Anxiety and Depression: The Adaptive Emotions 9780773592582

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ANXIETY AND DEPRESSION

Anxiety and Depression THE ADAPTIVE EMOTIONS

Charles G. Costello

McGill-Queen's University Press MONTREAL & LONDON 1976

© McGill•Queen's University Press 1976 ISBN 0 7735 0255 6 Legal Deposit Third Quarter 1976 Bibliothcque Nationale du Quebec

Design by Anthony Crouch MMGDG Printed in Canada by John Deyell Company

This book was written with the help of a grant from the Government of Alberta. It has been published with the help of a grant from the Social Science Research Council of Canada using funds provided by the Canada Council.

ACKNOWLEDGMENTS The lines from "Do Not Go Gentle into That Good Night" by Dylan Thomas which appear on page 81 are reprinted from Collected Poems by permission of the Trustees for the Copyrights of the late Dylan Thomas and J. M. Dent & Sons Ltd., and from The Poems of Dylan Thomas, copyright 1952 by Dylan Thomas, by permission of New Directions Publishing Corporation, New York. The extracts from The Cocktail Party by T. S. Eliot which appear on page 89 are reprinted here by permission of Faber and Faber Ltd and Harcourt Brace Jovanovich, Inc.

With love to my wife Violet, and my children Charles, Violet, Catherine, Richard, and Joanne Yvonne.

Contents Acknowledgments

~

Chapter One The Signalling Function of Emotion

1

Chapter Two The Nature of Anxiety

19

Chapter Three The Nature of Depression

47

Chapter Four Research and Clinical Strategies

103

Notes

131

Index

145

The Signalling Function of Emotion

1

In the mid twentieth century the times in which we were living were called the Age of Anxiety. More recently they came to be called the Age of Depression. Since no one has yet announced an end to the Age of Anxiety, we are now presumably living in an Age of both Anxiety and Depression. Anxiety and depression have always been considered bad things, which we could well do without. But we need not tremble in the face of these emotions. They are not necessarily bad. Indeed, it may be argued that they are as important as man's reason to the development of rich lives for both individuals and the societies in which they live. There are people who suffer prolonged periods of intense anxiety and depression. These periods can be extremely painful, and we do well to use all our resources to cure or, preferably, prevent them. Later on in this book I shall discuss in some detail these instances of what we shall call clinical anxiety and clinical depression. But the primary concern of the book is with the anxiety and depression which we all experience to some degree or other at some time or other. It is these ubiquitous experiences that are usually being referred to when we speak of the Age of Anxiety and the Age of Depression. I have referred to anxiety and depression as emotions, as though we all knew exactly what the term emotion means. In fact, we do

2 Anxiety and Depression not. But however we may differ in our definition of the term, we will probably agree that anxiety and depression are emotions. And so, before discussing the nature of anxiety and depression, it may be as well to consider some of the characteristics of emotion and what we call emotional behavior. I shall not attempt here to construct a theory of emotion. I shall try rather to discuss in some detail a set of characteristics in relation to which emotions can be compared. Briefly these characteristics are the unusualness of an emotional behavior, its attention-gaining properties, and the degree to which it prompts interrogation. These are by no means the only yardsticks for the comparison of emotions. A good review of other yardsticks and of the problems of emotions in general will be found in Magda Arnold's Feelings and Emotions.' But the three characteristics which I have listed seem to have been more or less neglected. I shall argue that they are important in relation to the signalling function of emotion. Whether we are aware of it or not, their presence probably also helps us to arrive at a judgment of the genuineness of an emotional experience. I hope to demonstrate that this type of analysis of emotions will help us to understand the nature of anxiety and depression. When I refer in this chapter to emotions and emotional behavior, it will be for the most part negative, or unpleasant, emotions which I shall be considering. After all, our final goal is a greater understanding of anxiety and depression. Some reference will be made to the characteristics of positive, pleasant emotions, particularly the emotion of love, but they are very much comments en passant. Indeed, one of the reasons why I make no attempt at a theory of emotion is that the nature of positive emotions remains so elusive. At an abstract level, we may all be in agreement about which experiences and behaviors can be classified as instances of an emotion—anxiety, depression, love, and joy, for instance. But in everyday life whether or not an experience or behavior is considered to be an emotional experience or emotional behavior is often a more debatable issue. That this is so is perhaps more evident when we consider emotional experiences than when we consider emotional behaviors. We have little doubt from an experiential point of view that a pain is a pain or a smell is a smell, but we are not always too clear as to whether or not we are experiencing an emotion and, if

The Signalling Function of Emotion 3 we are, what emotion we are experiencing. One does not have doubts about a smell. We either smell something or we do not. We may not know what it is that we are smelling, and we may even feel that we imagine that we smell something, but of the smell experience itself we have no doubt. The same is true of pain. Our friendly dentist may persuade us that we are overestimating the amount of pain that we are experiencing, but we have no doubts about experiencing the pain itself. But when it comes to emotion, we find ourselves very often asking questions such as "Am I really happy that such-and-such has occurred?" "Do I really love her Although the role of judgment is more obvious in the case of experiencing emotion than in the case of observation of emotional behaviors, judgmental processes also play a role in determining whether or not we consider some instance of behavior to be emotional and how genuine we feel the emotion to be. The outcome of such judgments depends, to some degree, on the extent to which the behavior being judged satisfies the cluster of three criteria we have already mentioned: We are usually concerned, though perhaps unconsciously, with the extent to which the behavior is unusual and attention-gaining and whether or not it tends to elicit interrogation on the part of the person himself or on the part of observers. We must now discuss those three criteria in more detail. 1. Is the behavior unusual? Emotional behaviors are often found not to be those that one would expect on the basis of one's knowledge of a particular person's past behaviors, or they are not what one would expect on the basis of one's knowledge of the type of person he is in terms of some group or groups of which he is a member. The behavior is unusual in terms of the infrequency with which that particular person or that kind of person behaves in such a way and/or in terms of the circumstances in which the behavior occurs. 2. Is the behavior attention-gaining? To the extent that the emotional behavior is unusual, it will be attention-gaining. It will demand the attention of the behaving person himself and/or of people observing him. 3. Does the behavior prompt interrogation? When a person behaves in this unusual manner, observers usually show a strong tendency to question him about the reasons for his behavior.

4 Anxiety and Depression When an observer considers that a person's behavior is unusual, he is generally using as his reference point some group to which the observed person belongs. This is all he can do if he is seeing the person for the first time. Indeed, this lack of acq.iaintance with a person can make it difficult to decide whether or not the behavior can be considered unusual. If we see a woman cry, we generally consider it unusual because, though women in western cultures may cry more often than men, they do not make a habit of crying in public, and compared with other behaviors such as, for instance, eating and talking, crying is infrequent. If, however, we know the woman well and know that she cries frequently and at the drop of a hat, we will not consider her behavior as unusual and will probably question the extent to which she is genuinely emotional. We may feel she is "putting it on" and call her "a sentimentalist," or worse, "a neurotic." If we consider the tone in which we say that a person has the habit of behaving emotionally, we shall note an element of skepticism in it. There is an implication that the behaviors should be dismissed as not worthy of our attention. This is not to deny that we may often talk about a person being temperamentally emotional. We may describe a whole nation of people, such as the Italians, as being temperamentally emotional. Nevertheless, I think one will see, on reflection, that when one talks in this manner about an individual or national sterotype, one has lost an important sense of the term emotional. As the merchants, taxi drivers, and pedestrians of Rome shout and gesticulate, one may have to reassure the new and disconcerted visitor that they are not really angry. The same behavior from the usually stiff-upperlipped Englishmen of London's Bond Street would not so readily be dismissed. Their behavior would be considered emotional in a far different and perhaps truer sense than the behavior of the Italians. I have no doubt that the Italians know when one of their countrymen is really emotional. They probably note something unusual about his behavior—perhaps he becomes quiet! As Luigi Barzini warns us in his book, The Italians, appearances in Italy are not always illusory—not always trompe l'oeil. "Is the young man less in love with his young lady if he courts her in a dramatic way?" asks Barzini. "Is the man who watches the public's reaction from the corner of his eye less dominated by wrath, jealousy or

The Signalling Function of Emotion 5 love?" "Not necessarily, of course, not always. In fact, the thing and its representation often coincide exactly" he answers. On the other hand, he goes on, "They may also coincide approximately, or may not coincide at all. There is no sure way of telling."2 Barzini writes of "the convulsive gesticulations of unfelt sentiments and emotions,"3 and that Italians know "that the free expression of genuine emotions is a luxury for the privileged, often a dangerous and expensive luxury."' Among the Italian's rule for survival is the following, "One should always be on the qui vine, watch the horizon for the smallest cloud and people's faces for the smallest variation of mood."5 So it would seem that when we ascribe an emotion to someone, when we say he is sad, for instance, and mean it, the person's behavior will be found to be unusual either in terms of his normal behavior or in terms of the behavior of some group to which he belongs. We say a man is angry when he shouts though a person is close to him, or mumbles though a person is too distant to hear what he says. We say a man is angry when he gives someone blows on the face rather than talks to him. If the observed person is a boxer and happens to be in a boxing ring, such pugilistic behavior would not be considered emotional behavior. If he is dancing a jig in the ring, we suspect he is joyful and a search of the canvas for his challenger will probably indicate why. If the man is Irish and is engaged in a Donnybrook, we may very well decide that little emotion is involved. We can see then that the status of the same behaviors with reference to their emotional quality may change as a function of the unusualness of the behavior, which in turn depends on some group of which the observed person is a member and the circumstances in which the behavior occurs. When we say a person's behavior appears unusual to us, we are not simply referring to the topography of the behavior. In the circumstances in which we are inclined to call a person depressed, it is the absence of behaviors that strikes us as being unusual. The person does not eat, although it is a long time since he has eaten and food is readily available. He does not talk, although other people show a readiness to talk with him. As has already been noted, whether or not the behavior is seen as unusual also depends on our judgment about the appropriateness of the behavior in a particular context. A person's laughter is not peculiar in itself, but

6 Anxiety and Depression if one can see nothing very funny occurring, then one is inclined to decide that the person is happy. There is nothing peculiar about dancing. But if the person is not in a dance hall and one can hear no music being played, one possible conclusion is that the person is in a state of joy. There is nothing unusual about fixing one's attention on another person if the other person reciprocates or is engaged in some particularly interesting activity. Otherwise, one is inclined to decide that the unfortunate person who gazes is in the throes of love. One of the above examples is likely to give more trouble than the others. That is the example of laughter. There are some who may wish to consider all instances of laughter as indicating an emotion. But when a person laughs at a joke, what emotion is being experienced? Happiness? Joy? I can hear the best of jokes told by the best of comics and laugh loudly without being ready to say the hearing of it made me feel happy. Smiles and laughter are not unusual in themselves. Furthermore, we are usually aware of what it is that elicits them—for instance, acquaintances pass one another and smile. We do not consider these acquaintances to be in some emotional state. We do not give it a passing thought. That perhaps is the crux of the matter. Does the behavior of the other person give us pause? We see a young woman smiling down at a baby. If we also see the mother standing by, we assume that the young woman is smiling approvingly—an emotion is not involved. Perhaps we see that the baby is pulling a funny face and we assume that the young woman is amused. But perhaps no one else is around and the baby is fast asleep. We are inclined then to deduce that the woman is the mother and that she is happy. A person can be expected to smile at funny things and can be expected to give smiles of approval. But we are not quite so prepared to find someone who thinks she is unobserved smiling down at a baby who is fast asleep. Unusual behavior attracts the attention of observers and usually leads them on a search for reasons. Once the reason for the behavior has been found, it loses some of its interest. If we discover that a belligerent person is psychotic, the behavior becomes less interesting, because it has lost its signalling properties. The belligerent activity of the psychotic is not considered to be genuine

The Signalling Function of Emotion 7 emotional behavior in the same sense as the irate behavior of a frustrated customer in a store. With sincerity, we may ask the frustrated customer "Why are you so angry?" We feel that we know why the psychotic is angry even though our knowledge may be far from complete. We may still wish to call the angry behavior of the psychotic emotional behavior. We can do that. It is all a matter of strategy. We know that emotion does not lie out there in nature waiting for someone to recognize it. But if we call the angry behavior of the psychotic emotional as well as that of the frustrated customer in the store, we would probably want to distinguish between their behaviors in some other way. I have suggested that a useful distinction is in terms of accountability. One may say, in the case of the customer, that we can usually find sufficient reason for his anger. But is that always so? We may see someone become angry in circumstances that do not seem to justify it—a slightly leisurely pace on the part of the cashier, an article that is not in stock. We begin to suspect that there is something more to his anger than that. It is rather in the case of the psychotic that we may feel we have sufficient reason for the anger in the psychosis itself. What I wish to propose is that we note that certain behaviors in certain contexts have an unusualness or unexpectedness about them, that they tend to attract attention and elicit an investigative attitude in people. These behaviors are ones that we feel are genuine emotional behaviors. Some phenomena would then be considered occurrences which often accompany such emotional behavior—perspiration for instance, but would not themselves be considered a sufficient index of emotion. One could also recognize behaviors such as the "anger" of the psychotic and the tears of the perpetually weeping lady as being emotion-like, but not emotional in this genuine sense. Whether or not we consider and respond to some behavior as genuinely emotional will be seen to be related to the communicative aspect of that behavior. If a particular behavior does not show a responsiveness to environmental events, it loses its signal value. As an unresponsive barometer loses its status as a barometer, so an unresponsive aspect of behavior, though unusual in one sense, loses its status as emotional behavior. The adjustments of an elec-

8 Anxiety and Depression trician on the one hand and perhaps a physician on the other are required before the activities of the barometer or the person are of much interest to observers in general. If we are aware of sufficient reason for a person's unusual behavior in his physiological makeup, we are less likely to regard it as genuine emotional behavior. This point will become important later when we consider the role of physiological processes in producing anxiety and depression. It will be suggested that, to the extent that such factors are found to play the primary role in producing the behaviors that we generally associate with anxiety and depression, we are not inclined to regard them as having the same emotional significance as similar behaviors for which we cannot so account. At least this will be found to be the case in our everyday commonsense view of things. Scientists who are often interested in only one component of what are commonly called emotional behaviors may not be interested in such distinctions. A scientist who is concerned with what happens to heart rate during emotional experiences may see little point in issues surrounding the genuineness of emotional behaviors or the communicative nature of the behavior. This neglect may or may not be warranted. Be that as it may, in everyday life it is a distinction that is not ignored though, as we shall see, we could probably improve our use of the signalling function of our own and other people's emotions. This discussion of emotion clearly implies that cognitive factors, the way one thinks about some particular behavior, are important, and the role of cognitive factors in emotion has been stressed by a number of writers recently. But the emphasis has been different. It has been placed on how the cognitive appraisals a person makes of a situation affect his emotional behavior. For instance, Richard Lazarus has shown that the stressful effects of a stress film can be reduced if the viewer, first of all, listens to a commentary that de-emphasizes the stressful nature of the film. One of the films he has used is of a primitive ritual in which a stone knife is used to cut the penis and scrotum of adolescents entering manhood. The commentaries presented the filmed events from the point of view of detachment and scientific analysis. They also denied the harmful aspects of the ritual—the pain and potential physical harm of the ritual—and suggested positive aspects of the event, such as

The Signalling Function of Emotion 9 the joy experienced by the boys during such a significant ceremony ° This proposal, as to the manner in which our cogitations may affect our emotions, is an important one, and Lazarus has presented a considerable amount of empirical evidence in support of it? My own proposal is that our thought processes play a role in addition to the one suggested by Lazarus. They play a role, in the manner that has already been described, in the decisions we make as to whether or not we regard some unusual behavior as genuine emotional behavior. Perhaps even more important, the emotional behavior or experience itself initiates thinking as we search for reasons for the emotion. There is another important manner in which thinking may play a role in emotion. According to Stanley Schachter, emotions may begin as a diffuse state of arousal which will be labeled as one or other emotion by a person and experienced by him as one or other emotion as a result of the situation he is in. The kind of experiment that Schachter has used to demonstrate this is one in which a person whose general state of arousal has been increased by injections of the drug norepinephrine may experience anger and behave angrily if in the presence of an experimenter's confederate who behaves angrily. He may, on the other hand, experience euphoria and behave euphorically if in the presence of a confederate of the experimenter who behaves euphorically.' There is no doubt that, under some circumstances, even when a decision has been made that a person is experiencing an emotion and is behaving emotionally, there may be some doubts as to what the emotion is. He may feel, for instance, that he is in love, whereas others feel that he is insecure. Under these circumstances, the behaviors of people around him may influence the emotional person's judgment of the kind of emotion he is experiencing and may shape, to some degree, the emotional behavior. The processes identified by Lazarus and Schachter will need to be taken into account in any theory of emotion that aims at completeness. Here all we are trying to do is to identify some other important processes that are involved in emotional occurrences. Emphasis on the unusualness of the behavior that we tend to call emotional will, it is hoped, permit us to approach the problem of emotion from a new angle. Skinner's formulation was close to

10 Anxiety and Depression this when he suggested that it is changes in the responses that a person is accustomed to make in a situation which are the primary criteria we use when we say a person is behaving emotionally? But he places the emphasis on changes in the strength of the usual responses a person makes in a situation rather than on the occurrences of responses that a person is not accustomed to make in a particular situation. For instance, he has written "Emotion, so far as I am concerned, is a matter of the probability of engaging in certain kinds of behavior defined by certain kinds of consequences. Anger is a heightened probability of attack. Fear is a heightened probability of running away, and love is a heightened probability of reinforcing a loved person."" But does this approach to emotion work? Do we not too often find inconsistencies? A person may generally attack when angry, but sometimes he is too angry even to look at the person who angers him. A person, like an animal, may sometimes freeze in fear. One can love, not wisely but too well, and the poor recipient of our love is punished rather than reinforced. The philosopher Kenny seems to take an approach similar to Skinner's.11 He lists two criteria to judge the intensity of an emotion. The first criterion is the violence of the bodily changes. The second is the influence on voluntary action that the emotion has, and he writes that we may regard one emotion as stronger than another if it has a greater influence on voluntary action over comparatively long periods of time. By this criterion, how powerful an emotion is depends on how much of a man's behavior can be explained by reference to it. But is it not rather the case that how powerful we consider an emotion to be depends on how much of the person's behavior we cannot readily explain? Kenny's criterion might be acceptable if one were ready to accept as the explanation for a person's behavior "He is emotional!" But it is hard to imagine under what circumstances this would be acceptable to observers or even to the emotional person himself, except when he wanted to use the "explanation" as an excuse. Indeed, as we have already noted, to the extent that there are consistencies in behavior justifying our reference to dispositions, as in the case of our tearful lady, the behavior loses its status as genuine emotional behavior. The behaviors we tend to describe as emotional are unusual behaviors which attract our attention and for which we try to find

The Signalling Function of Emotion 11 a justification. It is perhaps because emotional behaviors elicit this need for justification that we have so often assumed that an emotion must always have an object, that it must always be directed to something or be about something. The present formulation may help to reduce some of the confusion surrounding the question as to whether or not all emotions have objects and the way in which objects of emotion differ from causes of emotion. It is not the case that emotional behavior is intentional in nature, that it is always directed towards an object. Rather it seems that emotional behavior is behavior that demands of the observer a search for its justification. Emotional behavior, far from being intentional, often has a meaninglessness about it which is upsetting and which sets people off on a search for reasons, including objects. It is, as we shall see, the function of emotion to set people oft on such a search. The kind of justification that one arrives at in an attempt to account for some particular emotional behavior is likely to be important in determining the further course of that behavior. The way in which a person talks about his unusual behavior or the way others talk about it may not always have a contribution to make to a causal, descriptive account of it, but will itself be an important component in the causal chain of behavior. For instance, the course taken by the anger of a woman who says she is angry at the way her husband has treated her might be very different from that taken if she says she is angry at the way in which the world treats her. In actuality, neither the husband nor the world, however perceived, may have played an important role as an antecedent to the woman's anger. She may be barking up two wrong trees. The object of an emotion is not in the same conceptual class as the cause of an emotion. This is because the object of an emotion exists in the verbal formulations that a person makes in order to justify his emotion or in the verbal formulations of the observers. The object of an emotion can never be a matter of fact in the same way that the cause of emotion may be. Over a very short period of time the object of the same emotional behavior may vary as the justifying formulations of the emotional person or the observers change. This is a variation that cannot occur in the cause of a particular emotional episode. People may spend considerable time arguing about the object of anger. An angry man, when asked by his wife why he is angry, may reply that he is angry at her. She

12 Anxiety and Depression may tell him sincerely and without wishing to provoke him further, that he is really angry at himself. An impatient motherin-law may protest that he is angry at nothing—but then she would probably be wanting to be provocative. What I hope to show is that, from the point of view of a clinician, more important than the question of what causes an emotion is what is the significance of the emotion. What are important are the hypotheses that the emotional person himself and his observers have about the significance of what he is doing rather than a factual account of what causes him to behave that way. This brings us to a proposal concerning the function of negative, unpleasant emotions such as anxiety and depression. The sequence of events seems to be as follows. Because of some event perpetrated either by an individual himself or by others in his environment, or by an event whose perpetration is anticipated, that individual's pattern of behaviors is no longer adequate to deal with his environment—this results in behavior that is unusual in the sense that we have described previously. This unusual behavior attracts the attention of the person himself or of observers or of both, and an attempt is then made to find justification for the behavior; this may result in an examination of the person's life style and the occurrence or anticipated occurrence which has disrupted or threatens to disrupt his usual pattern of behavior. Only when a satisfactory account of the behavior has been attained can the disrupting occurrences or anticipated occurrences be coped with, and this is achieved by some restructuring of the person's pattern of behaviors. Emotions attract the attention of people to situations that have important implications for the well-being of the individual and of some segment of the society in which he lives. Group members will often apply sanctions to the emotional person in the absence of some attempt at justification which may serve to delineate what it is in a situation that is of importance. The usual sanction will be to withdraw from the person who is exhibiting the emotional behavior without attempting to justify it. This proposed function of negative emotions will, it is hoped, become clearer at the end of the book when the natures of anxiety and depression, as examples of negative emotions, have been discussed. But at this point a comment on positive emotions may be helpful.

The Signalling Function of Emotion 13 The aversiveness, or unpleasantness, of negative emotions seems to be a consequence of the lack of structure in a person's emotional behavior. It is for this reason that a person attempts to give some structure to his behavior by formulating an explanation for it which may include designating an object of the emotion. But this creation of an object of one's emotions is often a means of avoiding a problem rather than an attempt to resolve the problem which the emotion highlights. The mother-in-law may be right! One of the basic arguments of this book will be that we should use emotional episodes as signals which indicate that we should examine the pattern of our activities. Only when the pattern has been modified in some way, will the general negative valence, its repelling property, cast over our world by the emotion, be removed and the pleasure in our activities be regained. Positive emotions appear to imbue everything with a positive valence, or attracting property. In love, filled with pride, joyful, happy, all our activities are particularly pleasurable. Positive emotions seem to occur when a change is taking place in the environment and the pattern of our activities is adequate for the accommodation of this change. The person experiencing a positive emotion behaves unusually as does a person experiencing a negative emotion. There is a lack of structure in his behaviors, but this lack of structure does not appear to be aversive. Whereas the person experiencing a negative emotion wants to give some structure to his experience, the person experiencing a positive emotion does not appear to want such a structure to be imposed. It seems then that the lack of structure of emotional behavior makes the emotion aversive when it is a negative one and makes it pleasant when it is a positive one. One might expect, therefore, that a person would not be so inclined to give an explanation if the emotional behavior were a positive rather than a negative one. Furthermore, one might expect less pressure for an explanation. These expectations are fulfilled when one considers everyday life. The question "Why are you happy?" is as reasonable as the question "Why are you depressed?" But the reply "I just am" would probably be more acceptable in relation to the question "Why are you happy?" than in the relation to the second, "Why are you depressed?" Paying attention to the implications of this intolerance of the lack of structure in negative emotions and the tolerance, and perhaps even the enjoyability, of lack of structure in positive

14 Anxiety and Depression emotions might reward anyone attempting to formulate a theory of emotions that would embrace both negative and positive ones. But the primary purpose of drawing the distinction here has been to highlight the aversiveness of the lack of structure in negative emotions and the consequent attempts of people to justify their emotions and to structure their behavior. The situation in which a person is behaving and the way he thinks about that situation are important for the understanding of emotions. But the presence of such thoughts—often technically referred to as cognitive appraisals—cannot, as R. S. Peters,12 for instance, suggests, be used as a criterion to classify behavior as emotional because we engage in cognitive appraisals prior to or concomitant with unemotional behavior. It may be that cognitive appraisals as antecedents of emotions have been emphasized by so many writers recently because they wished to emphasize the distinction between human emotions and animal emotions. The distinction itself is an important one. Human emotions, it must be recognized, are extremely subtle things, and their significance may be quite hidden and quite idiosyncratic. Clear-cut events in the environment may produce what look like emotional behaviors such as fear and rage. But are these emotions in the sense that we usually use the term? Would we say of a man running from a wild animal that he is emotional in the sense that we say it of a person who sits crying on a park bench? Perhaps we should call things like fear and rage reflex defensive acts to distinguish them from emotions such as anxiety and depression. If we should decide to consider fear as a reflex, then we would not have to pursue the problem of whether fear was a generic term with anxiety being derivative from it or if anxiety were a generic term with fear being derivative from it. This matter of how we should conceptualize fear and anxiety will be considered again in the next chapter when the nature of phobias is discussed. These reflex defensive acts, paradoxically enough, are closer to the rational coping behaviors of the human being than to his emotions. We can ask whether a person's fear is a reasonable one. We can ask whether his anger is justified. But we cannot in the same way ask whether someone's love for another person is reasonable, and there is also something wrong with the question when we ask if a person's anxiety is reasonable or if his depres-

The Signalling Function of Emotion 15 sion is reasonable. We previously distinguished between negative and positive emotions on the grounds that in negative emotions the emotional person is more likely to be pressured for a justification of his behavior and is more likely to attempt to meet such demands. It may now seem that, in attempting to distinguish emotions such as anxiety and depression from reflex responses such as fear, we are suggesting that such demands for justification would not be acceptable. But one can wish to have some justification for a person's behavior without wanting to determine whether or not that behavior is reasonable. Indeed emotional behavior can never be considered reasonable in the sense that a fearful response can be. Emotional behavior occurs because reasonable, appropriate coping behaviors are not possible in the situation. The emotional behavior is appropriate in a sense that it is functional—it serves to highlight the absence of appropriate coping behaviors. This function is mediated partly by the eliciting of questions about the reasons for the behavior. Human emotions should be considered as important evolutionary developments in their own right. We should not look upon them as elaborate developments from basic reactions such as fear and rage. We should not look upon them as elaborations that have got in the way of the development of human reason, as people like Arthur Koestler seem to believe.13 They are not evolutionary residuals. There is no obvious reason why one should agree with Fell that "of all facets of human behavior, emotion seems least amenable to adequate treatment in terms of a theory of man according to which human conduct is categorically divorced from infrahuman behavior."'" We should regard emotions as inevitable consequences of the development of human reason. Because of man's remarkable cognitive development, he has created a very complex and plastic environment which demands complexity and plasticity in his behavior. Fortunately, and not unexpectedly, man's cognitive capacities are flexible in nature. "The genetically controlled plasticity of mental traits is, biologically speaking, the most typical and uniquely human characteristic."15 But these cognitive capacities alone are not enough. The emotions have developed to act as monitors, brakes, and, in the case of positive emotions, charges, as the human being works his way through his environment.

16 Anxiety and Depression The relationship between human emotions and actions is not a very direct one. It is not a direct one in the same way as is the relationship between hunger and eating. Indeed the human being, when emotional, is often advised not to act while in that state. It would seem that he is well advised, because negative emotions occur when the person's patterns of behavior in some way do not match the demands of the environment. The only actions that would seem justified at all would be examining one's patterns of activities and perhaps inviting others to help in such an examination. These suggestions about negative emotions assign to the person a far more passive role than he was given in the theory of emotion proposed by Jean-Paul Sartre'° Sartre noted that people usually do think of themselves as being passive when emotional and think of either an external or an internal event as being the cause of the emotion. But, suggested Sartre, if one applied purified reflection to the matter, one would see that a person is quite active in his emotional state. He is acting emotionally in order to deny a situation that he knows he cannot handle rationally. Now, however one reflects on the matter, it does seem that a person may be quite active in doing something about his emotions, trying to control and cope with them, but, insofar as he is emotional, it seems that he is more passive than active. With the occurrence of emotion, a person is rendered inoperative in relation to the immediate demands of the environment. It is only when some readjustment of his pattern of behavior has been effected that he can once more be operative and he can once more be rational rather than emotional. Sartre's theory suggests that emotional behavior occurs as an alternative to rational behavior. Sartre, as Fell notes, sees emotion as representing "one means of achieving an end, a means chosen when other means (instrumental-rational-voluntary) offer no prospect of success. If the will appears to struggle with emotion, this means only that the situation which provoked the emotion is no longer evaluated as too difficult to be dealt with by instrumental or rational means."17 The alternative proposal being presented in this book is that emotional behavior acts as a brake on the movement of a person until he has developed a more adequate, rational approach to the environment. Emotion has a fundamental role to play in relation

The Signalling Function of Emotion 17 to instrumental activity in the world and is not a magical substitute for this activity. Negative emotions occur when a mismatch exists between the demands of the environment and the person's repertoire of behavior. Inquiry will generally lead us to the conclusion that the person is anxious if there is an emphasis on an anticipated change in the environment. The inquiry will tend to lead us to the conclusion that the person is depressed if there is an emphasis on a change that has already occurred. Before embarking on an analysis of anxiety and depression, let us once more ask the fundamental question: How is man to regard emotion? He can look upon emotion, and the old brain that seems to play such an important part in its production, as getting in the way of the new brain and the rational processes it mediates. This, as we have already noted, seems to be the view of Arthur Koestler, who blames the old brain for the slowness in the evolution of man. Or man can look upon emotions as important events in his life contributing to his evolution, particularly his cultural evolution. The suggestions made about anxiety and depression in this book imply acceptance of the second alternative. Perhaps it is in the face of the enormous complexity and change produced by cultural evolution, with its new forms of inheritance, that some fundamental emotions which are the products of biological evolution have had to develop to their present complexity as manifested in anxiety and depression. I argued earlier in this essay that human emotions such as anxiety and depression are not simply further developments of basic emotions such as fear, which we share with animals. But the emotions do make us more primitive beings. Anxiety sensitizes us to the fearful aspects of things to which we had become adapted. Depression makes us more vulnerable to the melancholic aspects of things to which we had grown accustomed. Taking a related emotion, mania makes us overresponsive to the rewarding aspects of things which we had placed at one time in their proper perspective. Anxiety can be particularly tormenting at night; depression is a hard thing to have in winter; mania is dangerous in spring. Now beginning with anxiety, we must look at these human emotions more closely.

The Nature of Anxiety

2

In the last chapter I proposed that behavior which is labeled emotional tends to be unusual behavior. This unusualness, I would suggest, results from the fact that objects in the environment have now lost their usual valences—their usual attracting or repelling properties. In the case of negative emotions this change in the valances of environmental objects occurs when a change in the environment makes a demand which a person cannot meet with his present pattern of behavior, and this gives him the opportunity to examine and reconstruct his pattern of behaviors so that they are better suited to accommodate the change in the environment. This unusualness of behavior is probably the reason why negative emotions are unpleasant. In an attempt to reduce this unpleasantness the person may try to designate something in the environment as the object of, or reason for, his emotion. Thus emotions serve an important role in monitoring the adequacy of man's behaviors in meeting the demands of the environment, and it is for this reason that emotions persist in the human species. This proposal concerning the functions of negative emotions may help us to understand the function of anxiety. That anxiety, despite its maladaptive appearance, does serve some function is suggested by its persistence in the species. It may appear maladaptive immediately and yet be adaptive in the long run. Primary consideration will be given to the periodic anxiety which all of

20 Anxiety and Depression us experience, but some attention will be given to the chronic, pervasive anxiety and the phobias that an unfortunate few experience. Consider, first of all, what kind of behaviors are manifested when a person is anxious. As we noted in the first chapter, efforts to find particular behaviors associated with particular emotions are misplaced. As Kenny has observed,' there are no particular forms of behavior characteristic of an emotion in the way in which eating is characteristic of hunger. Determining what kind of negative emotion is being experienced by a person may have to depend partly on discovering what kind of emotion the person says he is experiencing, but it would depend also on the results of enquiries into the kind of situational changes that have occurred or are likely to occur. If we look at the behaviors associated with anxiety and depression and other negative emotions, we are likely to find considerable overlap, so in considering what kind of behavior a person engages in when anxious we should not expect to find specific behaviors solely associated with anxiety. But we can examine to what extent anxious behaviors, whether or not they are peculiar to anxiety, can be characterized as unusual, attentiongaining behaviors that elicit interrogation. To provide a starting point that did not rely solely on my own observation or recorded clinical observations, approximately five hundred undergraduate students at the University of Calgary were asked what behaviors people exhibited when they were anxious. The most frequent behaviors that were suggested were: worry, talk, fidget, pace, tremble, perspire, and run. The most frequent response of the undergraduates was "worry." This is not a very discrete piece of behavior and indeed some may argue that it is synonymous with anxiety itself. But if we think of what a person is doing when worrying, we get the picture of one lost in thought and showing little responsiveness to events occurring around him. The picture may also include some of the other behaviors suggested by the undergraduates, such as fidget and pace. These are all unusual behaviors. They are likely to elicit questioning from others such as "What is wrong?" "Why are you worrying?" "Why are you fidgeting?" "Why don't you keep still ?" Trembling and perspiring, given normal surrounding tempera-

The Nature of Anxiety 21 tures and the absence of fever, are also unusual behaviors. Running is not a behavior that one might have expected to be associated with anxiety. Those students who suggested running probably were equating anxiety with fear. In any case, running is not, unfortunately perhaps, a common behavior, at least among adults. The suggestion that talking is associated with anxiety was another surprising response. Certainly one cannot say that talking, except in places such as cinemas, churches, and lecture rooms, is unusual. Probably the students were referring to the readiness of the anxious person to talk with someone about his anxiety—the readiness to try to account for his anxiety. Asking students who were mostly in an arts and science faculty what behaviors they associated with anxiety probably excluded the possibility of getting much in the way of suggestions about the physiological concomitants of anxiety, though "perspire" was one such suggestion. Had we asked clinicians or medical students, the data might well have been different. The physiological concomitants are the manifestations that clinicians seem to stress most often in their writings—things such as tense muscles, palpitations, pallor, faintness, increased blood pressure, nausea, vomiting, diarrhea, frequency of urination, headaches. It may well be that the medical orientation of most clinicians, even those not medically trained, is partly responsible for the little progress that has been made in our coming to agreement on the nature of anxiety. Perhaps the layman's more commonsense observations will provide us with a better starting point. When we consider the everyday observation of the anxious person's behaviors, they have the common characteristic of being unusual. The behaviors that appear to be demanded by the situation are not evident. For instance, we try to engage the anxious person in conversation but "his mind is somewhere else." The anxious person has a magazine in his hands but flips to and fro between the pages and is obviously not reading. I suggest that these unusual behaviors, occurring when a person is in an emotional state, have replaced the expected usual behaviors and serve as a sign to the person and his observers that something is lacking in his repertoire of behaviors. Anxiety occurs when a man distrusts himself in a situation. Anxiety sees to it that we not only take a little bit of what we fancy, but also a little bit of

22 Anxiety and Depression what we can digest. The anxious person must do something to cope with his anxiety and to resolve the problem of the mismatch between his repertoire of behavior and the environmental demands. Perhaps too much attention has been paid by psychologists to the former strategy, coping with the anxiety itself, and too little to the second strategy, reducing the mismatch between available behaviors and those required to deal adequately with the environment. Some clinicians seem to be making a massive effort to help others get their emotions under control by the use of drugs, or by training them to engage in behaviors that are incompatible with emotional behavior. As we shall see, this may be necessary as a first step when we are dealing with clinical anxiety—when the anxiety is intense. But it may be better for the majority of people to train them in the use of emotions so that they can get their lives under better control. People would see that their emotions act as fine monitors of life. By their momentary intrusion as events which characteristically have the appearance of, and are experienced as, being unstructured and uncontrolled, emotions keep us informed of the adequacy of our behaviors as human beings. Too much stress has been placed on an approach to the symptoms of anxiety to the neglect of its functions. Perhaps this concentration on symptoms is related to the emphasis on the notion of the maintenance of moderate levels of excitation. The position that many psychologists have taken is that organisms are energy systems and that individuals must maintain their level of excitation within homeostatic limits in order to survive .2 The emphasis seems to be put in the wrong place in such a formulation. Rather, it seems to be the case that all living things, by their nature, are progressing to higher levels of complexity. At each level of increased complexity, the individual, for the protection as much of the species as of himself, must learn about new environmental circumstances and must learn new behaviors to handle these circumstances adequately. Before he does so, and until he does so at some adequate level, he will experience anxiety. When the learning has occurred it may be that his general level of arousal will be reduced, but this is a secondary effect and not the individual's primary aim. It is perhaps because high levels of arousal may often accompany anxiety that twentieth-century North American psychology, with its emphasis on the concept of drive,

The Nature of Anxiety 23 has concentrated far more on research into anxiety than on research into depression. As is well known, Janet Taylor, the wife of Kenneth W. Spence, one of the foremost American drive theorists, developed a questionnaire method of assessing the individual differences in drive levels that could be used in testing some of the postulates in her husband's theory. The questionnaire was quickly adopted, however, as a measure of individual differences in anxious dispositions and spawned enormous amounts of research into anxiety conceived as a level of high drive .3 Anxiety occurs when an anticipated event is expected to make demands for which the person is unprepared. The anxiety occurs, and, in order presumably that its signal value will not be lost, its effects are pervasive. The valences of environmental stimuli change and the person becomes uncertain about his ability to deal even with things that were familiar to him. Anxiety becomes a powerful warning signal to the individual and to the members of his group that he is ill-prepared for an impending event. The anxiety is not a noxious condition which results in a rejection of the future possibility, as the bad taste of food can result in rejection of the food. It is not a noxious condition which motivates a flight response in the same way that the fear of an electric shock may motivate such a response. This is one of the problems with attempts to understand anxiety by studying what is called the conditioned avoidance response—one of the psychologist's most popular laboratory analogues. In the simplest form of the experiment, a rat is placed in one side of a piece of apparatus that has two compartments—the apparatus is called a shuttle box. A buzzer is then sounded, followed shortly by an electric shock delivered through a grid that makes up the floor of the compartment in which the rat finds itself. The rat soon learns to run to the other compartment to escape the shock when it is turned on. Eventually it also learns that the buzzing sound, which always precedes the onset of shock, is a signal that shock is on its way. When this happens, the rat will run from the diabolical compartment as soon as it hears the buzzer—in other words it has now learned to avoid the shock:' Not all psychologists working with the conditioned avoidance response use it as an analogue of anxiety in human beings. Those who do assume that, because the buzzer

24 Anxiety and Depression has been paired with electric shock, it begins to elicit anxiety in the rat and the rat learns how to make its avoidance response (running to the safe compartment) because every time it does so the anxiety is lessened and the animal enjoys a blissful relief. Would that anxiety were such a simple matter. But the world is not a shuttle box in which a clearly defined avoidance response can be made. Our experimental rats are luckier than we are. But if anxiety were simply an unpleasant condition like the experience of a painful electric shock then one could never learn new skills. Anxiety is indeed unpleasant, but it is an unpleasant state which puts a brake on a person's behavior, without halting it completely. One of the ways in which the probability of disengagement is kept low is by the person's fixation on the troubling anticipated event. Not only is the anxious person not able simply to dismiss the anxiety-provoking possibility, but he can become obsessed with it. By this means, anxiety ensures that the person does not approach the new situation ill-prepared and that, at the same time, he cannot simply abandon the new possibilities for his development. One of the primary sources of anxiety appears to be the possibility for progress to a different level of being. This seems to be more important than the threat of non-being emphasized by Tillich and many of his predecessors.'' This is not to say that the threats of death, of meaninglessness, of moral condemnation (Tillich's three sources of anxiety) never occur as antecedents of anxiety. They may do so, but probably not so often as the threat of becoming. Even those states called states of non-being may be regarded by the person as another level of being, and as such provoke anxiety. His problem is not how to assimilate some mysterious state of non-being. His problem is whether he can cope with the new form of being which is dying, with the new form of being in a meaningless world, with the new form of being when condemned as guilty of wrongdoing. Acceptance of the idea that the primary source of anxiety is the threat of non-being leads one to Tillich's conclusion that anxiety is biologically useless. He writes: There can be no doubt that fear which is directed toward a definite object has the biological function of announcing threats

The Nature of Anxiety 25 of non-being and provoking measures of protection and resistance. But one must ask: Is the same true of anxiety? Our biological argument has used the term fear predominantly, the term anxiety only exceptionally. This was done intentionally. For, biologically speaking, anxiety is more destructive than protective. While fear can lead to measures that deal with the objects of fear, anxiety cannot do so because it has no objects. The fact, already referred to, that life tries to transform anxiety into fear shows that anxiety is biologically useless and cannot be explained in terms of life protection. It produces self-defying forms of behavior. Anxiety, therefore, by its very nature transcends the biological argument .6 What Tillich seems to be proposing, when he notes that anxiety transcends the biological argument, is that anxiety elicits the selfassertive courage to be, which, for instance in its quest for meaningfulness in life, may jeopardize the individual's biological life. It is hard to reconcile the fact of the persistence of anxiety in the human species with the notion that anxiety is biologically useless. Though one may find it necessary to give an account of some phenomenon in psychological terms, as has been done in the present essay, it should be an account consistent with biology rather than one that transcends biology. Tillich's basic mistaken assumption seems to be that self-assertion in the face of anxiety necessarily endangers the life of the individual. So it may, if the signal function of anxiety is ignored. Because the source of anxiety is more subtle than the source of fear, the task of finding the source of anxiety and taking measures to cope with it is more difficult though not impossible. Another mistaken assumption is that what is biologically useful for the species needs to be of immediate biological usefulness for all the members of the species. We must remain aware of the possibility that anxiety is adaptive from the point of view of the species but not necessarily from the point of view of the individual. This is a matter to be discussed a little later on. Here, perhaps, a general comment can be made about anxiety and the meaningfulness of life. Existential writers generally propose that anxiety occurs as a response to any threat to the meaningfulness of one's life as a person. And yet many people will report

26 Anxiety and Depression experiences of anxiety and behave anxiously without any of the sophistication required to entertain notions of the meaning of life. Is is not preferable to conceptualize anxiety simply as a response to a change for which a person is not sufficiently prepared? Even when we talk of change we should not think in terms of some profound change. The import or meaning of a change may vary from being quite small to quite great. A person who feels inadequate to the task may be quite anxious as he prunes a tree in his garden. The implications of what he does are greater for the life of the tree than for his life. Though a tree may have considerable sentimental value in some instances, it is not true that pruning anxiety will be elicited only in these instances. On the other hand, one of the main arguments of this book will be that anxiety can serve a useful function only to the extent that it is selectively responsive to situations. Perhaps one could say that, when the organism is functioning properly, the response of anxiety will occur only in anticipation of changes that have some importance—that are meaningful. Those psychologists who propose that anxiety is a strong, unpleasant, and diffuse state of arousal usually assume that it serves to motivate action in somewhat the same way that fear operates. The account I am proposing is quite different because it argues that anxiety serves to delay taking action until the situation is more adequately assessed. The unpleasantness of the condition may, it is true, result in actions of a sort: fetishes, superstitious behaviors, magic, compulsion, and delusions. But these are stopgap behaviors about which more will be written later in the book. Before embarking on further discussions of anxiety, we should note that it has been suggested that anxiety is a myth. One may well ask how so persistent and so common a phenomenon as anxiety could ever be thought a myth. Sarbin,7 who has attempted to explode the myth of anxiety, pointed out that he did not wish to deny occurrences. His argument, similar to Gilbert Ryle's, is with the use of the term "anxiety" to denote a mental state which can cause certain behaviors. Whether or not Sarbin's historicolinguistic account of how "anxiety" came to denote a mental state is correct, I am in agreement with a statement such as "Anxiety as a mental state is probably a myth" but not with a statement such as "Anxiety is a myth." Sarbin may be right in suggesting that it is

The Nature of Anxiety 27 fruitless to search for the essence of anxiety, if, when we use the term anxiety, we are referring to a mental state. But it is not fruitless to search for the essence of those complex behavioral and experimental occurrences in relation to which people use the term anxiety. As far as the ontological question goes, what are important in emotions such as anxiety and depression, are things that in a sense do not exist at all, except in the formulations of the person exhibiting the emotion or of those observing him. This is anxiety-provoking enough in itself, and probably explains why Sarbin has suggested that psychologists have tended to reify concepts such as anxiety. Anxiety may be regarded then as a monitor, forcing us to keep abreast of the new demands that will be made upon us by our environment and forcing us to develop the appropriate new patterns of behavior. The mechanisms subserving this function appear to be firmly built into the gene pool of human beings. As one might expect, some individuals are born with too great an amount of this genetic disposition and then we get states of persistent, chronic anxiety with episodes of panic. In these cases, anxiety no longer serves as a fine monitor of the learning process, and may, on the contrary, have considerable interfering effects on learning efficiency. Furthermore, the persisting uncertainty which the chronically anxious person has about his ability to cope with situations may result in abortive attempts to simplify the problem by the development of a phobia. I have referred to the conditioned avoidance response and noted that some psychologists considered it to be an experimental analogue of anxiety. Other psychologists prefer to consider it an analogue of phobias—the fears of specific things or situations such as heights, crowds, dogs, and snakes. According to this view, a particular situation such as height becomes fear-provoking because it has been associated in the past with a traumatic event such as a fall or near fall. Anxiety may develop on this basis through a process of generalization—the original fear of heights generalizes, for instance, to thoughts about high places. Such learning-theory accounts tend to ignore completely the possible role of inherited constitutional factors. One well known behaviorist—Hans Jurgen Eysenck—does introduce constitutional factors into his theory .8 He proposes that people differ constitutionally

28 Anxiety and Depression in relation to autonomic reactivity and introversive predispositions. But these are only considered as the necessary bases on which conditioned responses such as anxiety are formed. The argument goes as follows: The sympathetic division of the autonomic nervous system mobilizes the body during stress; some people have overreactive autonomic systems which respond too readily and too intensely; some people are more introverted than others; introverts are conditioned more easily than extraverts; if then a person inherits a too responsive autonomic system and also inherits introversive tendencies, he will readily learn stress or fear responses. According then to the learning theory of anxiety, a neutral event through association with an unpleasant event, often a painful one, becomes itself unpleasant and elicits anxiety, sometimes called conditioned fear. The further development of the theory to account for phobias by using conditioned avoidance responses as their experimental analogue, I have criticized in detail elsewhere .° The main point of my argument was that the welllearned avoidance response is a most adaptive one. There is no uncertainty in the familiar avoidance situation and therefore no anxiety. The animal in the psychologist's popular avoidance-learning situation simply has to learn that whenever it hears a tone or sees a light come on that it must do something if it is to avoid getting a shock. It may simply have to run to another compartment or jump over a barrier into another part of the apparatus or it may have to press a bar. As I noted in my original article, "Responses learned in the usual avoidance procedure are adaptive because they enable the animal simply to avoid a noxious stimulus. If this were true also of the consequences of phobic behaviors, they could not be considered maladaptive and would not come to the attention of clinicians. The phobias are maladaptive because they prevent the occurrence of behaviors desired by the individual (for example, the claustrophobic person cannot sit in a lecture theatre or a cinema) and/or desired by society (as in the case of a child with a school phobia)."10 Phobias may be better regarded not as being the result of the learning of some maladaptive avoidance response, but rather as

The Nature of Anxiety 29 the failure to learn coping behaviors when faced with anxietyprovoking situations. The conditioned avoidance response itself, as studied in the animal laboratory, seems to be a clear example of a coping response. Miller and Weiss noted "Thus we suggest that having a coping response makes avoidance animals less afraid because relaxation (or safety) becomes conditioned to the response and then becomes increasingly anticipatory. Perhaps some of the various hypotheses we have discussed may provide the primitive basis for what, at its cognitively more complex human level, we call hope."" As I noted in response to some of my critics, "to develop this coping response learned in the laboratory avoidance situation one has to be a rat, preferably hooded and not albino, and one has to be a lucky enough rat to be assigned to the right condition. Phobic patients appear to be far more helpless than hopeful."I suggested in the last chapter, that we should distinguish between fear and anxiety. The use of the term fear should be restricted to encompass specific reflexive behaviors in both animals and man. Anxiety should be used to encompass the more complex emotional behaviors of men. Bolles reviews the literature on avoidance learning in animals and strongly suggests that what are being investigated are species-specific defense reactions is Acceptance of Bolles' position, for which he argues well, leads us once again to doubt the relevance of such avoidance-learning experiments to the understanding of anxiety in human beings. The main postulate of the theory that anxiety is conditioned fear cannot be accepted because classically conditioned responses are too readily extinguished to account for persisting anxiety responses. In other words, you may in the laboratory get a person's heart rate to increase every time a buzzer is sounded simply by pairing the onset of a buzzer with the onset of an electric shock —this is classical conditioning of the heart rate. But if you stop presenting the shock the buzzer soon becomes neutral again, and there is no increase in heart rate when the buzzer is sounded— the conditioned heart-rate response is extinguished. That anxiety responses themselves may be conditioned cannot but be accepted. Indeed anxiety may be particularly susceptible to conditioning because of its role as a warning signal. But conditioned forms of

30 Anxiety and Depression anxiety probably account for a very small percentage of all anxiety responses. It is the unconditioned anxiety responses that make up the bulk and which must be accounted for in other than conditioning terms. The position being taken will be clear if we consider the relationship between anxiety and pain. I am suggesting that pain may be one of the conditions that will evoke anxiety in an individual and this anxiety response may be conditioned. This is not to say that anxiety is the conditioned response to pain. In the same way that the experience of pain is built into the organism—is an unconditioned response—so, it is suggested, anxiety is built into the organism. We do not have to learn how to respond with pain or with anxiety. We should consider the possibility that chronic, pervasive anxieties are almost completely due to inheritance, and that it is because of the constitutional factors themselves and not simply because they may serve as a basis for differences in learning that the world is perceived as so uncertain and therefore so threatening. Solyom's finding of a significantly greater incidence of psychiatric illness in the families of phobic patients than in the families of matched controls suggests that inheritance is involved. Also supportive of such a hypothesis is his finding that phobic patients show more neurotic symptomatology related to depression, anxiety, obsession, hysteria, and hypochondriasis than matched normal controls. As Solyom notes, "being clinically phobic entails not only a multiplicity of fears but a variety of neurotic symptoms —something learning theory cannot explain and which should be taken into consideration in the treatment of phobias."14 The processes that are involved in making the chronically anxious person see the world as an uncertain place are still quite unknown. I have proposed elsewhere that the chronically anxious individual with his overreactive autonomic nervous system always has to contend with the perception of the physiological effects of such an overreactive autonomic system as a constant accompaniment to his perception of any other internal or external events 11 I also suggested that these physiological events, such as an increased heart rate, dizziness, and irregular breathing, are not things which a person can get used to, and therefore they always

The Nature of Anxiety 31 evoke uncertainty in him. It may be worthwhile spending a little more time on this proposal in the hope that it will at least give us a lead to understanding the unpleasant nature of anxiety occurrences. In formulating my proposal, I made use, in modified form, of an information-processing model developed by Teichner" to account for the interaction of behavioral and physiological stress reactions. According to Teichner, sensory processes are involved with signals from the external world and the internal, biological world. Information derived from these signals is referred to a short-term memory (STM) and from there to an attentional mechanism where it is compared with information from the longterm memory (LTM). Short-term memory refers to a memory system which enables one to hold new information for a short period of time. After reading one of these sentences a reader could for a short period repeat it. But soon the memory would fade. Information that is stored in long-term memory is, as the name implies, more permanently stored. As a result of these comparisons of information from STM and LTM the organism may engage in some action on the environment or search for further information in the environment and in the long-term memory. Action takes place when some level of matching between STM and LTM has occurred. In other words, the information in STM is to some degree familiar. The search processes are initiated when the matching has not reached a desired level and a person experiences discomfort as long as this mismatch continues. Unfamiliar information from either the external or the internal world results in increased arousal of the organism—in a sense the organism becomes agitated. This increased arousal, according to Teichner, results in an increase in the amount of informationprocessing activity. When satisfactory matching of STM and LTM information does not occur, a further increase in level of arousal is produced. There is another important assumption made in Teichner's model. It is that when action is initiated a representation of that action along with the concurrent information from the external and the internal world are stored in LTM. This increases the probability and speed of satisfactory matching whenever the same

32 Anxiety and Depression information is presented again. Storage in LTM, with increased familiarity of information, can occur, however, under circumstances in which such action on the environment is not involved. When first presented, the proposal, using this model, was an attempt to account for the anxiety that occurs in the persistently anxious person. With little modification it can be used in an attempt to account for anxiety in all individuals. The proposal essentially is that because of the genetic make-up of the human being, input from both the external and the internal world may be accompanied by input from the autonomic nervous system. In the case of the persistently anxious person, this accompanying input from the autonomic nervous system occurs in all situations. In the case of normal people, it occurs only under certain circumstances. These inputs from the autonomic nervous system are not readily associated with some appropriate action on the part of the person, so that they do not result in representation in long-term memory. You may know what to do when a missile comes your way— duck. But what do you do when your heart suddenly begins to pound—perhaps for no apparent reason? Recently, some evidence has indicated that under special laboratory conditions an organism can learn to control autonomic nervous-system responses.17 The laboratory conditions involve keeping the organism informed of the level of autonomic functioning—the level, for instance, of the heart rate. This control could hardly be learned unless the animal or human being under these laboratory conditions was becoming familiar with the input from the autonomic nervous system so that, in these cases, one would have to assume that the input from the autonomic nervous system was being stored in long-term memory. But the findings are quite controversial, and in any case the point is that, under natural conditions, inputs from the autonomic nervous system are not readily associated with a particular action and therefore are not readily stored in long-term memory. One could just as well say, of course, that because information from the autonomic nervous system cannot be satisfactorily matched with representations that are stored in long-term memory, action on the part of the organism cannot be initiated. Both types of situations probably occur, and both result in the organisms engaging in perseverative information-processing acti-

The Nature of Anxiety 33 vity which is continually increasing because of the relationship of such activity to the arousal mechanism. The proposal then is that the unpleasantness of anxiety occurrences lies in the persisting novelty of input from the autonomic nervous system. It is not being proposed that we can investigate anxiety simply by measuring some autonomic nervous system output such as heart rate. What is important is the person's level of awareness of this activity and the extent to which he can account for its occurrence. There is some experimental evidence that, in stress situations, a person's awareness of the activity of the autonomic nervous system rather than the actual levels of this activity is correlated with the degree of his disturbance." The more disturbed a person is, the more he overestimates the activity. It may seem that, in proposing that the persisting novelty of input from the autonomic nervous system is the prime contributor to the aversiveness of anxiety occurrences, one is reverting back to the James-Lange theory of emotion which emphasized peripheral, behavioral, and physiological events. The tag that gets over the essence of the James-Lange theory is: "I do not run because I am afraid—I am afraid because I run." But it is not being proposed that a person feels anxious because of the perception of one set of peripheral physiological events and feels depressed because of his perception of another set of peripheral events. All that is being suggested is that these peripheral physiological events are regular accompaniments of what we describe as emotional occurrences and we should consider the particular role they may play in relation to the unpleasantness of the occurrences. The complete account of the processes involved is obviously going to be a more complicated matter than any peripheralist theory would suggest. In any case, it may be worth noting, in passing, that Fehr and Stern's examination of the James-Lange theory of emotion demonstrates that, contrary to what is usually assumed, central processes were not ruled out in the James-Lange formulations'° To recapitulate, the person, when faced with a situation that demands action, will compare the information he is receiving with representations in his long-term memory. Only when satisfactory matching occurs will he feel ready to act. During this period of matching, there is increased activity of the autonomic

34 Anxiety and Depression nervous system. It is the input from the autonomic nervous system which produces the aversiveness of the experience which we call anxiety. In some people with a low threshold for activation of the autonomic nervous system, information input from all situations is accompanied by input from the autonomic nervous system, and so all situations are responded to with uncertainty and anxiety. Although all situations may appear uncertain and unpleasant to the constitutionally anxious person, those that are "objectively" uncertain may be expected to be particularly unpleasant. These are situations such as one in which a decision has to be made or in which one is waiting for an event to occur. That it is the unfamiliarity of events or situations that is so hard for anxious people to tolerate is suggested by their need to increase the familiarity of their surroundings. They do this by restricting their interpersonal contacts to well-known people and their movements to wellknown places. The refusal of the anxious patient to go to open social events or have in his house anyone but the most familiar of people constitutes one of the most difficult burdens for the spouse of the patient. The mother's hand or the tattered blanket provides one comforting, familiar object in a strange world for the anxious child. I suggested in the first chapter that negative emotions act as brakes and positive emotions as charges as a person works his way through his environment. There are times when an emotion such as love seems to have both negative and positive aspects—to act as a brake and as a charge. The love a person displays may look as though it is assisting him to venture into new territory. So Ford Maddox Ford wrote in The Good Soldier: As I see it, at least, with regard to man, a love affair, a love for any definite woman, is something in the nature of a widening experience. With each new woman that a man is attracted to there appears to come a broadening of the outlook, or, if you like, an acquiring of new territory. A turn of the eyebrow, a tone of the voice, a queer characteristic gesture—all of these things, and it is these things that cause to arise the passion of Iove—all these things are like so many objects on the horizon of the landscape that tempt a man to walk beyond the horizon, to explore. He

The Nature of Anxiety 35 wants to get, as it were, behind those eyebrows with the peculiar turn; as if he desired to see the world with the eyes that they overshadow. He wants to hear that voice applying itself to every possible proposition, to every possible topic; he wants to see those characteristic gestures against every possible backgound.2" But here is often another aspect. The lover seems uncertain about himself, about his own capacity to meet this new world. Ford continues a little later, the real fierceness of desire, the real heat of a passion long continued and withering up the soul of a man is the craving for identity with the woman that he loves. He desires to see with the same eyes, to touch with the same sense of touch, to hear with the same ears, to lose his identity, to be enveloped, to be supported. For, whatever may be said of the relation of the sexes, there is no man who loves a woman that does not desire to come to her for the renewal of his courage, for the cutting asunder of his difficulties and that will be the mainspring of his desire for her. We are all so afraid, we are all so alone, we all so need from the outside the assurance of our own worthiness to exist 21 This love may seem more like anxiety than love. Be that as it may, anxiety can also appear to act at the same time as both a charge and a brake. We noted earlier that anxiety may give us pause when we are on the threshold of a situation we are illequipped to handle. But it will also enable the situation to compel our attention. The anxiety-provoking situation may even fascinate us as the person who inspires our love may fascinate us. Whatever the mechanisms involved in producing anxiety and whatever the processes responsible for the unpleasantness of anxiety, it would seem worthwhile to give more attention to its possible genetic basis. Constitutional factors should be given time at least equal to that which is given to the investigation of environmental factors in the production of anxiety. There are no grounds for ruling out of court altogether learning approaches to anxiety. It may also very well be that those who suffer from chronic anxiety are qualitatively different from normal people, because repeated exposures to stress situations result in the kinds

36 Anxiety and Depression of reverse physiological effects that Selye and others have proposed.22 But I think one cannot ignore completely the question of the possible evolutionary significance of anxiety. if one attempts to answer this question, then the genetic contribution cannot be neglected. The question also necessitates close attention to the problem of the continuity or discontinuity of normal and pathological anxiety. Concern about the evolutionary significance of anxiety does not excuse us, on the other hand, from doing what we can to understand the underlying mechanisms of the phenomenon as it exists today. We must then get down to brass tacks and return to the problem of the nature of phobias. I suggested earlier that it is because of the anxious person's uncertainty, his feeling of insecurity as he faces the future with his available repertoire of behaviors, that he may try to pinpoint the cause of his trouble—that is, find an object of his anxiety. This, of course, was proposed by the psychoanalysts when they suggested that phobias developed as a result of an attempt to concretize a more general anxiety situation. Before the psychoanalysts, Spinoza noted that "An affect which is a passion, ceases to be a passion as soon as we form a clear and distinct idea of it." To say that phobias develop when the anxious person looks for an object of his anxiety may be an offensive formulation for some readers because it implies behaviors in the service of intentions. Until the problem of intentionality is solved by the new teleologists of Oxford University, it is better, therefore, to say that the phobic object serves the function of reducing the anxiety by its introduction of some structure into the situation. The implication is that the mismatch between environmental demands and the person's capabilities is unpleasant and that the provision of a phobic object provides an opportunity for the matching of environmental demands and behaviors—I can avoid elevators, dogs, crowds, and such things. This is an alternative hypothesis to one which suggests that through simple association an innocuous event takes on the unpleasant properties of the person's emotional state, that has itself been produced by some trauma. One is left with the question as to why some people suffering from pervasive anxiety develop phobias and others do not. Perhaps we should consider the possibility that when phobias develop there is another genetic aspect that predisposes the person to

The Nature of Anxiety 37 develop the phobia. For instance, some individuals for genetic reasons, may be programmed to react with fear to heights. If they are also, for genetic reasons, victims of chronic anxiety, they may become further sensitized to heights. Such a person may then begin to attribute his anxiety generally to the problems he has with heights. The hypothesis of an innate predisposition to fear things such as snakes has acquired plausibility from the observation that they may occur in chimpanzees from the time of their birth.24 On the other hand, not all people who say they are phobic about something seem to suffer from pervasive anxiety. But simple monophobias are very rare in the clinical situation. A very common clinical phobia, agoraphobia, is hardly distinguishable from pervasive anxiety. Both agoraphobics and those who have social phobias appear to differ from those who have specific phobias, such as phobias for animals, in that the former show pervasive anxiety. Langer" and Laderi" found that socially phobic people showed more spontaneous changes in their skin conductance during rest than did subjects who had phobias for small animals such as snakes and spiders. These small momentary increases in palmar perspiration which occur without any observable change in the environment have also been associated with pervasive anxiety. Perhaps the kind of phobias that are often investigated in populations of university undergraduates—such as phobias for snakes —can be seen as developing without a basis of pervasive anxiety. On the other hand, there is no good evidence that they develop, as many behaviorists seem to think, as the result of some conditioning through the pairing of innocuous with noxious events. It is equally likely that the person who is essentially normal was sensitized, during one period of particularly strong anxiety, to a particular object, such as a snake, and that this fear continues primarily because the person has little opportunity to become desensitized to the snake. The particular phobia developed during the crucial sensitization period may be a result of the person's particular genetic predisposition. The removal of such simple phobias seems to be quite easy with a variety of methods that have been developed by behaviorists and, in all probability, they have very little bearing indeed on the periodic anxieties that the normal person feels, on the pervasive anxiety of the chronically anxious person and on phobias that the chronically anxious person may

38 Anxiety and Depression

develop. It may be for this reason that behaviorists have been able to report little in the way of success with chronic anxiety states and clinical phobias despite their success with non-clinical phobias.' Some psychologists have questioned the usefulness of studying fears of snakes." But snakes and other small animals are not without a spokesman." In the first chapter, I suggested that we regard fears as reflexes and that fear and anxiety should be seen as independent, though related, phenomena with neither one derivative from the other. It may be necessary to maintain the distinction between fear and anxiety when considering the nature of phobias. Keeping this distinction in mind, the following kinds of phobias may exist. First, there appear to be in both animals and men a number of innate fears that either increase or decrease from birth, primarily as a result of maturation factors. These are fears of intense stimuli or novelty, and of potentially dangerous situations such as the dark, heights, and predators. The phobias we see in some cases may simply be innate fears that have not diminished with age in the normal manner. Solyom found that the following childhood fears were more frequently experienced by phobic patients than by matched normal controls: school phobias, nightmares, darkness, strangers, imaginary creatures, being alone, bodily harm.i° A second kind of phobia may develop when a person, during a transitory period of anxiety, is sensitized to a natural fear stimulus. Both Solyom31 and Marks and Gelder32 found that agoraphobia first appeared in late adolescence or later, and Marks noted that agoraphobia often develops after stresses such as bereavement, marital separation, accidents, or severe physical illness as A third kind of phobia is one that occurs in the generally anxious person. It may very well be based on a natural fear but now serves the function of structuring the person's experience and reducing its unpleasantness. One natural fear that would not serve the purpose of structuring experience is the fear of novelty. It may even be suggested that the anxiety of the generally anxious person is in actuality the persistence of the early innate fear of novelty. But there is a difference between the innate fear of novelty and the anxiety which it has been suggested is a response to uncertainty. The fear of novelty in children is only elicited by objectively novel events—strangers, for

The Nature of Anxiety 39 instance. In the case of general anxiety, familiar events are responded to as though novel. One may come back with the argument that events are responded to as though novel simply because, in the generally anxious person, habituation has not occurred. But the proposal that has been made in this book is not that anxiety is a response to the perceived novelty of events. Events are anxietyprovoking only to the extent that some action is demanded or is likely to be demanded of the person. We can listen quite happily to very novel musical compositions as long as we are not required to conduct the orchestra. The anxiety response that is being proposed is common to all men and does not habituate out. In the severely anxious person it is a matter of a basically adaptive process having lost its differential sensitivity. This is not to reject the idea that habituation mechanisms are impaired in generally anxious persons. Some evidence suggests that it is. In any case, insofar as an important component of situations that evoke anxiety is the demand for action, the kind of habituation mechanisms involved are likely to be more complex than those investigated by simply measuring a psychophysiological response to the repeated presentation of a tone—which is the manner in which it is usually investigated. The development of a phobic condition, however it comes about in the chronically anxious person, is not the only way in which the situation may become more structured. The anxious person, perhaps again through a process of sensitization, responds with greater than usual anger to some insult; and, because he has a set of behaviors that he can bring to bear in relation to his feelings of anger, continue to perceive his condition as one of anger rather than anxiety. A person when anxious, again through a process of sensitization, may be particularly susceptible to some physical illness, and because there are a set of procedures he can follow in relation to physical illness, such as attending physicians and taking medication, he continues to perceive his condition not as one of anxiety, but as one of ill health—he becomes, in other words, hypochondriacal. This is not to deny that sometimes the physiological, particularly endocrinological, concomitants of anxiety will produce real physical damage to the body. There are also other reasons why a person may emphasize the physical aspects of his disturbance apart from the need to provide himself with an excuse

40 Anxiety and Depression for engaging in a set of familiar behaviors. The relative status of physical versus psychological ill health for instance. But this is not a matter which has direct bearing on the issues of this book. People described simply as mad may be developing, through the same kind of mechanism, the more varied and esoteric structures to alleviate their general anxiety. Michelangelo, when he was seventy-four, wrote to a friend "You will say that I am old and mad, but I answer that there is no better way of keeping sane and free from anxiety than being mad."" The findings of MakhloufNorris, in studies of the personal construct systems of obsessive compulsive and anxious patients, led to the conclusion "that in neurotic patients the need for self-certainty is such that they construe the self in a way which predicts undesirable outcomes which are certain to be validated, rather than predict desirable outcomes which would be open to invalidation."ss Hysterics may, paradoxically, cultivate some peculiar and, in one sense, unusual behaviors in an attempt to provide structure to their lives. This reference to the hysteric may remind us of our reference in the first chapter to the woman who cries often and about whom we may be inclined to say that she is not really emotional. What seems to happen is that the hysterical person adopts some particular set of unusual behaviors. Their perceived value lies partly in the fact that, though generally unusual, they become familiar to the person and therefore provide some structure to his experience. Initially, the choice may also be made because of the attentiongaining value of the behaviors. Eventually, of course, as observers realize that the behaviors are expected of the person, they lose their attention-demanding properties, and indeed may result in people, including professional mental health workers, ignoring the tiresome, pseudo-emotional person. This need to structure one's experiences to alleviate anxiety appears to be the basis also for the development of myths and rituals. It is something anthropologists have suggested for some time ae The development of such rituals seems to be something that has been and is prevalent in more primitive societies. One of the characteristic things about anxiety in civilized societies is that socially accepted rituals are not associated with it. In the case of anger, we have some ritualization in boxing, and some might say even in war, though the antecedents of war are a more complicated matter

The Nature of Anxiety 41 than that. In the case of depression, crying has been ritualized into elaborate mourning rituals for at least one form of depression; that occurring after the death of someone. One must assume that in the case of anxiety, the rituals have not been useful—they have not alleviated the anxiety sufficiently to be perpetuated as a practice. One may want to consider the development of smoking behavior and pill-taking as ritualistic in part. If they are rituals, they too seem to be unsatisfactory ways of dealing with anxiety. Becker has written, "Modern man is not as wise as some of the primitive tribes who had special rituals during which the whole tribe was given license to defy the gods and the most sacred beliefs... . Modern man is not so fortunate and has to contrive his defiances in petty, lonely, and ingenious ways: and so in order to understand his efforts, we need to invent a psychiatric category instead of a ritual-religious one."37 In the same manner that one may try to avoid depression by protesting his helplessness and the meaninglessness of the world —a matter to be discussed more fully in the next chapter—so one may try to deny the inevitable uncertainty in his world and the inevitability of the anxiety this uncertainty evokes. Friedman notes how, in Tillich's system, "Pathological anxiety produces an unrealistic security as a defense against fate and death, an unrealistic perfection as a defense against guilt, and an unrealistic certitude as a defense against doubt and meaninglessness.'" All of these defenses may be called "whistling in the dark" defenses. Rather than attempting to develop rituals which may alleviate his anxiety, what appears to be required of man is a recognition that the emotion of anxiety occurs as an important warning signal that there is a mismatch between a person's behavior and some imminent change in the environment and that the warning must be heeded by that person and by the members of his society. The notion of anxiety as a signal is one that Freud developed. The notion has been extended a little here. For Freud, anxiety was a signal that some repressed urges, usually of a sexual nature, were coming to the fore. It may be useful now to see anxiety more broadly as a warning about the mismatch between environmental events and the person's pattern of behaviors. One of the situations provoking anxiety might very well be one in which an imminent

42 Anxiety and Depression

environmental change with sexual overtones cannot be met with an appropriate set of behaviors because of the lack of the usual maturational and experiential processes. This extension of the notion of anxiety as a warning signal is not based on a conception of anxiety as a purely individual matter. When considering the anxiety of an individual or a group of individuals, one should look both at the pattern of the lives and behaviors that they have developed and at the nature of the changes that are anticipated in their environment. It may very well be that, in some instances, one would see the fault lying not so much in the pattern of behaviors that the individual has developed as in the nature of the anticipated change in the environment or the speed with which that change is being introduced. In this way anxiety may be acting as a monitor, not only for the individual as he develops as a biological organism, but for society as it develops as a social organism. To suggest this is not to propose that we go back to some extreme environmentalist position. It does not entail adoption of the position that if we could put our society right people would no longer suffer from things such as anxiety. Perhaps if we could stop the development of society and the development of individuals in some way, anxiety would no longer occur. But, of course, that is not something that can be done short of blowing the world to pieces. As long as there is movement either of an individual or of a society, anxiety is inevitable. On the other hand, simply to try to set the individual straight by the use of drugs or behavior-modification procedures, without treating him in relation to the demands society is making on him, is short-sighted. The position that anxiety is as natural for man as, say, barking is for a dog, and that it is one of man's primary functions, serving as a monitor of his relationships with the demands of the environment, may appear to be a pessimistic one. On the other hand, if this is indeed the function of anxiety, then it is probably as well for us to get used to the idea and live with it. But the very acceptance of anxiety and other negative emotions as natural for man would probably reduce some of their unpleasantness. As Victor Frankl has noted: "Man is ready and willing to shoulder any suffering as soon and as long as he can see a meaning in it."3Ø Anxiety, when its function is understood by a person, may be as

The Nature of Anxiety 43 reassuring to him as the sound of a car's engine. It is a sign of progress or the possibility of progress. We may need to muffle the anxiety. But if we eliminate it altogether, progress will be doubtful. Because I have written about anxiety in the normal person and anxiety in the persistently anxious person—because I have not used the term neurotic anxiety—you may wonder if the person described as persistently anxious is neurotic or if the term neurosis is to be reserved for another class of people. Let us deal with this problem by considering how others have distinguished between normal anxiety and neurotic anxiety. Behaviorists, particularly of the Eysenckian variety, seem to regard neurotic anxiety as being simply an intense amount of anxiety or the result of the conditioning of anxiety responses to unusual situations—ones that do not elicit anxiety in normal people. If it is a matter simply of severity, of what use is the term neurotic? If the neurotically anxious person has been conditioned to fear unusual situations, what are these situations and, more important, in what way does this justify the use of the term neurotic even when used in a purely technical and non-derogatory sense? Psychodynamic theorists appear to favor the notion that neurotic anxiety is a result of a person's inability to face normal anxiety. Now one might, without falling into an infinite regress, entertain the possibility that the normal experience of anxiety, when one has not learned how to respond adaptively to it, will itself be one of the occurrences evoking anxiety. But why call this second-order anxiety neurotic anxiety? In any case, how do we separate the first-order (normal) anxiety from the second-order (neurotic) anxiety in a person's response to any situation? Rollo May has suggested that "The more nearly normal an experience of anxiety is, the more the occasion (precipitating event) and the cause of the anxiety are identical; the more neurotic the anxiety, the more the occasion and the cause are to be distinguished."40 This sounds like the distinction between fears with their specific objects and objectless anxiety. But it is not this distinction to which May is referring. In both normal and neurotic anxiety, there may be an identifiable object (occasion). In the case of normal anxiety, however, the occasion is really the cause of the emotion. In the case of neurotic anxiety the occasion is not

Ø Anxiety and Depression the real cause. Writing of one of his cases, May notes, "the particular event or experience which activated the conflict might be objectively a verifiably minor event, had its subjective significance in the fact that it served to cue off the conflict, and receded in objective importance, as the conflict became activated?' But is there any evidence which would justify such a distinction? Is it not the case that in both mild and severe anxieties the cause may be obscure, and each individual may try to pinpoint the cause of his anxiety on some object or occasion. The difference between the two individuals is simply a matter of the intensity' and frequency of anxiety responses. In instances of both mild and severe anxiety, the expectation with which a person comes into a situation will contribute always to the mismatch between the environment and the person's representations in long-term memory. It is often the representations in long-term memory themselves that produce the faulty expectation. I may remember only the pleasant things about someone. I go to meet him expecting friendliness. He is in a bad mood and is not receptive to me. The mismatch between the long-term representations of a friendly individual and the dour reality facing me evokes anxiety. In many instances, it will be the saliency of two conflicting sets of representations in long-term memory that will be the primary problem. If my friend tends to be unreliable, friendly one time and rejecting another, I may feel anxious as I prepare to meet him because I have two long-term representations which do not match. But this does not mean that we must agree with the assumption of psychodynamic theorists that the person with severe anxiety attacks always has a greater store of conflicting representations. Recognition that conflict may be important in some instances of anxiety does not mean that we must agree with May that "the problem of understanding neurotic anxiety boils down to the question of understanding inner psychological patterns which underlie the individual's excessive vulnerability to threat."42 There is another point which Rollo May has made about the prevalence of anxiety in the twentieth century. He has suggested that it is due to the fact that the values of our society are in doubt. He wrote, "when the presuppositions, the unconscious assumptions of values in a society are generally accepted, the individual can meet threats on the basis of these presuppositions.... But

The Nature of Anxiety 45 when the presuppositions in a society are themselves threatened, the individual has no basis on which to orient himself when he is confronted with a specific threat."43 Now the absence of values might be expected to increase the frequency of anxiety in some cases because such an absence means that one source of possible matching long-term representations is missing. On the other hand, values well represented in long-term memory may be responsible for an increased frequency of anxiety if they do not match the demands of the situation as perceived by the person. A man faced with the possibility of the termination of his marriage may have a readily available solution if it has been well instilled into him that divorce is a wrong thing. The solution can only be to stick with the marriage. Under these circumstances, there may indeed be less likelihood of anxiety than if the man did not have such a firm imperative to fall back on. But it may very well work the other way. A man who feels the necessity, for whatever reason, to terminate his marriage may very well be much more anxious if he is the bearer of such an imperative, simply because there is now a mismatch between what his values tell him he ought to do and what he nevertheless is about to do. Under these circumstances, the person with no strong values relating to divorce will be more likely to be free from anxiety. One cannot, therefore, in any general way attribute an increase in anxiety in a society to the absence of values. Perhaps we should abandon the term neurotic for the time being and concentrate on attempting to unravel the function of anxiety, mild or severe, in our lives. It has been proposed that anxiety is a response to the mismatch between the demands of the environment and the behaviors available in a person's repertoire. The nature of the mismatch between our behavior and the demands of the situation will often be a complex one, demanding in turn considerable skill in determining what exactly the mismatch amounts to. The detection routines themselves may alleviate some of the anxiety by giving some structure to the situation, and be far more useful than the development of ritualistic behavior, such as offering sacrifices to gods or consuming tranquilizing drugs. But the kind of treatment implications of what has been proposed about anxiety is something better left until the final chapter. At this point, we can consider the nature of depression.

The Nature of Depression

Can we begin to understand depression, despite its apparent maladaptiveness, in terms of its long-term adaptive function? In trying to understand the adaptive function of the occasional depressions that we all have, we may not only find ways of more adequately dealing with these periodic depressions but also find more useful procedures to alleviate those more or less pervasive depressions which, like pervasive anxiety, seem to be the result of some fault at a genetic level. One of the most characteristic things about the depressed person is his loss of interest in environmental events. As in anxiety, environmental events lose their differential value. Whereas in anxiety everything in the environment becomes mistily uncertain, for the depressed person everything in the environment becomes uninteresting. With milder depressions, we may lose our "pleasures of appreciation" as C. S. Lewis' calls them—pleasures in things like flowers, music, good wine, pleasure in the happy spirit of places. With the more severe depressions we may lose what Lewis calls our "need pleasures"—pleasures in things like food and sex. The change in the world, the change from an interesting world to an uninteresting one, may be so great that our perception is distorted even to the point where the world seems unreal. William James has described this condition in The Varieties of Religious Experience:

48 Anxiety and Depression The world now looks remote, strange, sinister, uncanny. Its color is gone, its breath is cold, there is no speculation in the eyes it glares with. "It is as if I lived in another century," said another, "things are not as they were, and I am changed."—"I see," said a third, "I touch, but the things do not come near me, a thick veil alters the hue and look of everything."—"persons move like shadows, and sounds seem to come from a distant world."—"there is no longer any past for me; people appear so strange; it is as if I could not see any reality, as if I were in a theatre; as if people were actors, and everything were scenery; I can no longer find myself; I walk, but why? Everything floats before my eyes, but leave no impression."—"I weep false tears, I have unreal hands: the things I see are not real things."2 Sean O'Casey describes a similar experience after his mother died: Although he hurried about, getting three pounds advance from the agent on his mother's five pound life insurance, registering her death, seeking a coffin, he scarcely seemed to move. Under the magenta sky, through the shimmering golden haze, everything seemed to come towards him, passing by ere he could see the shapes plain, or mind comment on what he saw, as they flowed by him under the magenta sky, through the quivering golden haze.... Throughout the golden haze he saw neither bird nor beast; yes, a butterfly; just one, a tiny white one, lost, knowing not whether to come or go, seeking, maybe, a sad sip of nectar from flowers decking the top of a coffin. Out of the enveloping haze a girl's hands wrapped up for him in tissue paper, tying it with black tape, a snowy shroud and soft pillow; the finest shift his mother had ever worn, the softest pillow her head had ever touched; while dimly he realized that a pound of his had gone into the sunny hilarity around him. Then the hand of another girl, in some faintly sketched-in shop, gave him half a dozen crimson gladioluses, that they might shine a torch of defiance beside the grey head of the brave, dead woman .3 When one is depressed it seems that the guts have gone out of life. In what way does the depressed person behave?

The Nature of Depression 49 When the undergraduate university students referred to in the last chapter were surveyed about the behaviors they associated with depression, they gave one or other of the three behaviors—cry, sulk, and withdraw. The depressed person no longer engages with the environment as we have come to expect him to do, or as we expect people in general to do. The behavior is unusual and readily elicits the questions: "Why are you crying?" "Why are you sulking?" "Why will you not join us?" Depression, like anxiety, puts a temporary brake on behavior because of a mismatch between environmental changes and one's repertoire of behaviors. But now it is not because of a mismatch between the behaviors and some anticipated event but because of the mismatch between the behaviors and the environment that has already been altered because of a change that has already occurred. Although it is often assumed that the environmental changes that may result in depression always involve the loss of something, that need not necessarily be so. A person may get a new job or may get married, for instance, but has not rearranged his pattern of behaviors to accommodate this change. This is as likely to produce depression as a loss of a job or a spouse. In one sense it is true that all gain involves a loss of something—a new job involves the loss of old colleagues; a spouse involves the loss of some freedom. But the disruptive effects of the change may not always be centered in these losses but in the gains. Paykel reports an investigation of life events experienced by 185 depressed patients in six months immediately prior to the onset of depressive symptoms. The same information was obtained from 185 controls from the general population matched for age, sex, marital status, social class, and race. Thirty-three life events were examined and for eight of them the differences were significant. In other words, these eight events occurred to a significantly greater extent among the depressed patients. Three events clearly involve loss—marital separation, death of an immediate family member, departure of a family member from home. In the other five events, the loss was not so obvious—increase in arguments with spouse, start of new type of work, serious illness of a family member, serious personal illness, change in work conditions. In a different approach to his data, Paykel does find some more clear-cut evidence in favor of the hypothesis that loss is an antecedent of depression. Two groups of events were selected from his

50 Anxiety and Depression list of thirty-three. One group he called entrances and they were events that involved the introduction of a new person into the social field. Specifically the events were engagement to be married, marriage, birth of a child, a new person in the home. The other group was called exits, and they were the events that involved departure from the social field—death of close family member, separation, divorce, a family member leaving home, marriage of a child, a son drafted for military service. Exits were reported by forty-six depressives and only nine controls. Entrances were reported equally by both groups. Paykel cautions us not to give his findings too much weight. He wrote: The findings for the exit-entrance [category] ... were important because they were distinctions that did discriminate contrasting events that behaved differently and hinted at some kind of specificity. Nevertheless, the range of events reported to excess by the depressives in the Yale University study was quite diverse. It would be hard to include all these events under a single formulation unless it were a very general one. Certainly, the events cannot all be regarded as separation or even included in the rather more general label of losses. It seems to be more helpful to acknowledge their diversity and to conclude that a variety of different kinds of events which are in some way noxious but do not include all events may converge on depression as a final common pathway:1 Paykel also makes a very important observation in relation to base rates for the population. He found that life events of an exit nature were found in 46 out of 185 depressives (25 percent) and in 9 out of 185 controls (5 percent). Paykel refers these figures to the general population and writes: Accurate figures for the occurrence of clinical depression in the general population are not available.... I shall use a generous estimate of 2 percent for the incidence of new cases in the 6 months for which data were collected. Among 10,000 subjects in the general population, there will be 9,800 non-depressives and 200 new depressives. Call the non-depressives "normals," although they include some old cases of depression. In 5 per-

The Nature of Depression 51 cent of the normals—that is, 490—an exit from the social field will have occurred. In 25 percent of the depressives—that is, 50, an exit will have occurred. The total number of subjects who experienced exits will be 490 + 50, or 540. Only 50 of these (9 percent) will become depressed. Less than 10 percent of the subjects who experience exits become clinically depressed; the large majority do not do so. The greater part of the variance in determining depression must be attributed to something else.' On the assumption that loss—particularly of a mother—is a critical antecedent of depression, scientists are currently investigating the behavior of animals which have been isolated. The work is exciting but one must watch for the dangers of anthropomorphism. Matching animal and human behavior—one of the more simple pleasures of zoos—and sometimes the basis of hilarious writings--can be misleading and is always open to debate—a little more open than the scientist would prefer. Some of this animal work, reviewed in the recent volume on Separation and Depression, may be more relevant to the understanding of anxiety than to the understanding of depression. This is the case with what has been called the isolation syndrome and the kennel dog syndrome, which has been described in the following way: Briefly put, if a puppy is placed in an isolation chamber from three until sixteen weeks of age, the time when it would normally be developing strong attachments both to places and to animate objects, it will, upon removal, show every evidence of profound emotional shock. Various sorts of bizarre behavior develop, many of which can be interpreted as attempts to escape from the entire outside world.. .. When it is offered an opportunity for companionship, such an animal tends to play by itself. These symptoms comprise the isolation syndrome. If, on the other hand, a puppy is reared in a kennel environment much beyond the age of four months (even though it has much canine and some human companionship), it will frequently show permanent shyness, timidity, and lack of confidence if it is taken from the kennel and removed to a home to be made into a pet?

52 Anxiety and Depression It can be argued that what is manifested in these animals is the lack of confidence in facing the challenges of the environment which is particularly characteristic of the anxious person. The experience of loss is one of the cornerstones of the psychoanalytic theory of depression .8 According to Freud, the loss, for instance, of a loved person may result in normal mourning or abnormal depression. The primary difference between the two conditions is the self-depreciation of the depressed person. The mourner sees the world as impoverished, whereas the depressed person looks upon himself as being impoverished. What happens in normal grief is that the bereaved person stops his preoccupations with memories of the lost person or thing and becomes involved in someone or something else. In the case of depression, things are more complicated. In the first place the person prone to depression because of an immature psychosexual development has an ambivalent attitude to the object now lost. Secondly, instead of simply forgetting the loss and turning his attention to other things, he identifies with the lost object. Now instead of an ambivalent love-hate relationship with some thing or some person outside, he has a love-hate relationship with himself. The depressive is not able simply to forget his loss because his relationship to the object, being partly hostile, was not fully in awareness. The implication is that since the relationship was to some degree unconscious it is not, now the object is lost, sufficiently under the bereaved person's control to be simply transferred elsewhere. According to Freud, the love and hate components of the ambivalent attitude become separated from one another and it is because the self-hate is no longer muted with self-love that the depressed person is in such a miserable state. One can see why psychotherapists who accept Freud's formulation try to get the depressed person to express his hostility outwards. In most variations of the psychoanalytic theme, the love component seems to be directed outwards after this separation, so that things and persons loved by the depressive tend to be idealized. Perhaps the most attractive feature of the psychoanalytic theory is its attempt to account for the loss of self-esteem in depressed patients. If indeed such a loss of self-esteem is an essential component of depression, then one cannot ever expect animal research to tell the whole story. One can be sympathetic with the failure

The Nature of Depression 53 to study self-evaluations on the part of the animal researcher. We shall see, however, that behaviorists working with human beings have neglected this component in their theories and in their research. Indeed, one behaviorist, Seligman, argues that the depressed person is free of self-blame since he perceives the world as under sources of control outside himself. The greatest faults with psychoanalytic theory are its abstruseness and the related fact that it is untested in any systematic way, and generally untestable. Two studies conducted by Laxer° suggest that low self-esteem may be an important component of clinical depression. In his first study he found that on admission to hospital depressed patients had a poorer view of themselves than did other psychiatric patients. In the second study he found that patients with a low mood had a poor view of themselves only if they blamed themselves for their failures. Laxer concludes that "low mood is not synonymous with the syndrome of depression and is not by itself to be taken as a prototype in normals for depression in psychiatric patients. A necessary additional factor it seems is aggression against the self as psychoanalytic theory suggests."10 What Laxer seems, on first glance, to have demonstrated is that though both depressed and nondepressed psychiatric patients may have low moods, only depressed patients have a low self-esteem. It may be, however, that low self-esteem was one of the signs used in diagnosing the depressed patients as depressed, so that one has simply come full circle. Another problem is that Laxer did not get his patients to evaluate things and people other than themselves. In one of my own studies with Andrew Comrey, it was found that people with depressive tendencies have a dim view of everything.11 The psychoanalytic proposition that in depression there is intense hostility turned inward against oneself does seem intuitively correct, but there is no good evidence to support it. Behaviorists do pay little attention to the differences between normal mood fluctuations and clinical depression—a criticism which cannot be leveled at the psychoanalysts. But the psychoanalytic attempt to account for clinical depression appears to be too complex by far. It will be suggested later that some clinical depression may be due to unfortunate inheritance.

54 Anxiety and Depression The notion of loss is central to the behaviorists' most popular account of depression. Their hypothesis is that a person loses some important positive reinforcers or an important source of positive reinforcement, and as a result the behaviors that were previously reinforced now extinguish. This hypothesis, on the face of it, makes a great deal of sense and is beautifully simple. Certainly, one clearly observable characteristic of depressed people is the absence of much in the way of behavior—or responses, as the behaviorists prefer to call the components of behavior. Although there is still room for argument about what is going on on the other side of the skin, there seems to be no doubt that responses that are followed by positive reinforcement (reward— but behaviorists do not like this term, it appears to have moral implications!) tend to be repeated and if they are not followed by positive reinforcement they tend to disappear—technically, they extinguish. Ergo, either the depressed person has lost someone who used to maintain his behavior by reinforcing these responses—someone who had been a source of reinforcement— perhaps a depressed man's wife has left him—or what used to be a source of reinforcement has stopped reinforcing—the wife is still around, but does not pay much attention to the poor man. Ferster appears to have been the first person to propose this hypothesis in any detail. He wrote that one of the ways "in which behavior may be radically weakened is by a sudden change in the environment, such as the death of a close companion. Under such certain conditions, such a sudden change may virtually denude an individual of his repertoire. The secluded elderly spinster lady, for example, may lose her entire repertoire on the death of her close companion, because each person's behavior was narrowly under the control of the other. The close interpersonal control in the case of the secluded ladies is an extreme case, but the same process may operate in a wide range of circumstances and in varying degrees."12 Though it is true that an important characteristic of the depressed person is his inactivity, the emphasis should be on the loss of his incentive to do anything. If we take the usual behaviorist's position, then we may assume that all that we need to do to remove a person's depression is to provide reinforcement for his behaviors again. But if we emphasize the general loss of incentive,

The Nature of Depression 55 then, of course, one would not expect to find much, if anything, that could act as a reinforcer for the person. The things one would expect to reinforce him have lost their effectiveness. We shall see later that, in some cases of depression, this may be because neural reward mechanisms in the brain are impaired. In Lawrence's Women in Love, Gerald Crich, after his father died, felt that "he would have to find reinforcements, otherwise he would collapse inwards upon the great dark void which circled at the centre of his soul." But he seemed unable to do so and life after his father's death continued to be "a hollow shell all around him roaring and clattering like the sound of the sea."a Life after his father's death was like Anna Karenina's life when she left her husband for her lover, Vronsky. The loss of structure in their lives resulted in the loss of incentive for• life. This is the main proposition to be developed in this chapter. But, before elaborating on it, I must emphasize the difference between the present position and the position of other behaviorists in the importance attributed to incentive. In doing this I shall discuss the work of Peter M. Lewinsohn because his is the most thorough program of research conducted within a behaviorist framework. Lewinsohn does acknowledge that we are not all in agreement about what things are reinforcing. It is one of the premises of folk wisdom that what delights one may not delight another. Incentive is then implied in Lewinsohn's theory. One man may have an incentive for mountain climbing, another for sitting by the fire with a book. But granted that this is so, Lewinsohn would argue that what we need to do is to determine what activities a person has an incentive for and then see how many of these activities he actually engages in. The more the merrier— or, more precisely, the more of his preferred activities a person engages in, the less depressed he will be. There is no suggestion in Lewinsohn's theory that the incentives for activities may themselves change. The distinction becomes clearer when one examines one of Lewinsohn's major research strategies—one which I have adopted with modifications for my research. The assumption from which this research starts is that daily variations in mood are similar to variations in depression—a somewhat risky assumption, as we noted before. Be that as it may, the research entails obtaining

56 Anxiety and Depression from the volunteers for the experiment daily recording of mood and activities. At the end of each day, for a period of about twenty-eight days, each person records his mood and indicates on a checklist of activities those activities in which he engaged during the day. It is in the way the checklist of activities is used that the difference between my approach and that of Lewinsohn is highlighted. We both begin with a list of 320 activities, each of which could be considered pleasant for someone or other. The activities range from "going naked" to "looking at the stars or moon"! Lewinsohn, who originally made up the list, calls it the Pleasant Events Schedule. Before the daily recording of mood and activity begins, Lewinsohn asks his volunteers to rate each activity on a 5-point scale of pleasantness (1=extremely unpleasant; 2= not pleasant; 3 =somewhat pleasant; 4= very pleasant; 5 =extremely pleasant). He then selects for each individual the 160 activities that are judged the most pleasant. It is this list of 160 activities that is used by the individual during the twenty-eight days of recording. My procedure differs in that all of the 320 activities are used throughout the experiment, and, more importantly, pleasantness ratings of the activities are obtained each day. The volunteers in Lewinsohn's experiments at the end of each day read through their individually tailored list of 160 activities and place a check mark beside the ones in which they engaged. In my experiments, the volunteers read through the complete list of 320 activities, check those in which they engaged during the day and on the 5-point pleasantness scale indicate how much pleasure they got from each activity engaged in during that day. This procedural difference is particularly important in relation to what is called the weighted activity score. As well as simply getting the sum total of activities at the end of each day—the raw activity score—one calculates the weighted activity score. This is the sum total of the activities, each one weighted by its pleasantness rating. What this amounts to is summing the pleasantness ratings associated with the activities checked for each day. Now the difference can be seen. Lewinsohn uses for each individual the pleasantness ratings obtained from that individual at the beginning of the experiment. He assumes that the pleasantness of an activity for a person remains constant over time. If you like sex,

The Nature of Depression 57 you like sex. I work on the assumption that people are far more fickle than that and that the pleasure we obtain from an activity may change from day to day. The incentive a person has for an activity may be as variable as his mood. Indeed, as will be argued in more detail, the two may co-vary—that is, shifts in incentive are associated with shifts in mood. Once again, an important difference between Lewinsohn's emphasis and mine can be seen. Lewinsohn's emphasis is on the rate of reinforcement. He would predict that even when pleasure ratings remained relatively low, moods would improve with an increase in the number of activities engaged in. My emphasis is on the strength of reinforcement. The prediction would be that even when the number of activities engaged in remains low, moods would improve with an increase in the pleasantness of these activities. At the present level of investigation—the study of the association between daily mood fluctuations and daily activities— experimental support has been found for both positions by both investigators! In one of his studies Lewinsohn compared old people with depressed people. He found that both groups engaged in fewer activities than did young nondepressed people, which is in line with his hypothesis. But he also found that, though the old people, when compared with the young, did not report less pleasure in the few activities in which they engaged, the reports of the depressed people did indicate that they obtained less pleasure in their activities than did nondepressed people, which is in line with my emphasis on incentive.'4 In one of our investigations, also, depressed people were found to engage in fewer activities and get less pleasure from them than did nondepressed people. Daily mood shifts were associated with both the number of activities and pleasantness ratings. In other words, people feel better on days in which they do more things and when they enjoy them more'' These studies are not likely to throw many people into paroxysms of excitement. They can be considered only as preliminary maneuvers in a search of experiential evidence to replace or buttress some of the many speculations about depression that have developed over time. Some time has been spent on them to reassure those who prefer the art of the soluble to the seductive

58 Anxiety and Depression art of theorizing that we are getting out of the armchair some of the time! Time was spent on them also to help make more explicit how incentives for activities may be related to depression. Before moving back into the more speculative aspects of the proposal and the more indirect evidence in the proposal's support, another difference between Lewinsohn's and my present position should be noted. Lewinsohn gives particularly strong etiological significance to the loss of reinforcers. This, for him, is the critical antecedent of depression. The loss of incentive which is being emphasized in this book is not given such clear etiological significance. Indeed, I have no wish at this point to argue that loss of incentive is the antecedent to depression. It may very well be the other way around—depression is the antecedent of a loss of incentive. What evidence there is suggests that it may work both ways—since we have found that morning moods are associated with the enjoyment of the day's activities—the better the mood the more we enjoy ourselves. But evening mood is also associated with our daily pleasure—the more we enjoy ourselves during the day, the happier we are come nightfall. The loss of incentive, rather than being considered an etiological factor, should be regarded, at this point, as the particularly important characteristic of depressed people. The etiological process is likely to be a more complicated matter. I am proposing that it involves the loss of structure in a person's life. Now we can go back to the main thesis of this chapter. The loss of structure in a person's life results in a loss of incentive for life and in depression. I shall argue later that, whereas in the case of anxiety things will once again take on a more benign appearance if the appropriate coping skills are developed to deal with the anticipated threat, in the case of depression, things will become interesting again if some restitutive action is taken to restore the structure in one's life. But what is the structure in life? Assuming that the essential characteristic of depression is a loss of incentive for life, in what way does a loss of structure in life lead to a loss of incentive for life? Would that sound evidence could be presented to help in answering these questions. Some evidence of a very indirect

The Nature of Depression 59 nature will be reviewed later. But all that can be done now is to try to make clear what it is that is being proposed about life, incentives, and depression. A person conducts his life in a number of situations, interacting with different people, guided by different rules. There may even be some very fundamental differences in a person's goals from situation to situation. A man may work at the office to make money and work on improving his home to please his wife. Or he may work at the office to please his boss and work on his house to protect his financial investment. If the multiple dimensions which can be used to describe an individual's life are not strikingly obvious to the most casual observer of men, a quick glance at any of the writings of social psychologists will quickly atomize the picture. The value of such analytic dissection of human behavior is not disputed. But, it is here being proposed that a person's life, from his own point of view, constitutes a whole. Though each aspect of that life can be analyzed separately, they are not lived separately. All the aspects of life from the more significant, a man's interactions with his wife, to the less significant, brushing his teeth, are interrelated. It is probable that the manner in which all the aspects of one life are interrelated can itself be dissected into a number of different dimensions. Our efficiency from one arena of life to another, the stress we experience in each one, in these and other ways perhaps the interrelatedness of a man's activities could be analyzed. But the one way that is important for the understanding of depression concerns the incentive to engage in activities—the reinforcing or rewarding nature of the various aspects of a man's life. My proposal then is that there is a mutual interdependence in a man's activities such that his incentive for one activity is dependent upon the opportunity to engage in the other activities that have become part of his life, and it is also dependent upon the reinforcement (reward) he experiences in these other activities. It is this interrelatedness of a person's activities that makes up the structure of his life. A loss of structure occurs when he does not engage, and perhaps is no longer able to, in one or more of these activities. There is little doubt that should this be found the correct way, or a useful way, of viewing human behavior, it will

60 Anxiety and Depression also be found that the matter is more complex than has here been stated. It is unlikely, for instance, that all activities are equipotential. It is far more likely that a person's activities can be arranged in a hierarchy such that behaviors lower in the hierarchy are far more dependent, in the manner proposed, on those higher in the hierarchy than vice versa. But without going into such complexities, if one for the moment simply accepts the basic proposition that such an interrelatedness between the activities of a person exist, then one can begin to understand the function of depression. Depression is an emotion in the interest of conservatism. Its function is to protect the level of complexity which has been reached by one's life. It protects against the fragmentation of life. If our lives have reached the complexity that is involved in the marriage state then it is not easily that we can go back to the lighthearted affairs of youth. Anxiety should also be seen as an emotion in the interest of conservatism insofar as it may force us to withdraw temporarily from embarking on new developments in our lives for which we are ill-prepared. But, as we have seen, this withdrawal does not come easily. The anxious person, even if only in his thoughts, becomes fixated on the new anxietyprovoking possibilities. Anxiety, more than depression, seems to be an emotion in the interests of growth, in that a person is forced to develop the necessary skills that are required if he is to feel comfortable as he embarks on the new situation in his life. Both anxiety and depression are necessary components of the mechanisms required for survival in the novel environments a human being must face through his own creations or the creations of others. It seems that just because it is the modifiability of behavior that has been important in the evolution of man, the basic monitoring mechanisms of anxiety and depression, with their restricted modifiability, have also evolved. It is when you have a variable climate that you are most in need of a reliable barometer. The mutual interdependence of behaviors without which depression, as environmentally produced, would not exist and in the interest of which depression occurs, may appear as a complexity but not a plasticity of behavior. lf, as some geneticists claim, the plasticity of behavior is the most typical and unique of human characteristics, it would lead one to wonder about the plausibility of the present proposal concerning the mutual inter-

The Nature of Depression 61 dependence of behaviors and the adaptive significance of depression. But this mutual interdependence, by maintaining the variability of behavior, does produce a plasticity. It not only prevents the fragmentation of behavior but also prevents any one behavior's becoming too dominant even when, as with eating in the obese person or research in the dedicated scientist, its strength is considerable. Forgetting basic activities such as sleep, one is still not going to find anyone whose sole preoccupation is the eating of food or the pursuit of truth. The gourmet and the scientist will always be found to have developed other interests. These interests are never overwhelmed by the predominant interest because the incentive for the latter is to some degree dependent upon engaging with satisfaction in the other activities. It is interesting to note that the process of depression itself may often involve the dominance of a response—the response of obsessive rumination—the painful perseverence, for instance, of guilty thoughts or the sad reminiscences of the lonely widow. It seems that the process of depression, which serves in part to protect a person from becoming dominated by one interest, often itself results in the dominance of a response. This is not the kind of paradox that is likely to go down well with a reader. The puzzle remains to be solved. We can note that this kind of thing also takes place at a physical level. The orthopedic surgeon must make a broken leg temporarily quite stiff to protect it against a permanent stiffness. A distant analogy, but it may help! In any case, all the strong emotions, such as anxiety and depression, seem to have one other thing in common, and that is that they may result in the fixation on some particular aspect of one's life. The depressed person may become preoccupied with the change in his life whether or not this involves a loss. The anxious person may become fixated on what it is he feels is causing his anxiety, though sometimes, as we have seen, this may be a spurious object of anxiety. The person unhappily in love may become preoccupied with the love object, and everything else in which he took interest now no longer interests him. This fixation seems to serve the function of holding the person in a situation despite its unpleasantness until something has been done about it. We should not assume that the depressed person is in a passive state simply because at an overt level he shows little in the way of

62 Anxiety and Depression behavior. At the covert level he may be engaged in a considerable amount of activity, though it may be perseverative and repetitious. It may very well be that here, also, we have the condition which is mainly responsible for the lack of interest in the environment. If a person is preoccupied with one particular thing, then there simply will be a reduced awareness of the environment. It is the change produced by the environment—the hunger relieved by food, the changes in color, the things people say to us—that is reinforcing. If we are not aware of these changes because of our preoccupations, then it would follow that we will find little that is reinforcing in the world. Often it seems it is the self, despite its uncertain conceptual status, with which we become preoccupied. Perception of the disintegration of ourselves may elicit anxiety as we become uncertain of our ability to meet present and future demands. Should behaviors be mutually interdependent, one could not protect oneself from the onset of depression by simply keeping as many options as possible open—by taking care not to put all one's eggs in one basket, as Arnold Lazarus has suggested."` We would too often find that the loss of eggs in one basket made the eggs in the remaining baskets less palatable. The human being is generally not able to keep the various arenas of his life independent of one another. Shand, some time ago, commented "Sorrow, whether caused by loss or destruction of an object of love, or by separation from it, or merely by the mood or temper, tends to destroy the belief in the intrinsic value of all other things previously valued:f 7 Stendahl noted that when your lover deserts you "If you try to find happiness in emotions of a different kind, your heart refuses to react to them. Your imagination shows you clearly the physical aspect of the position, placing you on a swift hunter in Devonshire Woods. But you are quite aware that it would give you no pleasure."8 Commenting on mood in general, Ryle wrote "Moods .. . monopolize ... somewhat as this morning's weather in a given locality made the same sort of difference to every section of that neighborhood, so a person's mood during a given period, colors all or most of his actions and reactions during that period. His work and his play, his talk and his grimaces, his appetite and his

The Nature of Depression 63 daydreams, all reflect his touchiness, his joviality or his depression. Any one of them may serve as a barometer for all the others."19 As music can change the space of a room to receive a dancer, as love can change the softness of the country to receive a lover, so can depression change the world, so that all that is left for one to do is cry. Our moods are by no means epiphenomena. It is our moods that can enhance, disrupt, or change completely our behaviors, even the best-learned ones. This is not to say that people do not differ in the degree to which their behaviors are interrelated. One may even agree with Becker that "the depressed person suffers ... from a too uncritical participation in a limited range of monopolizing interpersonal experiences. Consequently, when a crisis occurs, he becomes a victim of the narrowness of his performance world as validation for his identity. Accordingly, he falls prey to the poverty in alternative vocabularies of meaning."20 One may expect some kind of generalization gradient so that if one were to cultivate a variety of interpersonal relationships and to engage in a variety of arenas of life, the more distant ones from the crisis center would be less affected by the disturbance in emotion. One may even acknowledge the ability of some people to compartmentalize their lives. But the pervasiveness of the effects of emotions like anxiety and depression appears to be the more common phenomenon. These emotions give an effective tone to the world in the way other emotions, such as anger, do not. The way in which we can talk about depression, but not about anger, may be related to this characteristic. I can say "I feel depressed about life" and "Life is depressing." I can say "I am angry at him," but I cannot complete a sentence "He is ..." which would indicate something about the affective tone of the person. We may be able to say our tormentor is annoying, but not that he is angering. Love seems to be like depression and unlike anger in that it leads to a transformation of the world and particularly of the loved person. Stendahl in his book on love called this transformation process crystallization, "The continual acts of folly which make a lover see every perfection in the woman he is beginning to love.."'1 He also gives advice on what one can do to prevent the crystallization from occurring! Unfortunately, the way we talk about fear and anxiety does not

64 Anxiety and Depression fit in very neatly with this kind of analysis. One might have thought that fear would be like anger and that one could not transfer the emotion term to the object, but we do talk about something being frightening. Anxiety should behave like depression. But, though we can talk about things being depressing, we do not have a similar term for anxiety. Nevertheless, though examination of common language usage does not convincingly support the position, emotions such as anxiety and depression strike us as being pervasive in their effects and in being so are attention-gaining. Perhaps the more important the emotion, the more the emotion, to use Ryle's phrase, monopolizes situations so that behaviors in all situations are altered. Though these emotional behaviors are attention-gaining, the fact that behaviors in all situations may be altered by the person's depression, anxiety, or love often makes it difficult to determine what the situations or factors are that are responsible for the emotion. To digress a moment, it may be thought a simple matter to find the important factor in cases of love—cherchez la femme. But as was suggested earlier, la femme, like a phobic object, is often the scapegoat of our love state rather than the cause of it. Indeed, should la femme decide to respond and take on the status of an antecedent to our love, she may lose her status such as it is as the scapegoat of our love. This seems to be what happens to Mr. Lockwood in Wuthering Heights. He tells us: While enjoying a month of fine weather at the seacoast, I was thrown into the company of a most fascinating creature: a real goddess in my eyes, as long as she took no notice of me. I "never told my love" vocally; still, if looks had language, the merest idiot might have guessed I was over head and ears: she understood me at last and looked a return—the sweetest of all imaginable looks. And what did I do? I confess it with shame—shrunk icily into myself, like a snail; at every glance retired colder and farther; till finally the poor innocent was led to doubt her own senses, and overwhelmed with confusion at her supposed mis2 take, persuaded her mama to decamp.2 Some emotions, then, appear to be quite devastating in that their effects are so pervasive. Depression is one of these. Why is

The Nature of Depression 65 the human being plagued by such an emotion? Depression is the price we pay for the strong need to belong, to have roots, to have a sense of continuity in our lives, to have lives that are in some ways structured and meaningful. We can, perhaps, ignore these needs, but then we become alienated. If we remain aware of these needs and build a structured life to satisfy them, then we are vulnerable to the depression which will occur because of changes brought about through our own action or the vicissitudes of life —changes produced by events such as the death of others, our becoming redundant in our job, or the onset of disease. Perhaps it is because of this close connection between the meaningfulness of life and depression that the scholastics considered a melancholy disposition as preparing a man for the influx of divine grace. It could be that they had it the wrong way around. It seems rather that the man who is particularly inclined to create a meaningful world around him, one motivated by spiritual concerns as well as material concerns, is a person who can be expected to become, on occasion, melancholic. If it is true that some of the world's greatest achievers have been of a melancholic disposition, it is not that this disposition is a necessary antecedent to great achievements, but that it is an inevitable consequence of a life style required for such achievements. I said earlier that no attempt will be made to try to develop a theory of anxiety and depression that would suggest the processes underlying the phenomena. The emphasis is on the function that anxiety and depression appear to serve. But I have suggested elsewhere the way in which a general loss of interest in the depressed person may occur, and it may be useful for me to restate here the main observation I made in that paper?-" Psychologists have always emphasized the transmission of attractiveness from consequent to antecedent events. For instance, if somebody is in the habit of saying complimentary, reinforcing things to me, I begin to like being in that person's presence, even when he is not making complimentary remarks. As the compliments (the consequent events) were attractive, he (the antecedent event) has now become attractive. If a restaurant always serves me good reinforcing food (the consequent event), I may similarly become well disposed to the waiters (antecedent events) who bring me the food. But our everyday observations will show us

66 Anxiety and Depression that the attractiveness can eventually be transmitted in the other direction. My liking for the flatterer makes his compliments even more rewarding. My pleasure, as I greet my favorite waiter, makes the food even more palatable. In other words, the antecedent events and the consequent events (reinforcements) become mutually interdependent. The antecedent events put me in the right mood for the reinforcers. I would tentatively propose that it is in this way that environmental events, a person's behaviors, and his reinforcers become mutually interdependent. A pattern of behavior develops on the intactness of which the reinforcers depend for their effectiveness. With disruption of the pattern, we are no longer in the mood to enjoy things. This interdependency of man's behaviors may be one of the most important characteristics distinguishing him from animals. In the case of animals, it seems that withdrawal of one reinforcer will facilitate states associated with other reinforcers. So, for instance, an animal in the vicinity of food without the availability of food may show increased sex behavior 24 The behavior of depressed people suggests that in the case of man, the withdrawal of one reinforcer inhibits states associated with other reinforcers. There is no strong experimental evidence that how much we like something—how reinforcing it is—depends on what comes before it. Rats eat more as they become more familiar with the eating situation, but this could very well be because they are now less fearful of the situation. Psychologists have shown that both animals and human beings prefer to have control over the administration of electric shocks to their bodies than to have delivery of the shocks under the experimenter's control.' When the animal or human subject of the experiment has control over the shock, it appears to reduce its painfulness. Here we have evidence that antecedent events—whether or not one is in control—are important in relation to the impact of a noxious event—electric shock. It would seem worthwhile to try to demonstrate a similar process in relation to pleasant events. That something similar does occur with pleasant events is indicated by studies demonstrating that both animals and human beings prefer earned food rather than free food =" Give a rat a choice of pressing a bar for food or simply eating food that is made readily available and it will press the bar. A possible explanation for this finding is that the task performed to earn the food is rewarding

The Nature of Depression 67 in its own right (it may acquire this rewarding effect because of previous associations with food) and that it follows that an organism would prefer a rewarding task plus rewarding food to the rewarding food alone. But the alternative explanation that the food is simply more rewarding if preceded regularly by some task performance than if given freely is no less plausible. Perhaps it should be noted in passing that I do not feel that this evidence should be brought to bear against the welfare state! I noted above that it is generally assumed that attractiveness is transmitted from consequent to antecedent events. This assumption seems to rest on the fact that what is usually being discussed is the transmission of attractiveness from an unconditioned event or reinforcer to a to-be-conditioned event or discriminative event. So, if one always receives good food (unconditioned stimulus or reinforcer) in a restaurant (to-be-conditioned stimulus or discriminative stimulus) one may assume that the attractiveness of the food will be transmitted to the restaurant and not vice versa. Since backward conditioning cannot usually be obtained, eating good food before you go into the restaurant will not make the restaurant more attractive, we conclude that attractiveness is always transmitted from consequent to antecedent stimuli. When Charles C. Perkins writes that "There is considerable evidence that attractiveness is always transmitted to antecedent stimuli and never in a reverse direction," it can be seen from the supporting evidence he presents that he is clearly referring to the transmission of attractiveness from rein forcers to antecedent stimuli. When he discusses attractiveness in more general terms, he writes that there is evidence "that the attractiveness of a component stimulus depends on the context in which it occurs." He gives, as the most obvious example of this that "food is highly attractive under conditions of food deprivation, but in the absence of deprivation stimuli, food which cannot be hoarded will ordinarily be no more attractive than its absence."" Perkins goes on to suggest that not only may deprivation stimuli make food more attractive, but the occurrence of a salivation response to an antecedent stimulus will also make subsequent food more attractive. He calls this a differential reinforcement or preparatory response (PR) interpretation of classical conditioning. Perkins does not restrict his preparatory response hypothesis to classical conditioning and his experimental evidence comes from other kinds of

68 Anxiety and Depression learning situations. Perkins' general proposition is that the occurrence of another stimulus before an unconditioned stimulus or reinforcer will make it possible for the organism to make conditioned preparatory responses which increase the attractiveness of the stimulus situation at the time of occurrence of the reinforcing event. The main body of evidence he presents in support of this proposition began with an experiment by L. B. Wyckoff.'-" Wyckoff demonstrated the acquisition of a response which was reinforced only by a signal indicating whether or not a reinforcement (food) for pecking a key would occur later. He called these responses "observing responses." The pigeons in his experiment were trained to peck a translucent key in order to obtain grain. The pigeons were then presented with a choice. They could stand by and wait until the key was illuminated with a white light. Then they would peck. The peck was not always rewarded with grain—it was rewarded only half the time. The pigeon, instead of simply standing by, also had the choice of standing on a pedal. If it did this then the key was not illuminated by a white light. It was illuminated by either a red or green light. If it had been prearranged that the key peck on a particular occasion would be rewarded with grain, the key was illuminated red. If it was not going to be rewarded, the key was illuminated green. Wyckoff found that his pigeons soon learned to step on the pedal presumably so that they would know what was coming up. Wyckoff did not, in the design of his experiment, rule out the possibility that the pigeons learned the observing responses so that they could be more economical in their key pecking. In other words, if the key was illuminated red, the pigeon, knowing that this meant reward, would peck, whereas if it were illuminated green, it could save itself the trouble of pecking, knowing that it would not be rewarded. But this type of explanation has been ruled out in a series of experiments by Steiner.i0 This is not the place to go into the details of Steiner's experiment, but the results strongly suggest the possibility that an organism will make an observing response in the Wyckoff type of situation because it can prepare itself for the reinforcement when it is coming up. In this way the value of the reinforcement is enhanced. Another way of viewing what has been described is to think in terms of expectancies rather than in terms of attractiveness. Bolles

The Nature of Depression 69 has argued that experimental evidence on learning indicates that what is learned in the laboratory situation is that certain events, cues, predict other biologically important events, consequences 3t What I am proposing is that in the laboratory and in everyday life animals and human beings will also develop the expectancy that biologically important events are preceded by certain events. In the same manner that an organism may be disappointed if an expected consequence does not follow a certain cue, he may be disappointed if what has come to be perceived as a consequence is not preceded by a certain cue. After a day's work, a man's heart may grow light as he approaches his home because the sight of his home elicits the pleasant expectancy of good food and rest. If he should find himself later in life in an old folks' home, the sight of the home, though as reliable a cue for equally good food and rest, will not elicit the same pleasurable anticipation. Experimental demonstration of the processes involved in depression are not likely to be easy. One of the reasons for this is that the kinds of positive events over which an experimenter is able to, and can ethically, control in the laboratory are not particularly powerful events. The things that become rewarding in a person's life become uniquely rewarding. How can one manipulate in the laboratory rewards that have anything like the significance of one's spouse in a happy marriage, or a job that one is suited for? The second reason is that the kinds of preparatory controlling responses that one can associate with reinforcers in the laboratory are probably going to be quite simple responses isolated from the rest of the person's behavior. But one of the main characteristics of the human being that I have wanted to emphasize has been that a person's behaviors become closely related to form a pattern of life. It is when one of these behaviors in the pattern is no longer required that other behaviors become weakened and perhaps drop out altogether, even though the usual reinforcers that previously maintained them are still present. Ferster, who, as we noted previously, was the first person to emphasize the relationship between positive reinforcement and depression, has recently made a comment in an article on depression that, at first glance, is similar to the hypothesis I have proposed emphasizing the interrelatedness of behaviors. But closer examination reveals an important difference. Ferster wrote,

70 Anxiety and Depression A reduced frequency of some activities in a depressed person's repertoire may even lessen the effectiveness of reinforcers closely connected to physiological processes, such as eating or sex. Because these activities in their complete function also involve a complex collateral social repertoire, their reduced frequency does not necessarily mean that sex or eating is no longer reinforcing. Thus, if there is a depression of social activity, the by-product could be a reduced frequency of eating and sex. The depressed person's commonly reported lack of interest in hobbies and sports and lack of concern for emotional attachment could be an example of a lack of collateral social behavior, analogous to the connection between the physiological and social components of sex and eating. Playing bridge, for example, not only requires bidding, playing a hand, and scoring, but also arranging that four people meet, dealing with the interpersonal effects of winning and losing, and conversing before and after play and between hands. Emotional attachments, whatever their quality of affect, are expressed by substantial amounts of activity either reinforced or influenced in some way by the other person. Even fantasies surrounding an emotional attachment requires a substantial amount of "silent" if not overt talking. Thus, almost any significant activity occurs for multiple sources, and a depression may represent a weakening of one or more of these sources of behavior a2 Although Ferster begins by noting that a reduced frequency of some activities may lessen the effectiveness of reinforcers closely connected to physiological processes, such as eating or sex, he immediately goes on to say that the reduced frequency does not necessarily mean that sex or eating is no longer reinforcing. The rest of the discussion in the quotation above indicates that Ferster is concerned, here, primarily with chains of behavior. If eating, playing bridge, engaging in sex also necessitate the collateral behavior of a social nature, then, simply because the depressed person is not prepared to engage in these social behaviors, he will not engage in the sexual, eating, and bridge-playing behaviors. Ferster does not seem to be postulating the interrelatedness of behaviors which I have emphasized—an interrelatedness such that the reduction of some among a pattern of behaviors results in the

The Nature of Depression 71 loss of reinforcer effectiveness of other behaviors in the pattern. As we have already reluctantly observed, there is little in the way of direct evidence for the present proposal. We must make do with indirect evidence to which we can now come. There are a number of observations in the epidemiology of depression that we can perhaps understand better if we think of depression as occurring when a pattern of life has been disrupted. First, depressions occurring after the age of thirty seem to be more persistent than those occurring before the age of thirty» In general, older patients tend more towards depression and younger patients more towards anxiety?' The more developed one's pattern of life, the more serious one might expect the depression that would result from some break in the pattern, and the more difficult would restitutive action then be. As Becker noted "When one gets down to the last twenty years of a life-drama it becomes more and more difficult to justify abrupt changes in continuity: there is too much preceding plot for it to be re-manipulated with ease." Second, where a stable community has been established in which personal responsibility is emphasized, an increased incidence of depression has been observed. One might expect people in a stable community to have developed strong life patterns?' Third, depression has often been reported to occur more often in the middle and upper classes than in the lower classes,37 and one possible interpretation is that in the first two classes the expectation is developed that one is individually responsible for one's position in life—that things are under one's control. This third observation brings me to the learned-helplessness hypothesis, because this datum, at least as 1 interpret it, is not in line with this hypothesis. Spending some time on this laboratory analogue of depression may help to make the present proposal clearer. In any case, the learned-helplessness hypothesis is likely to become quite an influential one and for that reason alone is deserving of close attention. If an animal is given a series of severe electric shocks over which it has no control, it develops what has been called "learned helplessness."a8 This learned helplessness is demonstrated if, after the series of freely administered electric shocks have been presented, the animal is put into an avoidance situation—that is, a situation where it can learn on the presentation of a signal to make some

72 Anxiety and Depression kind of response, jump to another part of the apparatus, press a lever and so on, in order to avoid shock. Typically, in the learnedhelplessness experiments, the animal sits and takes the shock without doing anything about it. It has been suggested by these investigators that learned helplessness could be considered an analogue of depression in human beings. This is not convincing because it does not appear to be characteristic of the depressed person that noxious events do not elicit the usual defensive avoidance responses. Indeed, Lewinsohn has proposed quite the opposite—that depressed people are particularly sensitive to noxious events 39 What appears to be more characteristic of depressives is the lack of interest in what have previously been rewarding events. If the laboratory demonstration of learned helplessness is an analogue of anything among human beings, it is perhaps more an analogue of alienation than of depression. The animals in the laboratory experiments, like Samuel Beckett's tramps, see the world as a somewhat vicious one over which they have no control and develop such an apathetic, pessimistic approach to things that, even when control is made available to them, they no longer seem to care. Cohn Wilson made an interesting suggestion related to this when he noted that: Young and alert minds are always overcoming a brutalizing environment and apparently experiencing no ill effect.... On the contrary the evidence seems to indicate that pessimism is often related to lack of early struggles. Kierkegaard, Andreyev, Proust, Beckett, Greene and Eliot were all born in fairly comfortable circumstances; Proust frankly admits that most of his later troubles were the outcome of being spoiled by his mother. But the intelligent man who starts "at the bottom" of society cannot afford the luxury of cynicism or pessimism; he harnesses his mind to the problem of improving his position as he might harness a dray horse to a cart that is stuck in the mud. If he succeeds—as Lawrence, Wells, Shaw, Nexo and Gorki succeeded—then he has also got himself a practical view of the intellect and its relation to civilization so that he feels that the next step is to harness it to the problem of his age. Beckett's "nothing to be done" never entered his head because if he believed it he would still be drudging at some badly paying job.4°

The Nature of Depression 73 It is true that Colin Wilson is here concerned with the differential effects of rewards freely available and rewards for which one works. The former experience produces a pessimistic Beckett and the latter experience produces an optimistic Shaw. But though Wilson was concerned with rewards, it does suggest the possibility that unpleasant events that come uninvited and which cannot be dismissed, predispose one to pessimism but not to depression. Researchers who see in the learned-helplessness phenomenon an experimental analogue of depression might consider the first group of people named by Colin Wilson as more inclined to depression. Their position would be that people who have not learned control over their environments would be particularly susceptible to depression. Colin Wilson's first group is certainly a pessimistic lot if one goes by their literature with its "nothing to be done" and its "hollow men," but is pessimism the same as depression? There is no good reason to believe that it is. Any emotionally disturbed individual may tend to be pessimistic and the Newcastle group of researchers" have found equal numbers of both anxious and depressed patients to express pessimistic ideas. Pessimism is a kind of disengagement and in that sense can be seen as a defense mechanism. It is more akin to apathy, to a sense of alienation, and indeed to a sense of helplessness. The depressed person is not one who feels he is helpless. He is aware only too well that the job of reconstructing his life is up to him, but that it will take effort. He remains depressed until he makes the effort. The depressed person, particularly one with an institutionalized religious background, is often plagued with guilt. How could this be if he felt things were not under his control? Can a person feel helpless and also blameworthy? Why would a loss of self-esteem be so often a feature in depression if the depressed person felt things were not under his control? He may feel things are hopeless but this does not mean that he feels he is helpless. If animals are given training in avoiding shocks before they are made to endure the freely administered shocks, they are immunized against the deleterious effects of the free shocks—they do not show evidence of learned helplessness. This would suggest that one could protect a person from becoming depressed by training him in the control of events. But does this fit with commonsense observation? Is it not often the case that depression occurs when

74 Anxiety and Depression a person, after years of feeling he was at the helm—to use the ancient ship symbol of life—suddenly feels that things are not as easy as they once were. Once again the depressed person does not see things as not under his control. They are under his control but either the control is more difficult (as would happen when a person acquires a physical handicap), or the behaviors required are different from those which he had become used to (as would happen on the death of someone with whom life was closely shared). The link between control and depression, or any other kind of disturbed behavior, is not likely to be a simple one. When Dohrenwend investigated the relationship between stressful life events and psychological distress, she found that "women's symptom levels were more affected by events they did not control than by all events, suggesting that their psychological distress tended to be associated with the lack of power to control their lives. In contrast, men's symptom levels were more closely related to life change scores based on all events, including some that they probably influenced, than to scores based only on events beyond their control, implying that for them psychological distress may have been associated with their role in making their own and their families' way in the world."42 A recent brief report by Calhoun indicates some further complexities. The experimental evidence suggested a relationship between a predisposition to depression and the perception that one was not in control of significant outcomes in one's life. But when the subjects of the experiment were asked to indicate on a questionnaire the degree to which they attributed depressions to circumstances in life outside their personal control or to events within their control, no systematic relationship was found between such perceptions and the degree of depression. It would seem possible then that though there may be a general tendency for depressives to see life events as out of their control, there are individual differences in the extent to which they attribute the cause of their depression to events within or outside their control.43 Helplessness may be more closely related to anxiety than depression. Rollo May, in his review of early theories of anxiety, noted that the concept of helplessness has been used by many of them," and Mandler, more recently, has discussed anxiety in terms of

The Nature of Depression 75

helplessness." Then again, clinical observation would suggest that anxious people fear that they may lose control over their behavior. It does not suggest that they experience an actual loss of control. Since anxiety is an emotion elicited as one anticipates a situation with which one may not be able to cope, it would not be surprising if feelings of helplessness were to be related to this emotion. Berggren" found that in a situation where a subject had to choose between a sure win-or-loss game, playing a chance game with certain probabilities of winning and losing, or a skill game with comparable win-and-loss probabilities, that both a group with strong beliefs in external control of events and a group with high levels of test anxiety chose the sure outcome and/or the chance game more often and the skill game less often than those with a strong belief in internal control of events and those with low levels of test anxiety. Even so, perhaps both feelings of helplessness and feelings of hopelessness are worthy of investigation in and for themselves and not only as aspects of the anxious or depressed states. Some investigators have found that feelings of hopelessness are a more sensitive sign than depression of the seriousness of suicidal intent." The terms helplessness and hopelessness are often used as though they were interchangeable. But an examination of what appears to be implied by these terms will reveal a difference. This examination, at the same time, indicates how, though depression is most intimately related to the past, consciousness of the future is also involved. It indicates how this consciousness of the future differs from that in anxiety, an emotion which is most intimately related to the future. For this examination we can take as our starting point the discussion by Melges and Bowlhy of "Types of Hopelessness in Psychopathological Process." These writers note how discussions of depression in the literature usually isolate a factor of hopelessness as a central and basic theme in depression. They also note that associated with this factor are usually feelings of unworthiness, helplessness, indecisiveness, inability to act, and guilt about not maintaining duties. They note that "in a study of time sense in acute mental illness Melges and Fougerousse found that when compared with other diagnostic groups a diagnosis of depression

76 Anxiety and Depression (neurotic and psychotic) was significantly associated with a feeling of having `no purpose in life' combined with a preoccupation with the future and a relative lack of interest in the present. A focus on the purposeless future produces a sense of futility."48 What is important to note is that the depressed person is not concerned with his ability to cope with the future demands—he does not feel helpless as an anxious person may, but, rather, he feels no purpose in facing the challenges of the future—he feels hopeless. The depressed person feels no purpose in his future life because some past event has robbed his life of purpose. The discussion by Melges and Bowlby sometimes suggests that they are writing about helplessness rather than hopelessness. They note that "it is suggested that a key process in depression is a belief that available plans of action can no longer achieve established goals." But is it not the case that when a person is hopeless, rather than helpless, he loses his incentive for established goals because there has been a disruption in the context within which he has worked for such goals? The scientist who was suddenly deserted by his wife still has the available plans of action to achieve his established goal of scientific contribution. He may no longer engage in such activities, however, because with the disruption in his life he has lost incentive for that goal. He is likely to make remarks such as "What's the use? It is hopeless." The need to distinguish carefully between the loss of incentive for the goal and the feeling of inability to achieve a goal becomes clear when Melges and Bowlby go on to discuss further what they consider to be the key process. As we noted above, the key process in depression, they propose, is a belief that available plans of action can no longer achieve established goals. They say that it is to be noted that this process is also held to be fundamental to depression by writers from other frames of reference, even though different terms may be used to express it. On the one hand, Bibring, a psychoanalyst, posits ". . . that the basic mechanism of depression is the ego's shocking awareness of its helplessness in regard to its aspiration ... such that the depressed person ... has lost his incentives and gives up, not the goal, but pursuing them, since this proves to be useless," while, on the other hand, Lazarus, a behaviorist, holds that "depres-

The Nature of Depression 77 sion may be regarded as a function of inadequate or insufficient reinforcers . . . some significant reinforcer has been withdrawn."" One wonders how Bibring can suggest that a person may lose his incentive but not give up his goals. To say that someone has not given up a goal, but has given up pursuing the goal seems to be contradictory. If we ignore the contradiction, Bibring seems to be emphasizing the loss of incentive in depression which I have suggested is the key process in that emotion. Lazarus, by emphasizing the inadequate or insufficient reinforcers, appears to be talking about the loss of incentive for action rather than the feeling of inability to take appropriate action. There are times when those who are enthusiastic about the learned-helplessness analogue of depression refer to authorities such as Aaron Beck who comments on the hopelessness of depressed patients. But Beck is not likely to be enthusiastic about the notion that the depressed person feels helpless. He wrote in his book Depression—"The depressive's perseverating self-blame and self-criticism appear to be related to his egocentric notions of causality and his penchant for criticizing himself for his alleged deficiencies. He is particularly prone to ascribe adverse occurrences to some deficiency in himself, and then to rebuke himself for having this alleged defect. In the more severe cases, the patient may blame himself for happenings that are in no way connected with him, and abuse himself in a savage manner. Eighty percent of the severely-depressed patients reported this symptom: "i0 The notion of control appears frequently in discussions of depression. But the clinical impression one has of the depressed person is not that he feels he does not have control over the course of his life. It seems rather that he feels very much that the course of his life is under his control, but that he is making a bad job of it. Allen Watts, adopting the philosophy of Zen Buddhism, feels that the problem is that people assume that they should have control." This, in turn, he feels is the unfortunate consequence of the idea that man has an ego that can execute this control. Watts' position, as might be expected, is very different from that of Seligman, who believes that a person is capable of controlling his environment under most circumstances,

78 Anxiety and Depression but has developed the wrong expectancy that things are not under his control. There is always something seductive about Zen Buddhism, even when one recognizes that the adoption of a humorous fatalism does not permit one to be irresponsible. But even if the Zen Buddhist's way is a viable one in Western society, it is still difficult to see how one could approach a wholesale adoption of it. The ego may be a myth, but then it is likely that people in the West will labor under it for some time yet. My own concern is how to help people live within a style of life that is prevalent rather than attempt to find ways to persuade people to change their style of life. Even if one could, on an individual basis, make people adopt the philosophy of Zen Buddhism, it is by no means certain that this would be easily maintained in the company of others, who do not adopt such a philosophy. Seligman believes that the experience of loss of control over environmental events is important in the etiology of depression. But is it altogether implausible that things are the other way around? Why could it not be that a person, particularly a successful adult, very often feels that the environment is so much under his control that he becomes bored. Being bored, he begins to neglect aspects of his life, whether at home, at work, or in social relations. This then in turn leads to depression. Ferster has proposed that it is not only a complete control over the environment that may have deleterious effects, but also a constant schedule of reinforcement. He wrote: a pigeon ... pecking for food on a schedule requiring a fixed number of pecks per reinforcement will starve to death, because the bird does not peck often enough to produce the amount of food needed to sustain him. Yet, the same bird, when exposed to a variable schedule of reinforcement, sustains its activity easily, even when the amount of food received does not meet the bird's metabolic requirement. It is tempting to speculate that this particular schedule of reinforcement exemplifies the middle period of life when most individuals settle down to a routine in which there is a constant steady work requirement, as opposed to the variability in quality and amount of work that occurs as one prepares for a career or to climb a career ladder. Perhaps relevant here is the

The Nature of Depression 79 classical phenomenon of the professional, highly successful in his work, who, on reaching the pinnacle of success, undergoes a profound depression. The upwardly striving person is one whose schedules of reinforcement are variable, sometimes requiring large amounts of activity for reinforcement, and at other times requiring less. Such variable schedules of reinforcement are much less likely to produce low frequencies (strain) than the schedules associated with a stable work situation in which day in and day out there is a constant amount of activity associated with the required accomplishment.52

It would seem very plausible that such constant schedules of reinforcement may lead to boredom. I do not feel that in and for themselves they lead to depression, as Ferster believes. But since boredom may very well he an important antecedent to certain other activities, which in turn may lead to depression, a process to be detailed below, the nature of boredom would seem particularly worthy of investigative effort. The complaint of the adult that he has lost the magic of childhood is a familiar one. Allen Watts would have us adopt the Zen Buddhist approach. He quotes from the Taoist Chuang-Tzu "Can you be like a newborn child? The baby cries all day and yet his voice never becomes hoarse; that is because he has not lost nature's harmony ... the baby looks at things all clay without winking; that is because his eyes are not focused on any particular object. He goes without knowing where he is going, and stops without knowing what he is doing. He merges himself with the surroundings and moves along with it. These are the principles of mental hygiene." Is Watts right? And is the solution to find again our "natural endowment" the polymorphous eroticism of the child? Is it the strategy of the adult that is wrong, or is Alexander Nies right in noting that with age there is an increase in monoamine oxidase, the antagonist of norepinephrine, and that this makes life less exciting than when we were younger?" The possible role of norepinephrine in the production of depression will be discussed in more detail later. Briefly, norepinephrine is one of the neurohormones bathing the nerve cells of the bran. An increase in the level of norepinephrine is associated

80 Anxiety and Depression with an increased alertness and, possibly, as we shall see later, with an increased pleasure capacity. A decrease in the level of norepinephrine is associated with sluggishness and, possibly, a decreased pleasure capacity. What Nies has found then is that an enzyme—monoamine oxidase—which inactivates norepinephrine is increased with age. The resulting lower levels of active norepinephrine might then be responsible for the sluggish and poorly motivated older person. For all our fears of pharmacological experiments, one might be more optimistic if it were found that Alexander Nies was correct, because I think it would probably be easier to find a way to correct the biochemistry of the elderly person than to alter his life style. But whether it is the psychological process or the biochemical one that is important, they lead only to boredom with life and that is not depression. Depression can only be seen as a consequence of this boredom and only when a person permits the destruction of his structure of life either by neglecting parts of his life that are no longer as exciting as they were or by venturing into greener fields that cannot be sustained by his life structure. Though it may be more difficult to alter the old person's strategies of life than to alter the levels of the amines in his brain, this is not to say that an alteration in his strategies would have no effect on his biochemistry. There is evidence that the survivors in old folks' homes are usually the more aggressive type of old people:' Some recent findings in research with mice are interesting in this connection u° Approximately 80 percent of the norepinephrine molecules released from nerve terminals in the brain are inactivated by being taken back up into neurons. Anything that can decrease this active taking back of norepinephrine thereby prolongs the period of availability to post-synaptic receptors. Mice were made aggressive by long-term isolation and then placed eight to ten of them together in a group. The mice were permitted to fight for a period of fifteen minutes, then killed, and a biochemical analysis of their cerebral cortices was done. It was found that there was a decrease in the neuronal membrane affinity for the re-uptake of the neural transmitter norepinephrine into the nerve terminals of the cerebral cortex. This means that letting the mice fight resulted in an increase in the level of norepinephrine in the brain. Perhaps then the more militant old men and ladies are increasing

The Nature of Depression 81 their levels of norepincphrine and that this in turn not only keeps their pleasure capacity in tune, but also increases thc length of their lives. If they could, then the old should perhaps take the oftquoted advice of Dylan Thomas: Do not go gentle into that good night, 01d age should burn and rave at close of clay; Rage, Rage against the dying of the light.'

Most clinicians and most theorists have had the hunch that anger is in some way related to depression. I noted earlier that there is no evidence to support the psychoanalytic notion that depression is a result of hostility turned against oneself. Forster seems to be the only behaviorist who has made an attempt to relate the two phenomena. He has suggested that, because expressions of anger and aggression are punished, an individual learns how to suppress any beginning feelings of anger or aggressive behaviors. He notes: Because thc behaviors that actually suppress the punished acts are a prominent and frequent activity that do not serve any useful function in a person's commerce with the external environment, it subtracts from the finite amount of activity of which a person is capable. The metaphor of a fixed amount of energy which may be apportioned to the repression activity or the external world seems to convey the sense of the behavioral analysis. The repression of punished behavior appears to be a potentially serious contributor to depression, because it commits such a large part of a person's repertoire to activities that do not produce positive reinforcement.'" Ferster's argument, then, is that if all our time is taken up trying to keep our aggressive urges at bay, no time will be left for more useful behaviors—behaviors that are likely to result in our getting some positive reinforcement. Ferster is here presumably thinking primarily of useful interactions with other people that may be rewarding. On the other hand, if the alternative to spending time keeping the lid on our aggression is to let go and aggress, we are not likely to be rewarded by others. Even being angry with

82 Anxiety and Depression someone is not likely to result in that person reinforcing us by their pleasant behavior towards us. Should there be an association between aggression and depression, a plausible explanatory account of the link in behavioral terms does not yet seem to be available. It may be that a depressed person will be tempted to escape into apathy. To see the real world as absurd, as out of one's control—to seek a fragmentation of life—may work, to some extent, to alleviate one's depression. Expressions, therefore, of apathy should not come as a surprise, but should not, on the other hand, be considered to reflect the depression itself. Depression has a vested interest in the past; anxiety has a vested interest in the future. To try to escape them and have no continuity with the past and no roads leading into the future, will leave us wandering alienated in the present. We can, if we choose, become depersonalized, derealized, desensitized, desublimated, and helpless, but then we are hardly human at all. We may long for peace and quietness, but this desire is checked by other impulses. Even if we try to cheat depression by venturing into meaninglessness, we are going to have to contend with the anxiety aroused in the face of this new life style. In a very real sense "You can't win!" But when we reflect on what we are trying to win by such maneuvers, we will not be disheartened at being vanquished. To win would be to succeed in becoming nonhuman. Sartre sometimes seems to be describing apathy when he writes about depression. According to him, because one of the accustomed conditions of our activity has gone when someone dies or leaves us, we are reluctant to continue to act in the world without it. He goes on to say "My melancholy is a method of suppressing the obligation to look for these new ways, by transforming the present structure of the world, replacing it with a totally undifferentiated structure. What it comes to, in short, is that I make the world into an affectively neutral reality, a system which is, effectively, in complete equilibrium."" What I am suggesting is that, on the contrary, the depression serves to neutralize effectively the world around us until we have successfully engaged in some kind of restitutive activity to give life some semblance of the structure it had before—a protection against engaging, trying to act, without the unifying structure. . Seeing

The Nature of Depression 83 the melancholy as a goad to activity of this sort, one can see how the melancholy can be terminated. It is difficult to see how Sartre's melancholy can come to an end except by stating that time would result in its dissipation. Sartre's people who want to free themselves from the feeling that certain acts are in their power might be expected to experience helplessness and apathy, but not depression. Some psychologists write about depression as being the result of the blocking of the route to a desired goal. This they suggest results in the loss of incentive—in disengagement and consequent depression. I think we will find, however, that we have to distinguish between the frustration produced when we are striving for a particular goal for the first time and the frustration when the particular route to a goal that we have been used to taking is no longer available. Under the first condition, as Mandler, for instance, suggests,f0 anxiety is likely to occur, and under the second, depression. What needs to be emphasized is that the depressed person may feel he has considerable control over the environment. Indeed he may, because of some change—a promotion, for instance, have better control. What is important is that he no longer has available the same route to the goal and the route is important because it has become a familiar part of his life style. Seligman and other psychologists writing on learned helplessness mostly write about it as a transitory state produced by the delivery of noncontingent shocks. But there are times, extrapolating to depressions in human beings, when they look upon learned helplessness as a basic personality characteristic, predisposing to depression. For instance, Seligman has demonstrated that, in a skill task, people not predisposed to depression showed greater changes in expectancy for success following positively reinforced trials than did those who were predisposed to depression ." He interpreted this finding by suggesting that depressives tend to perceive reinforcement as more independent of response than do nondepressives. But an equally likely explanation is that the dime reinforcement Seligman used in his study is not an effective reinforcer for depressed people if, during the conduct of the experiment, they are indeed in a depressed state. One of my own students found that offering people dime rewards for improvement in performance on a motor skill task had no effect

84 Anxiety and Depression for nondepressed people, but significantly worsened the performance of depressed people!" A recent study presents evidence which is in line with the suggestion that learned helplessness is probably more similar to apathy in human beings than it is to depression a3 The study was concerned with fluctuations in mood over a four-week period and what is called by psychologists the cognitive style of the person. The particular cognitive style of interest was one that has to do with where a person attributes the control of events in his life. Depending upon their particular cognitive styles, people are known as either internals or externals. Internals are those who feel they have control over the events in their lives. Externals are those who feel that the events are under the control of something outside them. For instance, take the following two statements. "Many of the unhappy things in people's lives are partly due to bad luck." "People's misfortunes result from the mistakes they make." The person with an internal orientation will say that the second statement is the more true, whereas the externally oriented person will say that the first statement is more true. The investigators had predicted that an external orientation would be associated with feelings of depression. This is exactly what Seligman would predict since presumably those who feel that events are not under their control should feel helpless. What in actuality was found was that externals were not more depressed than internals—they had more feelings of alienation. Some indirect evidence in favor of the present proposal can be found in cross-cultural and cross-racial studies of depression. For instance, it has been found that depression occurs relatively infrequently among the American Negro ca What makes this finding particularly interesting is the independent evidence that the American Negro experiences very little in the way of personal control over the events in his life." It would not be too surprising, if my formulation is correct, to find the American Negro more apathetic and alienated than depressed. There is evidence, albeit controversial, that perceived lack of control over environmental events may actually protect against depression." Before the African countries became independent, it was noted by a number of observers that depression was very rare. With the coming of independence, depression has become

The Nature of Depression 85 more common. Of course, this greater increase in depression after independence may simply be a matter of better mental health facilities which increase awareness of such a problem. The absence of depression reported early in the century may simply reflect the absence of the appropriate observation techniques. It is difficult enough to obtain reliable statistics on such matters even in countries where mental health facilities and procedures have had time to develop.'" We also have to keep in mind that in the underdeveloped country mortality rates are usually higher and may account for the lower incidence of depression—a disturbance which occurs later in life. But other types of disorders such as mania have been observed and so perhaps we are justified in accepting, for the time being, these data as representing a true difference in the incidence of depression. Carothers noted that it is unlikely that genuinely depressive people are not recognized by European investigators as abnormal in Africa, because by African standards, the normal population in Europe is depressed. Carothers suggested that the absence of depression in the more primitive African societies was a result of the fact that the individual did not feel any personal responsibility for the events that occurred in his environment—they were out of his control. Carothers wrote "the potential tendency to simplify and synthesize is frustrated early and late and such organization as exists in African life is social—never cerebral; the individual is integrated in his society—not in himself."f8 Carothers' hypothesis, formulated to account for the supposed absence of depression in Africa, suggests that his view of depression was very similar to the one I am proposing. He wrote, for instance: "The development of depression in standard form is linked in high degree with personal integration, with a sense of personal continuity, and with a sense of responsibility for one's past and of a retribution that must follow for one's sins.' He quotes from Tooth "One of the most characteristic elements in the depressions of European psychotics is self-reproach ... but it is certainly true that self-reproach is very rarely met with in the content of African psychotics.' Carothers comments: "the man is not the unit: Misfortunes have social repercussions, grief is not borne in isolation, and the appropriate rites are publicly performed."'1 Similarly, Rollo May has suggested that anxiety and depression became more prevalent when the collectivism of the

86 Anxiety and Depression middle ages fell down and emphasis was placed on the individual and his control over his destiny in the renaissance.'= Now, after this long digression on learned helplessness and depression, let us go back to the relationship between loss of reinforcer effectiveness and depression. It is commonplace for people who find themselves in secure, solvent positions in life to yearn on and off for days when they had to work harder to obtain some of the pleasures in life. The notion that struggle is essential for happiness is one which is often noted by observers. Bertrand Russell, for instance, wrote: The human animal, like others, is adapted to a certain amount of struggle for life and when by means of great wealth homo sapiens can gratify all his whims without effort the mere absence of effort from his life removes the essential ingredient of happiness. The man who acquires easily things for which he feels only a very moderate desire concludes that the attainment of desire does not bring happiness. If he is of a philosophical disposition he concludes that human life is essentially wretched since the man who has all he wants is still unhappy. He forgets that to be without some of the things you want is an indispcnsible part of happiness.`a This formulation presumably would not be very acceptable to those reinforcement theorists who seem to feel that happiness is in direct proportion to the availability of reinforcers. They do not, of course, suggest that one could get the depressed person out of his depression simply by showering him with reinforcers. The reinforcers are to be used, they suggest, to build up the person's repertoire of behaviors again. But, as I have noted, the effectiveness of reinforcers seems to be dependent upon changes in the behaviors or pattern of behaviors themselves. A word or two more about effort and depression. Ferster, who originally suggested that the loss of a source of reinforcement (such as a spouse) was an antecedent to depression, also suggested that one may become depressed when the effort required to obtain reinforcement becomes too great. He wrote "the Salesman whose ratio of selling behavior to sales gets too large soon stops trying."' Presumably Ferster would consider Arthur Miller's Willy Loman to be a case of a man who became depressed because the effort

The Nature of Depression 87 required to make a sale was too great. Willy may have been depressed. But was it the effort required in making sales that made him depressed? Was it not the loss of structure which he could not face and restructure? "Work a lifetime to pay off a house. You finally own it, and there's nobody to live in it." "I don't want a change. I want a Swiss cheese." He was fatigued, he wanted attention, he was guilty. There are so many antecedents to his depression. But they all add up to the one lack of structure. If only he could have got down to restructuring his life. But all that made him happy was to look forward to an impossible dream. Willy's depression also seems to be partly because his son Bill's life has no structure, he "can't take hold of some kind of life."" It is the social patterns of one's life that seem to be typically in need of protection and which depression protects. It has been suggested before by Averill that grief functions to ensure group cohesiveness in species where a social form of existence is necessary for survival.' This is accomplished, he suggests, by making separation from the group an extremely stressful event. All I am suggesting is that the maintenance of interpersonal and group cohesiveness is one aspect of the general need for the human being to maintain the pattern of his behaviors. But it is an extremely important aspect. What is the particular circumstance that will make a person extremely happy? It is the circumstance under which he is happily in love with another person. It is then that the reinforcing value of things around him seems to increase dramatically. When can one feel most acutely depressed? When one is in the throes of unrequited love, or perhaps, as with Anna Karenina, when the love experience is short-lived because it has no place in the pattern of life one has developed. So our emotions act as fine checks and balances, encouraging growth as long as it is a systematic growth with some continuity and as long as it respects the lives of others with whom we have become closely related either through choice or fortuitously. Emotion itself is a passive phenomenon but it goads us into deliberations. We cannot simply submerge ourselves even in a positive emotion like love. Paul tried to do this with his love for Miriam in Lawrence's Sons and Lovers. He courted her now like a lover; often when he grew hot, she put his face from her, held it between her hands and looked in his

88 Anxiety and Depression eyes. He could not meet her gaze. Her dark eyes, full of love, earnest and searching, made him turn away. Not an instant would she let him forget. Back again, he had to torture himself to a sense of his responsibility and hers. Never any relaxing, never any leaving himself to great hunger and impersonality of passion; he must be brought back to a deliberate reflective creature. And if from his depth of passion she called him back to the littleness of personal relationship, he could not bear it, "leave me alone—leave me alone!" he wanted to cry; but she wanted him to look at her with eyes full of love. His eyes full of the dark, impersonal fire of desire did not belong to her 77 Depression sees to it that our self-assertive tendencies do not get out of hand to the neglect of our integrative tendencies. If there is self-assertion it must not be selfishness but Spinoza's striving to preserve one's own being which, as Tillich has pointed out, cannot be done without recognition of the fact that we are part of something larger than ourselves. One recalls Donne's beautiful lines, "No man is an Band intire of it seife; every man is a peece of the Continent, a part of the maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as if a Mannor of thy friends or thine own were; Any man's death diminishes me, because I am involved in Mankind; And therefore never send to know for whom the bell tolls; It tolls for thee."78 In despair from the pain of our loneliness and depression, our integrative tendencies may grow to such a strength that we seek comfort in an all-encompassing religious view of the world, "the religious urge appears to be a primitive tendency, possessing biological survival value, to unify our environment so that we can cope with it."i9 If one thinks in terms of needs, then one of the needs, the dissatisfaction of which is signaled by depression, is the need to belong. At times the need to be free will grow stronger than the need to belong and we may try to move on. But freedom is a doubtful blessing when men in general, and not the individual man, are to be considered. And so depression forces us to look back and often to go back. Like Arnold Wesker's Beatie, we cannot ignore our roots any more than her Norwich family can

The Nature of Depression 89 ignore the roots of their plants. Perhaps the importance of belonging is reflected in the fact that one of the most consistent of epidemiological findings is the relative immunity of married persons to the occurrence of mental disturbances 8° George Poulet, in his comment on Proust, describes this need to belong: For the anguish of solitude is not only that of being detached from things and beings, it is being detached from fixity, from the permanence one would like to have beings and things possess and give us by return; it is to feel one's self betrayed, without any help from them, to the indeterminate power of thought, which ceaselessly imposes upon us metamorphoses, which perpetually changes us into another "self" and which every instant makes of us, and for us, a stranger!". The uninvited guest in Eliot's The Cocktail Party understands well what is happening to Edward's sense of self as a result of his separation from his wife. ... There's a loss of personality; Or rather, you've lost touch with the person You thought you were. You no longer feel quite human 8' and a little later he says: Most of the time we take ourselves for granted. As we have to, and live on a little knowledge About ourselves as we were. Who are you now? You don't know any more than I do, But rather less. You are nothing but a set Of obsolete responses. The one thing to do Is to do nothing. Wait 83 Edward is distressed because now he has "nothing but a set of obsolete responses." He is not bereft of responses because an important source of reinforcement—his wife—has been lost. The responses remain but they have lost their significance. De Laguna points to the reason for the importance of the self:

90 Anxiety and Depression As the preservation of the individual organism is a means necessary to the biological end of reproduction, so is the preservation of the individual person as a self a necessary means to the maintenance of culture. The self which must be preserved if the ideal world of culture is to be perpetuated and developed is itself also ideal. It is the center around which the personality structure is organized. It is from the self that human actions must be oriented, and this self can only be preserved in its integrity if it is also an ideal object to which man directs his own activities. Since man creates—or generates—himself as a person in generating his human world, not only is this world the end for which the preservation of the self is a necessary means, but the world is a necessary condition for the preservation of the self.84 De Laguna also describes well what may be the evolutionary aspects of the maintenance of culture: The advent of man (genus homo) marks the third stage in the continuous course of evolution. As a living organism, man is structured for the end of reproduction, but this end is no longer primary or dominant. The end for which man is uniquely organized lies outside himself as an individual and also beyond the reproduction of his structure in other individuals, although it must include these ends as subsidiary. Man's unique goal is the maintenance of the culturally patterned human community and its "way of life." It is not to be supposed that man with his distinctive teleonomic structure arose first, as the result of natural selection, and then as a result of his genetically determined organization, produced, or generated, the cultural world in order to attain the end to which his biological organization was directed. Man did not come first, and then his culture. Rather we may suppose the world of human culture has had an evolutionary continuity with the "behavioral environment," the proto-cultural world, of man's anthropoid ancestors, and that the evolution of this world and of man as a distinctive biological species occurred together in mutual dependence. The organization uniquely distinctive of the human individual, the organization he must achieve for himself is that of the person. As the evolution of man from his hominid predecessors and the

The Nature of Depression 91 evolution of culture took place in mutual dependence, so the transformation of each human individual into a person can only be achieved within a cultural world he shares with other persons, and which he re-creates as his in becoming himself. The person, too, must maintain his own existence. But since he can exist as a person only as a self within a world he shares with other selves, so he can maintain his self-existence only by so acting as to maintain this common world. By making it his, he re-creates it both for himself and others. The end to which man's teleonomic structure is directed thus transcends the maintenance of his existence as an individual and the maintenance of his organic structure in the reproduction of offspring. Yet in this very transcendence of the ends for which all living beings are organized, continuity of the evolutionary course of nature is manifest.85

There are other accounts of depression which view the emotion as an adaptive mechanism. Dennis Hill notes the communicative

aspect of all symptoms including those of depression 86 All symptoms evoke protective responses in the observer. But he also seems to imply that depression is adaptive in another sense when he writes that it is "a response to a crisis situation in the patient which demands a personal reappraisal, the result of which is a catastrophic lowering of self esteem." This is a formulation that is similar to my own. But Hill stops there. He does not explain why this catastrophic lowering of self-esteem and the resulting depression are necessary. Another account emphasizing the adaptive function of depression has been proposed by D. Russell Davis.' He also views depression as an adaptation to crisis. The cardinal characteristic of depression, he says, is reduction in responsiveness to a wide range of stimuli. This reduced responsiveness is due to habituation (which he suggests is another term for experimental extinction) the essential condition for which is repeated stimulation without reinforcement. The biological value lies in the facts that it cuts short ways of responding that have proved ineffective and thus protects the organism from the effects of repeated stimulation, and that it allows new ways of responding to emerge. This reduced responsiveness (habituation, experimental extinction) recovers after a rest. Where it is slow to recover as in some cases

92 Anxiety and Depression of clinical depression, it is because the circumstances are such that the stimulation continues without reinforcement. "The patient, because he is depressed does nothing to change the situation from which arise the stresses perpetuating the depression." Now there seem to be inconsistencies in Davis's account. If the adaptive function of depression is to protect one from the effects of repeated unreinforced stimulation and to allow new ways of responding to emerge, how can persistent depression be explained as due to the continuation of stimulation without reinforcement and the fact that the patient because he is depressed does nothing to change the situation? How can one explain the increased magnitude or duration of an adaptive phenomenon as being due to the failure of this phenomenon's usual adaptive function? Davis suggests that "ECT breaks the deadlock, when it restores responsiveness for sufficient time to enable the patient to do something about his situation." It seems then that when depression is protracted we have to relieve it so that the patient can do something new, which is what depression is supposed to enable him to do in the first place. A more detailed account of the adaptive function of depression has been presented by Klinger. According to Klinger, when an individual can no longer attain a goal, when, in other words, he is no longer rewarded for his efforts and is under extinction conditions, he is frustrated, and he will go through an incentivedisengagement cycle of invigoration, aggression, depression, and recovery. He writes: if one method for attaining an incentive is blocked, the organism would clearly benefit from a tendency to attempt other methods and, if its repertory of efforts failed, to try again with greater physical and psychological force: the invigoration and aggression phases. On the other hand, such an organism would totally exhaust itself pursuing its first blocked goal if it did not incorporate a mechanism for annulling its commitment to an inaccessible incentive, thus ending that particular current concern. If, however, rest or the end of hard striving carries positive incentive value, it would be important that the disengagement process be affectively aversive in order to prevent failure from taking on a

The Nature of Depression 93 net positive incentive value, which would surely be a dangerous state of affairs. Depression, of course, embodies the properties of such a mechanism. Within this framework, then, some degree of depression is a normal, adaptive part of the process of disengagement from incentives. Since perpetual depression would leave the organism incapacitated, there is obvious need for a recovery phase 88 Like Davis, Klinger seems to be arguing that disengagement from goals that we cannot achieve is adaptive because it conserves our energies for more useful pursuits. But recognizing that one might very well get into the habit of disengagement, he notes that the depression that is an important part of the disengagement cycle is aversive. What he does not do is demonstrate how the aversive properties of depression itself may be adaptive in provoking other responses. Indeed, noting that depression may have widespread effects resulting in an overall loss of incentive value, he suggests that in order that there may be renewed responsivity to incentives, depression must spontaneously recover. There does seem to be a difference between Davis's and Klinger's accounts. Davis seems to be saying that as long as one engages in unreinforced behavior, one will become depressed and that this aversive state will result in cessation of such unreinforced behavior. Klinger, on the other hand, suggests that one, first of all, stops making the unreinforced response and this disengagement results in depression. For Davis the depression, by leading to a cessation of unreinforced behavior, provides the opportunity for engaging in other behaviors. But, as we have noted, Davis recognizes that very often depression just does not result in that consequence, and, on the contrary, the depressed person may not engage in any behaviors at all and has to have his depression removed in order to engage in behaviors. For Klinger the adaptive function of depression seems to be that it rules out the possibility that one is positively reinforced by the relief that one gets when disengaging from a frustrating course of action. But once again he does not show how the depression may then result in more fruitful responding, which it would have to result in if it were really an adaptive mechanism. Instead, like Davis, he argues that

94 Anxiety and Depression the depression must be lifted in order that the organism may once more engage with the environment. Klinger compares the adaptive function of depression from an individual point of view with that from a population point of view. He notes what seem to be the maladaptive aspects of depression from an individual point of view. He notes that depressed individuals often experience actual deteriorating health and higher rates of mortality. But there seems to be a failure here to recognize the difference between depression to which an organism responds and depression to which an organism does not respond. As I have suggested, we should probably look for the adaptive significance of depression in its signal value and the responses to which it leads in order to alleviate the depression. It would not, then, be surprising that, if depression were not itself dealt with adaptively, it would lead to maladaptive consequences such as death. As I also noted previously, one must consider the possibility that any inheritable characteristic may manifest itself in art extreme form in some individuals, and in such cases the adaptive aspect of the characteristic is not served unless it is ameliorated in some way. One should try to seek the adaptive functions of an inheritable characteristic that will serve both for individuals and for the species. What Klinger tries to do is show how, though depression may be maladaptive for the individual, it results in benefit for the species. He notes: Viewed from a population standpoint, there are several advantages to the demise of depressed individuals. First, severe depression is a consequence of losing a major incentive, which in a natural setting, is likely to involve loss of a mate, progeny, or territory. Insofar as the loss is related to relative incompetency on the part of the individual, there is a eugenic advantage in eliminating the incompetents. Insofar as the individual has been prevented from reproducing while still laying claim to a share of the food supply, there is a reproductive advantage in his demise. Thus, a characteristic disadvantageous to certain individuals may benefit the species and may, therefore, be selected for in the course of evolution 69

The Nature of Depression 95 One of the problems with this formulation is accounting for the fact that the depressed individual, while having lost incentive for reproductive activities, is also likely to lay very little claim on the food supply. But a more important problem is that it bases its argument for the evolutionary function of depression on the extreme manifestations in certain individuals when it is likely that the evolutionary formulation must be based on the manifestation of the characteristic in all the members of a species. Another formulation of depression in adaptive terms, which is more common among clinicians, conceptualizes depression as a "depletion syndrome." Beck has commented on this formulation: they postulate that the patient exhausts his available energy during the period prior to the onset of his depression and that the depressed state represents a type of hibernation, during which the patient gradually builds up a new store of energy. Sometimes the fatigue is attributed to the sleep disturbance. Against this theory is the observation that even when the patients do get more sleep as a result of hypnotics, there is rarely any improvement in the feeling of fatigue. It is interesting to note that, furthermore, the correlation between sleep disturbance and fatigability is only .28. If the sleep disturbance were a major factor, a substantially higher correlation would be expected . . . fatigability may be a manifestation of loss of positive motivation 90 Grinker has also commented on the conservation-of-energy hypothesis. "Unfortunately this speculation is not validated by techniques which measure stress responses. In states of depression, including the isolated, retarded, and withdrawn depression, plasma cortisone levels are elevated ... these subjects are not conserving energy in a facultatative hibernation, but are mobilizing additional resources as in typical stress reactions."91 Price discusses a number of hypotheses which have attempted to place mania and depression in the phylogeny of behavior °= Among these is the hypothesis that draws a parallel between phasic depressive illnesses and states of hibernation and aestivation in certain mammals. Price does not feel that the lack of

96 Anxiety and Depression seasonality in depression is anything to worry about in drawing the parallel between depression and torpidity, but he does remind us that depression is a more complicated phenomenon than torpidity. In a paper full of intriguing hypotheses, Price also discusses one which relates depression to social competition. In this view depression is seen as a kind of yielding behavior in the face of social competition. Noting that social competition or fighting between members of the same species has been very largely ritualized, he writes: Why is it advantageous for the yielder in a social contest to be depressed and inefficient? We can visualize a gradient of fighting from killing at one extreme, through wounding and hitting, to signaling at the other extreme. Along this gradient of ritualization the method of fighting varies from physical to psychological. Let us now consider the behavior of the winner of the contest. His behavior is not much affected by the method of fighting he has used: he takes possession of whatever the contest was about. It is different with the loser of the contest. His behavior is profoundly affected by the place along the ritualization gradient that the method of fighting occupied. At one extreme he is dead; at the other, he has merely received signals. If he has merely received signals, he is physically fit and might choose to ignore the ritual contest and engage in destructive fighting, or he might claim that the ritual was null and void in some way and insist on repeating it. This sort of behavior would counteract all the gains to be derived from ritualized fighting; in fact, the ritualization of fighting requires that the loser should yield 93 The best way, according to Price, that the loser can be made to yield is by developing some psychological incapacity which he suggests is what we now recognize as depressive illnesses. This is certainly a hypothesis that is worth looking into further. My own formulation, however, suggests that things are more complicated than this. Another hypothesis discussed by Price seemed to be more closely related to the one that I am proposing here. This hypothesis has to do with the adaptive function of elation and depression and

The Nature of Depression 97 sees these states as concerned with the formation and disruption respectively of the pair-bond, particularly the relation between husband and wife. Noting the grief that follows bereavement and the first phase of mourning, which is characterized by anxious searching for the lost loved one, Price comments: since in primitive times a lot of bereavement must have been of the "missing, believed killed" variety, the advantage of this searching is clear. After a while, according to Bowlby, the searching is superseded by a phase of despair, which approximates closely to the picture of depressive illness. The function of this phase is said to be the loosening of association formed during the paired relationship, although why the symptoms of depression should be necessary for this process is not clear. However that may be, the depression would perform a valuable stay-put function, in case the husband was merely detained by adverse circumstances, such as a broken leg. Even more important, the loss of interest and libido would serve to inhibit any further pair-bond formation during the period when the husband was likely to appear, and thus avoid the triangular situation, with its risk of bloodshed and group disruption ai This is similar to the formulation I am proposing in that it emphasizes the function of depression in the interest of conservation of already established interpersonal relationship. The proposal that I am making differs primarily in that it points to mechanisms of a more general nature rather than ones related only to specific pair bonds. It is in the overall conclusion to his paper that it can be seen that Price's views on depression are very similar to those that I am proposing. In the conclusion, he writes: These considerations of the adaptive value of affective disorders are, of course, extremely speculative. Testable predictions are difficult to derive, and a final answer is unlikely to be obtained. However, they may serve to emphasize that depressive behavior may be something more than just an error in the clockwork; and they may direct attention away from the subjective experiences of the patient to changes in the way of his life. Does he

98 Anxiety and Depression stay put or move on? Does he fall in status in his group or family? Is the diet of his (or her) children altered? Does he sell his shares or take out more life insurance? Does he put an extra bolt on the door at night? These are the sort of things that will affect his "fitness" in the genetic sense, and may even, in the individual case, give some clue as to what function the depression is performing.a 5 Depression in clinical conditions is no longer the fine monitor of our life, but has become a crippling disorder of affect. It is not my intention to deal, to any extent, with such cases of depression. There is little that can be said despite some decades of research on the nature of the constitutional factors underlying such depression, and, in any case, this is a job for the biochemist, physiologist, and geneticist rather than for the psychologist. But it is interesting to note, in passing, that what little evidence we have on the processes underlying depression seems to fit in with the characteristic that I feel is so typical of depressions—the loss of interest in the environment. This evidence indicates that a decrease in norepinephrine available at the brain receptors is associated with depression," that substances such as imipramine which release norepinephrine rapidly from stores in the brain alleviate depression and facilitate rewarding self-stimulation, and conversely that substances such as reserpine which deplete the brain of norepinephrine produce depression and suppress rewarding self-stimulation." This is important evidence and is deserving of a closer look. It is well established that reserpine depletes the brain of norepinephrine. The conclusion that it produces depression is based on more indirect observations—those of a clinical nature and those made in animal-analogue situations. In the case of human beings it has been found that if reserpine is used for the treatment of hypertensive patients, 15 to 20 percent of them will appear depressed. If rhesus monkeys are fed reserpine for a period of about eighty-one days, they will exhibit the decreases in locomotion and visual exploration and the increase in huddling behavior that can be produced by separation from mothers and peers. As we noted previously, these are behaviors thought to mimic the depressed behaviors of humans.

The Nature of Depression 99 The evidence that drugs such as imipramine, which are known to increase the availability in the brain of neurohormones such as norepinephrine, actually alleviate depression is not as strong as one would wish. In my own review of the data, published in 1970,08 I found that where controls had been used, fourteen of the studies reported significantly greater effects for the antidepressant drugs, but another fourteen presented negative results. In the case of ones reporting positive results, there were a number of methodological problems which will not be repeated here. But, as an example of the problem, imipramine will produce side effects in a fair number of patients who receive it. This means that it is very hard to keep the investigators blind as to which patients had the drug and which patients had the placebo. This lack of blindness may contaminate any findings that one may get based on the ratings given by the investigators. What is meant by rewarding self-stimulation? This refers to the experimental demonstration that if electrodes are permanently implanted in the brain of an animal, particularly in what is known as the medial forebrain bundle, and if the animal can make a response such as bar-pressing to produce stimulation of the brain through these electrodes, it will learn to do so. Indeed, stimulation through electrodes placed anywhere along the medial forebrain bundle appears to produce positive reinforcing effects. In some cases the rate of self-stimulation has exceeded eight thousand responses per hour. That these reinforcing effects are not special and peculiar ones and are similar to those involved in the animal's usual interaction with an environment is indicated by the following findings. Stimulation of these reward centers in the brain will elicit eating in the presence of food and sexual behavior in the presence of a mate. On the other hand, if lesions are made in these areas of the brain they may produce deficits in natural behavior such as eating and mating. That there is a link between norepinephrine and the rewarding effects of stimulation is suggested by the following findings:00 (1) that norepinephrine is released from terminals of the medial forebrain bundles during rewarding stimulation; (2) that reserpine, which depletes the brain of norepinephrine, suppresses rewarding self-stimulation, and imipramine, which increases the available norepinephrine in the brain, facilitates rewarding self-stimulation; (3) that if fine cannulae are

100 Anxiety and Depression implanted in the region of the brain at which electrical stimulation is known to induce eating in a previously satiated rat and small doses of norepinephrine are administered through the cannulae, similar eating behavior will be induced; (4) that norepinephrine in the brain of rats will be reduced by 90 percent by the administration of a chemical compound (6-OHDA) into the ventricles of the brain—if these rats are trained to press a bar for food reward and then the spring tension on the bar is increased, the rats stop performing, suggesting a motivational deficit; (5) that the level of brain norepinephrine will be reduced by up to 60 percent in the macque monkey by administration of 6.OHDA. The monkeys in one such study showed a syndrome which the investigators termed "amotivational" for about six hours. The animals were conscious but relatively inactive and failed to respond to the social milieu of the other monkeys. The usual way of describing the function of the reward mechanisms in the brain is to say that they are activated by behavior that has previously produced pleasure and that this activation produces facilitory feedback which keeps the behavior going. According to Stein, in primary depression the deficiency may arise from within the reward system itself. In secondary depressions on the other hand the reward system itself is essentially normal, but its output is suppressed or overridden by the excessive activity of an antagonistic anxiety-punishment system. It is not clear if Stein considers primary depression as being mainly a consitutional-congenital deficit, and secondary depressions as being environmentally produced. If one is correct in assuming that there are depressions which are primarily endogenous in origin, then the deficit may be in the reward mechanisms or in some antagonistic punishment system or in both. The more important problem for the formulation that I have been proposing is why, when there has been some disruption in one's pattern of behaviors, behavior which would normally result in facilitory feedback from the reward system no longer does so. It does not seem possible to explain this in terms of activation of some antagonistic punishment mechanism. One can see how this might on occasion result in suppression of behavior. It is by no means the case that we always lose incentive for those things that are suppressed because of our expectation of punishment and quite the contrary is often

The Nature of Depression 101 the case. But that is another matter. The problem here is that a person may lose his incentive for engaging in behaviors which have not been associated with punishment at all. Now one possibility is that punishment associated with one particular behavior generalizes to other behaviors. So for instance the person who leaves his family and as a result is subject to criticism either from others or from himself may lose incentives for his work and other activities because the punishment associated with this behavior of leaving his family generalizes to the other behaviors and suppresses them. But it is possible that only the reward mechanism itself is involved. The process may be something of the following sort. Input-response connections that are well established in a person's pattern of behaviors, in his life style if you wish, though they are temporally and spatially quite distant, are dependent for their maintenance and further strengthening on continued activity in any one particular input-response connection. What is implied here at a neurochemical level is firstly, that, not only is the availability of norepinephrine necessary for responding in a situation to be rewarding, but that continued responding in a situation is necessary if norepinephrine levels are to be maintained. Secondly, cessation of activity of one of the responses in the pattern not only results in depletion of norepinephrine in relation to the particular input-response connection involved but will also result in depletion of norepinephrine at the sites mediating the other responses that are established in the life of the organism.]°" It is Iikely that pharmacological procedures will be needed to reduce the depression of the clinically depressed. It is unlikely that pharmacological procedures could eliminate depression completely from the lives of such individuals, or indeed that it would be advisable to do so, even if one could. One of the things that I have wanted to emphasize is the importance of anxiety and depression in the life of the human being. All that one should hope to do for the chronically ill individual is to make more efficient the important mechanism of his negative emotions. Once having done this, what the person needs to do is to learn how to utilize these emotions in his development rather than look upon them as unfortunate intrusions on his life. In the first chapter, I suggested that if we can find sufficient physiological reason for a person's unusual behavior, we are less

102 Anxiety and Depression likely to regard it as genuine emotional behavior. If a person is continually depressed and we know that he is so for physiological reasons then his behavior is no longer attention-gaining except for the professionals who are attempting to put his physiological condition right, and his behavior does not elicit enquires from observers about what is wrong. The implication is that it is only when the unusual behaviors maintain their discriminatory functions, responding to situations differentially, that they maintain their status as emotional behaviors. This is a discrimination that occurs mostly over a temporal dimension. At least with certain emotions such as anxiety and depression, once the emotion occurs it tends, as I have suggested, to be pervasive in its effect—all aspects of the environment are responded to emotionally. It is time now to take a closer look at the similarities, differences, and interactions between anxiety and depression. It is time also to consider what relevance the present proposals may have for man's approach to the problem of anxiety and depression.

Research and Clinical Strategies

The general significance of anxiety and depression in the life of the human being has been the primary issue of this book. Although some comments have been made on the processes that may be involved in anxiety and depression, no attempt has been made to detail a particular theory around some component of these emotions—a theory that would lead to obvious and specific research and therapeutic techniques. Unlike, for instance, George Mandler's interruption theory of anxiety, there is not one clearly identifiable program of research that follows from the present formulation. Unlike Joseph Wolpe's theory of anxiety, one cannot point to a therapy that is as specific as the systematic desensitization procedure which followed from Wolpe's formulation. In this concluding section of the book, it is again the general implications of the present formulation of anxiety and depression that will be further elaborated. The specific implications of the formulation in terms of research and clinical practice will develop, if the formulation is germinal at all, over time. But there are certain research and therapeutic strategies which can be said to be favored by the view that I have presented. The first task then is to indicate what these strategies are. In doing so, it will be seen that though one of the arguments of this book has been that we must try to maintain a general view of the significance of anxiety and depression, it by no means follows that one should neglect

104 Anxiety and Depression to do research at very precise and sometimes very molecular levels of analysis. I hope to demonstrate, however, how a general formulation such as the present one can highlight the significance of such fundamental research. I noted in the last chapter that there has been research on chemical substances in the brain that seem to be related to the rewarding effects of self-stimulation. Because the loss of incentive in depression has been emphasized, this is an area of research particularly favored by the present formulation. Other somatic aspects of depression such as sleep disturbances and fatigue are often noted in the literature. But these appear to be quite peripheral aspects and have often been found in a variety of disordered affective states rather than being pathognomic of one. It would seem more fruitful at this time to try to ferret out those physiological processes that are related to the essential function of depression. Even if it could be demonstrated that specific conditions such as menstruation and fatigue are precursors to some episodes of depression, we are likely to find that they are related because the physiological processes they set in motion are related to fundamental physiological processes underlying depression. It is unlikely that we will find that the immediate physiological effects of these conditions are directly related to the essential nature of depression. The search for physiological aspects of anxiety has been a shotin-the-dark approach. Here too, we must try to determine physiological processes related to the essential nature of anxiety. If some intracranial locus of security and confidence could be found, we might have the lead that we need. In this connection, the work on physiological mechanisms involved in voluntary action, conducted by Vanderwolf,' may help. Although I believe that we must deal with praxes, the intentions with which people make movements, we should not neglect processes, in other words, the physiological bases of these actions. There seems to be little doubt that these physiological processes may set severe limits on the availability of certain behaviors to a person, no matter what his intentions may be. Though it will be argued later that the clinician will find that he must keep in mind that a person has intentions and follows rules to realize these intentions, not all researchers need work at that level of analysis. Indeed it is quite likely that the breakthrough in attempts to determine the causal factors of

Research and Clinical Strategies 105 anxiety and depression will come from basic physiological investigations. In attempting to determine the processes involved in making anxiety an unpleasant event, the approach cannot be based purely on conceptual analyses. There is a place for conceptual analyses involving action-and-reason explanations. But there is also a place for an analysis in terms of mechanical causal events. To use Wilfred Sellars's terms, both the manifest image of man and the scientific image of man must be given their due? This is no place to enter into a description of the anatomy of the brain or the detailed neurophysiological evidence reviewed by Vanderwolf. Let us note only that Vanderwolf's research has revealed the importance of certain parts of the brain in the performance of voluntary movement. He has written: a rat with a large medial thalamic lesion is grossly deficient in the ability to avoid a painful shock even though it is not paralysed in the usual sense and possesses adequate sensory and learning abilities and motivational capacity. The defect appears to lie in the initiation of movement, in dysfunction of a mechanism linking perceptual, mnemonic, and motivational systems to the voluntary motor system. There may be two distinct phases in higher level motor control. First a programming mechanism must select from a large number of possible movements those which are appropriate in a given situation. The central representations of these movements must be maintained in a subthreshold state of excitation for some time in such a way that they can be activated in a particular sequential order ... then at an appropriate moment, a trigger mechanism fires off whatever motor activities have been programmed. Since medial-thalamusdamaged rats usually perform appropriately in aversive situations [avoidance-learning situations], provided they move at all, the lesion appears to interfere more severely with the triggering than with the selection of movement .3 It may come as a surprise that a research strategy involving avoidance learning in animals should be noted as one favored by acceptance of this book's formulation of anxiety and depression. This may seem a case of eating one's cake and having it. But three observations may be redemptory. Firstly, Vanderwolf's

106 Anxiety and Depression findings did not originate solely in voluntary movement in avoidance-learning situations but in a variety of situations. One such situation simply involved placing the rat on a small platform and recording the time taken to leave the platform. Medialthalamus-damaged rats were slow to initiate movement in this situation. Rats that had been operated on were also slow in making the investigative response of rearing when lights and a buzzer were presented to them as they rested in their cages. Secondly, though it can be argued that the solution to the problems of anxiety and depression are unlikely to be found solely on the basis of animal research, such research will inevitably be involved in the search for the basic physiological mechanisms involved. Thirdly, the particular case that was made against avoidance-learning experiments questioned them as an analogue of phobias. Vanderwolf's research points to the possibility that the avoidance-learning situation may be one of a number of situations in which impairment of voluntary behavior can be demonstrated. The usual avoidance situation, it was argued earlier in this book, demonstrates how an animal can learn an adaptive avoidance response. Because it is an adaptive response, it cannot readily be considered as providing an analogy for maladaptive phobias. On the other hand, determining the conditions under which an animal does not show this adaptiveness may very well have important implications for the deviant behaviors of human beings. Even here one must proceed cautiously. Learned helplessness as manifested in impaired avoidance learning has already been questioned as an analogue of depression. To think of impaired avoidance learning as demonstrated in the Vanderwolf experiments as revealing a defect in the triggering of voluntary action and, as such, representing an experimental analogue of the anxious person's behavior would then seem cavalier. But a case is not being made for the Vanderwolf experimental situation as an analogue of anxiety. All that is being proposed is that Vanderwolf may be getting at some very fundamental neurophysiological processes which are involved in the distress of the anxious person as he contemplates taking action on his environment. It is the two phases, particularly the second one, postulated by Vanderwolf to be involved in higher-level motor control, that will remind the clinician of the anxious person's behavior. In the

Research and Clinical Strategies 107 second phase, central representations of movements, selected in the first phase, must be maintained in a subthreshold state of excitation for some time, in such a way that they can be activated in a particular sequential order. Perhaps the most consistent complaint of anxious people has to do with the difficulty they experience in waiting. Waiting in turn at a store's checkout counter; waiting for traffic lights to change; waiting for an appointment. When reference is made to mild forms of anxiety we usually talk about being anxious to do something—for instance being anxious to let someone know how we feel. We have noted that the same somatic symptomatology very often appears to occur with different disordered affects. That this is so in the case of anxiety and depression has been demonstrated in the extensive studies by a group of researchers in Newcastle, England.' Research on symptomatology common to anxiety and depression is unlikely to be of much help since what is required above all at this time is a careful distinction between the two. Until this is done we cannot expect much progress in identifying their essential natures. Carney commenting on the difference in results from the studies that have attempted to identify endogenous depression and reactive depression noted that Certain differences from the result recorded by Kiloh and Garside are perhaps worthy of comment. A significant negative correlation between anxiety and a diagnosis of endogenous depression was found in the present inquiry (-0.619) in contrast to the small negative correlation (-0.192) recorded in their studies. This is also reminiscent of the negative correlation between depressed mood and guilt on the one hand, and agitation and psychic anxiety on the other hand, in Hamilton's investigation.... These observations may at first sight appear anomalous in that a state of anguished hand-wringing restlessness is widely thought to be a common feature in, and even pathognomic of one form of endogenous depression. However, a much less specific form of anxiety with motor unrest is a common component of a neurotic form of depression which is one of the most common syndromes encountered in psychiatric practice. The two phenomena are not easily differentiated and failure to discriminate between them may have caused the discrepancy

108 Anxiety and Depression to which reference has been made. More detailed clinical analysis in definition may serve to eliminate disagreement of this kind in future studies." Carney was concerned here with the distinction between two manifestations of anxiety. The passage has been quoted because it provides a clear example of the kind of obscurity that may surround the investigation of symptomatology—an obscurity that will have to be avoided as we try to differentiate anxiety from depression. Though the Newcastle group found many similarities between anxiety and depression they also found consistent differences between them. The differences were as follows: (1) in the case of anxiety, the disorders seemed to have started earlier and more gradually; (2) anxious patients showed evidence of early disorders of a social type such as poor school adjustment and difficulties in their relationships with their parents; (3) there was a greater incidence of disorders in the relatives of anxious patients; (4) depressive disorders tended to remit, even if only for short periods of time, whereas anxiety tended to persist. Now what is the significance of these differences in the light of the present formulation? Anxiety, it has been proposed, is an emotion that guides our actions in relation to future demands. It is not surprising therefore that it should become manifest earlier in life than depression, the role of which is to protect our past. It follows that, if anxiety becomes manifest earlier in life than depression, then those who suffer from severe anxiety will show a greater disruption of early social and educational development than those suffering from severe depression. The tendency for depression to remit may itself account for the finding of a greater incidence of disorders in the relatives of anxious patients. It would be harder to detect reliably instances of a disorder that fluctuates than it is to detect instances of a more persistent disorder. On the other hand, the greater incidence of disorders in the relatives of anxious patients may very well indicate greater inheritability of anxiety than of depression. If that is indeed so, its significance remains obscure. What of the relatively greater persistence of anxiety? This reflects, it would seem, the greater incidence of novel changes in a person's life than of changes in established pat-

Research and Clinical Strategies 109 terns. All future events, in that they are all novel to some degree, have the potential of eliciting anxiety. The occurrence of the most familiar event is not precisely the same as the last occurrence of that event, and, for the anxious person who for constitutional reasons is unable to impart a sense of familiarity to stimuli, it is novelty enough. The pursuit of differences between anxiety and depression, the teasing out of basic neurophysiological processes that may be involved in these emotions—these are strategies that are important for any formulation, and not only for the one that is being proposed in this book. The only contribution that the book may make is in demonstrating how one may remain aware of the significance of the findings of such specific research strategies. There are some research problems that are particularly germane to the present formulation: for instance, the determination of the conditions under which events may lose their reinforcer effectiveness; the determination of the conditions under which habituation does and does not occur to stimuli; and the relationships between societal structures and the incidence of depression. Like any formulation, specific or general, the present one will have to stand the test of empirical research into those processes that seem to be particularly implied by the formulation. But the proposal has immediate implications for our whole approach to these important emotions and their disturbances. It is for this reason that I shall now elaborate the general implications, though the validity of the formulation stands in abeyance. It is generally assumed that anxiety and depression are bad experiences and that we should do everything within our power to reduce them. This is a natural assumption since the experiences are unpleasant, and an individual has a natural inclination to reduce an unpleasant experience. But society does not always permit the individual an easy escape from his unpleasant experiences. The child may find school unpleasant, but the child is not permitted, at least for some years, simply to stay away from school. It is true that some psychologists, such as Skinner, feel that school need not be as unpleasant as it is. But until school can be made pleasant (and despite Skinner's optimism there is no guarantee that it will ever occur that school is always pleasant) society is likely to continue to insist that the child goes to school.

110 Anxiety and Depression Society does this because, though the child's natural inclination is to avoid the unpleasant situation, society feels the child must nevertheless suffer for the good of society. Despite the unpleasant experiences individuals in a society may have in a particular situation, society may encourage and indeed insist that they enter the situation on the grounds that, for other reasons such as the development of technical skills and the economic status of the society, it is good for the individuals to enter the situations. Society, no doubt, would reduce the unpleasant experience of school and try to make experiences increasingly positive, as long as the child became educated. It is true that society tends to use punishment far too much, positive reinforcement fa: too little, and perhaps this is because it is so much easier to use punishment. If Skinner can show the way, society presumably would be quite happy to make things more positive than negative. A society, for its own good, must always consider whether its attempts to remove unpleasant experiences is a wise course of action. If anxiety and depression are important warning signals, chemical comforts must come under close scrutiny. Let us go back for a moment to the use of punishment in our society. To the extent that there is uncertainty about the relationship between an individual's behaviors and the sanctions for those behaviors, the individual is likely to become anxious. The anxiety serves as a warning to the society that the relationship between its sanctions and the behaviors sanctioned is an uncertain one in need of further attention. Simply alleviating the anxiety with drugs will not do. Perhaps it is fortunate that a direct therapeutic attack on the symptom of anxiety, particularly chronic free-floating anxiety, is unsuccessful in many cases, and inefficient in others. Freud recognized that "one can hardly ever master a phobia if one waits until the patient lets the analysis influence him to give it up ... one succeeds only when one can induce them through the influence of the analysis to ... go about alone and to struggle with their anxiety while they make the attempt."6 Behavior therapy has recognized that the effects of desensitization therapy often seem to be to get the phobic patient to approach the phobic object despite his fears. One of the signs that this is so is the frequently noted

Research and Clinical Strategies 111 lag of verbally reported changes in fear behind the change in approach behavior. As a result, some behavior therapists have concentrated on simply helping the phobic patient to approach the phobic object, leaving the felt anxiety and physiological manifestation of anxiety to take care of themselves. On the basis of the present formulation of anxiety one might expect that therapies aimed at helping the patient to increase his knowledge of the feared situation and to acquire skill in handling the situation would be found to be particularly beneficial. This is so because, as I have argued, the function of anxiety is to delay approach behaviors until adequate knowledge of the situation has been acquired. The assumption that systematic desensitization works through a passive process of deconditioning has been questioned by some behaviorists. Goldfried's review of systematic desensitization studies led him to a view of the process similar to the one reported by subjects in Paul and Shannon's study of group desensitization:7 "subjects in the group seemed to perceive the desensitization method as an active mastery technique which they could acquire and use themselves, more than in the individual application. Clients' descriptions of utilizing desensitization training to master anticipated areas of stress themselves suggest the development of a confidence-building 'how to cope' orientation." Goldfried's own experimental work has indicated the particular therapeutic effectiveness of training people in relaxation as an active coping skill Goldfried and D'Zurilla have proposed a program of effective problem solving.10 The way in which one may learn to cope with anxiety appears to be a particularly important area of research for the future. Peck has reported that in a study of the degree of agreement, across eight countries, on the definition of effective coping behavior, coping with anxiety was the least firmly and commonly defined of all the areas.'1 Anxiety is always on the frontier of knowledge as a safeguard that a job will be done properly. For this reason Kierkegaard considered anxiety to be "one of the best teachers."12 But perhaps we have to know how to listen to the teacher. It has already been noted that a person may seek relief from anxiety and depression by a retreat from a meaningful life into

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alienation. Getting into the proper mood for something becomes a more and more tricky business as man becomes more sophisticated and as the sophisticated person becomes older. He may in old age give up and become apathetic, a condition sometimes mistaken for wisdom. Alternatively, instead of disengagement, a person may become manic. Then he tries to do without the structure of his life and to silence his conscience. He can become fascinated with all that is incompatible with depression—the laughter, the dance. But the manic with his impossible dreams is an alienated from the world as the pessimist. The manic seems often to behave not only as though nothing has changed, nothing has been lost, but also as though he can master the future. Anxiety as much as depression is often on the other side of the coin from mania. It may be objected that this description of the manic person implies that he makes a choice of such impossible dreams when in actuality he is the victim of his constitution. It is hard not to get trapped in the ancient problem of freedom versus determinism. Nevertheless, it is not a problem to he thrashed out here. The functional descriptions of emotional behaviors such as mania serve merely to indicate the consequences to which they lead. In the case of mania the consequences are similar to those of alienation. Depression and anxiety like other negative emotions reduce us to primitive beings. But they do so in the interests of our humanity. They do so in order that we may make up for what we have lost in the complexity of our lives and in order that we may be well prepared for the increased complexity into which the future beckons us. These emotions do not have their source in accidental aspects of our nature as the Stoics believed. Their source is in the essential nature of man. Our efforts should not be directed at desensitizing people, but rather at helping them to develop a tolerant sensitization—one which will enable them to use the cue function of their negative emotions. Perhaps an approach that emphasizes the role of such emotions will help to reduce some of the despair of man because anxiety and depression are so pervasive and so persistent that we call ours the Age of Anxiety and sometimes the Age of Depression. Above all we must help people to rid themselves of the Proustian notion that the only true paradise is always the paradise we have lost. We can help them to look for those things in the para-

Research and Clinical Strategies 113 dise lost that they can take with them into the future. This they have no choice but to do. If they neglect it, then they can expect to be depressed and to become fixated on an even more enchanting past. Then we have what Kahn calls an existential aging long before the biological end of life.'" Negative emotions are not the enemies of human happiness. They are the protectors of the meaningfulness of human life, and it is only through meaningful lives that we can be happy. Drugs may indeed all but remove our anxiety and depression. But we must try to predict the kind of world this will produce and ask ourselves if that is the kind of world we want. Should we be enthusiastic about finding a drug that will remove depression if depression is an important unpleasant event evoking reconstitutive behaviors that maintain a given level of complexity in the organism? The argument that one could reduce the depression without removing it is not a strong one because the individual would not take the drug unless his depression was reduced to a level that did not bother him. The argument that one could use the drug only for those with intense persistent depression is stronger, but there are problems. Who decides when depression is intense enough to be removed? Does it not seem that, with the availability of drugs, people have become less and less tolerant of unpleasant affect? On the other hand, if all the controversy over the question of the unitary or binary nature of depression were resolved, and if it were demonstrated that certain depressions were entirely constitutional in origin, and if the constitutional depression could be reliably differentiated from those due to both constitutional and environmental factors, then an argument could be made for the use of drugs or other treatment to reduce the intensity of the depression. Such pure constitutional depressives would best be considered as unfortunate victims of the overshooting of important genetic characteristics of man. But how are we to restrict the use of the drugs? Were we to develop an effective set of antidepressant drugs, we could all be equipped to keep depression at bay. And then we could break from our associative chains—our families, our jobs, our neighborhoods—with impunity. If such drugs were completely effective and removed all traces of depression, there would no longer be any need to belong and only a state of anarchy could result. Should

114 Anxiety and Depression there remain at a very basic level a remnant of the need to belong and a trace of the depression that occurs when that need is thwarted, we might then, as an atomized mass of lonely individuals, be well primed for the architects of totalitarian states. Nisbet noted in his book, Community of Power, "The total State is rational in that it recognizes in human personality certain basic needs for security and recognition and strives through every art and technique to satisfy those needs in calculated political terms.' Later in the same book he adds "The process is not too difficult, or even too violent, providing the masses have already been created in significant size by processes that have destroyed or diminished the social relationships and cultural values by which human beings normally live and in which they gain not merely their sense of order but their desire for freedom."" If society were to choose not to develop techniques for the removal of depression from the face of the earth would people simply have to suffer their depressions? The answer is "No." A society can work on fundamental changes which would reduce the likelihood of some losses such as the loss of a spouse, the loss of a job. But it is unlikely that these and similar losses can be avoided altogether. Men must learn to cope with depression rather than to try to gain freedom from depression. How can they cope? What indeed does one mean by coping with depression? It does not simply mean that one must put up with the depression, though developing greater tolerance for the experience as for all unpleasant experiences might be worthwhile. We may not agree with the Stoics that emotions are to be suppressed, but we may recognize that we need to be stoical in our tolerance of their inevitable presence. Coping with depression means the ability to identify the significance of the depression in terms of the change in the structure of our lives and the ability to restructure our lives. Rather than turning our attention from the loss to the search for other reinforcers, we must fix our attention on the loss, the implications of the loss for our life and the ways in which that life may have to be restructured to accommodate the loss. As with anxiety, I am suggesting that the behaviors elicited by the negative affect, in this case the preoccupation with the loss, be harnessed by the therapist and guided along more productive lines. I am not suggesting that the only way to cope with depression

Research and Clinical Strategies 115 is for the widow to find a new husband, the worker to seek again the promotion, the retired man to try to regain employment. In some cases, of course, these approaches may be very viable ones and would be encouraged. Yet, to suggest that the depressive must restructure his world is by no means to suggest that in all instances he must try to regain exactly the same structure now lost. But we are getting into the therapeutic implications of this position on anxiety and depression too soon. This is a matter best left to the end. There are still some points of a more general nature to be made. The difficulty into which the psychoanalysts got themselves— the complexity of their system reaching its zenith in Jung's archetypes—was due to the fact that they had hoped to find solutions to the individual's problems in the individual himself. Freud's intellectual revolution has often been compared to that of Copernicus in that the human being was given another blow to his pride. But Freud still thought that the individual was the center of things. And yet perhaps the world does not go round the individual—the individual passes through the world as one of its barometers. This brings us back to the evolutionary significance of anxiety and depression. It is not easy to account for the evolution of anxiety and depression by Darwinian selection. Is it plausible to suggest that to the extent that an individual is more predisposed to anxiety and/or depression, he will be more fit in the Darwinian sense— that his adaptations are such as to make him more likely to contribute a more than average number of genes to future generations? Perhaps some individuals with a marked absence of anxiety die on places like racetracks or, being psychopaths, become incaracerated in prisons before they produce offspring. Primary psychopaths or sociopaths—no final agreement has yet been reached on the appropriate term—have been described as those who show "an inability to form lasting emotional relationships with others, failure to grasp the meaning of responsibility, repeated and inadequately motivated aggressive acts, absence of neurotic guilt and anxiety, apparent failure to profit from experience.' Whether or not primary psychopaths are indeed deficient in the emotion of anxiety has not, on the other hand, been clearly established. If one were to restrict the meaning of the term anxiety purely to the

116 Anxiety and Depression response to cuts associated with future punishment, then there is some experimental evidence that psychopaths are deficient in anxiety. This research, reviewed by Trasler, has indicated that primary psychopaths are deficient in the formation of anticipatory fear responses." For instance, one visually and consecutively presents to a person the series of digits from 1 to 12. The person has been told that he will receive an electric shock when the number 8 appears. Then it is found that, whereas normal people show increased palmar perspiration as the digit 8 approaches, psychopaths do not show this anticipatory increase in palmar perspiration. If one were to accept the response in this situation as an adequate indicator of anxiety, then one could conclude that primary psychopaths are deficient in anxiety. But such restrictive operational definitions of complex emotions are of doubtful value. The possible lethal consequences of ignoring the cue function of depression is suggested by the evidence for the increased probability of serious physical illnesses such as coronary heart disease following life changes." There is no evidence that depression does indeed follow such life changes and precede the physical illness. Clinical observation suggests that bereavement, which is generally followed by depression of some degree, may result in physical illnesses particularly in older people'" It is a matter that would seem worthy of investigation. What would need to be remembered in such an investigation is that the depression may not be of clinical intensity. In passing and in connection with psychopathy we might ask how, if anxiety and depression are acting as the monitors they were supposedly designed to be, we have come to create the world we have? Surely we would not have created terrible weapons of destruction and sources of pollution. We would not permit models of violence to exhibit themselves to our children through the media. Could it be that our politicians and high executives are deficient in the dispositions to anxiety and depression? The possibility that we can account for the evolution of anxiety and depression in terms of Darwinian organic adaptation could be tested, but it is probable that we would find ourselves forced to adopt an account in terms of biotic adaptation. This involves the distinction between those behaviors that are directly adaptive for

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the individual and indirectly adaptive for the species of which he is a member and those behaviors that are adaptive primarily because they provide warning signals to the species, but may not be adaptive for the organism itself. Characteristics of the first sort are probably those which occur in all members of the species to the same extent. Characteristics of the second sort are probably those that appear in members of the species in varying degrees, with the maximum degree being harmful to the individual. Some evolutionists are uncomfortable with this kind of formulation, but others feel that such a formulation is required even to account for some of the behaviors of animals. For instance R. C. Lewontin in his review of a book by G. C. Williams wrote, If a bird gives a warning cry or makes a conspicuous display of his plumage at the approach of an enemy, all the individuals in the population will be benefited by the warning, but there is no special differential benefit in fitness to the altruist who has given the warning. On the contrary, the very act of giving a warning cry or making a display will call the bird to the attention of the enemy and in this way may prejudice the survival of the foolish Samaritan. Since any gene causing such behavior will not be increased in the population by differential fitness and, indeed, may be decreased, we cannot explain the evolution of such characteristics by Darwinian selection 20 Only if we are prepared to accept such formulations of evolution can we think of emotions such as anxiety and depression as adaptive whilst recognizing that they may be antecedents of fatal psychosomatic illnesses and perhaps suicide. In his book, Williams makes the following observation: We ordinarily expect selection to produce only "favorable" characters. But here again there are exceptions. In the effects of a gene there may be influences on more than one character. A given gene substitution may have one favorable effect and another unfavorable one in the same individual, often, but not necessarily, in different parts of the life cycle. The same gene may produce mainly favorable effects in one individual, but

118 Anxiety and Depression mainly unfavorable effects in another, because of differences in environment or genetic background. If the mean effect is favorable, the gene will increase in frequency, and so will all its effects, both positive and negative ... the favorable selection of the genetic basis for deleterious effects must be ascribed to other effects of the same gene. Favorable selection of the gene is inevitable if it has a favorable mean effect compared to the available alternatives of the moment."' Williams also noted that "the deterioration and abscission of the older leaf is senescence, and is not adaptive. It represents a measurable loss of materials and energy, and is the price paid for an adaptive deployment of materials that is presumably worth the price."' We may similarly have to view anxiety and depression as the unfortunate price we have to pay for the exercise of other adaptive functions such as the learning of new skills and the maintenance of some continuity in our lives. After all the discussion and comment and passing references, I have not, it is true, given any clear indication as to what causes anxiety and what causes depression. But emotions in the individual are like revolutions in a society. We can no more answer the question "What causes an emotion?" than we can answer the question "What causes a revolution?" In attempting to understand any revolution, the historian and political scientist are required to do considerable and careful analysis, at the end of which there can be no certainty that the analysis is a correct one. This is true also in the case of the individual person's separate emotional occurrences. What then are we to do, not only to help men survive but also to give them better lives? It seems that above all we must develop explicit detection strategies to determine the significance of emotional occurrences and strategies for keeping life on an even keel without sacrificing growth. If we do not develop appropriate strategies in living, we are likely to resort to rituals and myths that will be adaptively primitive despite the technological finesse we can use in their development. We are not likely to develop these strategies solely on the basis of the strategies which rats use to avoid laboratory shocks. In the case of each emotional person we are not looking for the cause of his emotion, but for the key to his

Research and Clinical Strategies 119 emotion—the ultimate rather than the proximate cause. In this search, the stated objects of his emotion may sometimes help. At this point we can consider the implications of the present formulation of anxiety and depression for the assessment of the significance of any particular occurrence in an individual and for treatment. The first task facing the clinician will be to decide whether or not the person is severely disturbed. Does the person show severe persistent anxiety or severe depression? If the argument of this book is accepted, those who are classified as severely disturbed will be those in whom the emotions of anxiety and/or depression are not serving their usual functions. For this first task, general measures of a physiological nature will probably be developed. It is in relation to this first task that the identification of syndromes may be of value and that the person may be considered from a biological point of view. Psychologists have recently become disenchanted with general trait measures of personality. Disappointed with their inability to predict a person's behavior on the basis of such general trait measures they have concluded that there is little consistency in people's behavior and that behavior is situation-specific. But even the most severe critics of the trait approach to personality have acknowl edged that trait measures may be of value in work with severely disturbed people. Mischel for instance has written: "Whereas dis• criminative facility is highly functional ... diminished sensitivity to changing consequences (i.e., indiscriminate responding) may be a hallmark of an organism coping ineffectively. In fact, indiscriminate responding (i.e., "consistent" behavior across situations) tends to be displayed more by maladaptive, severely disturbed, or less mature persons."2 At the first stage of assessment then, when one wished to determine the severity of the person's emotional disturbance, trait measures might still be of value. Once the clinician had decided that the person was severely disturbed— that there was something wrong biologically—his task would be to reduce the severity of the disturbance. He would have to restore to the person's anxiety and/or depression its function as an emotion. But the problem would not end there. There might be some clinicians who would prefer to accept only the responsibility of detecting the severely disturbed person and of reducing the severity of the disturbance. But then there would be a need for

120 Anxiety and Depression another class of professionals prepared to help people to become aware of the discriminative signal function of their emotions as an aid in improving the quality of their lives. It is understandable that clinicians in mental hospitals and psychiatric clinics should have been preoccupied mainly with reducing the disturbance in those severely disturbed. But attention must be paid to the role of emotions in the lives of those in whom the severity of the disturbance has been reduced and in those who experience emotions in a less severe and more normal manner. This is not an argument solely for preventive care, though it may very well he that not all severe disturbances arc the result of inheritance. It may be that with the repeated evocation of relatively mild episodes of anxiety and depression a person may become severely disturbed. In that case, attention to the normal functioning of these emotions would be required as a preventive measure. But even were it not the case that such repeated occurrences of normal emotional episodes resulted in chronic disturbance, there would be sufficient reason for the education of people in the proper use of their emotions. It is generally recognized that, apart from people who find their way into psychiatric clinics and mental hospitals, there are those whose lives are far from satisfactory—people who live in one place and yearn to live in another, people who do one job and feel they would be much happier doing another, people whose educational programs, friendships, and marriages go awry. Among these people we can include those whose severe anxiety and depression have been reduced through pharmacological means or the application of behavior-modification procedures, but who remain discontented with life. After a decade of applying behavior-modification techniques, I wonder if the practice did more to relieve my own anxiety by providing me with some structure. One is reminded of a comment made by Rollo May, "it seemed to me that the central `motif' the particular `genius' or `charter' (in Malinowski's sense) of a given historicial period, will be what, in deteriorated form, is obsessively clung to at the time of disintegration of the period. With regard to the present period, we shall indicate below that the dependence on science as a form of magic is what many persons in our day cling to as a method of allaying anxiety and may well be what the next age will attack."24

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It is not only for the sake of the individual person that attention must be paid to the normal episodes of anxiety and depression. By determining the significance of emotional episodes in individual people, we can detect faults in a society's way of life as a whole, so that these too can be corrected. Too much must not be made at least at this stage of our knowledge of the distinction between normal episodes of anxiety and depression and clinical episodes. Those seeking professional help, though some may want thereby to call their anxiety or depression clinical, may reveal more defects in their society than in themselves. Weissman and Klerman did a content analysis of psychotherapy with depressed women. They found that the women were far more inclined to deal with practical problems than with soul-searching and noted "The therapist familiar with the realities of working and lower class life will not be surprised if the patient wants to talk about housing, crowding, unemployment and extended family life rather than about interpersonal, dynamic and early experiences." ' It is then the significance of emotional episodes that we must learn how to identify. For people in general, the situationist's position must be accepted. The problem is not one of predicting a person's behavior, and so the failure of general trait measures to help in these instances is no great problem. The task is to determine what it is in the life of the individual now to which the emotion points, and to do something about this so that plans can be made for more satisfactory behavior in the future. The task of the professional helper is to determine what the essential nature of the problem is. This is something that seems to have been neglected by therapists of all persuasions, whether of the psychodynamic or the behaviorist sort. The psychodynamic investigations and the behavioral analyses always start after the decisions about the problem have been made. How they are to arrive at such decisions is always neglected. In emotional disturbance, to determine the essential nature of the problem one must determine the significance of the emotional episode. But how does one go about determining the significance of such episodes? Mischel, who argues against the trait approach to personality, tells us that among the variables which we will have to take into account in assessment of personality are "cognitive and behavioral construction competencies, encoding strategies and

122 Anxiety and Depression personal constructs, behavior-outcome and stimulus-outcome expectancies, subjective stimulus values, and self-regulatory systems and plans.'" Even without going into the complex nature of each of these variables, it is clear that, if, in order to determine the significance of an emotional episode, one were required to measure all of these variables and their interaction, the task would be a formidable one. But such a multivariate approach to an individual's emotional episodes would be required only if we wished to provide a complete causal account of the episode, and that is not what we want to do. Our task is rather to find the key to the emotional episode. What is meant by determining the key to the emotion? It can perhaps be made clear by comparing the task of the clinician with that of the detective who must solve a case of murder. As it is the de tective's task to discover who committed the murder, so it is the clinician's task to discover the key to the emotion. It is not required of the detective to provide a complete causal account of the murderer's act. It should not be expected of the clinician to provide a complete causal account of an emotional episode. How then can one go about finding the key to an emotional episode? Where does the clinical detective look for his clues? Unfortunately, rather than looking for the clues to an emotional episode, clinicians have relied on general physiological and psychological measures which are of use only in attempts to provide a causal account of emotions in general. Even the psychodynamically oriented clinician, despite his intensive investigation of each individual case, has emphasized general dispositions. Because of this the art of clinical detection has not been developed, not at least in a communicable form. All that can be done here, therefore, is to indicate the kinds of strategies that may be useful in our work of detection. Thorough dialectical interrogation of the emotional person will be the primary strategy. Let us take the case of the person who is anxious. The task would be to determine what is the crucial nature of the mismatch between the anticipated demands of the environment as the anxious person sees them and his preparedness as he see it. An attempt to determine the significance of emotion by a functional analysis of the behaviorist sort will

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not work. In a functional analysis the behaviorist attempts to determine the antecedents and the consequences of any particular behavior. But the anxiety and depression observed by the clinician are not episodic events like a tic. The patient is in a state of anxiety or depression when first observed by the clinician. The antecedents have already occurred, and as long as the patient remains anxious or depressed one cannot refer to consequences without taking into account the emotional state itself. The question we wish to answer is not what kind of disease this person has. It is not what kind of personality he has. But also it is not what is the situation in which the person is anxious or depressed. The question we are asking comes after the diseasetype question has been asked. The personality question will not permit us to handle the uniqueness of the clinical problems which face us. One might have thought that the situationist approach would generally have been the correct one to take. In some instances of anxiety, as we have already noted, it may very well be situation-specific, and then a behavioral analysis may do. But one could expect that in many cases of anxiety and perhaps in all cases of depression, because of the pervasiveness of the effects of these emotions, behavioral analysis would come up with the same pattern in all situations; and yet one would not have the heart of the matter. It is too easy to be seduced by the offerings of functionalanalysis methodology because it enables us to escape the mysteries of la vie intericure. But the more we consider a statement such as "In the end, we find ourselves dealing with two events—the emotional behavior and the manipulable conditions of which that behavior is a function—which comprises the proper subject matter of the study of emotion,' the more we realize that it gives us little real guidance. The whole question of what is emotional behavior has been begged. The interrogation of a person may very well result in false leads. What he says cannot be taken at face value. He may designate objects of his emotion that have little or nothing to do with the crucial problem. The anxious person may say that he is anxious because of an impending examination. But on interrogating him, one determines that there is no mismatch between the demands he expects the examination to make of him and his

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preparedness as he sees it. On the other hand, should the clinician get close to the key to the emotion, the person may very well try to come up with something in the nature of an alibi to cast doubt on the clinician's hunch. For instance the clinician may have a hunch that, as a person approaches a final examination, the anxiety is evoked because the person realizes he will now be expected to be less dependent on his parents, and the crucial mismatch is between the future demand of independence as he sees it and his perception of his preparedness. With increased awareness of the mismatch one may expect increased anxiety, and so the emotional person may resist the clinician's proposal. Indeed, a clue that one is on the right track may very well be this increased resistance. In the same way that the detective in his hunt for the murderer may keep in mind certain broad classes of motives for murder—murder for love, money, revenge—so the clinician may keep in mind some broad classes of mismatch, as he hunts for the clue to an emotional episode. One source of clues may be in the mismatch between the competencies that a person has and the competencies demanded by a situation. This will provide clues perhaps to the significance of a person's anxiety but is not likely to be relevant in relation to an episode of depression. One would not be interested in the person's general cognitive skills and repertoire of behaviors, but in those specific ones that appear to be demanded in some anticipated situation. The mismatch may be in relation to a nonsocial situation, such as taking an examination, or it may be related to social situations, such as attempting to establish a relationship with someone, closing off a relationship with someone, discussing with a superior an aspect of one's work situation. In some instances it will be found that there is no real discrepancy between the demand of a situation and the competencies of the person. The competencies of the person are hidden perhaps under a self-assessment such as, "I am no good at examinations." Though a person may identify a particular situation as the reason for his anxiety, one may find that even when one takes into account the person's perception of his competencies and his perception of the demand of the situation, there is still insufficient reason for the anxiety. On interrogating beyond the particular justifications offered by the individual, one may find that the

Research and Clinical Strategies 125 anxiety is provoked more by a mismatch between what an individual feels his capacities are and the outcome of his behaviors in a particular situation. We have referred to a hypothetical case of an anxious person who expected a greater demand on him for independence should he pass a final examination. Similarly, a person may be more anxious over his capacity to deal with some expected outcome of failing an examination than about failing the examination itself. The beliefs a person has about the outcome of his behavior in some situation often involve assumptions on his part as to the way in which other people will respond to his behavior. In an attempt to reduce some of his anxiety, the person has structured the situation in accordance with certain specific expectancies rather than searched for the mismatch which lies at the root of his anxiety and attempted to resolve the problem. It is probable that the source of an emotional episode will often be found in the value system of the individual. A person may be anxious about an impending event because it involves a conflict of values. A girl intending to marry the military man she loves may wonder how, as a pacifist, she can live with the situation. A person may become depressed not because of an actual loss suffered because someone he loves has died, but because a conflict of values results in a psychological loss. A child of Catholic parents who has been divorced may feel that he has lost his parents because what he has done is not acceptable in their value system. It may not be sufficient to determine by the application of a pleasant-events schedule what pleasure a depressed person obtains from things. We may also have to determine the value he places on certain things. The divorced person may find no pleasure at all in thoughts about his parents' view of his action. He may, on the other hand, place considerable value on his parents' thoughts about his action. Another source of clues closely related to the person's values will be the explicit or implicit rules he follows in his behavior. How are his rules threatened in anxiety, and how have they been transgressed in depression? It will be these rules that determine the meaning or the meaninglessness of certain events. In our search for the keys to particular emotional episodes, the technical terms of physiology and psychology will not be sufficient for the task. As

126 Anxiety and Depression Harr: and Secord='' and others have emphasized, the ordinary language of people will nccd to be exploited and explored to the full. This is not to suggest that we abandon psychological theories and rely solely on everyday language. It is simply to note that I am in agreement with those who feel that present theories are not adequate to the task. The development of adequate theories will probably have to take into consideration the ordinary use of language. Whatever it is that is the key event at the heart of emotional disturbance, it will be an event that has significance in relation to some major theme in the life of the person. The approach to the assessment of an individual's emotions must involve a search for consistencies in his behavior—a search for themes. It is an approach similar to that which was described by F. H. Allport: By making a thorough sampling of the individual's actions, we can describe teleonomically a number of consistencies, that is, certain things which the individual is generally trying to do. When we have these before us, we can prepare ourselves, in our perceptual setting, to recognize and react to an individual of whom all these behavior trends are at one and the same instance true. And when we turn from the records which we have been compiling about the individual and encounter the behaving individual himself, our anticipation (or "set") becomes realized in appropriate behavior. Our "set" fits the reality of the individual; and we can be aware, in the full psychological sense, that "this is he."29

F. H. Allport's approach to the individual case seems to be the approach required, rather than that of M. B. Shapiro, who has also been active in the assessment of individuals who are suffering from depression.10 Shapiro has been concerned in measuring the symptoms of depression, particularly the affective component. His assessment procedure, therefore, is a useful monitoring device to determine the success of various therapies rather than an assessment procedure which might indicate the nature of the problem and the appropriate therapeutic procedures. Would one ever know when one has arrived at the heart of the matter, when one had found the real reason for the emotional dis-

Research and Clinical Strategies 127 turbance? The answer is "No." The answer is "No" because the reason can only be found in the way the world is being perceived by the disturbed person. All that one can do is to take the formulation that has survived the argument and get the disturbed person to act as though it were true. Apart from psychoanalysis, there appear to be two primary approaches to the treatment of anxiety. One involves the use of tranquilizing drugs and the other behavior-modification procedures, particularly systematic desensitization. When a person is severely and persistently anxious, then drugs and behavior-modification procedures may be required to reduce the severity of the disturbance, But if the person's capacity to experience anxiety is not removed completely, and it has been argued in this book that mankind should not attempt to develop his technologies in this direction, then the clinician must help the person further. The formulations which have been proposed do not result in a specific therapeutic procedure in the manner that Wolpe's ideas on reciprocal inhibition led to systematic desensitization, or the catacholamine hypothesis of depression developed by Schildkraut provides a rationale for the use of antidepressant drugs. The present formulations would suggest that such specific procedures, though they may play a role in therapy, can never be completely adequate in the treatment of any problem. The task with which the emotional person is faced can be described as involving the restoration, planning, and development of his life. Emotional episodes will always involve these components, though the task may be a major or minor one and the person may or may not need the assistance of professional people. If professional help is needed it will probably have to take the following form. The first thing that will be required is to train the person in detecting the key to his emotional state. The next step will be to train him in the ways in which the problems to which his emotions point can be solved. In some instances the main problem will be to determine the key to the emotion. What needs to be done then will be obvious. If, for instance, a person realizes that he is anxious because he is indeed ill prepared for an examination, the solution is a fairly simple one. He must get better prepared or abandon the idea of taking the examination. But in most instances, it is not likely to be that simple. What is the divorced

128 Anxiety and Depression person to do about the psychological loss he feels because of his parents' disagreement with his action? What is the girl to do about her pacifist ideas if she marries her military man? Cases such as these cannot simply be treated as a psychoanalyst may treat them, as due to the development of some faulty psychodynamics in the person. There is no reason to look upon such people as irrational, and therefore the simple application of Albert Ellis's rational therapy will not help. One of the things that will always need to be examined is the context within which certain values are in conflict. One will very often find that, given the person's set of assumptions, the ways in which he construes his world is quite logically consistent. As we have noted many times now, a person strives to give a structure to his world in order to reduce the anxiety-provoking uncertainty. But where anxiety persists, it will be found that somewhere a particular belief is not held strongly enough, a particular value is uncertain and uncertainly held, there is less than complete confidence in other people's behaviors. Obviously, there is no simple set of therapeutic procedures that can be applied to problems of this sort. They are problems which will involve changing and restructuring fundamental value systems and styles of life. Both the emotional person and the clinician will be brought to the realization, as they negotiate the changes and restructuring, that what they are doing has implications not only for the life of the emotionally disturbed person himself, and for the clinician, but, insofar as they are creating models of man, they have implications for the society in which they are living. The complexities that will always be involved in adequate procedures are obvious and one can only note the main stages that are likely to be involved. They are: 1. The key to the emotion will always involve some discrepancy between some aspect of the structure of the person's life and an anticipated action, as in anxiety, or a past action, as in depression. Where this discrepancy lies must be identified as precisely as possible. 2. Since most situations will involve other people, he will then have to decide whether or not he will attempt to produce a change in these other people, or effect a change in himself; In

Research and Clinical Strategies 129 most cases, he would choose the latter course as being the more likely to be successful. 3. He will have to assess the impact on the structure of his life of any particular change that he intends to make; a change that might result in a match between his life structure and the accommodation of the future or past event may result in its incapacity to accommodate some other future or past event. There are obvious similarities between the kind of clinical interrogation that is being proposed here and Harre and Secord's use of challenges to investigate people's attitudes" and Albert Ellis's rational therapy '' There is nothing new, therefore, in the approach that is being suggested. But in that this kind of approach is shown to follow inevitably from the analysis of anxiety and depression that has been proposed in this book, the approach is provided with a further rationale. The procedure is likely to be more complex than that proposed by Ellis. I described the assessment process as a dialectical interrogation. The therapy process also can be described in this manner. Indeed assessment and therapy are not easily separated in such an approach. The kind of complexity involved is that which is indicated by the following quotation from Aaron Esterson's book The Leaves of Spring: "The observer radically restructures his view of the situation, reconciling the events that contradict him in a new, more comprehensive synthesis. And this he repeats when further contradictions appear in conflict with his new gestalt." Esterson goes on, "By such acts of comprehending, dialectical reasoning progresses. Each totalizing unification is a synthesizing act of consciousness, reconciling the elements of experience in a new whole that transcends the observer's existing gestalt, which is dissolved into, and preserved in, the wider synthesis."33 The method of reconstruction is a dialectical one insofar as it aims to examine through discursive procedures the basic assumptions and biases that are present in both the troubled person's and the therapist's views of the situation. It is certainly not a dialectical method which attempts to restore to intellect the place it lost from the onslaughts of empiricism. Since it uses the information function of emotion, it can be said to retain a considerable amount of empiricism. It would seem to be the fault of

130 Anxiety and Depression many therapists that, starting with a particular philosophical position, they believe that they can impose this philosophy on their patients. There is no doubt that, given patients who are tired and suffering enough and given procedures as drastic as those portrayed by Anthony Burgess in his The Clockwork Orange, the therapist may be successful in this. But there are some people who will not come his way and some who even when they do, will not be helped. These are people whose philosophies of life, whether ill or well formulated, for better or for worse, are different from those of the therapist. If for nothing else the dialectic is attractive because of its undogmatic spirit. But there is more to it than that. Dialectic reasoning must be relied on as well as demonstrative reasoning. People do, in their daily lives, engage in dialectical reasoning and therefore one cannot expect ever to be able to get to the heart of the matter in an individual case through demonstrative reasoning. The dialectical method is required because, though analogies and metaphors may have a poor status in present-day science, they are by no means absent in the thinking of people in general. If the therapist finds himself under dialectical attack he will find it difficult not to meet the troubled person on the same ground. The dialectic that is being talked of here has nothing as grand about it as Hegel's idealistic dialectic or Marx's dialectic materialism. Though it is believed that anxiety and depression are the result of a relentless evolution, it is also believed that they have evolved to protect us in the face of an uncertain world that has nothing of the destiny that these thinkers seem to have believed in. What we must help the patient to learn is how to meet the erosion of his past and the uncertainty of his future with the fluidity of the dialectic, using his emotions as monitors. We are not likely to be of much help if we cannot as therapists do this.

Notes NOTES TO CHAPTER ONE Magda 13. Arnold, ed., Feelings and Emotions (New York: Academic Press, 1970). 2 Luigi Barzini, The Italians (Toronto: Bantam, 1965) pp. 89-90. 3 Ibid., p. 104. 4 Ibid., p. 172. a Ibid., p. 236 (italics added). Richard S. Lazarus and Elizabeth Alfert, "Short-Circuiting of Threat by Experimentally Altering Cognitive Appraisal," Journal of Abnormal and Social Psychology, 69 (1964): 195-205. I have made reference to only one aspect of Lazarus's conceptual analysis and empirical investigation. That his approach to the problem of emotion is far broader can soon be discovered in his writings—in for example, Richard S. Lazarus, James R. Averill, and Edward M. Opton, "Toward a Cognitive Theory of Emotion," in Magda B. Arnold, ed., Feelings and Emotions. 8 Stanley Schachter, "The Assumption of Identity and PeripheralistCentralist Controversies in Motivation and Emotion," in Magda B. Arnold, ed., Feelings and Emotions. n Richard I. Evans, B. F. Skinner: The Man and His Ideas (New York: Dutton, 1968). io Ibid., p. 11. 11 Anthony Kenny, Action, Emotion and Will (London: Routledge and Kegan Paul, 1963).

132 Anxiety and Depression

R. S. Petcrs, "Motivation, Emotion, and the Conceptual Schemes of Common Sense," in Theodore Mischel, ed., Human Action: Conceptual and Empirical Issues (New York: Academic Press, 1969), pp. 135-65. 13 Arthur Koestler, The Ghost in the Machine (New York: Macmillan, 1967). 14 Joseph P. Fell, Emotion in the Thought of Sartre (New York: Columbia University Press, 1965), p. 237. 1:' Theodosius Dobzhansky and M. F. Ashley Montagu, "Natural Selection and the Mental Capacities of Mankind," Science, 105 (1947): 589. 16 Jean-Paul Sartre, Sketch for a Theory of the Emotions (London: Methuen, 1962). 17 Fell, Emotion in the Thought of Sartre, p. 100. '=

NOTES TO CHAPTER TWO Kenny, Action, Emotion and Will (London: Routledge and Kegan Paul, 1963), p. 47. 2 See the discussion by Epstein of his and other similar views in Seymour Epstein, "The Nature of Anxiety with Emphasis upon its Relationship to Expectancy," in Charles D. Spielberger, ed., Anxiety: Current Trends in Theory and Research II (New York: Academic Press, 1972), pp. 291-337. 3 Though the notion of drive or energy levels has been called into service more often to account for the nature of anxiety, it does make an appearance in theories of depression emphasizing conservation of energy. See for example Arthur H. Schmale, "Adaptive Role of Depression in Health and Disease," in John Paul Scott and Edward C. Senay, eds., Separation and Depression (Washington, D.C. American Association for the Advancement of Science, 1973), pp. 187-214. Comments on these theories will be reserved for Chapter 3. ' Although this is still the most generally accepted account of what goes on in the conditioned avoidance-response situation, the issue has become a highly complicated and controversial one. The best accounts of this controversy can be found in Robert C. Bolles, Theory of Motivation (New York: Harper & Row, 1967), and 1 Anthony

Notes 133 R. J. Herrnstein, "Method and Theory in the Study of Avoidance," Psychological Review, 76 (1969): 49-69. • Paul Tillich, The Courage to Be (New Haven, Connecticut: Yale University Press, 1952). • Ibid, p. 80. • Theodore R. Sarbin, "Ontology Recapitulates Philology: The Mythic Nature of Anxiety," American Psychologist, 23 (1968): 411-48. 8 H. J. Eysenck and S. Rachman, The Causes and Cures of Neurosis (London: Routledge and Kegan Paul, 1965). O C. G. Costello, "Dissimilarities between Conditioned Avoidance Responses and Phobias," Psychological Review, 7 (1970): 250-54. 10 Ibid., p. 251. 11 Neal E. Miller and Jay M. Weiss, "Effects of the Somatic or Visceral Responses to Punishment," in Byron A. Campbell and Russell M. Church, eds., Punishment and Aversive Behavior New York: Appleton-Century-Crofts, 1969), pp. 360-61. 12 C. G. Costello, "Conditioned Avoidance Responses and Phobias: A Reply to Wolpe and to Powell and Lumia," Psychological Review, 78 (1971) : 350. 13 Robert C. Bolles, "Species-specific Defense Reactions and Avoidance Learning," Psychological Review, 77 (1970): 32-48. 14 L. Solyom, P. Beck, C. Solyom, and R. Hugal, "Some Etiological Factors in Phobic Neurosis," Canadian Psychiatric Association Journal, 19 (1974): 75. 1'' C. G. Costello, "Anxiety and the Persisting Novelty of Input from the Autonomic Nervous System," Behavior Therapy, 2 (1971): 321-33. 10 Warren H. Teichner, "Interaction of Behavioral and Physiological Stress Reactions," Psychological Review, 75 (1968): 271-91. 17 See review by N. E. Miller, "Autonomic Learning: Clinical and Physiological Implications," in Muriel Hammer, K. Salinger, and S. Sulton, eds., Psychopathology: Contributions from the Social, Behavioral and Biological Sciences (New York: John Wiley, 1973), pp. I27-45. 18 George Mandler, Jean M. Mandler, Irwin Kremen, and Robert D. Sholitan, "The Response to Threat: Relations among Verbal and Physiological Indices," Psychological Monographs, 75 (1961): No. 9, Whole No. 513.

134 Anxiety and Depression Fred S. Fehr and John A. Stern, "Peripheral Physiological Variables and Emotion: The James—Lange Theory Revisited," Psychological Bulletin, 74 (1970): 411-24. 20 Ford Maddox Ford, The Good Soldier (New York: Random House, 1955), p. 114. 21 Ibid., p. 115. 22 Hans Selye, The Stress of Life (New York: McGraw-Hill, 1956). 23 Benedictus de Spinoza, Ethics (New York: Hafner, 1949), p. 256. 24 I. M. Marks, Fears and Phobias (New York: Academic Press, 1969). 25 Peter J. Lang, Barbara G. Melamed, and James Hart, "A Psychophysiological Analysis of Fear Modification using an Automated Desensitization Procedure," Journal of Abnormal Psychology, 76 (1970): 220-34. 26 M. H. Lader, "Palmar Skin Conductance in Anxiety and Phobic States," Journal of Psychosomatic Research, 11 (1967): 271-81. 2' For a good review of this literature see Marks, Fears and Phobias. 28 Allan Cooper, Joseph B. Furst, and Wagner H. Bridger, "A Brief Commentary on the Usefulness of Studying Fears of Snakes," Journal of Abnormal Psychology, 74 (1969): 413-14. 23 Donald J. Levis, The Case for Performing Research on Nonpatient Populations with Fears of Small Animals: A Reply to Cooper, Furst, and Bridger," Journal of Abnormal Psychology, 76 (1970): 36-38. ao Solyom, Beck, Solyom, and Hugal "Some Etiological Factors in Phobic Neurosis," p. 72. 31 Ibid., p. 72. 32 I. M. Marks and M. G. Gelder, "A Controlled Retrospective Study of Behaviour Therapy in Phobic Patients," British Journal of Psychiatry, 111 (1965) : 571-73. 33 Marks, Fears and Phobias, p. 128. 34 Quoted in Rudolph and Margot Wittkower, Born under Saturn (New York: W. W. Norton, 1969), p. 74. 33 Fawzeya Makhlouf-Norris and Hugh Norris, "The Obsessive Compulsive Syndrome as a Neurotic Device for the Reduction of Self-Uncertainty," British Journal of Psychiatry, 122 (1973): 287. 36 See for instance A. M. Hocart, "Ritual and Emotion", Character and Personality, 7 (1939): 201-11, and G. C. Homans, "Anxiety and Ritual: The Theories of Malinowski and Radcliffe-Brown," American Anthropologist, 43 (1941): 164-73.

10

Notes 135 37

Ernest Becker, Angel in Armor (New York: George Braziller, 1969), p. 26. 38 Maurice Friedman, To Deny Our Nothingness (New York: Dell Publishing, 1967), p. 277. 39 Viktor E. Frankt, Psychotherapy and Existentialism (New York: Washington Square Press, 1967), p. 56. 40 Rollo May, The Meaning of Anxiety (New York: Ronald Press, 1950), p. 336. 91 Ibid., p. 254. 42 Ibid., p. 199. 93 Rollo May, "Historical Roots of Modern Anxiety Theories," in Paul H. Hoch and Joseph Zubin, cds., Anxiety (New York: Hafner, 1964), p. 15.

NOTES TO CHAPTER THREE • C. S. Lewis, Four Loves (London: G. Bles, 1960). 2 William James, The Varieties of Religious Experience (New York: Longmans, 1902), pp. 151-52. 3 Sean O'Casey, Autobiographies ll (London: MacMillan, 1963), pp. 23-24. d Eugene S. Paykel, "Life Events and Acute Depression," in John Paul Scott and Edward C. Senay, eds., Separation and Depression (Washington, D.C.: American Association for the Advancement of Science, 1973), pp. 224-25. • Ibid., p. 232. • Desmond Morris, The Naked Ape (Toronto: Bantam, 1969). • John Paul Scott, John M. Stewart, and Victor J. DeGhett, "Separation in Infant Dogs: Emotional Response and Motivational Consequences," in John Paul Scott and Edward C. Senay, eds., Separation and Depression, p. 12. 8 Reference to the psychoanalytic theory is not correct because there are a number of psychoanalytic theories of depression. It is the theory first clearly formulated by Freud putting an emphasis on loss that concerns us here. An excellent guide through the maze of the other psychoanalytic theories of depression can be found in Joseph Becker, Depression: Theory and Research (Washington, D.C.: Winston, 1974). Becker's book is an excellent up-to-date review of depression in general.

136 Anxiety and Depression 9 R. M. Laxer "Self-Concept Changes of Depressive Patients in General Hospital Treatment," Journal of Consulting Psychology, 28 (1964): 214-19, and "Relation of Real Self-rating to Mood and Blame and Their Interaction in Depression," Journal of Consulting Psychology, 28 (1964): 538-46. in Ibid., p. 545. 11 C. G. Costello and Andrew L. Comrey, "Scales for Measuring Depression and Anxiety," Journal of Psychology, 66 (1967): 303-13. " C. B. Ferster, "Animal Behavior and Mental Illness," The Psychological Record, 16 (1966): 348. Peter Lewinsohn has elaborated further on this behavioral hypothesis of depression. He has proposed: (1) that a low rate of response-contingent positive reinforcement results in the low rate of behavior of the depressed person, (2) that the low rate of response-contingent positive reinforcement acts as an unconditioned eliciting stimulus for other depressive behaviors such as depressive mood, fatigue, and somatic symptoms, (3) that the total amount of response-contingent positive reinforcement received by a person is presumed to be a function of the following variables. (a) The number of events which are potentially reinforcing for the individual. Individual differences are recognized and are thought to be the result of both biological and experiential factors. (b) The number of potential reinforcing events which are provided by the environment. (c) The instrumental behavior of the person—that is the extent to which he possesses the skill to emit the kind of behaviors that will elicit reinforcement from his environment. It is the first and major proposition of the behavioral theory that concerns us in this book. A detailed presentation of Lewinsohn's position can be found in Peter M. Lewinsohn, "Clinical and Theoretical Aspects of Depression," in Karen S. Calhoun, Henry E. Adams, and Kevin M. Mitchell, eds., Innovative Treatment Methods in Psychopathology (New York: Wiley, 1974), pp. 63-120. 13 D. H. Lawrence, Women in Love (Middlesex: Penguin Books, 1970), p. 363. Peter M. Lewinsohn and Douglas J. MacPhillamy, "The Relation14 ship Between Age and Engagement in Pleasant Activities," Journal of Gerontology, 29 (1974): 290-94. See also Douglas J. MacPhillamy and Peter M. Lewinsohn, "Depression as a Function of Levels of Desired and Obtained Pleasures," Journal of Abnormal Psychology, 83 (1974): 651-57. 15 C. G. Costello, T. B. Rogers, and G. P. Belton, "The Relationships

Notes 137 between Mood, Activity Levels and the Pleasantness of Activities." Manuscript. 16 Arnold Lazarus, "Some Reactions to Costello's Paper on Depression," Behavior Therapy, 3 (1972): 248-50. 17 Alexander F. Shand, Foundations of Character (London: MacMillan, 1920), p. 354. la Stendhal, On Love (New York: Doubleday, 1947), pp. 16-17. 19 Gilbert Ryle, The Concept of Mind (London: Hutchinson, 1949), p. 99. 220 Ernest Becker, "Toward a Comprehensive Theory of Depression: A Cross-Disciplinary Appraisal of Objects, Games and Meaning," Journal of Nervous and Mental Disease, 135 (1962): 34. 21 Stendhal, On Love, p. 12n. 22 Emily Brontë, Wuthering Heights (New York: Washington Square Press, 1960), p. 5. 23 C. G. Costello, "Depression: Loss of Reinforcers or Loss of Reinforcer Effectiveness?" Behavior Therapy, 3 (1972): 240-47. 24 J. E. Staddon and Virginia L. Simmelhag, "The 'Superstition' Experiment: A Re-examination of its Implications for the Principles of Adaptive Behavior," Psychological Review, 78 (1971): 3-43. 25 See, for example, Pietro Badia, Bonnie McBane, Steve Suter, and Paul Lewis, "Preference Behavior in an Immediate versus Variably Delayed Shock Situation with and without a Warning Signal," Journal of Experimental Psychology, 72 (1966): 847-52. 26

See, for example, D. Singh, "Preference for Bar-pressing to Obtain Reward over Free-loading in Rats and Children," Journal of Comparative and Physiological Psychology, 73 (1970); 320-27. 27 Charles C. Perkins, Jr., "An Analysis of the Concept of Reinforcement," Psychological Review, 75 (1968): 160. 28 Ibid., p. 163. 26 L. Benjamin Wyckoff, Jr., "The Role of Observing Responses in Discrimination Learning," Psychological Review, 59 (1952): 431-42. so J. Steiner, "Observing Responses and Uncertainty Reduction," Quarterly Journal of Experimental Psychology, 19 (1967): 18-29. 31 Robert C. Bolles, "Reinforcement, Expectancy, and Learning," Psychological Review, 79 (1972) : 394-409. 32 C. B. Ferster, "A Functional Analysis of Depression," American Psychologist, 28 (1973): 858.

138 Anxiety and Depression 33

See review of data in Aaron T. Beck, Depression: Causes and Treatment (Philadelphia: University of Pennsylvania Press, 1972), p. 51. 34 E. H. Uhlenhoth and Eugene S. Paykel, "Symptom Configuration and Life Events," Archives of General Psychiatry, 28 (1973): 744-48. 35 Becker, "Towards a Comprehensive Theory of Depression: A Cross-Disciplinary Appraisal of Objects, Games and Meaning," p. 30. a° N. A. Chance, "A Cross-Cultural Study of Social Cohesion and Depression," Transcultural Psychiatric Research, 1 (1964): 19-21. 3' See for instance, Robert E. Clark, "Psychoses, Income and Occupational Prestige," American Journal of Sociology, 54 (1949): 433-40, and E. G. jaco, The Social Epidemiology of Mental Disorders (New York: Russell Sage Foundations, 1960). 38 Martin E. P. Seligman, Helplessness: On Depression, Development, and Death (San Francisco: W. H. Freeman, 1975). 39 Peter M. Lewinsohn, "The Behavioral Study and Treatment of Depression, in M. Hersen, R. Eisler, and P. Miller, eds., Progress in Behavior Modification (New York: Academic Press, 1975). 40 Colin Wilson, Beyond the Outsider (Boston: Houghton Mifflin, 1965), p. 32. 41 Martin Roth, Clair Gurney, R. F. Garside, and T. A. Kerr, "Studies in the Classification of Affective Disorders: The Relationship Between Anxiety States and Depressive Illness, I," British Journal of Psychiatry, 121 (1972): 147-61. 42 Barbara Snell Dohrenwend, "Social Status and Stressful Life Events," Journal of Personality and Social Psychology, 28 (1973): 232. 43 Lawrence G. Calhoun, Thomas Cheney, and A. Stephen Dawes, "Locus of Control, Self-Reported Depression and Perceived Causes of Depression," Journal of Consulting and Clinical Psychology, 42 (1974): 736. 44 Rollo May, The Meaning of Anxiety (New York: Ronald Press, 1950). 45 George Mandler, "Helplessness: Theory and Research in Anxiety," in Charles D. Spielberger, ed., Anxiety: Current Trends in Theory and Research (New York: Academic Press, 1972), II, 359-74. 40 T. Berggren, "Some Behavioral Relationships Between ExternalInternal Locus of Control and Anxiety with Implications for a Theory of Anxiety," University of Uppsala, Report 129, 1972.

Notes 139 47

Kenneth Minkoff, Eric Bergman, Aaron, T. Beck, and Roy Beck, "Hopelessness, Depression and Attempted Suicide", American Journal of Psychiatry, 130 (1973): 455-59. 48 Frederick T. Melges and John Bowlby, "Types of Hopelessness in Psychopathological Process," Archives of General Psychiatry, 20 (1969): 693. 40 Ibid., p. 693. J0 Beck, Depression, p. 24. 51 Alan W. Watts, Psychotherapy East and West (Toronto: Mentor Books, 1963). 52 Ferster, "A Functional Analysis of Depression," p. 864. 53 Watts, Psychotherapy East and West, p. 148. 54 Alexander Nies, Donald S. Robinson, John M. Davis, and Lewis Ravaris, "Changes in Monoamine Oxidase with Aging," in Carl Eisdorfer and William E. Fann, eds., Psychopharmacology and Aging (New York: Plenum Press, 1973), pp. 41-54. 5 Jack Botwinick, Aging and Behavior (New York: Springer, 1973). '6 Bruce L. Welsh, Edith D. Hendley, and Ibrahim Turek, "Norepinephrine Uptake into Cerebral Cortical Synaptosomes After One Fight or Electroconvulsive Shock," Science, 183 (1974): 220-21. '" Dylan Thomas, "Do not go Gentle into That Good Night," in Collected Poems (London: J. M. Dent, 1952). 58 Ferster, "A Functional Analysis of Depression," p. 867. " Jean-Paul Sartre, Sketch for a Theory of the Emotions (London: Methuen, 1962), pp. 68-69. 60 Mandler, "Helplessness: Theory and Research in Anxiety." °1 William R. Miller and Martin E. P. Seligman, "Depression and the Perception of Reinforcement," Journal of Abnormal Psychology, 82 (1973): 62-73. 62 Julie Rowney, "A Test of Three Hypotheses of Depression," Diss., University of Calgary, 1975. 63 Bernard S. Gorman and Alden E. Weissman, "The Relationship of Cognitive Styles and Moods," Journal of Clinical Psychology, 30 (1974) : 18-25. 64 Arthur J. Prange and M. M. Vitols, "Cultural Aspects of the Relatively Low Incidence of Depression in Southern Negroes," Internation Journal of Social Psychiatry, 8 (1962): 104-12. John Lamont and Carol Tyler, "Racial Differences in Rate of Depression," Journal of Clinical Psychology, 29 (1973): 428-32.

140 Anxiety and Depression Herbert M. Lefcourt, "Internal versus External Control of Reinforcement," Psychological Bulletin, 65 (1966): 206-20. °° See for review of relevant literature, Ari Kiev, Transcultural Psychiatry (New York: The Free Press, 1972). °i J. E. Cooper, R. E. Kendell, B. J. Gurland, L. Sharpe, J. R. M. Copeland, and R. Simon, Psychiatric Diagnosis in New York and London (London: Oxford University Press, 1972). 08 J. C. Carothers, The African Mind in Health and Disease: A Study in F_thno-Psychiatry (New York: Negro Universities Press, 1970), p. 103. 09 Ibid., p. 148. i° The reference is on page 148 of Carothers' book and is taken from G. Tooth, Studies in Mental Illness in the Gold Coast (London: His Majesty's Stationery Office, 1950). Carothers, The African Mind in Health and Disease: A Study in '' Ethno-Psychiatry, p. 148. 72 May, The Meaning of Anxiety, p. 121. '' Bertrand Russell, The Conquest of Happiness (New York: Liveright, 1930), pp. 28-29.

°-'

Forster, "Animal Behavior and Mental Illness," p. 347. Arthur Miller, Death of a Salesman (New York: The Viking Press, 1958). 70 James R. Averill, "Grief: Its Nature and Significance," Psychological Bulletin, 70 (1968): 721-48. 77 D. H. Lawrence, Sons and Lovers (Middlesex: Penguin Books, 1961), p. 347. i8 John Donne, Seventeenth Meditation in Devotions upon Emergent Occasions, ed. Anthony Raspa (Montreal and London: McGill-Queen's University Press, 1975), p. 87. '0 H. Hoagland, "Some Comments on Science and Faith," Conference on Science, Philosophy and Religion, New York, 1941, Mimeo. Quoted in Clyde Kluckhon, "Myths and Rituals: A General Theory," Harvard Theological Review, 35 (1942): 45-79. 80 See for instance, E. H. Uhlenhuth and Eugene S. Paykel, "Symptom Intensity and Life Events," Archives of General Psychiatry, 28 (1973): 473-77. 81 Georges Poulet, "Proust and Human Time," in Rene Girard, ed., Proust: A Selection of Critical Essays (New Jersey: Prentice Hall, 1962), p. 153.

'' 75

Notes 141 T. S. Eliot, The Cocktail Party (London: Faber and Faber, 1950), p. 30. 83 Ibid., p. 31.

82

Grace A. De Laguna, On Existence and the Human World (New Haven: Yale University Press, 1966), p. 23. 83 Ibid., pp. 149-50. 86 Dennis Hill, "Depression: Disease, Reaction or Posture?" American Journal of Psychiatry, 125 (1968): 445-57. 87 D. Russell Davis, "Depression as Adaptation to Crisis," British Journal of Medical Psychology, 43 (1970): 109-16. 88 Eric Klinger, "Consequences of Commitment to and Disengagement from Incentives," Psychological Review, 82 (1975): 14-15. 89 Ibid., p. 15. 90 Beck, "Depression: Causes and Treatment", p. 36. For the nonprofessional reader: the correlation coefficient is a statistic describing the degree of association of two phenomena. In magnitude it goes from 0 (no association) to 1.00 (complete association.). A correlation of .28 between sleep disturbance and fatigability means that only about 8 percent of a person's fatigability could be attributed to his sleep disturbance. 91 Roy R. Grinker, "Reception of Communications by Patients in Depressive States," Archives of General Psychiatry, 10 (1964): 578. 92 John S. Price, "Genetic and Phylogenetic Aspects of Mood Variation," International Journal of Mental Health, 1 (1972): 124-44. 93 Ibid., p. 135. 94 Ibid., p. 141. 95 Ibid., p. 142. 96 Joseph J. Schildkraut, "The Catecholamine Hypothesis of Affective Disorders: A Review of Supporting Evidence," American Journal of Psychiatry, 122 (1965): 509-22. 9' Larry Stein, "Chemistry of Reward and Punishment," in D. H. Eitran, ed., Psychopharmacology: A Review of Progress, 1957-1967 (Washington, D.C.: U.S. Government Printing Office, 1968), pp. 105-23. 98 C. G. Costello and G. P. Belton, "Depression: Treatment," in C. G. Costello ed., Symptoms of Psychopathology: A Handbook (New York: Wiley, 1970), pp. 201-15. 99 In summarizing these data, I have relied mainly on two reviews of the literature. They are: Seymour S. Kety, "The Biogenic Amines 84

142 Anxiety and Depression in the Central Nervous System: Their Possible Roles in Arousal, Emotion and Learning," in Francis O. Schmitt, ed., The Neuorosciences: Second Study Program (New York: Rockefeller University Press, 1970), pp. 324-36, and Morris A. Lipton, "The Neurobiology of Mood and Psychoses," in James L. McGaugh, ed., The Chemistry of Mood, Motivation, and Memory (New York: Plenum Press, 1972), pp. 149-57. 110 For a process of this sort to be involved one would require evidence that norepinephrine is involved in the formation and consolidation of patterns of stimulus-response associations. A review of literature by Kety in "The Biogenic Amines in the Central Nervous System: Their Possible Roles in Arousal, Emotion and Learning," indicates the following supportive evidence: (1) The presence of norepinephrine-containing axons of brain stem neurons terminating in the cerebral hippocampal and cerebellar cortex with a wide distribution of association with the cortical cells. (2) The fact that norepinephrine does not easily pass the blood-brain barrier. Thus it would not readily be removed by the capillaries, and such a mechanism would further assure the widespread distribution of any of this substance that might be released from endings near the cortical surface. (3) The fact that RNA and protein synthesis, which appear to be involved in consolidation of activity at cortical synapses, have been found to be stimulated at sites of increased neuronal activity. (4) The fact that cyclic adenosine monophosphate, which appears to mediate the effects of norepinephrine on central neurons, is involved in protein synthesis in mammalian cells.

NOTES TO CHAPTER FOUR 1 C.

H. Vanderwolf, "Limbic-diencephalic Mechanisms of Voluntary Movement," Psychological Review, 78 (1971): 83-113. 2 Wilfrid Sellers, Science, Perception, and Reality (London: Routledge and Kegan Paul, 1963). Vanderwolf, "Limbic-diencephalic Mechanisms of Voluntary 3 Movement," p. 86. 4 Martin Roth, Clair Gurney, R. F. Garside, and T. A. Kerr, "Studies in the Classification of Affective Disorders: The Relationship between Anxiety States and Depressive Illnesses, I," British Journal of Psychiatry, 121 (1972) : 147-61.

Notes 143 • M. W. P. Carney, M. Roth, and R. F. Garside, "The Diagnosis of Depressive Syndromes and the Prediction of ECT Response," British Journal of Psychiatry, 111 (1965): 659-74. 9 Sigmund Freud, Beyond the Pleasure Principle (New York: Bantam, 1959), p. 399. o Marvin R. Goldfried, "Systematic Desensitization as Training in Self Control," Journal of Consulting and Clinical Psychology, 37 (1971): 228-34. 8 Gordon L. Paul and Donald T. Shannon, "Treatment of Anxiety through Systematic Desensitization in Therapy Groups," Journal of Abnormal Psychology, 71 (1966): 133-34. • Marvin R. Goldfried and Christine S. Trier, "Effectiveness of Relaxation as an Active Coping Skill," Journal of Abnormal Psychology, 83 (1974): 348-55. 10 Marvin R. Goldfried and Thomas J. D'Zurilla, "A BehavioralAnalytic Model for Assessing Competence", in Charles D. Spielberger ed., Current Topics in Clinical and Community Psychology, I (New York: Academic Press, 1969), 151-96. 11 R. F. Peck, "Developing Internationally Acceptable Concepts and Measures of Effective Coping Behavior." Paper presented at Annual Meeting of the American Psychological Association, 1971. 12 Soren Kierkegaard, The Concept of Dread (Princeton: Princeton University Press, 1944). 13 Eugene Kahn, "An Appraisal of Existential Analysis," in Hendrick M. Ruitenbeek ed., Psychoanalysis and Existential Philosophy (New York: Dutton, 1962), pp. 215-16. 14 Robert A. Nisbet, Community and Power (New York: Oxford University Press, 1962), p. 196. 18 Ibid., p. 199. 18 Robert D. Hare, "A Conflict and Learning Theory Analysis of Psychopathic Behavior," Journal of Research in Crime and Delinquency, 2 (1965): 13. 17 Gordon Trasler, "Criminal Behaviour," in H. J. Eysenck, ed., Handbook of Abnormal Psychology, 2nd ed. (San Diego, California: Robert R. Knapp, 1973). 18 See for instance, Richard H. Rahe, Jack L. Mahan, and Ransom J. Arthur, "Prediction of Near-future Health Changes from Subjects' Preceding Life Changes," Journal of Psychosomatic Research, 14 (1970): 401-6. 19 See for instance Karl Stern and Gwendolyn M. Williams, "Grief

144 Anxiety and Depression Reactions in Later Life," American Journal of Psychiatry, 108 (1951): 289-94. 20 R. C. Lewontin, "Adaptation and Natural Selection," Science, 152 (1966): 338. 21 G. C. Williams, Adaptation and Natural Selection: A Critique of Some Current Evolutionary Thought (Princeton, N.J.: Princeton University Press, 1966), pp. 26-27. 22 Ibid., p. 227. 23 Walter Mischel, "Toward a Cognitive Social Learning Reconceptualization of Personality," Psychological Review, 80 (1973): 258. 24 Rollo May, "Historical and Philosophical Presuppositions for Understanding Therapy," in W. D. Numokawa, ed., Human Values and Abnormal Behavior (New York: Scott Foresman, 1965), p. 78. 2" Myrna M. Weissman and Gerald L. Klerman, "Psychotherapy with Depressed Women: An Empirical Study of Content Themes and Reflection," British Journal of Psychiatry, 123 (1973): 55-61. 26 Mischel, "Toward a Cognitive Social Learning Reconceptualization of Personality," p. 252. 27 B. F. Skinner, Science and Human Behavior (New York: MacMillan, 1953), p. 168. 28

R. Harre and P. F. Secord, The Explanation of Social Behavior (Totawa, New Jersey: Rowman and Littlefield, 1972).

F. H. Allport, "Teleonomic Description in the Study of Personality," Character and Personality, 6 (1937): 214. 30 See for instance M. B. Shapiro, "Short-term Improvements in the Symptoms of Affective Disorder," British Journal of Social and Clinical Psychology, 8 (1969): 187--88. 31 R. Harre, and P. F. Secord, The Explanation of Social Behavior. 32 Albert Ellis, Reason and Emotion in Psychotherapy (New York: Lyle Stuart, 1962). 33 Aaron Esterson, The Leaves of Spring (London: Tavistock Publications, 1970), p. 199.

29

Index

This is primarily a subject index. An author has been listed only when his data or ideas have received more than a passing reference. The topics of the book—anxiety and depression—have not been listed.

Action: relationship to emotion, 16-17; motivated by anxiety, 26 Activities: relationships with mood variations, 55-58; level of, in old people, 57; level of, in depression, 69-71 Aggressive behavior and norepinephrine, 80-81 Aging: and activity levels, 57; and pleasure capacity, 57; as a factor in depression, 71; and monoamine oxidase and norepinephrine, 79-80 Agoraphobia similar to pervasive anxiety, 37-38 Alienation: in absence of life structure, 65; and the learnedhelplessness analogue, 72; and perceived lack of control, 84; as haven from anxiety and depression, 111-12 Allport, F. H., 126 Anger as a coping response, 14-15

Apathy: as an escape from depression, 82; perceived lack of control in, 82; similarity of learned helplessness to, 84 Arousal: role in emotion, 9; distinguished from anxiety, 22-23,26; effects on information processing, 31-33 Autonomic nervous system: role in fear acquisition, 28; role in anxiety, 28-34; difficulty in controlling activity of, 32; persisting novelty of its output, 33; importance of awareness of, 33 Autonomic reactivity, inheritance of, 27-28 Avoidance responses in depression, 72 Barzini, L., 4, 5 Beck, A. T., 77,95 Behavioral analysis, limitations of, 122-23

146 Anxiety and Depression Behavior therapy for phobias, 37-38 Bereavement, phases in, 97 Boredom as an antecedent of depression, 78-80 Bowlby, J., 75, 76, 77 Carothers, J. C., 85 Cognition, role of, in emotion, 14 Conditioned avoidance response: described, 23; as an analogue of anxiety, 23-24; as an analogue of phobias, 2729; as a species-specific defense reaction, 29 Control: loss of, in learned helplessness production, 7172; failure to learn and depression, 73-75; fear of loss of, in anxiety, 75; notion of, in Zen Buddhism, 77-78; loss of, in depression, 77-78; excess of, in depression, 78-79, 83; perceived lack of, in apathy, 82; internal versus external orientation distinguished, 84; perception of, and mood fluctuations, 84; external orientation and alienation, 84; perceived lack of, as protection against depression, 84-85 Coping: relationship to emotion, 16-17; absence of, in anxiety, 21-23,27; absence of, and emotion, 15, 22-23; with the source of anxiety, 25; phobia conceived as such, 28:9; cross cultural aspects,111; developed through systematic desensitization, 111; with depression, 114-15

Davis, D. R., 91,93 De Laguna, G. A., 89, 90 Drive and theory of anxiety, 22-23 Effort: as an antecedent of depression, 86-87 Emotion: three important characteristics identified, 2; elusive nature of positive, 2; signalling function of, 2, 6-8,12-13, 15,19,21-22,87-88,102,112, 121; genuineness of, 2-10; unusualness of emotional behavior, 3-13,19-21; attention-gaining aspect of, 3, 6, 10-12,64; as a prompt to interrogation, 3,5,10; circumstances of occurrence of, 5-9, 20; accounting for one's, 6-7, 10-15, 19; role of cognitive factors, 3,8-9,14; role of arousal, 9; defined as increased strength of response, 9-10; effects on voluntary action, 10; causes of, 11-12, 16, 118-19; objects of, 11-13, 19, 118-19; produced by behavioral inadequacy, 12-14, 16-17,19,21; negative versus positive, 12-14,15,34; unpleasantness of negative emotion, 12-14, 19; pleasantness of positive emotion, 13; human versus animal, 14-15, 17; evolution of, 15, 17, 19; relationship with reason, 1517; relationship with action, 16-17; relationship with coping, 15-17, 22-23; and active versus positive role of actor, 16, 87; James-Lange theory, 33;

Index 147 and fixa ion, 61-62; pervasiveness of effects of, 63-64; adaptive aspects, 112-13; searching for the key to, 118-28 Emotional temperament of Italians, 4-5 Evolution: of emotion, 15, 17, 19; of anxiety, 19, 22, 25, 27, 35-36, 60, 115-17; of depression, 60, 95, 115-17; and the maintenance of culture, 89, 90, 91 Existentialist views of anxiety, 25-26 Extinction as the antecedent of depression, 91-94 Eysenck, H. J., 27, 28 Fatigue: in depression, 95-96; common in many disorders, 104 Fear: as a reflex, 14, 38; distinguished from anxiety, 14, 17, 29, 38; as a coping response, 14-15; accounting for one's, 14-15; biological function of, 24-25; objects of, 24-25; role of introversion in acquisition of, 28; role of autonomic nervous system, 28; role of conditioning, 28; innate, 38; in childhood, 38; of novelty, 3839 Ferster, C. B., 54, 69, 70, 78, 79, 81, 86, 87 Fixation: in anxiety, 24, 35, 6062; in depression, 61-62 Freud, S., 52 Frustration as an antecedent of anxiety and depression, 83 Goldfried, M. R., 111

Grief, function of, 87 Guilt in depression, 73 Habituation in anxiety, 39 Helplessness: closer relation to anxiety than to depression, 73-74; differentiated from hopelessness, 75-77 Hill, D., 91 Hopelessness: as a sign of seriousness of suicidal intent, 75; differentiated from helplessness, 75-77 Hostility, depression as a result of, 81-82 Incentive: loss of, in depression, 54-55, 57-60, 72, 76-77, 83, 93-95, 98, 100-101; loss of, and loss of structure, 55, 5861; variations in, related to mood variations, 57; loss of, and fixation, 61-62; role of punishment in loss of, 100101; role of brain's reward mechanism, 100-101; and norepinephrine levels, 99-100 Inheritance: of anxiety, 30, 35, 108; of phobias, 30, 36-37; Introversion: inheritance of, 2728; role in fear and anxiety, 28 Isolation in anxiety and depression production, 51-52 James-Lange Theory, 33 Kenny, A., 10 Klinger, E., 92, 93, 94 Koestler, A., 15,17 Laxer, R. M., 53 Lazarus, R., 8, 9 Learned helplessness: described,

148 Anxiety and Depression 71-72; in animals, 71-73; as an analogue of alienation, 72, 84; as an analogue of depression, 72-73, 77; immunization against, 73-74; as a personality disposition, 83-84; as a characteristic of depressives, 83-84 Learning theory: of anxiety, 23-30, 35-36; of phobias, 2730, 37-38 Lewinsohn, P. M., 55, 56, 57, 58, 72 Lewontin, R. C., 117 Loss producing depression, 49-55, 65 May, R., 43, 44, 45, 74 Melges, F. T., 75, 76, 77 Mischel, T., 119,121 Monoamine oxidase, increase with age of, 79-80 Mood: variations in, and activities, 55-58; variations in, and incentives, 56-58; related to reinforcement, 56-58; related to pleasure, 56-58; morning versus evening, 58; general effects of, 62-63; fluctuations of, and perceived control, 84 Myths, role of, in structuring of anxiety, 40 Nies, A., 79, 80 Norepinephrine: briefly described, 79-80; reduction with age, 79-80; and aggressive behavior, 80-81; depletion of, in depression, 98-101; and rewarding self-stimulation, 98101; depleted by reserpine, 98-99; increased by imipra-

nime, 99; levels of, and incentive, 99-100 Novelty as a stimulus to anxiety, 33-34 Objects: of emotion, 19; of fear, 24-25; absence of, in anxiety, 24-25; of anxiety, 36-37,4344; of love, 64 Pain, relationship of, with anxiety, 29-30 Paykel, E. S., 49,50, 51 Perkins, C. C., 67, 68 Pessimism distinguished from depression, 73 Phobias: as coping responses, 27-29; conditioned avoidance response as analogue of, 2730; inheritance of, 30,36-37; associated neurotic symptomatology, 30; psychoanalytic theory of, 36; information theory of, 36; as concretizations of anxiety, 363-37; rarity of monophobias, 37; agoraphobia, 37; social phobias, 37; for animals, 37-38; behavior therapy for, 37-38; learning theory of, 37-38; and childhood fears, 38; kinds listed, 38; role of sensitization processes, 38; general anxiety in etiology of, 38-39; discordance between manifestations of, 110-11 Pleasure: and mood, 56-58; capacity in depression, 57; capacity in old people, 57-58 Price, J. S., 95,96,97 Psychopathy, lack of anxiety in, 116

Index 149 Reason, relationship of, to emotion, 15-17 Reinforcers: loss of, in etiology of depression, 54-55, 58-59, 62,69-71,77,81-82,86,8990; rate and strength of, in depression, 56-57; strength of, and mood, 56-58; rate of, and mood, 56-58; and the transmission of attractiveness, 6568; effectiveness of, and life structure, 66; antecedent events and effectiveness of, 66-69; loss of effectiveness of, in depression, 70-71, 86; constant schedules of, in depression, 78-79; increase in effectiveness of, in love, 87 Reserpine, depression produced by, 98-99 Reward system of brain and incentive, 101 Rituals: in structuring of anxiety, 40-41; in mourning, 41 Sarbin, T. R., 26,27 Sartre, J. P., 16, 82, 83 Schachter, S., 9 Self-esteem, loss of, in depression, 52-53,73,91 Seligman, M. E. P., 53, 77, 78, 83,84 Self-stimulation and norepinephrine levels, 98-100 Skinner, B. F., 9,10 Social adjustment in anxiety, 108-9 Social class as a factor in depression, 71 Social phobia similar to per-

vasive anxiety, 37 Stein, L., 100 Stress: role in etiology of anxiety, 35-36; role in etiology of agoraphobia, 38; sex differences in effects of, 74 Structure of behavior, 12-13; and positive emotions, 13-14 Structure of life: loss of, and loss of incentive, 55, 58-61; loss of, in depression, 58-63, 65,69-71,80,86-87; individual differences in, 63; and alienation, 65; and the effectiveness of reinforcers, 66; restitution of, to alleviate depression, 82-83; and significance of depression, 114-15 Structuring of anxiety, 39-41 Systematic desensitization as an active mastery technique, 111 Teichner, W. H., 31 Therapy: main stages of, 12829; as a dialectical procedure, 129-30 Tillich, P., 24,25, 41, 88 Uncertainty in anxiety production, 23,30-31,33-34,36,3839, 41-42 Vanderwolf, C. H., 104, 105, 106 Voluntary behavior and anxiety, 104-7 Watts, A., 77, 78, 79 Williams, G. C., 117,118