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by Barbara G. Shmagin and Deanna R. Pearlmutter
WHILE
depression as a mental health problem has received major emphasis in the literature, it would appear that only minor attention has been given to the secondary gains of a depressive illness. One reference can be found in the writings of Fenichel, who recognized the secondary gain of depression when he quoted from a Nestroy play: “If I could not annoy other people with my melancholia, I wouldn’t enjoy it at all.” (in Gaylin, 1968, p. 116.) Generally, depressive reactions are charac-
terized by persistent and pervasive feelings of worthlessness and guilt. Decreased appetite, weight loss, diminished interest in sex, insomnia, malaise, headaches, constipation, and vague gastrointestinal dysfunction comprise the somatic picture. Although there is individual variation, the depressed person tends to fixate on his failures, exaggerate them, and ignore his successes and abilities. Less effective in his daily work, he finds his usual activities, interests, and hobbies fail to provide satisfaction. Depending on the severity, degree, and type of 63
Psychiatric Care
symptoms, depression may be classified broadly as neurotic or psychotic. Whichever classification, the interpersonal past has taken its toll on the personality structure of the individual, predisposing him to depression. To one degree or another, the past interpersonal relationships involved extreme direct or indirect rejection of the child by the parents. The child becomes enraged that his needs for love and esteem have been ignored. His guilt, however, prevents him from expressing his anger at the rejecting parents. Instead, he represses his anger, burying his growing hostility, with the result, his feelings of worth,lessness become profound. Because the depressed person cannot consciously handle the rage he feels toward his parents and the subsequent guilt, he displaces the rage onto himself, introjects the parental attitude toward him, believing it is his worthlessness that prevents others from loving him. The depression provides a release from the more painful anxiety of guilt; this decrease in anxiety is termed the primary gain of the psychiatric symptom. The symptom now expressed, the person’s neurotic depression masks his anxiety, thereby affording him protection from the anxiety connected with the current precipitating stress. (Chapman, 1967) As he protected his parents’ image by terming himself worthless, and protected them from his rage, so, too, he protects himself from his rage and anxiety concerning rejection. Once the depression has been established, however, the person may find that he now derives an extra degree of satisfaction because of it. He may receive extra attention from others, especially if he is hospitalized. For example, one of our depressed patients told us, “One good thing about being in the hospital my wife can’t ignore me anymore. She has to visit me, have sessions with the social worker and the doctor. It’s not like at home when she talks on the phone all day.” Or, the depressed person may now have the means to escape from responsibilities and stress. Depression may permit
i r g
0
64
him to assume an invalid role (especially if he is hospitalized) that will “excuse” him from his usual obligations. For example, we recall one patient whose hospitalization allowed her to reassign to a relative the care of a child whom she regarded with ambivalence. For another patient - a married teacher - hospitalization provided an escape from his classroom (and his marriage) where he felt inadequate and unappreciated. The secondary gain of depression, then, is the additional gratification the depression provides the person. Moreover, feelings of inferiority and worthlessness may be used to advantage, for “frequently they [depressed patients] try to captivate their objects . . . by demonstrating their misery and by accusing the objects of having brought about this misery, and by enforcing and even blackmailing their objects for affection.” (Gaylin, 1968, p. 115) By insisting that they are unloved, depressed persons almost force others around them to contradict these sentiments and refute their accusations. Such behavior, intended to meet narcissistic needs, seems to contradict the depressed person’s conscious feeling that he is worthless and helpless. However, the “depressed patient, who seemingly is so extremely sub missive, is actually often successful in dominating his entire environment. . . .” (Gaylin, 1968, p. 116) The secondary gain of depression, then, is related to the primary gain in that the person sets up a situation in which the depression serves to get him what he wanted from his parents. Therefore, although secondary gains are not directly connected to the basic interpersonal prob lems of depressed patients, they do give their symptoms an added emotional premium (Chapman, 1967), and are a reflection of their frustrated desire to have their parents accept them. The secondary gains of depression may be minor, or they may’reach such proportion as to outweigh the original emotional problem and become an obstacle to the therapist in treating the person’s original depression. While a de-
Number 2
pressive illness may provide secondary gains such as additional attention, and allows the patient to withdraw from others, in a sense, the “gain” is no gain at all; it is simply a replication of the original rejection. Persistent moaning and selfabsorption are certain to cause others to shun or withdraw from the depressed person eventually. One of our depressed patients, who was extremely self-centered and withdrawn, constantly focused on all her inadequacies. Whenever there was a lag in a conversation between patients and staff, she was quick to voice her expressions of hopelessness and bemoan her fate. While the staff members were forced to turn their attention to her, the other patients ignored her. Depression, then, can be viewed as an extinction phenomenon in which the patient turns increasingly inward, rejecting the people and activities that have reinforcement potential. Behaviorists propose that there is an inverse relationship between positive reinforcement and the intensity of the depression. The depressed person elicits less social reinforcement from others and
is less apt to be the object of attention and interest. The person’s withdrawal from society has been compared to the “disengagement” of the elderly. (Friedman and Katz, 1974) Thus, symptoms of depression often provide secondary gains : Depressed patients obtain narcissistic gratification because of their disorder; they may exploit the kindness and attentiveness of others, shirk responsibility; and avoid the demands of interpersonal interaction. Indeed, the secondary gains may be so reinforcing to the patient that the original depression cannot be affected by the treatment plan. References Chapman, A. H., Textbook of Clinical Psychiatry, Philadelphia: J. B. Lippincott Company, 1967. Fenichel, Otto, “Depression and Mania,” in W. Gaylin’s T h e Meaning of Despair, New York: Science House, Inc., 1968. Friedman, Raymond and Martin Katz ( 4 s . ) ,T h e Psychology of Depression: Contemporary Theory and Research, New York: Hemisphere Publishing Corporation, 1974. Gaylin, Willard, T h e Meaning of Despair, New York: Science House, Inc., 1968.
BE IDENTIFIED As A Specialist Other professionals have their registries and listings, and now for the first time educators, researchers, clinicians, administrators and consultants with masters or doctorate degrees in psychiatric-mental health nursing will be able to achieve national visibility through the National Directory of
Specialists in Psychiatric-Mental Health Nursing. Those meeting the criteria will be referenced by name, specialty and geographic location in an independent directory which will be made available to community, state and federal health agencies, legislators, universities and colleges, insurance companies, hospitals and consumers. Listing in more than one category is possible. The benefits of such a directory are limitless. You can’t afford not to be included. ACT NOW and take advantage of special charter membership rates in effect until August 31, 1977. For further information regarding criteria, fees and applications write:
National Directory of Specialists in Psychiatric-Mental Health Nursing, 15 Brattle Street, Cambridge, Mass. 02138. 617-492-5238 65
by Barbara G. Shmagin and Deanna R. Pearlmutter
WHILE
depression as a mental health problem has received major emphasis in the literature, it would appear that only minor attention has been given to the secondary gains of a depressive illness. One reference can be found in the writings of Fenichel, who recognized the secondary gain of depression when he quoted from a Nestroy play: “If I could not annoy other people with my melancholia, I wouldn’t enjoy it at all.” (in Gaylin, 1968, p. 116.) Generally, depressive reactions are charac-
terized by persistent and pervasive feelings of worthlessness and guilt. Decreased appetite, weight loss, diminished interest in sex, insomnia, malaise, headaches, constipation, and vague gastrointestinal dysfunction comprise the somatic picture. Although there is individual variation, the depressed person tends to fixate on his failures, exaggerate them, and ignore his successes and abilities. Less effective in his daily work, he finds his usual activities, interests, and hobbies fail to provide satisfaction. Depending on the severity, degree, and type of 63
Psychiatric Care
symptoms, depression may be classified broadly as neurotic or psychotic. Whichever classification, the interpersonal past has taken its toll on the personality structure of the individual, predisposing him to depression. To one degree or another, the past interpersonal relationships involved extreme direct or indirect rejection of the child by the parents. The child becomes enraged that his needs for love and esteem have been ignored. His guilt, however, prevents him from expressing his anger at the rejecting parents. Instead, he represses his anger, burying his growing hostility, with the result, his feelings of worth,lessness become profound. Because the depressed person cannot consciously handle the rage he feels toward his parents and the subsequent guilt, he displaces the rage onto himself, introjects the parental attitude toward him, believing it is his worthlessness that prevents others from loving him. The depression provides a release from the more painful anxiety of guilt; this decrease in anxiety is termed the primary gain of the psychiatric symptom. The symptom now expressed, the person’s neurotic depression masks his anxiety, thereby affording him protection from the anxiety connected with the current precipitating stress. (Chapman, 1967) As he protected his parents’ image by terming himself worthless, and protected them from his rage, so, too, he protects himself from his rage and anxiety concerning rejection. Once the depression has been established, however, the person may find that he now derives an extra degree of satisfaction because of it. He may receive extra attention from others, especially if he is hospitalized. For example, one of our depressed patients told us, “One good thing about being in the hospital my wife can’t ignore me anymore. She has to visit me, have sessions with the social worker and the doctor. It’s not like at home when she talks on the phone all day.” Or, the depressed person may now have the means to escape from responsibilities and stress. Depression may permit
i r g
0
64
him to assume an invalid role (especially if he is hospitalized) that will “excuse” him from his usual obligations. For example, we recall one patient whose hospitalization allowed her to reassign to a relative the care of a child whom she regarded with ambivalence. For another patient - a married teacher - hospitalization provided an escape from his classroom (and his marriage) where he felt inadequate and unappreciated. The secondary gain of depression, then, is the additional gratification the depression provides the person. Moreover, feelings of inferiority and worthlessness may be used to advantage, for “frequently they [depressed patients] try to captivate their objects . . . by demonstrating their misery and by accusing the objects of having brought about this misery, and by enforcing and even blackmailing their objects for affection.” (Gaylin, 1968, p. 115) By insisting that they are unloved, depressed persons almost force others around them to contradict these sentiments and refute their accusations. Such behavior, intended to meet narcissistic needs, seems to contradict the depressed person’s conscious feeling that he is worthless and helpless. However, the “depressed patient, who seemingly is so extremely sub missive, is actually often successful in dominating his entire environment. . . .” (Gaylin, 1968, p. 116) The secondary gain of depression, then, is related to the primary gain in that the person sets up a situation in which the depression serves to get him what he wanted from his parents. Therefore, although secondary gains are not directly connected to the basic interpersonal prob lems of depressed patients, they do give their symptoms an added emotional premium (Chapman, 1967), and are a reflection of their frustrated desire to have their parents accept them. The secondary gains of depression may be minor, or they may’reach such proportion as to outweigh the original emotional problem and become an obstacle to the therapist in treating the person’s original depression. While a de-
Number 2
pressive illness may provide secondary gains such as additional attention, and allows the patient to withdraw from others, in a sense, the “gain” is no gain at all; it is simply a replication of the original rejection. Persistent moaning and selfabsorption are certain to cause others to shun or withdraw from the depressed person eventually. One of our depressed patients, who was extremely self-centered and withdrawn, constantly focused on all her inadequacies. Whenever there was a lag in a conversation between patients and staff, she was quick to voice her expressions of hopelessness and bemoan her fate. While the staff members were forced to turn their attention to her, the other patients ignored her. Depression, then, can be viewed as an extinction phenomenon in which the patient turns increasingly inward, rejecting the people and activities that have reinforcement potential. Behaviorists propose that there is an inverse relationship between positive reinforcement and the intensity of the depression. The depressed person elicits less social reinforcement from others and
is less apt to be the object of attention and interest. The person’s withdrawal from society has been compared to the “disengagement” of the elderly. (Friedman and Katz, 1974) Thus, symptoms of depression often provide secondary gains : Depressed patients obtain narcissistic gratification because of their disorder; they may exploit the kindness and attentiveness of others, shirk responsibility; and avoid the demands of interpersonal interaction. Indeed, the secondary gains may be so reinforcing to the patient that the original depression cannot be affected by the treatment plan. References Chapman, A. H., Textbook of Clinical Psychiatry, Philadelphia: J. B. Lippincott Company, 1967. Fenichel, Otto, “Depression and Mania,” in W. Gaylin’s T h e Meaning of Despair, New York: Science House, Inc., 1968. Friedman, Raymond and Martin Katz ( 4 s . ) ,T h e Psychology of Depression: Contemporary Theory and Research, New York: Hemisphere Publishing Corporation, 1974. Gaylin, Willard, T h e Meaning of Despair, New York: Science House, Inc., 1968.
BE IDENTIFIED As A Specialist Other professionals have their registries and listings, and now for the first time educators, researchers, clinicians, administrators and consultants with masters or doctorate degrees in psychiatric-mental health nursing will be able to achieve national visibility through the National Directory of
Specialists in Psychiatric-Mental Health Nursing. Those meeting the criteria will be referenced by name, specialty and geographic location in an independent directory which will be made available to community, state and federal health agencies, legislators, universities and colleges, insurance companies, hospitals and consumers. Listing in more than one category is possible. The benefits of such a directory are limitless. You can’t afford not to be included. ACT NOW and take advantage of special charter membership rates in effect until August 31, 1977. For further information regarding criteria, fees and applications write:
National Directory of Specialists in Psychiatric-Mental Health Nursing, 15 Brattle Street, Cambridge, Mass. 02138. 617-492-5238 65
