Talking about depression: schizoid-paranoid and depressive position in Hong Kong

Talking about depression in Hong Kong, I have been thinking about the Schizoid-paranoid and depressive positions described by Melanie Klein. I have been wondering if such positions might be applicable in this context, and if Hong Kong Chinese culture may influence their development and/or the movement between one and the other.

Schizoid-paranoid and depressive position in Melanie Klein

Melanie Klein

In the schizoid-paranoid position, the term schizoid means that the object is split; it is not recognized as a whole (i.e. good AND bad), but it is separated as good object or bad object. Paranoid instead refers to one’s own fear of being invaded and or annihilated by the object; however, Klein makes clear that this is actually just the projection of an inner destructive fantasy, which is simply experienced as external.

Melanie Klein describes the “depressive position” as a more mature position. This is interesting, because it goes against the common sense, which considers anything beginning with “depress” (depression, depressive, etc…) as pathological. Instead, in Klein’s terms, “depressive position” is the ethical position, as it implies feelings of guilt, grief, and the desire for reparation. The depressive position is more desirable than the schizoid-paranoid position; however, Klein makes clear that the latter does not simply overcome the former, but more likely there is a fluctuation between the two Ps(n)–>D(n)–>Ps(n+1).

The paranoid-schizoid position represents at the same time the phase preceding the depressive position, the defense against it (It takes a great deal to access the depressive position; indeed, the schizoid-paranoid position represents a much more “basic” functioning of the mind) and also as a regression from it.

Use of defense mechanisms in Chinese contexts

It is often reported that in Chinese culture, teachings focus on the repression rather than the expression of feelings and emotional vulnerability (Ots, 1990). Kleinman showed that the Chinese tended to manifest distress primarily somatically, likely as a consequence of suppression/repression. Yu (2006) found that among a sample of Hong Kong undergraduates, “participants were more inclined to the neurotic and immature defense styles, and were more likely to use such defenses as somatization, dissociation and autistic fantasy” (p.170). In contrast, he observed that among Westerners “humor, anticipation and rationalization” are ranked highest on average. Finally, he found denial clearly higher among Hong Kong Chinese than among the Western counterpart (Yu, 2006). Tseng (2004) observed that Westerners might consider some defense mechanisms that are frequently used by the Chinese as “immature”, although these mechanisms can be “adaptive” in a Chinese society.

Ho (1996) suggested that the social structure of the Chinese (filial-piety) allow an affect-role dissociation that may serve as a defense mechanism to fulfill obligations with emotional detachment.

Is Hong Kong Chinese culture and lifestyle hindering from a depressive position?

Cheap, fast and no-frills

Can we find in the Hong Kong Chinese culture and in the social discourse circulating in Hong Kong anything that might describe one position better than the other?

For example, Chinese culture makes a clear distinction between insiders and outsiders. Liu (1984) observed that in Hong Kong people tend to have a suspicious attitude towards outsiders and distrust of them. Chinese society has been defined as a “low trust” society (Fang & Faure, 2010). Trust is exactly one of the qualities that we expect to find in a “depressive position”, in Kleinian terms.

Chinese communication has been described as insider-oriented meaning that the Chinese tend to speak more openly with people they know, or they have been introduced to (“insiders”), but they rarely speak to the people they do not know (“outsiders”) (Gao & Ting-Toomey, 1998).

Together, these seem to be mechanisms belonging to a schizoid-paranoid position (splitting “the good” Vs “the bad”) rather than a depressive position. Also the so-called filial piety may be thought as a way for overcoming the Oedipus complex, just like a strong hierarchy seems to be the way for preventing the conflicts.

Finally, particularly in Hong Kong, Chinese culture emphasizes the action and the speed over the speech and reflection (to some extent it emphasizes the acting out; few researches point out impulsivity as a common factor among the Chinese).

Walking fast in Hong Kong

Is it then possible that the Hong Kong Chinese culture and the social discourse circulating in Hong Kong somehow limit the access to a “depressive” position, favoring instead a schizoid-paranoid type of functioning? (The schizoid-paranoid position is described by Melanie Klein in terms of a defense of the Self; however, it may be that the Self in a Chinese context has a different nuance than in Western societies).

Then, it may be that Chinese culture, particularly in Hong Kong, has evolved so as to prevent a depressive position (for example, literature normally shows that Chinese more than Westerners encounter more difficulties in recognizing or naming one’s own feelings and emotions; as mentioned above, it seems harder in this cultural context to recognize the object as contemporary good AND bad, or inside AND outside, mine AND not-mine. There is a much more clear cut in Chinese culture).

When feelings of guilt (although Chinese culture is commonly described as a culture of shame more than guilt), or loss of the object, or distrust arise, they may become unbearable. At this point, as the schizoid-paranoid position is not optimal (and these defense mechanisms are not always applicable) and the depressive position is not easily accessible, one may end up experiencing clinical depression (or even suicidal fantasies; suicide may also frequently be considered as a homicide/suicide, thus still belonging to the schizoid-paranoid position).

Then, an idea (not yet an hypothesis, just an idea) is that Hong Kong Chinese culture may be limiting this fluctuation between the two positions, making somehow hard to reach a depressive position. This emphasis on action, speed and efficiency may give the impression of a smoother functioning (“don’t think too much” I often hear people saying; as if without thinking life would be easier). Until something “goes wrong” and the breakdown comes…

(just some thoughts; please, forgive the oversimplifications and generalizations)

References

Fang, T., & Faure, G. O. (2010). Chinese communication characteristics: A Yin Yang perspective. International Journal of Intercultural Relations, 35(3), 329–333.

Gao, G., & Ting-Toomey, S. (1998). Communicating Effectively with Chinese. London: Sage Publications.

Ots, T. (1990). The angry liver, the anxious heart and the melancholy spleen: The phenomenology of perceptions in Chinese culture. Culture, Medicine & Psychiatry 14:21–58.

Tseng, W.-S. (2004). Culture and psychotherapy: Asian perspectives. Journal of Mental Health 13:151–161.

Yu, C.K.-C. (2006). Defence mechanisms and suggestibility. Contemporary Hypnosis 23:167–172.

Factors Affecting the Understanding and Use of Psychoanalysis in Hong Kong, Mainland China, and Taiwan

The Journal of the American Psychoanalytic Association (JAPA) has just published an article that partially summarizes my research in Hong Kong. The paper is entirely written by me, and you can find it at this url: 

http://apa.sagepub.com/content/early/2015/06/24/0003065115590419.abstract

The paper is a milestone in my research in Hong Kong; however, it cannot be considered as definitive, as I am currently working on several other publications and a book, where I try to further expand some lines of research highlighted here. Work in progress.

I hope you may want to read this paper and leave some comment here.

Psychoanalytic Listening: where theory and practice merge

Listening as the Core of Psychoanalysis 

To date, previous attempts to describe theoretical common grounds among psychoanalysts have been unsuccessful. Instead, it is here proposed that psychoanalytic listening is what best describes the essence of psychoanalysis. At the same time, because this refers to a practice rather than a theoretical definition, it is inclusive of the majority of orientations and schools in psychoanalysis and is capable of being distinguished from other counseling orientations. Furthermore, investigating the listening, rather than remaining at the theoretical level, allows one to investigate and compare different realities in which the psychoanalytic theory is absent. Indeed, psychoanalytic listening seems the most flexible yet comprehensive concept.

  Listening in Freud and after
In 1912 Freud wrote the seminal text Recommendations to Physicians Practicing Psychoanalysis in which he listed a number of technical rules for conducting psychoanalysis. First, “not directing one's notice to anything in particular and in maintaining the same ‘evenly-suspended attention’” (Freud, 1912, p.110) is the counterpart to the demand made to the patient to obey to the fundamental rule of the free association. Second, he noted that the analyst should maintain emotional coldness “and concentrate his mental forces on the single aim of performing the operation as skillfully as possible.” (p.114). Third, the analyst should do everything not to become a censorship of his own in selecting the patient’s material (metaphor of the receiver).

A more extensive literature review about psychoanalytic listening indicates that:

        a) while hearing is directed toward what is being said, listening is directed toward what is not being said;

        b) there is speech beyond the speaker and his/her intended meaning, and this ‘beyond area’ should be the focus of the analyst;

        c) the analyst listens what remains implicit and what is not being verbalized, including his/her feelings and reactions toward the client;

        d) psychoanalytic listening is not intentional, the patient is required to free associate and say whatever comes to mind, while the analyst is required not to focus on anything in particular;

        e) listening and questioning are intertwined, and together they may lead to a different disposition that allows unconscious material to emerge;

        g) there is no dialogue in analysis, but instead, an asymmetrical conversation;

        h) the aim of the psychoanalytic conversation is to reflect to the analysand his/her speech;

        i) the content of communication should be read at the light of the transference between analyst and analysand;

        j) generally the analyst sits behind the analysand, so as to avoid eye contact and interfere as little as possible with the flow of the analysand, who instead lays on a couch;

        k) psychoanalysis is more effective when it sustains the formulation and the articulation of questions rather than the production of answers;

        l) the analyst’s engagement in the treatment is more important than the mastery of any techniques.

Towards a definition of psychoanalytic listening

What I propose here is a list of items that was determined by reviewing: a) existing literature describing the listening in psychoanalysis, and; b) existing literature describing the listening in other psychotherapeutic/counseling approaches. 
Items were generated based on their satisfaction with two criteria: 1) they should be applicable to psychoanalysis in a broad sense, meaning that they should reflect the similarities and commonalities among different orientations, and; 2) they should be able to draw a clear differentiation between psychoanalysis, and any other psychotherapeutic or counselling approaches.

Then, a total of 177 Hong Kong professionals were surveyed to develop and assess the scale’s internal psychometric properties. The factor analysis confirmed a clearly defined, simple unidimensional structure, with 8 items. The Cronbach alpha of this scale was α = .75 and thus was regarded as satisfactory.

Psychoanalytic Listening Scale (PLS)

1.         I let clients start talking from where s/he prefers

2.         When I listen to a client, I listen to ambiguity and contradictions in his/her speech, what potentially opens to another possible meaning

3.         I encourage clients to reflect and question his/her own words

4.       My feelings and reactions to clients are meaningful to understanding them and their treatment

5.       Therapy proceeds depending whether I am really engaged, more than for the other techniques that I master

6.         I help clients formulate new questions, rather than giving them answers

7.       I follow the client’s associations rather than trying to impose a direction to the helping process

8.         I encourage clients to keep their questions open-ended

All items were assessed on a 6-point Likert scale, ranging from 1 = strongly disagree to 6 = strongly agree.
Higher scores indicated that a therapist is able to suspend his/her attention and free his/her listening from any assumptions concerning the content and the meaning of the client’s speech, and follow the talking of the client instead.

These eight items represent a simple yet meaningful solution that has emerged from this study (supported by statistical procedures); however, there are also numerous ways for defining a psychoanalytic listening.