Christian Gaedt -1-
Depressive Disorders in Poeple with Learning Disabilities…..
Depressive Disorders in People with Learning Disability: Psychoanalytically Orientated Concepts in the Understanding of Challenging Behaviour[1]
Summary
The basic depressive reaction to experiences of loss and separation, as described in psychoanalytic developmental psychology, with its multiple psychomotor, aggressive and vegetative components, serves as an explanatory model for specific psychopathological phenomena often observed in the mentally handicapped. In reference to this theoretical model, such manifestation are interpreted as depressive disorders. These disorders are characterized by a strong tendency towards self-devaluation, but differ in the extent and dynamics of this tendency. For dealing with these problems therapeutically, a classification into three groups is suggested: self-unstables, self-destroyers and quiet depressives. Re-enactments in connection with depressing experiences often influences everyday life in residential group settings or in families. in ways often difficult to recognize, family members or caregivers are forced to play roles in these re-enactments; this emphasizes the importance of psychoanalytic models in supervision and family counselling.
Introduction
Because of the non-specific and diverse character of depressive symptoms in the mentally handicapped it is hardly possible to give a complete description of all clinical manifestations related to depressive disorders in mentally handicapped persons (cf. Dosen & Menolascino, 1990). It is apparent that there is a greater variety of symptoms which can be observed in these persons than in the typical psychiatric textbook description of depression due to aggressive elements and the broad spectrum of psychosomatic concomitants; on the other hand the core symptoms of depression such as depressed mood,apathy, inappropriate guilt, suicidal ideation etc. lose significance. This is why attempts to use typical classification systems for assigning symptoms to a specific depressive disorder are often disappointing (cf. Zwanikken, 1988; ). Only for bipolar mood disorders (BMD) and major depression a systematic diagnostic approach seems to be successful (c.f. Sovner, 1990; Dosen and Gielen, 1993, Ruedrich, 1993); even in this area there serious doubt due to the restrictivness of the items (Cooper and Callacott 1994). This diagnosis, even so, covers only a small part of the whole spectrum of behaviours observed in every-day life and usually interpreted as indicative of depressive phenomena.The organic orientated explanations, furthermore, probably appropriate to the BMD, are not satisfactory for most of the other forms of depressive reactions. For the caregivers or the therapist, however, an understanding of the behaviour disturbances is important; it makes it easier to cope with the very challenging situations.
One way of understanding these disorders is offered by the developmental perspective. (Sroufe and Rutter, 1984; Trad, 1986, Dosen, 1993) Based on the theory of psychoanalytic developmental theory this paper focusses on the "basic depressive reaction" and considers the various depressive phenomena as transformation of this basic reaction corresponding to different developmental stages and various disturbing events in the developmental process.
Depressive reactions in early stages of development
I would like to start with the studies of Mahler and her colleagues (1980) concerning early developmental stages in normal children. These studies demonstrate that in normal early development, separation experiences can trigger certain forms of behaviour which the child psychiatrist would label as "depressive symptoms" at a later point in life. The following depressive phenomena may be observed in obviously normal children: drop in spirits, sadness, inhibited play behavior, slowing down of movements, escape into fantasy, crying fits, clinging behaviour and regressing to symbiotic experiences. Often one will find also hyperactivity, restlessness and temper tantrums. The spectrum becomes broader if one includes children with problematic development. These include affective dullness, desperately trailing behind the mother, deliberately running away and placing oneself in danger, auto-aggressive masturbation, alternating between extreme closeness and aggressive withdrawal, tendency towards fluctuations in mood and temper tantrums, ambivalency and chronic undecidedness.
According to Mahler depressive crises are an integrated part of the normal course of development. Depressive reactions are concomitants of the struggle for separation and autonomy, which is characteristic for early developmental stages.
The "basic depressive reaction"
Sandler and Joffe (1980) analysed the pattern of the primitive depressive reaction. According to them, a depressive affect always results when a person feels helplessly confronted with an impending or realized loss of a positively experienced "state of the self" situation characterized by separation and loss. Together with the depressive affect aggressive, psychomotor and vegetative phenomena are also included in the fully developed reaction. In this respect, experiences of depression including the various accompanying effects are a normal reaction to disappointing situations in which one feels helpless and at the mercy of uncontrollable forces. In principle, this bio-psycho-social reaction is a normal response to disappointing situations and is not characteristic for those persons vulnerable to depression. But on account of additional devaluating experiences and the lack of sufficient narcissitic reserves, a special defence mechanism becomes predominant in these children and is triggered with a very low threshold. By re-directing the activated aggressive impulses against the self a desperate attempt is made to protect the object. In the child's striving for safety (Sandler and Joffe 1969) this becomes for the depressive structured ("worthless") child the only way to restore and stabilize in its inner world a good relation to the significant ("idealised") object.This is the starting point for various forms of self-devaluation characteristic for depressive syndromes.
Depressive reactions: The "self-unstable"
The concept of a psychobiological basic reaction in response to experiences of loss proves to be useful for understanding many disturbances in mentally handicapped persons. This concept is complemented by the findings described by Spitz & Wolf (1946) and Bowlby (1952) in young children having experienced traumatic separation. Bowlby descibes a reaction pattern which includes a early phase of protest followed by a phase of despair and a final emotional withdrawal. This psychopatholgy can also be observed in mentally retarded adults with specific depressive vulnerability when they are confronted with disappointing events.
Often the reactions to anticipated frustrating situations are disguised and characterized by the attempt to avoid the depressive affect or to keep it from rising into conscious awareness. In this case, as Sandler and colleagues (1980) have pointed out, defence mechanisms play a significant role. Persons anticipating a emotionally disturbing event might retreat into a fantasy world, and we see them thumb-sucking or rocking the body to and fro. One may also observe compulsive rituals as an expression of the attempt to gain magical power over the disappointing world. It is also possible that the depressive affect may be disguised by an inversion of affect; this explains why clowning around frequently is observed in stressful situations. Another self-protective measure can be observed. In this case the affected person shows exaggerated shyness in response to attempts to establish contact with them, and refuse to participate in activities they actually have been looking forward to. In this way they avoid being confronted with anticipated disappointments.
Depressive changes in mood are not always detectable, but very often the aggressive elements are predominant. In particular, the immediate reaction to disappointing situations - the protest phase in the terminology of Bowlby - is connected with dramatic aggressive and auto-aggressive behavior. For the parents or caregivers this reaction is often difficult to understand and to cope with. The caregivers often get themselves into unresolvable conflicts because these reaction patterns are frequently triggered in connection with unavoidable events occurring in the course of everyday life in the facility, for example, after visits of parents or after termination of intensive individual training measures. Other factors which may elicit such reactions are fluctuation of personnel, transferral to another department, new admissions, or parties linked to strong emotional feelings.
In terms traditionally used in psychiatry this psychopatholgy can be described as an atypical manifestation of a reactive depression. If it is a passing and singular behaviour, it will not be of any relevance. The problem arises, if and when these persons provoke such situations time and again to relive their characteristic emotional experiences. I will come back to this later when discussing the problem of re-enactment This process is not actually triggered by these persons, but they pursue it actively, due to their proneness toward depressive experiences. An important prerequisite is an "unstable self" accompanied by the tendency to feel unworthy of love and a lack of narcissistic reserves, which is not untypical for mentally handicapped persons. I have termed this group as the "self-unstables".
The "self-destroyers"
Characterstic of the "self-unstable" group are repeated, but passing crises. During these crises the normal interaction patterns are interrupted for some hours or even some days by highly individualised depressive reactions. There is, however, another group of persons with a severe "self-pathology". This group is characterised by permanent pathological interaction style. The depressive crisis is only the high point of a never ending drama..
I will give an example: for many years educational and therapeutic efforts were directed at influencing the aggressive and auto-aggressive behavior of Peter M., 25 years old and moderately mentally handicapped without success. It was characteristic for him to select a "favorite" male staff member to built up a exclusive relationship to him. He did not make any difficulties in the presence of this staff member at the beginning. Peter, however, constantly badgered him with requests and questions and his clinging behaviour became more and more obtrusive. Finally, rejections and frustrations were inevitable.Even in case of minimal rejection, Peter would start fights with him which led quite often to physical injuries. If the caregiver finally stayed away because he could not cope any longer with this situation, Peter would withdraw completely from the rest of the world, and refuse to eat and speak. Without any apparent reason, he will show violent auto-aggressive behaviour time and again (such as banging his head against the wall or beating his fists on his eyes). It always will takes a long time before his behavior approaches normalcy and his search for an exclusive relation will start again.
The exclusive type of relationship can be interpreted as a desperate attempt to stabilize a extremely vulnerable "self". These persons cling to the caregiver and try to prevent even the shortest separation by reacting aggressively. When disappointed they belittle their caregiver, threatening with aggressive behavior which can hardly be brought under control. They produce a hostile atmosphere and provoke violent subjugation by their caregivers. If it is not possible to put a stop to this process, these individuals fall into a deep depression in which they may stay for months. Through their violent auto-aggressive behavior they cause consternation and concern in their social environment.. The clinical picture is very similar to that Blatt (1974) and Diepold (1984) describe as "introjective depression" in children.
According to Jacobson (1983), the dynamics of these depressive disorders can be traced back to the fact that these persons stabilize their self-esteem by participating in the grandiosity of an object. Only on this way they can get the necessary feelings of self-worth. This arrangement is inevitably an unstable one and must be constantly demanded and verified. Disappointments lead to rapid displacement of the objects of cathexis accompanied by temporary aggressive withdrawal from the frustrating object followed very soon by attempts to restitute the grandiosity of the object through intensified self-devaluation (masochistic submission). If this is without success, the individual may withdraw completely from the external world. Then, the disappointing, bad object is internalized; the conflict is transferred to the inner world (melancholic introjection). Self-devaluation develops into inner self-destruction.
To characterize the pathology of the self which is present in these cases, this group could be described as "self-destroyers", because their self-hatred is so destructive. As the "self-unstables", this group suffers from an unstable regulation of their self-esteem. Contrary to the "self-unstables" though, these persons practice their self-devaluation in a particularly aggressive and destructive fashion. Since the regulation of self-esteem through participation requires more mature object relations, one can assume that the "self-detroyers" have a higher developmental structure.
The "quiet depressives"
Besides the "self-unstable" and the "self-destroyers", who are in the focus of educational specialists and therapists, there is another group of mentally handicapped persons. This group often goes unnoticed, living on the fringe of what is going on around them. These persons are the "quiet depressives". Only with a great deal of commitment and inexhaustible patience can they be brought out of their shell, often surprising their environment by showing unexpected abilities. Their expressive behavior shows the typical characteristics of depression described in the literature: empty gaze, face expressing resignation, slowed-down movements, minimal amount of spontaneous activity. They are often underweight, are not good eaters and have sleeping problems. At best, attempts to establish contact with them are tolerated; frequently, however, such offers are rejected.
This phenomena corresponds to psychophysiological hospitalism, well-known from child psychiatry. Hospitalism can also occur in the later course of life after long-standing and severe disturbances of fundamental emotional interaction processes. These persons have reduced their expectancies and hopes to a minimum and have organized their life, so to speak, to burn on a low flame. Of course, it is still possible to disappoint them. In such cases a dynamic process of rebellious behavior and protest is triggered; however, it does not last very long because their reservoir of energy is quickly depleted. From the viewpoint of self-pathology, one could speak of a "withdrawn self".
Depressive re-enactments
The dramatic aspects of depressive processes in persons with mental handicaps do not become plainly visible as long as the interaction with the social environment is left aside. Re-enactments play a significant role in these processes. There are many examples of re-enactments in day-to-day life, some of which are quite harmless, but they nevertheless have their origins in a depressive reaction.
The following are examples for such enactments: despite warnings from others, a staff member gives Johann S. one more chance and takes him to the village inn. There, Johann throws his drink into the staff member's face and starts to smash up the place. In the end the caregiver - against his own conviction - is forced to overpower Johann and lead him away. Hartmut W., for instance, clings to passers-by until they finally turn away from him in disgust or use brutal force to defend themselves. Helga K., who doesn't have any problems telling time from her wrist watch, comes to her therapy session a half hour too early, starts pounding against the loked door, and finally withdraws in disappointment and retreats to her bed.
One gains the impression that these persons want to experience their identity through such enactments. In the case of depressive enactments the outcome is either an increase in lability or a further step toward self-destruction and/or confirmation of being worthless. In reference to disorders stemming from early developmental stages, which is the usual case in mentally handicapped persons with psychiatric disorders, Blanck & Blanck (1980) mention "transference-phenomena" and "object restoration" (p. 111), and mean re-enactments of early object relations. These persons influence social situations in such a way that affective states, which were characteristic for their relations to primary attachment figures of early childhood, come to life again. In current situations they experience the affective states they actually produce themselves as if these states were caused by the persons they interact with. There is no possibility for them to dissociate themselves from these experiences.
These re-enactments resembling transference phenomena are typical for the course of therapy in psychiatrically ill mentally handicapped (Gärtner-Peterhoff et al., 1987). They also occur outside of the therapeutic setting. The re-enactments are an element of cognitive, affective and behaviour-related schemata which are used by these patients to control their relationships to their social environment, and are an integral part of their self-concept. Once a depressive way of experiencing has become a firmly-rooted component of a person's identity, it will be constantly reproduced through mechanisms of distorted perception and manipulative interaction with significant others. In this way, the "quiet depressive" makes sure that the social environment does not change him/her, and so his/her self-experiencing remains stable. The "self-unstable" will regulate their sensitivity for experiences of loss in such a way that they will recur time after time. The "self-destroyer" will carry his idealizing into the extreme so that the feared disappointments will throw him off balance again and again. The pathology has become normal for these individuals; they strive for and defend this way of experiencing their environment even if it is humiliating, causes pain or has devastating effects. The therapist must not only expect resistance in these persons, but also opposition in staff members as well as counter-reactions of other group members since they are all part of the enactments (cf. Michels et al., 1990).