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The impaired vitality and self-reproaches of the depressed are often aggravated by an inability to settle to work. A task is required from them, for the restoration of their health – that of taking responsibility for their mental life, and for any harm that has befallen their good objects in phantasy or dream life. Once this responsibility is acknowledged, a process of reparation may start, and with it a capacity for meaningful work in the external world.
Mourning is the psychological work needed for recovering the will to go on after bereavement. But deprivation in childhood impedes mourning in adult life. Primitive defences against mental pain established in infancy continue to resist the experiences of sadness in later life. Then external loss or misfortune, or grievance and factiousness directed against the good objects of the inner world – or both – fabricate a universe in which the depressed cannot live with zest or, in suicidal states, at all.
In general practice, I have often found that a shallow emotional response to loss is associated with psychosomatic disturbance involving the eyes, nose, throat or chest. Conversely, a flow of tears may be a prelude to a change of heart, a move from resentment and guilt towards the revival of painfully fond feelings.
The effort by a family doctor to work with a depressed patient on the mysterious nature of the disorder, provides a model for the structural basis of future mental health. Internalisation, then identification, with the ‘family at work’ and the responsibility for guarding its welfare from attack by hostile parts of the self, enhances the appreciation and enjoyment of life and work in the wider world. The following case histories illustrate some experiences in these areas.
A fifty-five-year-old workman came to the practice with a tendency to chest pain and attacks of wheezy bronchitis. The onset had been gradual over some years – those following the death of his mother. He was a melancholy, untidy man, the express