According to the World Health Organization, by 201O depression will be the single largest public health problem after heart disease. It will affect between 25 and 45 per cent of the adult population, with rising rates in children and adolescents. According to the American Academy of Child and Adolescent Psychiatry, there are currently nearly 3.5 million depressed children in the US, and more than 6 per cent of American children are taking psychiatric medication. Back in 1950, however, depression was estimated to affect only 0.5 per cent of the population. What could have happened over the last half century?Generally spoken, depression is the name of a unique disease. It has specific biological markers and is found in all human societies. It involves symptoms such as insomnia, poor appetite and low energy, and this loss of biological, vital tone is ascribed to a chemical problem in the brain. Once we have developed these initial symptoms, culture may then help to shape them, giving prominence to some and encouraging us to remain discreet about others. We might have no problem telling our friends or our doctor about feeling exhausted, but remain reserved about revealing our loss of libido.
According to this view, our biological states will become interpreted as moods and emotions by our cultural surroundings. Low energy, for example, may become interpreted as 'sadness' or 'guilt' in one society but not in another. Similarly, how a culture responds to these feelings will vary widely, ranging from concern and care to disregard and dismissal. Some cultures will supply rich vocabularies to describe these feelings and will accord legitimacy to them, while others will not. On this view, what we call 'depression' is the particular Western medical interpretation of a certain set of biological states, with brain chemistry the basic problem.
An alternative perspective sees depression as the result of profound changes in our societies. The rise of market-driven economies creates a breakdown of social support mechanisms and of the sense of community. People lose their feeling of being connected to social groups and so feel depleted and solitary. Deprived of resources, economically unstable, subject to acute pressures and with few alternative pathways and hopes, they fall ill. The causes of depression, according to this view, are social. Sustained social pressures are bound to end up affecting our bodies, but the pressures come first, the biological responses second.
This social view is echoed in the perspective of some psychoanalysts, who see depression as a form of protest. As humans are taken to be units of energy in industrialized societies, they will resist, whether they are conscious of this or not. Thus, much of what is today labeled depression could be understood as old-fashioned hysteria, in the sense of a refusal of current forms of mastery and domination. The more that society insists on the values of efficiency and economic productivity, the more depression will proliferate as a necessary consequence. In a similar way, the more modem society urges us to attain autonomy and independence in our search for fulfillment, the more resistance will take the form of the exact opposite of these values. it puts misery in the midst of plenty. Depression is thus a way of saying NO to what we are told to be.
Historians of psychiatry and psychoanalysis have mostly agreed that depression was created as a clinical category by a variety of factors in the second half of the twentieth century: there was a pressure to package psychological problems like other health problems, and so a new emphasis on surface behavior rather than on unconscious mechanisms came to the fore; the market for minor tranquillizers collapsed in the 1970s after their addictive properties were publicized and so a new diagnostic category - and remedy for it - had to be popularized to account for and cater to the malaise of urban populations; and new laws about drug-testing favored a simplistic, discrete conception of what illness was. As a result, as we have seen drugs companies manufactured both the idea of the illness and the cure at the same time. Most of the published research had been funded by them, and depression came to stand less for a complex of symptoms with varied unconscious causes than simply that which anti-depressants acted on. If the drugs affected mood, appetite and sleep patterns, then depression consisted of a problem with mood, appetite and sleep patterns. Depression, in other words, was created as much as it was discovered.
Today, as we have seen, there is some skepticism about the claims made for anti-depressant drugs. It is now well known that most studies of their effectiveness are industry funded and that, until very recently, negative results were hardly ever published. Claims for the specificity of the drugs have also been seriously put in question. But, despite such wariness, the idea of depression as a brain problem retains its attraction even for the skeptics. When newspaper articles point to the dangers of particular drugs like Paxil and Seroxat, suggesting that they increase the risk of suicide, the reasons for this are then explained biochemically: the drug causes the suicidal thoughts. These critics of the drug thus share the belief of its makers: that our thoughts and actions can be determined biochemically.
The implication of such critiques is simply that the drugs aren't good enough: they need to be more specific, promoting positive rather than negative thoughts. This perspective ignores completely the idea that the suicides may sometimes be due to poor initial diagnosis - for example, as we will see later on, misdiagnosing melancholia as 'depression' - and, just as significantly, failing to consider that depression may itself be a protective mechanism which, if removed, makes desperate action more likely. Some studies, in fact, have claimed that mild depressions may actually protect against suicide. In other cases, the way that the drug dumb down a person's mental states may short-circuit the production of genuine defenses against suicidal feelings.
Thus the myth of depression as an exclusively biological disease has come to replace the detailed study of the variety of human responses to loss and disappointment. Social and economic forces have certainly played their part here in this effort to transform grief into depression. We are taught to see nearly every aspect of the human condition as in some sense subject to our conscious choice and potential control, and so when drugs companies market their products they play on these modern ingredients of our self-image. We might be ill, but we can choose to take the drugs and so become well. Not to do so would appear irrational and self-destructive. Even in the shanty towns of Lima in Peru, large colorful posters urge the public to ask their GPs for name-brand anti-depressants. The drugs, it is claimed, will restore us to our former selves.
Although plenty of studies exist which show that anti-depressants, in fact, do not do what they are supposed to do, our society seems only to have ears for the positive PRo We know that most research is industry-funded, that the drugs are not as specific as they claim to be, that they do have serious side-effects and produce significant withdrawal problems and that, over time; psychotherapy provides a better and more solid treatment. Yet· the prescriptions still continue, together with new and scientific-sounding propaganda issuing from the drugs companies. Worldwide, this constitutes a market that runs into billions of dollars, and it would be difficult to imagine anyone within the industry deciding that the time was right to close it down.
And while studying a particular anti-depressant may not prove so difficult, but a project which sets out to question the very validity of anti-depressants themselves will not find funding easily. To conduct such studies and disseminate their results requires powerful backing, which means the kind of money that only industry really has. In addition, for such studies to count as 'scientific' they must use the same language and diagnostic systems as the purveyors of the drugs. Otherwise, no meaningful comparisons, it is believed, can be made. This has the unfortunate result that even the most basic concepts - such as depression itself - tend to avoid critical scrutiny.
Yet why should we see depression as a single, unique entity? Clearly, this is what the drugs industry wants us to do, since this is what allows the sale of drugs that claim to treat it. But we should not hold the pharmaceuticals companies solely responsible here. Contemporary society - which means us - also plays its part in shaping how we wish to see ourselves and our ailments. When things go wrong, we want to be able to name the problem quickly, which makes us all the more receptive to the labels that doctors and drugs companies offer us. Most of us also want to avoid the labor of exploring our inner lives, which means that we prefer to see symptoms as signs of some local disturbance rather than difficulties which concern our whole existence. Being able to group our feelings of malaise, anxiety or sadness under the blanket term 'depression' and then take a pill for it will naturally seem more attractive than putting our whole life under a psychological microscope.
But what if depression itself were as multiple and varied as those who are told that they suffer from it? Why not see the manifest symptoms of depression as more akin to states like fever: they might look the same across a wide range of people but their causes will be quite diverse. Just as a fever may be a sign of malaria or of a common flu virus, so loss of appetite, say, could be a sign of being in love without knowing it or of a refusal of the overwhelming demands of other people or of some private grief Discovering these causes can never be achieved in the space of a ten- or twenty minute G P consultation, but requires long and detailed listening and dialogue. There is a crucial difference between surface phenomena, such as apathy, insomnia and loss of appetite, and the underlying problems which are generating these states, usually far removed from our conscious awareness.
What about the psychological therapies here? Surely they are available through GPs and hospitals and provide the necessary counterpoint to drug-based treatments? Don't they provide precisely the space for listening that the depressed patient needs? Unfortunately this is far from the case. Psychological therapies are often available, but the term itself can be misleading: it nearly always means short-term cognitive behavioral therapy (CB T) and hardly ever refers to long-term psychoanalytic psychotherapy. CB T sees people's symptoms as the outcome of faulty learning. With proper re-education, they can correct their behavior and bring it closer to the desired norm. In itself, CB T is a form of conditioning that aims at mental hygiene. It has no place for the realities of sexuality or violence that lie at the heart of human life. These are seen as anomalies or learning errors rather to be a result. Rather, what matters is to allow what is being expressed in the symptom to be articulated, however at odds with social norms this might be. The patient is the expert here and not the analyst.
Tile patient certainly knows more than the analyst about the sources of his or her problems, but this knowledge is rather peculiar. It is not conscious but unconscious knowledge. The patient knows it without knowing it, in the same way that we can be aware that our dreams mean something without being able to explain or interpret them. Analysis will aim to bring unconscious material to light, and this will always be a difficult and unpredictable process. Nothing can be known in advance, and the relationship between patient and analyst may well turn out to be as turbulent as any other form of intimate human bond. These features of analysis mean that it can hardly fit in with what our contemporary anti-risk society deems desirable: swift and predictable results, absolute transparency and the removal of unwanted behavior. It is precisely CBT and not analysis that claims to offering these latter solutions. The price to be paid, however, is a cosmetic treatment that targets surface problems and not deep underlying ones.
Thinking about mourning and melancholia allows us to move beyond these surface features to what lies beneath them. Unlike publicizing the latest antidepressant drug, it does not mean big business for anyone. Yet as we read through paper after paper on depression considered as a brain disease, we totally lose any sense that at the core of many people's experience of inertia and lack of interest in life lies the loss of a cherished human relationship or a crisis of personal meaning. If these factors are recognized at all, they become transformed into vague talk of 'stress' and relegated to the diagnostic periphery. In our new dark age- individual experience and unconscious interior life no longer have any place in the way we are encouraged to think about ourselves. Our wants and wishes are taken at face value, rather than seen as masking conflicts and often incompatible unconscious desires.
Depression is far too general a term to help us here. Although not all occurrences of depressive states indicate an underlying mourning or melancholia, these concepts can none the less allow us to approach the problem of loss with greater clarity. They can tell us something about why a depressive reaction can develop into a serious, sustained dejection or, at times, into a terrible, unending nightmare of self-accusation and guilt. In everyday life, the most obvious triggers for depressive states concern our self-image. Something happens to make us question the way we would like to be seen: our boss makes a critical comment, our lover becomes more distant, and our colleagues fail to acknowledge some achievement. In other words, an ideal image of ourselves as lovable is punctured.
But depressions are just as likely not only when an ideal image is compromised but when we actually manage to attain our ideal: the athlete who breaks a world record, the seducer who finally makes his conquest, the worker who gets the long-awaited promotion. In these instances, our desire is suddenly removed. We might have striven for years to achieve some goal, but when there is no longer anything to attain we feel the presence of a void at the core of our lives. Most people will have experienced this in some form after finishing exams. The long-awaited moment has been reached, and now there is only the blues.
These depressive states do not always lead to long, serious periods of despair and despondency, but, when they do, we can suspect that questions of mourning and, in some cases, of melancholia are at play. Ups and downs are of course a part of human life, and it would be a mistake to pathologize every episode of the blues. But when the downs start to snowball, gathering their own depressive momentum, we must ask what other problems they have revived or absorbed. In most cases, these will not be available to conscious introspection, and will require careful analysis and dialogue to become clearer--take for example loss and mourning.
To start thinking about the question of loss and mourning, we can begin with Freud's brief essay Mourning and Melancholia, drafted in 1915 and published some two years later. We might take it for granted that both mourning and melancholia involve responses to a loss, yet when Freud wrote his essay this was far from obvious. If mourning refers to the work of grief subsequent to a loss, associating melancholia with the experience of loss was by no means a received viewpoint. Before Freud, the medical literature had not linked them in such a systematic way.
Reading earlier texts, we come across occasional associations between melancholia and loss, but these tend to be treated as contingent and rather episodic details. Robert Burton, author of the vast Anatomy of Melancholy, first published in 1621, quipped that melancholy was 'known to few, unknown to fewer', but recent studies of the concept of melancholy have highlighted its shifting forms and the instability of its characterizing symptoms. If we associate it today with the blues or a painful nostalgia, it was often linked in the past to manic states or to periods of creativity.
Looking through the different descriptions, the most common symptoms would be a sense of fear and sorrow without obvious cause. Until well into the nineteenth century, sadness and feeling low were not defining features of melancholy. Indeed, fixation on a single theme, later known as monomania, was a much more common criterion. And the clinical picture of melancholia that we can 'distil from such accounts puts a greater emphasis on anxiety than on depressive feelings.
This might seem surprising, especially given the tendency of some psychiatric thinking to separate anxiety from depression. Although most working psychiatrists are well aware that the two states cannot be so readily differentiated, it is still common in the literature to find the two treated separately. Yet anyone who has experienced a loss might be familiar with the unsettling rhythm of a sense of depletion followed by one of expectant dread. Anxiety, indeed, in its purest form is found in melancholia, and we will try to explain why this is the case later on.
Freud saw both mourning and melancholia as ways that human beings respond to the experience of loss, but how does he differentiate them? Mourning involves the long and painful work of detaching ourselves from the loved one we have lost. 'Its function,' Freud writes, 'is to detach the survivors' memories and hopes from the dead.' Mourning, then, is different from grief Grief is our reaction to a loss, but mourning is how we process this grief Each memory and expectation linked to the person we have lost must be revived and met with the judgment that they are gone for ever. This is the difficult and terrible time when our thoughts perpetually return to the one we have lost. We think of their presence in our lives, we turn over memories of moments spent together, we imagine that we see them in the street, we expect to hear their voice when the phone rings. Indeed, researchers claim that at least 50 per cent of bereaved people actually experience some form of hallucination of their lost loved one. They are there haunting us during the mourning process, but each time we think of them, some of the intensity of our feelings is being fractioned away.
Everyday actions like going to the shops, walking in a park, going to the cinema or being in certain parts of one's city suddenly become incredibly painful. Each place we visit, even the most familiar, revives memories of when we were there with the person we loved. If shopping at the supermarket or walking down the street with one's partner had never been a particularly special experience, doing it now becomes painful. It isn't just the revival of happy memories linked to those places that matters, but the fact of knowing that we won't see them there ever again. Even new experiences can become agonizing. Seeing a film, viewing an exhibition or listening to a piece of music make us want to share it with the one we've lost. The fact that they aren't there makes our everyday reality seem acutely lacking. The world around us seems to harbor an empty space, a void. It loses its magic.
Over time our attachment will lessen. Freud told one of his patients that this process would take between one and two years. But it would not be easy. We recoil, he said, from any activity that causes pain, and so there is 'a revolt in our minds against mourning'. This is an important and perhaps neglected point. Freud is suggesting that there might be nothing natural about mourning. It won't happen automatically, and we might even be doing our best to resist it without being aware of this consciously. If, however, we are able to follow the mourning process through, the pain will grow less, together with our feelings of remorse and self-reproach. We realize little by little that the one we've loved is gone, and the energy of our attachment to them will become gradually loosened so that one day it may become linked to someone else. We will realize that life still has something to offer.
A woman who had lost her mother at a very young age was haunted by the powerful image of the sweetshop where she had worked. The details of the shop, the colors and odors were all as present to her as they had been so many years ago, and, as she observed, they were now even more so. The mother's death had made these sensations sharper, as if they had been amplified by her absence. As they took on the value of a marker for the lost mother, so they grew in intensity. Yet after a protracted and difficult work of mourning, the sweet-shop appeared to her in a dream surrounded, for the first time, by other shops. 'The sweet-shop,' she said, 'was just one shop among all the others.' The mourning had loosened the attachment to the one privileged marker, and the shop was no longer special.
Freud doesn't refer simply to mourning here. He uses the expression 'the work of mourning', in a phrase that echoes the concept he had already introduced in his book The Interpretation of Dreams, 'the dream work' or 'the work of dreaming'. The dream work is what transforms a thought or wish we might have into the manifest, complex dream. It consists of displacements, distortions and condensations, equivalent to the mechanisms of the unconscious itself Freud uses the same kind of expression to talk about mourning to indicate, perhaps, that it isn't just our thoughts about the lost loved one that count, but what we do with them: how they are organized, arranged, run through, altered. In this process, our memories and hopes about the one we've lost must be brought up in all the different ways they have been registered, like looking at a diamond not just from one angle but from all possible angles, so that each of its facets can be viewed. In Freudian terms, the lost object must be accessed in all its varying representations.
When Freud talks about the lost object here he doesn't just mean a person lost through death. The phrase can also refer to a loss that is brought about through separation or estrangement. The one we've lost may still be there in reality, although the nature of our link to them will have changed. They might even be living in the same house, or the same city, and it is clear that the meaning of loss will depend on the particular circumstances of each individual. Bereavement is perhaps the clearest example of a loss since it marks a real, empirical absence, but Freud intended his ideas to have a much wider scope. What matters will be the removal of any reference point that has been important in our lives and that has become the focus of our attachments. In mourning, this reference point is not just removed, but its absence is registered, inscribed indelibly in our mental lives.
It is tempting to associate Freud's idea of the work of mourning with some of the developments in art taking place around the same time that he wrote his essay. There, in the Cubism of Picasso and Braque, we see the image of a human being reassembled as a group of multiple perspectives. Different angles and aspects of the conventional image of a person or object are combined and reshuffled to give the resulting Cubist image. The model becomes equivalent to a series of fragments seen from different points, a process that seems to embody Freud's notion of a person being mourned through the piecemeal collection of our representations of them.
This parallel between the artistic process and the work of mourning can be found in other practices beyond Cubism. Think, for example, of the very different art of de Chirico and Morandi. In de Chirico's work, we see the same collection of motifs - a fountain, a shadow, a train on the horizon repeated again and again but in different configurations. The elements are often identical, but their arrangement changes. These paintings occupied him for at least fifty years, and were sometimes produced on a daily basis. In Morandi's work, we see the same group of bottles and jugs moved around endlessly to create different configurations. Their composition even evokes comparison with a family portrait, as if the jugs and tableware had taken the place of family members arranged carefully to be photographed. Like the work of mourning described by Freud, a set of representations is given a special value, focused on and reshuffled.
Mourning for Freud involves the movement of reshuffling and rearranging. We think of our lost loved one time and time again, in different situations, different poses, different moods, different places and different contexts. As the writer and psychiatrist Gordon Livingstone observed, after losing his six-year old son to leukemia, 'Perhaps that's how it is with a permanent loss: you examine it from every angle you can think of and then just carry it like a weight.' If this aspect of the work of mourning will eventually exhaust itself, why is it that Morandi or de Chirico remained caught for so long reconfiguring the same elements? It was quite common in the art of the nineteenth century to produce multiple variants of the same image, understood as a quest for perfection, but there is something more here than the practice of an old artistic vogue. Pursuing the analogy with mourning, might this indicate an arrest or stagnation of the mourning process?
We tend to repeat things when we remain trapped in them. When Edgar Allan Poe's mother died when he was a boy of almost three, he was left alone in the house overnight with his baby sister and the corpse until a family benefactor found them. In his work he returns again and again to the image of the blank stare of the dead, and the proximity of death is everywhere. Burials are premature, bodies won't stay dead, dying chambers stretch out to infinity, cadavers rot and decay, and blood seeps from a corpse's mouth. Before his own death, the specter of a ghostly woman that haunts these stories would invade his waking life in a series of terrifying hallucinations. Poe's literary effort to describe this encounter with death from every possible angle suggests that the work of mourning could not be completed. Rather than laying his mother to rest, her presence became increasingly real, despite his attempt to transpose the horror of what had happened to another, symbolic level through his writing.
Trying to represent an experience from several different angles is an essential part of the work of mourning, but other processes are also necessary, as we shall see.
For example, how is melancholia distinguished from mourning? Freud argues that while the mourner knows more or less what has been lost, this is not always obvious to the melancholic. The nature of the loss is not necessarily known consciously, and may just as well involve a disappointment or slight from someone else as the loss occasioned by bereavement, or even the collapse of a political or religious ideal. If the melancholic does have an idea of whom he has lost, he does not know, Freud says, 'what he has lost' in them. This brilliant point complicates the simple picture of grief We have to distinguish whom we have lost from what we have lost in them. And, as we will see, perhaps the difficulty of making this separation is one of the things that can block the mourning process.
The key feature of melancholia for Freud is a lowering of self-regard. Although melancholia shares with mourning such features as 'a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love' and an inhibition of activity, its prime distinguishing trait is 'a lowering of self-regarding feelings to a degree that finds utterance in self-reproaches and self-reviling , and culminates in a delusional expectation of punishment'. The melancholic represents himself as 'poor, worthless and despicable, and expects to be cast out and punished'. Melancholia means that after a loss, one's image of oneself is profoundly altered.
The melancholic believes himself worthless and unworthy. And h'e will insist on this quite vocally. These comments already help to divide up the clinical picture. Many depressed people feel worthless, but the melancholic is different in that he may articulate this without the reticence often found in others. Similarly, many neurotic people will link their feelings of unworthiness or uselessness to aspects of their physical image: their body just isn't right, their nose or hair is all wrong. But the melancholic has a much deeper complaint. For him, it is the very core of his being which is unworthy or wrong, and not only its surface features. Where a neurotic might become uneasy on having an evil thought or impulse, the melancholic will condemn himself as an evil person. This is an ontological complaint, concerning his actual existence. Where the neurotic person may feel inferior to others and inadequate, the melancholic will actually accuse himself of worthlessness, as if his life itself were some kind of sin or crime. He doesn't just feel inadequate: he knows he is inadequate. There is certainty here rather than doubt.
Melancholic’s will berate themselves endlessly for their faults. No amount of rational advice or persuasion can stop them. They have a conviction that they are in the wrong. In contrast to the paranoiac, who blames the outside world, the melancholic only blames himself. Freud uses this motif of self-reproach as a defining feature of melancholia, thereby setting it aside from many other cases of depressive feeling. Historically, the distinction between a natural and an unnatural melancholia had often been unclear: to what extent was a certain melancholia a part of human existence and to what extent was it an illness that needed to be treated? How could one distinguish between melancholic despair and that induced by a 'true' sense of sin?
The need of the melancholic to berate himself puzzled Freud. Why this insistence on self-blame? Could it be that when the melancholic was so busy blaming himself, he was really blaming someone else? In his Characters of 1659, the essayist Samuel Butler claimed that 'A melancholic man is one that keeps the worst company in the world, that is, his own.' Freud has exactly the opposite thesis: that the company kept by the melancholic is that of his object. He has turned his reproaches towards someone else against himself.
These clamorous self-reproaches are in fact reproaches directed to another person who has been internalized. The melancholic has identified completely with the one they've lost. This does not always mean that a real separation or bereavement has taken place. It may be someone the person loves, or has loved or even should have loved. But once the loss has occurred, their image has been transferred into the place of the melancholic's ego. The anger and hatred directed at the lost person are similarly displaced, so that the ego is now judged as if it were the forsaken object. In Freud's famous phrase, 'the shadow of the object' has fallen on the ego, now subject to the merciless criticism so singular to the melancholic subject. Spears have become boomerangs.
Let's illustrate the contrast between a neurotic self reproach and a melancholic one. A woman presents with two symptoms: a paralyzing mutism, which emerges in certain social situations, and a pervasive hypochondria, which sends her from one doctor to another. Although she has not connected the two phenomena, a relation between them certainly existed. The mutism expressed for her the proposition 'I've got nothing to say', while the hypochondriacally anxieties took the form of the belief 'I've got something inside me.' She exhausted herself with a perpetual self reproach that there was 'something wrong' with her, that’s he 'wasn't right', phrases that echoed her father's continued invectives against her in her childhood and adolescence. These reproaches now took the form of her presenting symptoms.
Although the two propositions 'I've got nothing to say' and 'I've got something inside me' seemed the two opposing poles of the spectrum of her misery, her daydreams revealed a particular proximity between them. The visits to the medical specialists would from time to time result in minor operations. She would imagine how the doctors would remove something from her body, leaving, as she put it, 'nothing inside me'. The daydreams would then continue as follows: returning home to her husband, would she still be loved by him despite her loss? These scenarios evoked for her the fascination in her childhood with a certain fictional character with a missing limb. Her symptoms asked the question: 'Can I be loved with nothing , inside?' And we can note that the hypochondriac-symptoms had been established in the months following her first pregnancy which ended with an abortion.
We can see how the self-reproach here, which might seem at times existential, has been linked systematically to the representation of the body. This contrasts with the clinical picture of a melancholia, where the question of bodily organs does not function in the same causal sense. Madame N--, a patient of the French psychiatrist Jules Seglas, observed that she didn't have a stomach or kidneys, but this was not the reason for her torments. She saw herself as the cause of all the world's evils, including her child's death from meningitis. We could contrast our patient's question 'Can I be loved with nothing inside?' to Mme N--'s conclusion 'I've got nothing inside because I didn't love.'
Neurotic symptoms are ways of asking a question.
In our example, self-reproaches concealed a question about love. In a melancholia, on the contrary, the self-reproaches are less a way of asking a question than a kind of solution. The subject is guilty. They have been condemned. There is a certainty here of being the worst, the least lovable, the greatest sinner. This emphasis on the person's exceptional status (the most ... , the greatest ... , the worst ... ) led Karl Abraham to caution against confusing the diagnosis of melancholia with that of paranoia. Couldn't being the worst actually be a form of megalomania?For Freud, the melancholic's self-reproach is in fact a reproach to the lost loved one. But why a reproach in the first place? Surely the dead and departed only merit our sympathy? There’ may be anger for the very simple reason that, when someone vanishes, we hold their departure against them. Funeral chants in many cultures often bitterly chastise the deceased for having abandoned the living. And this rage is ubiquitous in the mental life of bereaved people. They may find it difficult to mourn a loss when tender feelings jostle with fury at that person for having died. Absence is never accepted without rage. Mourning a loved one, a man described his terrifying dream of a cracked gravestone, as if 'shattered by an act of revenge'. Making sense of this was difficult since he felt no conscious anger, yet further dreams showed how real this was. He couldn't forgive the dead person for departing. The dream is exemplary in that it shows how difficult it can be to build a memorial for someone if rage continually shatters it.
Trips to visit the loved one's grave brought out the same dilemma. Each time he set off for the cemetery, he would find himself in the wrong place: he would miss the correct tube stop or become lost in the maze of streets surrounding the graveyard. These misadventures left him in utter despair, until he suddenly realized that they were playing out his reproach to the dead. Finding himself alone and without bearings in a strange place, he said, it was as if he admonished the dead: 'Look what you are doing to me, you have left me lost! I've been abandoned by my guide.' This cycle of losing his way was a concealed form of fury: 'I held him responsible', he said, 'for my being left, bewildered and frightened.'
This is one of the most important discoveries of psychoanalysis: the fact that we can feel fury without being consciously aware of it. It can even emerge when we are quite literally not conscious. Several studies of behavior during sleep have shown how acts of violence can be carried out towards the bedfellow, with absolutely no recollection upon waking. Sleep medicine experts claim that such violence, which can range from serious assault to slaps and punches, affects around 2 per cent of the general population, yet the figure is no doubt higher, given the obvious barriers against reporting it. Where the sleep medicine researchers look to brain chemistry for explanations, psychoanalysts make the hypothesis of unconscious hostility which we do our best to ignore in our waking lives and which uses night-time as its alibi.
The fact that affection and hatred are so closely linked in our emotional life is still, more than a hundred years after the invention of psychoanalysis, difficult for most people to accept. When I wrote a newspaper column about it a few years ago, an editor phoned me in bewilderment: 'How,' he asked, 'can someone feel both positive and negative feelings towards the same person?' This difficulty is no doubt one of the reasons why we tend to avoid thinking about it. Anthropologists, for example, once debated with some passion the strange ambivalence found in funeral rituals in many cultures. The dead would be venerated yet also treated as dangerous enemies. This tension was rationalized as a conflict between positive feelings for the living and negative feelings towards a corpse, or between the world of the living and the world of the dead. Yet Freud then pointed out that the relations between the living were themselves ambivalent. As he wrote in Totem and Taboo, 'In almost every case where there is an intense emotional attachment to a particular person we find that behind tender love there is a concealed hostility in the unconscious. '
Freud thought that such hostility was due to the disappointments and frustrations that are an inevitable part of our early relations with our caregivers. Demands for love would be left unsatisfied, expectations unanswered and sexual and romantic wishes thwarted. At an even more archaic level, Freud believed that our first relations with our caregivers always contain components of hatred, as a natural reaction to whatever is outside ourselves. We can't control what is outside us, and our parents wield a fearsome power over us. However much they love us, we are still more or less at their mercy at the start of life. Hatred is a basic reaction to those who have such power over us.
Problems in accepting these unconscious hostilities towards a loved one were once claimed as the most frequent cause of depressions. Unable to articulate our anger, we would become withdrawn and exhausted. Our energy would be sapped, as we inhibited our anger and sometimes turned this anger against ourselves. These once popular ideas are usually dismissed today with the observation that if the depressed person is asked whether they are angry, they will often say 'No.' Hence anger cannot be the cause of the depression. This simplistic criticism completely misses the point: the anger is not admitted to consciousness, and its traces will emerge only with detailed and lengthy analytic exploration.
Although few analysts would accept that this is the universal cause of despondency and dejection, blocked out fury is certainly the cause of many instances of exhaustion and loss of interest in life. The link with exhaustion may be illustrated by the fact that often a baby will scream and cry and then suddenly, from one moment to the next, fall into the deepest sleep. We usually say that the infant has cried itself to sleep, but at times the sleep might be a defense against the pain of frustration or disappointment. Working with young children, I have observed on a few occasions how they can literally start to fall asleep in sessions when difficult material is coming to light. They will immediately forget what question has been asked or what theme was being discussed.
If hostility to those we love can be defended against with such vigor, in some cases it can be present in consciousness to serve a particular function. Speaking about the man who had left her, a woman remarked that 'If someone leaves you, it's worse than if they died. You know they are still alive. It's unbearable.' The only thing, she said, that stopped her from killing herself was her hatred of this man: 'I was about to do it,' she said, 'but my hatred kept me alive.' And the only way to get over him, 'to mourn him', she explained, 'was to denigrate him, to make him valueless, to kill him.' This use of hatred had a very precise role, and it evoked for her one of the central threads of her childhood. Growing up in a violent, strife-torn family with an alcoholic father and an aggressive, punitive mother, she said that the only thing that stopped her from going mad was her continuous hatred of her father: this hatred was what gave her a compass, an orientation in life. By focusing her hatred on him, she said, she kept her sanity.Hatred may play this role as a focus, a point of consistency when all else seems unstable and liable to collapse. But hatred - whether it is conscious or not can also complicate the mourning process quite seriously. Loss and bereavement do not always allow a ventilation of the feelings we might have repressed, and in general hostility to the dead is not well tolerated by us. It is far easier to express anger with the living, as we see when a stormy relationship suddenly becomes idealized by one partner after the death of the other. All the friction and turbulence seem to be miraculously airbrushed away, to leave an icon of saintliness in place of the dead partner. We find this obstruction frequently when we are exploring the lives of bereaved people: they become angry with colleagues, friends or lovers without linking this displacement consciously to their loss. Undertakers, doctors or hospital staff may also be recruited as targets, and time and time again we see the emergence of an 'enemy' in that person's circle after a significant loss. The anger is displaced on to someone else.
We can see this process clearly in a dream described by the writer Loan Didion after her husband John Gregory Dunne's death. She and her husband are flying to Honolulu and have assembled with many other people at Santa Monica Airport. Paramount Pictures have arranged planes for them and production assistants are distributing boarding passes. She boards the plane, but there is confusion. There is no sign of John. She worries there is a problem with his pass and decides to leave the plane and wait for him in the car. While waiting, she realizes that the planes are taking off one by one. Finally, she is alone on the tarmac. Her first thought in the dream is anger: John has boarded a plane without her. But the second thought transfers the anger: Paramount has not cared enough about them to put them on the plane together.
The partition of feelings at the end of this dream shows nicely how anger at a death cannot easily be directed at the one who has departed. It searches for another outlet, another target to displace itself to. We shift the anger away from the one we love. We can find another illustration of this process in the dream of a man mourning the death of someone he dearly loved. He dreamt repeatedly that he was furiously striking a leather pouch. Although he continued to batter it in the dream, he was also aware that this object 'wasn't the real target'. This realization, staged within the dream itself, would allow him to engage more clearly with his anger at the dead.
Didion's dream also suggests something else. In the move of the dreamer's reproach from her husband to Paramount, don't we see the necessity to blame something more than him? In the same way that some, might blame fate or destiny, isn't this reproach directed to the symbolic* universe itself, represented here by the anonymous film company? Paramount is in the place of the agency pulling all the strings, arranging everything, in charge: what analysts would call the big Other. The departure of her husband is not simply a matter between the two of them but will involve this symbolic agency itself.(Symbolic refers to the order of language, representation and law which is imposed on us, rather than symbolism as such).
Situations of loss and separation often involve appeals to this mysterious higher power. The American analyst Martha Wolfenstein noticed how some of the children she worked with would make bargains with fate. In one case, a girl's father had a heart-attack when she was eight. She then developed compulsive rituals to distance any bad thoughts or words that might come into her mind. Being good meant for her that nothing bad would happen. When the father died six years later, it was as if fate had failed to keep its side of the bargain, and so she herself was released from it. She became promiscuous and gave up her previous diligence at school.
Displacements of our feelings are especially apparent in the hatred that often emerges towards a surviving parent. After her father's death, a woman could think of little else but her fury at her mother. This rage was perplexing to her, as she had imagined their relations to be good. Beyond the rage that the mother, unlike the father, had 'escaped death', there was, she said, also a hatred here of her mother as being the one 'somehow responsibJ.e' for her love for the deceased. In another case, a similar hatred vented on the mother after the father's deatP was linked by the patient to her father's hatred of the mother: she had simply taken over his aggressive passion, identifYing herself with his position. We might guess here that giving up the hatred would have meant, at some level, giving up the father.
We can also find many cases where the rage unleashed at a loss is linked to a change in the constellation of the family. A woman in her mid-fifties was terrified at the sudden pangs of fury she experienced after the death of her younger brother. The siblings had been brought up by the mother after the father had left during her second pregnancy, and the brother had become the object of all the mother's idealizations: he was the most beautiful, the most intelligent, the most successful. This untarnished image was never contested by the sister, and its role became clearer during her analysis. Faced with the mother's long bouts of misery and the string of anonymous men she would be forced to watch the mother entertain during her childhood, the brother's image took on a privileged position. In effect, it acted as a barrier between herself and her mother. Like the hatred described by the patient we discussed earlier, it functioned as an anchoring point in an unstable and precarious universe.
Once the brother's image was no longer present, there was nothing to place between herself and her mother. This left her open to the question of what she was for the mother, and the contingent, threatened aspect of her own existence would come painfully into focus. Her feelings here oscillated between fury at the brother and an acute sense of dread and anguish linked to the mother. Although her anger at the brother for dying was unpalatable to her, it was strangely more grounding, she said, than the sense of anguish. This sort of feeling is often described by those whom a loss leaves alone with someone else: usually a parent. When one parent dies, there is no barrier to separate the child from the other parent, and one response to this can be the sense of anguish which signals that a barrier has been removed. There is not only the anger at the person for leaving, but the anger for having left us with someone else.
This rage we feel towards the dead can be devastating in both mourning and melancholia. It can get in the way of the work of mourning, confronting us with our fundamental ambivalence towards the one we've lost. These mixed feelings make us feel guilt, and so we may find that we chastise ourselves for what we could or should have done: we should have called or visited more often, been more agreeable, offered more help in some situation, and so on. Freud believed that it was this degree of ambivalence rather than the intensity of positive feelings towards the lost loved one that was the decisive factor in mourning. The more robustly we have tried to repress these ambivalent feelings previously in our relation with the person we have lost, the more they will interfere with the work of mourning. It was even argued by some post-Freudians that mourning would only truly be over when the mourner could acknowledge their delight at the death of the one they loved.Although Freud didn't hold such an extreme view, his idea of what gets in the way of mourning is quite radical. He is arguing, after all, that the decisive factor, iS not the strength of our attachment to the one we have lost. It isn't love, but the mixture of love and hate that matters. We'll have difficulties in mourning not because we loved someone too much, as common sense might suggest, but because our hatred was so powerful. Perhaps it is the very effort to separate the love and hate that incapacitates the mourner, leaving them trapped in a painful and devastating limbo that can take the form of exhaustion or panic.
In a case described by the psychoanalyst Helene Deutsch, a man went into analysis suffering from a variety ofunexplained physical symptoms and a compulsive weeping which seemed to occur without any precipitating cause. Some years before, his mother had died and, hearing the news, he had left at once for the funeral, yet had felt no emotion at all. He tried to recall the treasured memories of her, yet even then he could not feel the suffering he wished for. He began to blame himself for not having mourned, and often thought of his mother in the hope that he might weep.
The analysis revealed that he had had an intense hatred of her from his infancy, which had been revived later in life. Her death produced the reaction 'She has left me', with all its accompanying anger. Instead of a sense of grief, there was only a coldness and indifference due to the interference of the hostile impulses. His guilt was generating the physical symptoms through which, Deutsch thought, he was identifying with her illness year after year. The compulsive weeping was the subsequent expression of his feeling, yet isolated from the thoughts about the death of his mother. It had been split off due to the strength of the ambivalence.This kind of unconscious conflict gives the clue to many apparently unmotivated depressions, which are in fact the expression of emotional reactions once withheld and remaining latent ever since. They might emerge on the same day of the week or time of year that a loss had taken place in the past, yet the link is not made consciously. All we experience is the sadness and feeling of emptiness. Note how this is different from the clinical picture of melancholia where all the blame is focused on the self In melancholia, this hatred will ravage the person's own ego, which has now become equated with the hated, unforgiving love object. The self is treated mercilessly.
The physical symptoms of Deutsch's patient mimicked those of his mother's illness, and this sort of identification is present to some extent in every mourning process. In melancholia it is pervasive, since the self is entirely swallowed up in an identification with the lost loved one. But in a general sense, we always identify with the ones we have lost. After his father died, a five-year-old boy would fit himself into a suitcase in the corner of the room, where he would remain motionless. When a friend asked his mother what he was doing, she replied that he was just sitting in a suitcase. Yet, as he saw clearly many years later, he had created his own private coffin, an enclosed space where, he could act out an identification with the beloved father whom he had last seen in a coffin. Describing the funeral of her mother, a woman said that as the hole .... was being dug in the earth, every strike of the spade felt like a strike deep within her own chest. She felt as if she were with the coffin being lowered into the ground. These are examples of homeopathy with the dead: we inhabit their space, taking on aspects of their behavior, mannerisms, and even their ways of looking at the world.
In the early days of psychoanalysis, Josef Breuer observed a strange phenomenon with his patient Anna O. One day she told him there was a problem with her eyes: she knew she was wearing a brown dress, but she was seeing it as blue. Yet when checked with visual test-sheets, she could distinguish all the colors correctly. It turned out that the key detail lay in the material of the dress. During the same period a year previously she had been making a dressing-gown for her father during his fatal illness. This gown had been made from the same material as the dress she was now wearing, yet had been blue, not brown. Her visual disturbance, then, was both a kind of blocked memory and identification with her father; as the one wearing the blue garment, she had in effect taken his place.
Such identifications can take many forms. In one case, a woman found herself rubbing the towel a second time over a dish that she had already dried, echoing her late father's habit of endlessly cleaning his shoes during his depression. They can also take morepositive forms. A woman mourning her husband not long after his death noted how, when confronted with a problem, 'I deliberately. looked at this in a way that my husband might have done had he been alive. I was surprised that I could honestly face and deal with it in a way I never could have previously.' In another case, after the loss of her husband, a woman took over his business, which became the main pursuit of her life. She turned it into an even more successful enterprise, emulating not only her husband's interests but his ways and methods of handling business matters.
If this is an example of the kind of identification we find in mourning, in melancholia something different will happen. As the psychoanalyst Edith Jacobson pointed out, the melancholic might, instead of taking over the ideals and pursuits of the husband, blame herself endlessly for her inability to carry out his business or for having ruined him, unaware that these self-reproaches unconsciously referred not to herself but to him. In one of Abraham's cases, a woman endlessly accused herself of being a thief, when in fact it was her deceased father who had been imprisoned for larceny. The identifications have this persistent accusatory quality.
And example can be found in the Dutch film The Vanishing, directed by George Sluizer. It tells the story of a man searching for his abducted wife, who disappears one day when they stop at a motorway service station. The abductor watches his efforts to find her and, at the end of the film, offers him the opportunity to learn her fate. Desperate to know, he allows himself to be drugged, so as finally to solve the mystery of what happened to her. When he wakes up, he finds that he has been buried alive. His passion to re-find her covered over a profound identification with her: solving the mystery was in fact an alibi for wanting to join her. He put himself literally in the place of the lost object, with lethal consequences.
Similarly, in the film Random Hearts, Harrison Ford and Kristin Scott Thomas play two characters whose spouses die in a plane crash. As the story unravels, it turns out that the spouses had been travelling together: they were going to Miami not on business but to continue their lonJstanding affair. Ford becomes obsessed with finding out everything about the relationship: where they went, what they did, which hotel rooms they stayed in and so .... on. As his morbid quest gathers momentum, he increasingly involves Scott Thomas, almost forcing her to share his obsession. As they visit the places where their spouses had conducted their romance, they become lovers themselves, as if they had come to inhabit the place of the dead. An incidental photograph of the two of them in a club before they become lovers is printed in a newspaper, yet it is not long before this 'untruth' becomes truth. It is as if they are being powerfully pushed into the place of the dead by a structure that is beyond them. They have ended up taking the place of the dead lovers.
Such unconscious identifications are far more common than we might think. We often hear of someone dying not long after the death of a loved one, especially after decades of marriage: we could think of the singer Johnny Cash or the politician James Callaghan, both of whom passed away soon after the death of their beloved wives. Grief is no longer included as a cause of death on death certificates, as it once was, but there is little doubt that in many cases the surviving partner wishes literally to join their lost love. In some cases this takes the form of a conscious wish, but it is just as often the result of unconscious forces. As in Random Hearts, there is a sense that a higher power, some force or destiny, is pushing the characters into an identification with the dead.
We also often learn of people's sense that they are doomed to repeat the life history of a deceased parent or family member, perhaps because of feelings of responsibility for their death. The psychoanalyst George Pollock thought that people's sense of a destiny often emerges when a parent or sibling has died when the person is young. They feel responsible for the death or illness, and so feel doomed to share the same fate. Van Gogh's experience illustrates this. He was named after a sibling predecessor who had died before his birth. He would often pass his brother's tombstone, and was inscribed in the parish register under the same number as his brother: twenty-nine. He would later commit suicide on the twenty-ninth day of July.
Another example is that of the psychoanalyst Marie Bonaparte, a Greek princess who was one of the first generation of Freudians and who also happened to have been the occasional baby-sitter of Prince Philip. Bonaparte's mother had died of TB at the age of twenty-two when Marie was one month old. She had been told that her birth had been paid for with her mother's life. Given the same name, Marie would become convinced that she too would share that fate. She began to develop symptoms that mimicked those of TB: she lost appetite and weight, contracted frequent respiratory infections and had bloody mucus in her throat.
Ignoring these identifications can be catastrophic. It can blind one to the danger of a suicide or gradual giving up of the will to live. It may also obscure the true meaning of a patient's symptoms, which may be mimicking those of a lost loved one. Yet, sadly, both medicine and psychology remain dangerously oblivious to these so common occurrences. Medicine doesn't want to know anything about the wish to die.
And psychology tends to shy away from the Freudian idea of identification with the lost object. Yet example after example shows that this is a basic human response to loss. Either we take traits from the one we have lost, singular features that remain part of us, or, as in the melancholic case, we take everything. As the American analyst Bertram Lewin put it, the melancholic punishes the lost loved one in effigy, yet it is their own self which has become this effigy.
Curiously, the very process by which Freud characterized melancholic identification was later used to describe the actual constitution of the human self Our egos, he wrote, are made up of all the leftover traces of our abandoned relationships. Each broken relationship leaves its stamp on us, and our identity is a result of the building up over time of these residues. It's less 'You are what you eat' than 'You are what you've loved.' This gives a real twist to the earlier theory. Just when it seemed that the serious pathological state of melancholia had been explained, the same theory was being used to describe the most basic features of our identity. Was the building up of our ego really a melancholic process? Or could there be a subtle difference in the mechanism?
The idea of building our egos out of abandoned, relationships certainly rings true. When we experience a break or disappointment in our involvement with someone we love, we often take on some of their attributes: a tone of voice, a taste for a certain food or even a way of walking. It's as if we remain trapped inside their images. This process is represented graphically in John Carpenter's film The Thing. An alien life-form starts to take over the members of a scientific team in a remote Arctic research station. As it pursues its colonizing aim, it takes possession not only of humans but of dogs and spiders, combining their bodies in horrific hybrids. At the end of the film, when the alien is finally destroyed, we see it decompose into each of the images it has donned until that moment: the individual members of the team, the dog, the spider are all paraded before our eyes in the agony of the alien's death throes. This terrifying molting of images gives the model of the human ego, constructed from all those we have identified with, all those we have become.
But why should we see this process as characteristic of melancholia rather than mourning? There must be a difference first of all in terms of the self-reproach that Freud had set at the heart of melancholia. The identifications that build up our egos do 'not necessarily involve an attack on ourselves. We could also argue that perhaps the ego is built up not simply through our experience of loss, but through the registration of loss. The key feature here is the fact that a loss has been processed and represented. A loss, after all, always requires some kind of recognition, some sense that it has been witnessed and made real. That's why so much effort is made today to commemorate and mark traumatic events of the past, from the horrors of the Great War to the injustice and violence in a country such as South Africa. The Truth and Reconciliation Commission, after all, was less about punishing the perpetrators than about recognizing and registering their crimes. A separation, perhaps, only becomes a loss when it is registered.
Let's take an example here. A young couple fall in love and become engaged. The man goes to visit his family and tells them the good news of the engagement. As he is returning, he learns that his fiancée has been killed in a tragic accident. Yet when he expects to be able to share his grief with his friends and family, he realizes that none of them had ever actually met his lost loved one. He had only mentioned her to them very recently, and so he is faced with the problem of mourning someone who had not existed for those around him. No one else knew her. We see here a very particular situation. There has been a tragedy, but he feels the immense difficulty of registering this. When he went to meet her parents later on, he was in the strange situation of being the man she had been engaged to, yet whom they had neither met nor heard of.
In another case, a woman conducted a long relationship with a man in secret over several years. They knew each other intimately, yet, since they were both married, they shared the facts of their affair with no one. As they often emphasized to each other, secrecy was crucial. When the man withdrew from the relationship, mourning seemed impossible. How could she convey what had happened when, in a sense, the relationship had had no existence for those around her? In situations such as this, and in the case we mentioned above, there is the real problem of the absence of a third party. We suddenly become aware of the fact that we need other people not just to share our feelings with, but actually to .... confirm our own experiences, to make us sure that we have really lived them.
Survivors of the concentration camps reported a common nightmare of returning home yet finding no one to notice them or believe what had happened to them. It wasn't only the horrors of the camps that would return to torment them, but the agonizing feeling that there was no one there to authenticate their experience. Without some form of third party, we have no anchor, no way of believing in the authenticity of what we have gone through. Although Hamlet knows perfectly well that his uncle is guilty of murder, is it an accident that he has to wait for the Ghost to appear before passing a death sentence on Claudius?
This kind of triangle, in which we need the presence of a third party to confirm what we feel for someone else, is exploited relentlessly by daytime television. Countless chat shows invite guests to declare their sentiments on air for someone they love or, in some cases, wish to separate from: people begin marriages or end them, confront parents or reconcile with them, confess sins or swear fidelity. Crucially, all these performative actions, in which speech is used to do something, such as swearing or confessing, take place on a stage, in front of an audience. These shows rely on the principle that words ultimately require someone to sanction them beyond their immediate addressee, in the same way that a marriage or a funeral ceremony requires the symbolic presence of a priest or some sort of facilitator. In many cases, someone who has experienced a loss will seek out a third party perhaps an analyst or therapist - in order to perform this authenticating function.
In the mourning process, this kind of sanction is often represented in dreams. There is a significant difference between those dreams which involve the mourner's interactions with the dead or departed, and those in which the mourner talks about that person to someone else. Some time after her mother's death, a woman caught in a painful and protracted grief dreamt that she was telling a faceless third party that her mother had died. Although she could not fill in any detail of this listening figure, the dream marked a moment of change for her. By introducing a basictriangulation, it showed that the loss was being registered, transformed into a message to be transmitted to someone else and accepted, at some level, by herself.
References used in the above starting with the top:
Arthur Kleinman and Byron Good, Culture and Depression(Berkeley: University of California Press, 1985); Spero Manson and Arthur Kleinman, 'DSM-IV, Culture and Mood Disorder: A Critical Reflection on Current Progress', Transcultural Psychiatry~ 35 (1998), pp. 377-86; and Alice Bullard, 'From Vastation to Prozac Nation', Transcultural Psychiatry, 39 (2002), pp. 267--94.
J. Takahashi and A. Marsella, 'Cross-Cultural Variations in the Phenomenological Experience of Depression', Journal of Cross Cultural Psychology, 7 (1976), pp. 379--96.
David Healy, The Anti-Depressant Era (Cambridge, Mass.: Harvard University Press, 1997) and The Creation of Psychopharmacology (Cambridge, Mass.: Harvard University Press, 2002); S. Jadhav, 'The Cultural Construction of Western Depression', in V. Skultans and J. Cox (eds), Anthropological Approaches to Psychological Medicine (London: Jessica Kingsley, 2000); Alain Ehrenberg, La Fatigue d'Etre Soi: Depression et Societe (Paris: Odile Jacob, 2000); and Nikolas Rose, 'Disorders without Borders? The Expanding Scope of Psychiatric Practice', Biosocieties, I (2006), pp. 465-84.
Hina Singh and Nikolas Rose, 'Neuro-forum: An Introduction', Biosocieties, I (2006), pp. 97-102; Giovanni Fava, 'Long-term Treatment with Antidepressant Drugs: The Spectacular Achievements of Propaganda', Psychotherapy and Psychosomatics, 71 (2002), pp. 127-32; David Healy, 'The Three Faces of the Antidepressants', Journal of Nervous and Mental Diseases, 187 (1999), PP.174-80, and 'The Assessment of Outcomes in Depression: Measures of Social Functioning', Journal of Contemporary Psychopharmacology, II (2000), pp. 295-301.
For depression as protection, see David Healy, Let Them Eat Prozac (New York: New York University Press, 2004).
For ”Lima,” see Laurence Kirmayer, 'Psychopharmacology in a GlobalizingWorld: The Use of Antidepressants in Japan', Transcultural Psychiatry, 39 (2002), pp. 295-322.
Effectiveness of anti-depressants, see Giovanni Fava and K. S. Kendler, 'Major Depressive Disorder', Neuron, 28 (2000), pp. 335-41; S. E. Byrne and A. J. Rothschild, 'Loss of Antidepressant Efficacy During Maintenance Therapy', Journal of Clinical Psychiatry, 59 (1998), pp. 279-88, Peter Breggin and David Cohen, Your Drug May Be Your Problem (New York: Da Capo Press, 1999); David Healy, Let Them Eat Prozac, op. cit, and any issue of the journal Ethical Human Psychology and Psychiatry.
For Melancholy and creativity, see Peter Toohey, 'Some Ancient Histories of Literary Melancholia' , Illinois Classical Studies, 15 (1990), pp. 143-61.
'Hallucination of lost loved one', see Paul Rosenblatt, Patricia Walsh and Douglas Jackson, Grief and Mourning in Cross-Cultural Perspective (New Haven: HRAF, 1976); Bernard Schoenberg et aI., 'Bereavement, its Psychosocial Aspects' (New York: Columbia University Press, 1975); and Ira Glick, Robert Weiss and Colin Murray Parkes, The First Year if Bereavement (New York: Wiley, 1974).