This probably did not happen in CRR's
first example.
3. The winner must acknowledge receipt and acceptance
of the yielding
signals. In some species there are inherited signals for this; eg, mounting in some monkeys and feeding in some
birds.
4. The yielder must recognise the acknowledgement of
the winner.
Sometimes all
four stages are included in a ceremony of "conditional reconciliation", as Franz de Waal
has described for the chimpanzee in Fabrics
of the Mind.
Incidentally, I must clarify one point about the
effect of a catathetic signal on the
sender's RHP. Sending a catathetic signal and thus (by definition)
lowering the recipient's RHP does not in itself raise the absolute RHP of the sender, only if it
elicits an anathetic signal from the recipient. To the extent that it lowers the
recipient's RHP, widening the
RHP gap, it raises, or rather makes more favourable, the relative
RHP of the sender. The effect of this
rise in relative RHP depends on whether the relationship is symmetrical or
complementary. If the relationship is symmetrical, it increases catathetic signalling; if the sender is the dominant member of a complementary
relationship, it reduces catathetic signalling. This follows from the sender's
definition of the catathetic signal: in a symmetrical relationship it is a signal
of favourable relative
RHP; in the dominant member of a
complementary relationship it is a
signal of insufficiently favourable relative RHP (see my chapter in Social fabrics of the mind).