The psychoanalytic approach to human psychology is based upon two major paradigms. The first is biological (Sulloway, 1979). Men and women are viewed as possessing what have been described as ‘stupendous and fundamental’ biological drives. The individual must employ and satisfy these motivations and affects—hunger, sex, fear, aggression, love, and hate—in order to manage the tasks of the life cycle. The biological paradigm of psychoanalysis is particularly important when considering depression, because it gives full recognition to the power and substantiality of those drives and affects. Abnormalities in these drives and affects play a large part in the pathogenesis of depressive states.
The second paradigm is based upon a view of the human as a being saturated with meanings, intentions, and purposes. Fulfilling the basic aims of life, including having and rearing offspring, always involves operating through and within kinship and other groups. Success will depend upon capacities for achieving intermediate aims, such as finding and keeping a love object. At least some degree of harmonization of the ‘stupendous and fundamental’ drives with those organizations connected with the higher faculties is necessary for an individual to be capable of loving and working. These are capacities that Freud argued had become life aims in their own right. A damaged capacity to develop, sustain, and achieve aims of this central kind is a crucial part of the causal sequence leading to depression. In turn, depression, once established, will lead to further deterioration in these ego functions.
Modern psychodynamic views of depression see it as a complex disorder of functioning, with its origin in infancy and childhood. The earliest years are an intense formative time when both innate and environmental factors will determine the development, or absence, of crucial psychological and relational capacities. The unique make-up and experiences of individuals over the unfolding life cycle leads to a vulnerability, which in turn, through final common pathways, culminates in depressive syndromes with familiar constellations of symptoms. The difficulties in loving and working, which potentially arise out of an unsatisfactory childhood situation, operate as intermediate and partial factors in a complex interaction with life events.
There is considerable agreement between the various psychoanalytic accounts of depression that have been developed over the century since Freud and Abraham began their investigations. There are also some differences. Different constituents have been focused upon as if they were the whole. Probably each theory has a contribution to make to getting an overall picture. Some theories, for example, emphasize the diminished sense of personal efficacy and potency (e.g., Bibring, 1953). Others focus on problems with the individual's sense of self (e.g., Kohut, 1971), while still others consider as crucial the role of conflicts between impulses of love and hate (e.g., Jacobsen, 1946; Klein, 1935). Depressive disorders, arising out of individual lives and histories, are complex conditions.
While these differences may arise in part from focusing upon different aspects of the same entity, they extend into important questions of etiology. For instance, both Kohut and Winnicott, albeit in rather different terms, proposed that idealization of the self and others is a developmentally normal stage en route to normal self-esteem. Klein, on the other hand, thought that many of the problems with diminished self-esteem, failed grandiosity or narcissism that are seen in depression, which undoubtedly go on to cause problems of their own, are secondary to more basic conflicts between loving and hating impulses towards external objects.
Other differences concern the emphasis given to genetic, constitutional, or endogenous versus environmental factors. Also important is how and to what extent early feeding and nurturing experiences influence the content and form of adult thinking, feeling, and relating. There are different positions on methods of reconstructing the subjective world of infants and their relationships. While the implications of some psychoanalytic accounts of depression are limited to the disorder, others are more far-reaching. Some suggest that the mental operations seen in depression have a central role in normal development as well, and what began as a set of ideas and observations about depression has grown into a general theory of emotional development.
What follows is an account of the main themes in the foremost psychoanalytic/psychodynamic accounts of the nature and origin of depression.
Freud, as his title Mourning and Melancholia (1917) indicates, was linking together these two processes as being different kinds of reaction to the same kind of event, involving a loss. This can be the loss of a love object, or perhaps more usually in the case of melancholia (a variety of major depressive disorder) some less tangible loss or injury involving an individual's wishes, ideals, beliefs, or hopes, all of which contributes to a sense of self.
There are important points of difference between mourning and melancholia. Although it is quite common to mourn for a lost self, in mourning in general it is the world that is felt to have lost meaning. In melancholia by contrast it is the self that is experienced as reduced and impoverished. In mourning, as well as there being some anger, there are also prominent feelings of sadness and longing, and some characteristic forms of sympathetic identification with the lost object. In melancholia, there exists a higher level of anger and destructiveness, which may be turned upon the self dangerously as in suicide.
Mourning has an adaptive function, whereas melancholia is maladaptive. Freud viewed mourning as an active psychological process rather than simply a passive registering of the loss or bereavement. Recollections of the lost or abandoning love object are ‘worked over’ repeatedly. This is an involuntary process that involves picturing the bereaved in periods of intense longing and psychological absorption (hypercathexis was the term coined by Freud's translators). Although emotionally painful, it is through this means that the reality of the loss is slowly accepted, and the tie to the object relinquished or modified, until eventually the resources of the individual are freed once more, so that a new adaptation becomes possible. In melancholia there is less obvious evidence of relinquishment and less consequent adaptive development.
As well as having made specific contributions to the understanding of grief and depression, Mourning and Melancholia marked a period in psychoanalysis when earlier models based upon viewing the psyche as a ‘mechanism’ were succeeded by object relations theories. All versions of object relations theory are based on the idea that relationships in infancy and childhood with parental and sibling figures are essential in their own right. With regard to our particular subject, disruptions and abnormalities in early nurture and feeding relationships, and in the way they are internalized, give rise to a susceptibility to depressive disorders in the adult.
The distinctive feature of psychoanalytic object relations theories is their concern with the phenomenon of an inner, subjectively imbued world of thought, imagination, and representation. The inner world is constructed through the internalization of the earliest relationships with parents and siblings. What is encountered—and what is perceived—in the world is shaped, and shapes, the inner models of emotional life. According to psychoanalytic accounts, the interplay of these interactions can be seen in our inner world of thoughts, feelings, imagined discourses, and dreams.
Mr A's marriage was spoiled by powerful feelings of anger and hostility that he couldn't account for. He feared that they were out of control and were destroying his marriage, leaving him struggling, depressed, abandoned, and bleak. The patient felt that his wife was ‘addicted’ to her family. In particular, he hated the attention that she lavished on her sister who was still breast feeding her 3-year old son. Mr A felt that his quarrelling was compulsive. ‘I just cannot stop having a go about her sister,’ he said, after he had quarreled again about his wife's attachment to her. His wife, N, had become angry and called him an Inquisitor. He had smashed a valuable bowl. That night he had a dream.
‘There was only a flat and sandy island with water all around. There had been a nuclear explosion. The ground was contaminated by radioactive fall-out. Everything was finished. There was no chance of escape for me and the other people there. N was among them and she had decided to leave me. I was crying, ‘Do you really like hurting me? You are doing this because I have put all my hope with you.’
The analyst saw this dream as depicting the condition of Mr A's inner world and the nature of his unconscious fantasy life. Using a model based upon the notion of powerful conflicts between love and hate, the nuclear explosion could be understood as representing the patient's angry explosions at being passed over, as he experienced it, in favor of his wife's family. The radioactivity represented their emotional fall-out.
The atmosphere in the dream is that of a nuclear winter. Nothing good in his inner world is felt to survive the massiveness of his rage. No sense of life remains, no good relationships nor hope for the future seem possible. The prevailing thrust of the internal relationships, as well as the actual argument connected with them, has become the intended infliction of hurt. The patient experiences himself as abandoned to his desolate fate. In this way, the complex affects of depression are considered to arise meaningfully out of this conflict of powerful feelings.
The condition of the internal representation of the primary love objects—in infancy, mother and her breast, and father—is a central issue in some psychoanalytic accounts of depression. Important functional capacities within the individual's psyche are located in the internal object. These are connected with providing support and love, and the ability to manage feelings. The ego's attempt to spare the love object from harm is a central theme in the syndrome of depression. If the love object at the center of the ego is felt to be hurt, damaged, or weakened—for instance by high levels of internal hostility or rivalry—then the individual feels bad or damaged: the stability of the ego is diminished. Being loved or unloved is linked with the moral distinction between good and bad. This intertwining of the most important dimensions in emotional life is central in depression.
The outward form taken by these core inner issues varies greatly. Blatt (1974) has identified two main types of depression characterized by different stances towards the object and the self. In what Blatt terms the anaclitic form of depression, the person feels that if they are able to restore a particular relationship with an external love object, by whatever means necessary—pleading, cajoling, threatening, then their happiness, and sense of personal worth and goodness, will be restored. The individual's efforts are devoted to changing the outside world, which is felt to hold the key to restoring well-being. The case described in the illustration above is of this type.
In contrast, the person manifesting the introjective form of depression is focused upon their inner world where they are concerned with whether their natures and impulses are good or bad, and with trying to sort out their inner relationship with important figures in their lives. ‘Was I good or bad in my relationship with father or mother?’ ‘Was mother or father good or bad?’ ‘How, and on what terms, can they be preserved or looked after?’ are the sorts of unspoken questions that lie behind these self-examinations. Whereas those with the anaclitic form may be thought of as preoccupied with the possibilities of cure by the power of another's love, the introjective individual believes in a cure by moral effort.
Noting the exaggeration of moral judgement that occurs in depression, Freud was concerned to understand how and why floridly unrealistic beliefs that the self is harmful and bad can become so prominent. He described the setting up of a critical agency as a ‘grade’ within the ego that ‘henceforth will judge the ego’. Subsequently, he combined his earlier idea of an ego-ideal (v.i.) with the critical agency, to arrive at the notion of the super-ego. The super-ego is therefore one part of the individual's mind acting upon another part of that same mind. It is this attribute of being capable of ‘action within’ that makes it such an important concept in depression. It covers a much wider range of conscious and unconscious operations than those we customarily recognize as the work of conscience.
We know through introspection that there are two kinds of mental experience: awareness and self-awareness. Self-awareness is consciousness of being aware. Conscience is a subspecies of self-awareness, where the feeling of not having lived up to one's ethical or moral values results in guilt. This is mature conscience in its familiar form. But even in relatively normal and healthy people an inner voice is often too ready to criticize, blame, and accuse the self. In those with a predisposition to depression it is often as if someone within the individual's mind was judging and observing in a spoiling, superior, sadistic, or overindulgent way.
Sometimes the familiar forms of super-ego functioning such as the conscience are manifestations of the highest ethical or moral values. However, often super-ego functioning consists of the postulation of morals as a camouflage: it is moralism rather than morals that holds sway. Indeed, Freud went further when he recognized that the super-ego quite regularly functioned as a psychologically primitive set of omnipotent, defensive, narcissistic functions, which are capable of operating in a way that damages an individual's mental functioning.
With the frighteningly destructive power of the melancholic super-ego in mind, Freud pointed out that the greatest danger facing the ego in melancholia was losing the approval or love of the super-ego and, by implication, gaining its hatred. This kind of super-ego functioning is what makes melancholia into such a serious mental illness. It has the power to degrade the ego's capacity for mature thought and judgement into, quite literally, murderous impulses directed at the self or sometimes at others.
At first in psychoanalysis the normal super-ego was approached from the angle of its being a part of child development. However, subsequent psychoanalytic work was concerned with working out the infantile origins of this severe depressive super-ego. Klein (1933) reported fearful fantasies of hostile figures in the play of children between 2¾ and 4 years (some of whom were depressed: for example, Erna), which she controversially considered to be manifestations of the super-ego originating in the first months of postuterine life. These had the primitive ferocity found in melancholia, which existed as well in lower-key forms in chronic depressive states. Klein considered that the nature of these fantasies indicated that they derived from the infant's earliest relationship with the mother's breast. This early super-ego is not an exact copy of the real character of the child's parents but is shaped as well by fantasies about them colored by the child's own angry and hateful feelings. These amalgams of reality and fantasy then come home to roost within the child, where they may operate as a source of persecution. To a certain extent, this is viewed as normal: the ordinarily hungry and screaming infant becomes frightened after a while, as it feels its world has become imbued with its angry and destructive feelings.
Later developments in this line of work have included ideas about the existence of an ‘ego-destructive super-ego’, which, through countless inner attacks—in the form of contemptuous thoughts about others as well as about the self—can produce stupor-like states, and erode connections between thoughts and ideas (Bion, 1962; O'Shaughnessy, 1999).
Jacobson (1954), following the early work of Rado (1927), while agreeing with Klein about the importance of primitive destructive objects in depression, disagreed about their origin. Jacobson argued that severe disillusionment about the parents in the first year of life damages the infantile ego and initiates a premature formation of the super-ego. As a consequence, she reasoned, it is not possible for the maturing individual to give up the tendency to cling to what is essentially an idea of a magical power based upon infantile beliefs. By continuing the struggle with the love object intrapsychically, the self maintains its utter dependence on it. It becomes the victim of the super-ego: in its fantasy life it is tortured as if it were a helpless and powerless child by a cruel condemning mother. The enduring hope is of gaining the approval of this powerful entity so that it will relent, and offer softness and support, as originally the mother's breast had done.
Jacobson underlined the distinction that exists between representations of the deflated and worthless parents, and those who are perceived as inflated and punishing ones—good or bad. The child, and later the adult, still hopes to regain love and security from the ‘God-like parents’ by pleading, by atonement and abasement. But the parents, who in infancy were felt to be omnipotent, are not only turned into bad hostile punishing beings; once deprived of their power they appear low, bad, defiled, empty, and castrated—parents from whom nothing can be expected. This deflation and destruction of the parental images inevitably leads to self-deflation and self-destruction.
Abraham (1911) was the first to propose that issues connected with the infant's feeding relationship with mother are central in depression. Longing, disappointment, and disillusionment arising from these earliest desires are at the center of much depressive feeling. Deutsch (1932) also thought that the deeper dispositional elements in depression can be traced to the earliest ego frustrations, separations, and disappointments. Depressive reactions can be found in the early postnatal separations from the object, while early manic reactions could be traced to the restoration of the same object.
One of Klein's (1935) additions to the original work on mourning and melancholia was the hypothesis that the reaction to any loss occurring later in the life cycle will be influenced by revived aspects of the reaction to loss at the earliest stages of development. Weaning—losing the breast—was regarded as the prototype of all later losses. However, the repeating sequences of hunger, feeding, satisfaction, and the comings and goings of people (the father or the siblings and the mother's own comings and goings) were also seen as powerful additional stimuli to the baby's rapidly increasing capacity to recognize the breast (and the mother) as separate from, rather than as part of him. Giving up the beliefs and attitudes associated with a split world, experienced in terms of the exclusive possession of wholly good objects and the expulsion of wholly bad ones, precipitates a phase of mourning and grief. The infant experiences the forerunners of the adult emotions of concern and regret at its inability to protect the mother from its demands. Klein termed this constellation of feelings ‘the depressive position.’
The early loss of the object during weaning may result in depression in later life, if the infant has not been able to establish a loved object securely within at the early period of development. While it was recognized that good maternal care or, alternatively, a depriving, severe, or cruel upbringing, had a big effect upon the child's capacity to internalize a good object, the focus of these investigations was upon the development of the inner world of the infant and, in this internal world, the role of its aggressive, hostile, and loving feelings. In a subsequent development Bion (1962) examined the function of the mother as an essential environmental factor in the infant's psychological development.
The mother's mental functioning, the nature of the mother-and-baby's rhythms of comings and goings, of the repeated cycles of hunger, feeding, and satisfaction, and of the presence of other people, are key parts of the infant's environment as is the infant's own temperament. Day-to-day features of the maternal environment, as well as major traumatic events such as early maternal death or extended separations, influence whether the deep-seated and passionate wishes of early infancy can be relinquished in favor of the infant's being able to connect with the mother on a basis of reality. When things go well this internal reality is of a mother who is able to console and feed as well as to let the child wait. It is also one where the nature of the mother's relationship with the father is accepted. When the representation of the mother is less benign and reliable the individual may nurse unrealistic hopes based upon compensatory exaggerations of the unsatisfied wishes and needs of infancy and so be vulnerable to a depressive illness when these break down in adulthood.
Even after a normal development, much of the original power of the oral needs, wishes, and longings of infancy persists into adult life. Although their mode and totality of expression is suppressed, they continue to exercise a determining influence upon the psyche. Food is always intimately bound-up with love and vice versa. Relinquishing love objects later in life revives the intense pangs involved in leaving behind the earliest oral satisfactions and fantasies. Surmounting the power of the oral needs, wishes, and longings of unrequited infantile need and love is a major developmental and emotional challenge.
The intimate relationship that exists between aggression, emotional ambivalence, and depression has been repeatedly emphasized in psychoanalytic studies (Abraham, 1911, 1924; Freud, 1917; Klein, 1935, 1940). Abraham (1911, 1916), based upon observations made in the course of the psychoanalytic treatment of patients with psychotic depression, concluded that the patients’ capacity to love was being overwhelmed by feelings of hatred about which they were often acutely anxious. Freud suggested that in states of depression, aggressivity towards others is held back and turned upon the self. Depression, anxiety, and self-reproach then ensue because the self has become identified with the lost object. However, there is no consensus on the precise nature of the role of aggression in the etiology of depression. Bleichmar (1996) described the four main psychoanalytic positions on the role of aggression in the following way:
As a necessary part of the human condition and a fundamental factor in every depression (for example, Klein, 1935, 1940).
As part of a larger configuration that consists of frustration, rage, and failed attempts to gain a desired end. When for external or internal reasons the ego is unable to attain its goals, aggression is turned towards a fused representation of self and object (v.i.), with an ensuing loss of self-esteem.
As a by-product of a diminished self-esteem as the outcome of primary fixations to experiences of helplessness especially in childhood (e.g., Bibring, 1953).
As a secondary phenomenon in response to what is primarily a failure in a parental external object, which gives rise to pain and narcissistic rage (v.i.) (e.g., Kohut, 1971).
In the history of psychoanalytic thought, several constitutional or temperamental factors—considered to be inherited, at least in part—have been put forward as predisposing to later difficulties. Deutsch (1951), in a discussion of the pre-psychotic personality of manic-depressives, suggested a specific ego-weakness manifesting as a vulnerability and intolerance towards frustration, hurt, and disappointment. Klein (1930) thought that there were innate differences between individuals in terms of their tolerance of anxiety stirred up in the course of development as well as in terms of aggressiveness and envy. When these feelings are pronounced they give rise to difficulties in making secure internalizations of good objects. However, there is always a difficulty in determining the direction of the effect.
Most psychoanalytic accounts of the contribution of nature and nurture to the development of neurosis and mental illness were formulated before the advent of modern genetics. We now know more about environmental and genetic factors, and their complex interactions. The issue now before us is the way in which nature plus nurture leads to the phenomena we are examining. However, one of the challenges is identifying the psychological correlates—the psychological manifestations at the level of character—of the genetic factors contributing to depression.
Various phenomena in depression are recognized under the central psychoanalytic concept of narcissism. Some of the descriptive usages of the term refer to states of the ego—the self—and the ego-ideal, which are of central importance in depression. These range from a normal degree of self-regardingness, confidence, and morale (with a realistic view of the self as competent, and at least to a degree lovable), through to an increased preoccupation with the self. In this second state, the self may be experienced as inadequate, weak, and marginal on the one hand or self-admiring and perfect (with omnipotent control over the self or others) on the other. These different states of mind are all positioned on the narcissistic dimension of attitudes to the self.
The terms ‘narcissistic injury’ or ‘narcissistic wound’ tend to be associated with the idea of traumatic insults to the natural expectations of the self. However, these terms are also employed when referring to the kind of hurt suffered by the vain or conceited. The term ‘narcissistic’ also designates a constellation in the personality of traits of selfishness, ruthlessness, contemptuousness, and superiority. Some quite major personality shifts or orientations, such as withdrawal from the outside world to a preoccupation with the self or internal objects, and fusions or identifications of self and objects are also called narcissistic.
Most of these usages, while to some degree descriptive, have developmental or etiological implications that vary according to the theoretical model employed. For example, Jacobson stressed the ‘narcissistic breakdown’ of the depressed person as the central psychological problem. By this she meant the loss of self-esteem, feelings of impoverishment, helplessness, weakness, and inferiority that is so often felt. However, the meaning she is giving to the term ‘narcissistic breakdown’ can only be fully understood in the context of her overall view of depression as a condition arising out of early disappointment, and the sort of parental images that she postulates this gives rise to.
In an attempt to reduce the lack of definition arising from the conceptual range and power of the term ‘narcissism’, Jacobsen introduced the term ‘self-representation’ meaning the ‘concept’ of the self—the unconscious and preconscious images that people have of the body, self, and personality.
Bibring (1953) also emphasized the centrality of the sense of helplessness and powerlessness in depression. In Bibring's view the subject's representation of his incapacity to attain goals is more important in the etiology of depression than object loss per se. Of course, this representation may include the inability to achieve the presence of the love object. The representation of self-incapacity arises out of a fixation to experiences of helplessness and powerlessness. Each time the depressive person feels he cannot fulfill his aspirations, all previous experiences—either real or imaginary—in which the feeling of helplessness dominated will be reactivated.
The view taken of the nature of narcissistic attitudes and positions is one of the major differences between psychoanalytic accounts of depression. Kohut (1971) suggested that the development of the sense of the self was an independent line in development that is damaged in those vulnerable to depression. Parents who can provide phase-appropriate idealizing, grandiose, and narcissistic attitudes towards the child are key to satisfactory development of self-esteem. Also, the parents need to be satisfactory models for these narcissistic wishes. Kohut felt that a parent's failure to meet such needs—either by failing themselves, or being depressed, excessively critical, or denigrating, or by the absence of the sort of overvaluation that parents normally invest in children, interferes with the development of what is often termed ‘healthy narcissism’.
In contrast, Klein felt that while there are healthy forms of narcissism—certain kinds of pride and self-respect, for instance—other forms, including superiority and self-idealization, are the outcomes of defenses against primitive impulses of aggression and rivalry towards early providing figures. These result in confusions and acquisitive identifications between the self and object.
Identification plays a crucial part in depression. In the phrase, the ‘shadow of the object falls on the ego’ Freud was expressing vividly the idea that the effects of aggression and frustration were being directed at the ego when, in reality and originally, they have been felt about the lost object. The self identifies with the object in the sense that it treats itself as if it were that object. Through this means it sustains the belief that the object lives. This preserves its relationship with an object whose loss cannot be faced. This is sometimes described as a narcissistic form of identification because of the sense of being in the individual's interest rather than those of the object.
Identification is encountered in other phenomena in depression. For example, in Klein's depressive position, the child's sympathetic identification with the mother is based upon the child's love and concern about fantasized damage done to the object. The ego, by sharing and suffering the imagined pain of the object, seeks to spare that with which it is in sympathy. Klein thought that some of the self-hatred found in depression is based upon the ego's dislike of, and despair at, the nature of its own hostile impulses.
Evidence concerning psychoanalytic approaches to depression may be considered from two angles. First, there are many empirical research approaches that bear upon the broad psychoanalytic propositions outlined in the earlier ‘Psychoanalytic/psychodynamic accounts of depression’ section on the inner structure of depression and etiological factors influencing the development and course of depression. Unfortunately, it is beyond the scope of this chapter to examine these further but it is an essential part of the scientific enterprise to consider how the findings of observational studies may be corroborated and drawn together by what is postulated about the inner world in depression.
The second contribution of research is the employment of outcome evaluation tools in the form of efficacy and effectiveness studies to form a view of the value of psychoanalytic approaches as treatments of depression. These will now be reviewed.
The term ‘psychodynamic psychotherapy’ encompasses all those therapeutic approaches, derived originally from psychoanalysis and depth psychologies, in which the dynamic role of unconscious processes and the significance of the therapeutic relationship are central. While psychodynamic psychotherapies vary a lot the ideas of psychoanalytic and depth psychology are common denominators underlying the approach to treatment.
In any appraisal of research evidence it is important to bear in mind any limits that follow from the test conditions employed. Most efficacy studies of treatments for depression have studied short courses of treatment with short follow-ups and inadequate concealment of treatment allocation, conducted with patient populations who offer good prospects of responsiveness (e.g., minimal comorbidity), thereby optimizing the chance of the treatment concerned being shown in a good light. However, depression is usually a long-term condition marked by relapse. Effectiveness studies of therapy conducted in real clinical practice with clinically representative populations have been less frequently reported. The treatment periods required with such populations are longer than those used by efficacy studies (Morrison et al., 2003).
A recent systematic review of controlled trials for treatment-refractory depression (Stimpson et al., 2002) found few randomized controlled trials (RCTs), and none involving psychological treatments, which met more exacting criteria for methodological adequacy. The paucity of outcome research on psychological and drug treatments whose test conditions are adequate in terms of the nature of the clinical problem is the key fact, especially with respect to long-term refractory depression. This conclusion applies to trials of psychodynamic psychotherapy also.
The RCT evidence that is available suggests that both antidepressant medication and psychological therapies generate an improvement over the short term of approximately 12–13 points on the Beck scale (NICE Depression Guideline, 2004). Among the psychological therapies, this type of evidence is strongest for cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (Department of Health 2001; NICE Depression Guideline 2004). There is also evidence in favor of couple therapy on systemic lines when compared with medication, for a clinically-representative sample of depressed patients (Leff et al., 2000).
The increasing influence of evidence-based approaches in public sector health care has lead to more studies of psychodynamic therapy using RCT methodology in the past 10 years (Fonagy et al., Open Door Review of Outcome Studies in Psychoanalysis and Psychoanalytic Psychotherapy, Second Edition 2002).
The Sheffield Psychotherapy Project (Shapiro et al., 1994) compared 8 or 16 weeks of an ‘exploratory therapy’ (a form of psychodynamic-interpersonal therapy) with ‘prescriptive psychotherapy’ (somewhat resembling CBT) for depressed patients. The two therapies were found to be equally effective, but patients with more severe depression did better with 16 weeks of therapy. The patients were followed-up for a year when 57% of treatment responders had fully, and 32% partially, maintained their gains, and 11% had relapsed. This study has been replicated (Barkham et al., 1994).
The work of Guthrie and her colleagues evaluating the effectiveness of Hobson's brief psychodynamic-interpersonal therapy (Guthrie et al., 1998, 1999) has been extended to the treatment of patients who have made suicide attempts (Guthrie et al., 2001). Relative to a treatment-as-usual control condition, patients who had self-poisoned and presented to emergency services, showed significant reductions in suicidal ideation and reduced Beck Depression Inventory scores at 6 months follow-up following four sessions of home-based psychodynamic-interpersonal therapy. These results indicate the potential benefit of a psychodynamic treatment approach to an important clinical problem associated with depressive symptomatology.
An RCT of home-based brief therapy for depressive symptoms has been reported by Cooper et al. (2003). Women suffering from postnatal depression received either routine care or one of three psychotherapies (nondirective, CBT, and psychodynamic) over a 10-week period and were then assessed up to 5 years postpartum. Unlike patients receiving nondirective and CBT, only the psychodynamically treated group showed a significant reduction in depression (Structured Clinical Interview for DSM-IIIR) relative to the controls at post-treatment. By the 9-month follow-up, however, the benefit of treatment was no longer apparent. These results were compatible with therapy speeding a recovery, which would, in the majority of cases, have occurred spontaneously over time.
Gallagher and Thompson (Thompson et al., 1988; Gallagher-Thompson and Steffen 1994), reported studies that establish the empirical validity of psychodynamic psychotherapy for depressed patients over the age of 65 years. These compared the relative benefits of brief psychodynamic therapy and CBT for elderly depressed patients and for their clinically depressed caregivers (Gallagher-Thompson and Steffen, 1994). Psychodynamic psychotherapy had clearer effects for those depressed caregivers who were newer to the care-giving tasks while CBT seemed to offer most for longstanding caregivers, findings that suggest treatment-specific effects.
The combination of psychodynamic psychotherapy with antidepressant medication has been evaluated using RCT methodology. Within the test conditions employed combined treatment appears to offer a benefit over and above drug treatment alone. Burnand et al. (2002), for example, showed a significant incremental benefit of psychodynamic psychotherapy over clomipramine alone in 74 patients with major depression. The therapists who were nurses had a 6-month manual-based training. Benefits were evident on clinical and health economic measures (accounting for hospitalization rates and days lost from work). The cost saving was $2311 (US) per patient over the treatment period.
Further evidence for the benefit of a combined psychotherapy–medication approach has been provided by de Jonge et al. (2001). Sixteen sessions of ‘short psychodynamic supportive therapy’ improved the outcomes of patients with major depression on a variety of measures of depression and quality of life over a 6-month period. Promising though the results of both these studies seem, the absence of long-term follow-up assessments should be noted.
Few other trials of psychodynamic therapy as a treatment for depression have been carried out by neutral researchers. Some investigators sympathetic to other therapies have used dynamic therapy as a comparator (e.g., Bellack et al., 1981). Roth and Fonagy (prev. citation) caution that these trials were unlikely to have employed psychodynamic psychotherapy administered by appropriately trained practitioners and their results may not derive from a proper test.
The generic efficacy of psychotherapy compared with no treatment has been established for a long time. Study after study, meta-analysis after meta-analysis, has validated psychotherapy as an evidence-based treatment. ‘The available research has led to one basic conclusion: psychotherapy in general has been shown to be effective. Positive outcomes have been reported for a wide variety of theoretical positions and technical interventions. The reviews cover data from mildly disturbed persons with specific limited symptoms as well as from severely impaired patients…’ (Lambert, 1992, p. 97). Throughout this literature the size of the effect is remarkably stable, and is comparable with that found in education and with psychoactive medication (see Lambert and Bergen, 1994 for a complete review).
Psychodynamic and psychoanalytic approaches are simultaneously types of therapy and a research methodology. This is not only true from the practitioner's point of view. The patient seeking help may well be motivated as much by a need to ‘research’ and understand his or her own life as by the need for symptomatic relief. At a certain point in the course of a psychodynamic psychotherapy, customary distinctions between cure and knowledge may cease to operate. A deeper understanding of oneself may in and of itself be a kind of cure, which, as well as helping to modify symptoms, can lead to benefits such as the growth of an active capacity to reflect upon internal states. This may be an important part of what is needed to recover the capacity to act, or to make relationships. Operating together synergistically, developments such as these may lead the individual to become both more engaged and more resilient—to become more capable of the demands involved in having a life, and less vulnerable to breakdown in the future.
Establishing the justification for therapeutic claims of this sort involves moving beyond theory-neutral treatment trials to investigate the question of whether specific treatments possess specific elements capable of leading to types of change not available otherwise. Theory-informed research strategies, perhaps involving clinical case studies, and well-designed longitudinal effectiveness studies may be required to investigate unrealized or unoperationalized functions of the personality. These may provide information about therapeutic possibilities that can complement that obtained from Type I RCTs.
An example of the potential value of retrospective longitudinal effectiveness studies comes from a body of research that has sought to investigate the clinical impression that improvement may continue after psychodynamic psychotherapy ends, in some instances even after a period of possible deterioration. Sandell's (1987) important study demonstrated patients gaining in strength and capacity after treatment had ended. A carefully designed naturalistic long-term follow-up study showed that a clinically representative group of patients with significant depressive symptomatology had, after long-term psychoanalytic psychotherapy, moved into the normal range of scores (Leuzinger-Bohleber et al., 2002). At follow-up, they were doing better in terms of days off work than the normal population. This study included in-depth interviews that made it possible to discern distinct and differing patterns of change in the way that various personality types managed their thoughts and feelings. These patterns included the demonstrable emergence of reflective functioning.
The therapeutic possibilities of a reflective, insightful personality function are one reason, if reasons should be needed, for wanting to study the interior, subjective side of experience. Most depressed patients, as well as experiencing symptoms are preoccupied with what they feel are failures to fulfill their wishes or live up to their standards. On closer acquaintance, these states often appear to be concerned with failed or lost relationships. Most important are the absent or lost love objects, stretching back to childhood relationships with mother or father or other aspects of upbringing. There are often concerns about the goodness of others’ motives and dispositions as well as with one's own. Thus many depressed patients have ideas as to why and how they came to be depressed. As the patient's view of what has been affectively significant in his or her life is the raw material out of which potent ego functioning may arise it is important to have considered to what extent they are right in these ideas. A realistic knowledge of inner life and cure can be closely connected.
In the view of psychoanalysis, men and women are subject to a wide variety of internal states and emotions arising out of their lives so far that are often difficult to manage. The treatment is based on the idea that the patient can internalize a vital yet subtle capacity to learn about and use these states of mind in the further conduct of their lives. This involves a therapeutic process based upon the repeated and sustained understanding of the functioning of areas of their personality hitherto unexplored. This process takes place within a specialized relationship with an analyst/therapist (Milton, 2001).
The therapeutic benefit arises as a by-product of personal growth rather than as a result of self-conscious learning techniques or by striving for change directly. An overforceful, overdirected search for ‘improvement’ can be counterproductive.
Most patients will be helped by an assessment consultation before they start treatment. This gives an opportunity to work out whether they want to embark upon a treatment that requires active engagement in a process that can be emotionally challenging as well as supportive.
Before treatment begins the therapist tells the patient about the basic form of the treatment and agrees a regular time for the sessions. Most often this takes the form of once-weekly sessions of 50 minutes each. In more intensive forms of treatment the sessions may be two to five times weekly. The regularity and consistency of the setting provides parameters within which the patient can relate and the therapist work. The therapist needs to make sure that the sessions will not be interrupted. Alterations of frequency, time, and the room should be kept to a minimum. Well in advance the therapist tells the patient of holiday breaks. Of course, there may be circumstances when the therapist has to cancel or rearrange sessions; the patient should not be unrealistically protected from all of the irregularities ordinarily encountered in life.
When people become emotionally important it is normal to be sensitive to their absence. Most people, but particularly those with a disposition to depression, are vulnerable to interpersonal situations hinting of emotional deprivation or loss, and react to separations. Those liable to depression are insecure in their relationships. As a result they may find it difficult to manage the combination of separateness and dependence that is part of therapy. However, these difficulties stirred up by the course of therapy provide an opportunity for new learning. A key part of the therapist's work is the recognition and understanding of the patient's feelings about the breaks, gaps, limitations, and frustrations inherent in the therapeutic encounter. Therefore the patient's reactions, which may include distress, anxiety, emotional coolness, withdrawal, anger, or the recurrence of previously remitting depression shouldn't be damped down or avoided.
The therapist's process of understanding may allow the depressed patient to renew contact with a good, containing, and understanding external object when previously the patient felt unable to find good experience. When this happens the therapist takes on some of the resonance of a primary good object—the mother and her breast, or father—for the patient. This ameliorates the patient's internal world, which will have been felt to have become a source of pain containing unresponsive, abandoning, damaged, or dead objects.
Ms H returned for her first session after a gap over the Christmas break. After a pause she said in a hoarse voice that she had a ‘flu’. Judging by her haggard look it seemed likely that the state of suffering was emotional as well as viral. The patient began to cry. She said she was worried that she was worrying her sister, who was as a consequence losing weight. The therapist interpreted whether the patient was making herself ill because of her guilt about her sister but the patient became still—almost statue-like—not saying anything further for 20–30 minutes.
During this time the therapist essayed a number of comments, which led nowhere. The main burden of these was that the patient was having to face many painful things in her life where she was unable to help or affect matters. Her father was mentally ill, and her mother was dead, and she'd been unable to avert the bad outcome she now had to live with. Perhaps nobody could have done so. Perhaps these losses had been in her mind especially at Christmas, a time of families. He suggested that she felt it important to show him what she'd felt. Speaking didn't seem enough.
She then spoke of a relative who had invited her to his house. Speaking crossly, she said she was unable to go because she got a panic attack at the very thought of being in a room with a child whom she might have to look after. She had then been left with her sister, whom she felt had had such a horrible time and whom she was now exposing to her broken-down state. The therapist, who really felt not able to bear the increasing pain of this account, interrupted and spoke of the patient's crossness with her difficulties—with herself being vulnerable. This crossness, he suggested, made her more needy not less.
The patient fell silent again. Eventually the therapist just said quietly that she must have found Christmas hard. Unlike his earlier more complicated interpretations this simple statement seemed to strike a chord. The patient could talk more easily, apparently now feeling that she'd be listened to, and also seeming to feel that she was being understood. She seemed to take a different, softer attitude to her experiences of the holiday. It was better to cry, she said. Today before she came, she'd been trying to cry but no relief came. It had been a horrible year. All her family were failures. As she left at the end of the session she asked, ‘What's the date of the next session?’. It turned out that this had not been fixed, as the therapist thought it had.
This illustration shows how the duration of the Christmas break cannot be interpreted away. Instead the patient has to convey her feelings more directly, and the therapist has to accept this, until eventually the patient gets the sense that the message has made its mark. Then she is able to feel helped by an understanding that is simple. The fact that the time of the next session hadn't been fixed suggests that the therapist might have been finding the painfulness of the feelings encountered in the treatment of very traumatized and depressed patients difficult. The patient's inquiry after her next session, however, reveals her basically positive response to the work of the session even when—or perhaps because—she has been conveying, with the utmost power the hopelessness of her situation and the uselessness of the therapy.
The therapist's sensitivity to what it is like to wait when feeling in need is essential, as it forms the basis of understanding that can safeguard the patient and the treatment. Reactions to gaps can threaten the patient's stability and their experience of the therapy as providing something meaningful.
Psychoanalytic psychotherapy, especially when treating patients who are depressed, is preferentially concerned with areas of personal functioning involving loving, hating, destroying, repairing, and so on, in relation to others who are, or who have been, of central emotional significance. In depression, feelings of disappointment, love, anger, criticism, neglect, or undermining destructiveness are turned inwards in ways that end up causing suffering, or victimhood. This can be seen in all aspects of a person's ways of communicating, relating, and thinking.
The patient making more meaningful contact with these sorts of feelings and intentions is the key to recovery. As a result of the way the analyst and the patient work together on these sorts of issues, there is a tendency for the patient to find they can perceive and engage with their world with an enlarged repertoire.
A depressed patient with a history of severe emotional deprivation in infancy was just coming to be able to realize that she was locked as if without air in a bleak, lifeless, emotionally responseless world. In one session when the atmosphere of claustrophobic desolation was palpable the patient was able, almost for the first time, to refer openly to its impact upon her. She managed to say, ‘Just a few moments ago I had this feeling of wanting to flail my arms about, to slap myself.’ As if to spare the analyst, she added, ‘I feared that it might disturb you’. Actually, although she was speaking quietly and gave no sign of acting upon her impulse, this whole sequence was electric. It had nothing of the ‘as if’ about it.
It was an achievement for this patient to be able to speak of this bleak state and its self-directed expression. The analyst's thoughts about the first origins of patient's feelings was that her mother had often been stuporose and neglectful. It was easy to imagine the patient as an infant who had been left emotionally to experience an emptiness, or absence, made asphyxiating by the accumulation of her own unmet expectations and needs. The impulse to flail her arms may arise from a situation that is intolerable but at least it draws it to the attention of others. However, the analyst's just referring the patient's impulse back to a reconstructed original infantile situation with her mother would not help by itself. What is more important is the analyst's awareness of the potential this expression of impulse has now for the patient's future emotional growth.
Making emotional contact with the depressed patient is a first task of the therapy. Although particularly important in the early stages, this is something that requires attention in each and every session regardless of the phase of the therapy. Many depressed patients have experienced developmental injuries, or much personal adversity and loss. The therapist's sensitivity to the impact of these on the patient's functioning is important. Environmental adversity commonly can take the form of early losses, a chaotic upbringing with many caregivers, gross maltreatment and neglect, or childhood sexual abuse. However, less obvious, yet no less damaging, injuries can arise from more subtle disappointments and humiliations such as cold care and emotional unavailability. Equally, patients can suffer a great deal from the damaging consequences of their own psychological defenses or internal object relations.
While differences in theory and in training affect the ‘what and why’ of interpretation it is important that whatever their orientation the therapist employs open-minded formulation rather than imposes theory-driven formulae. The goal is to understand the person rather than the material. However, making emotional contact depends on more than the therapist's knowledge and sensitivity. It is powerfully affected by factors operating in the patient. Nuances in the patient's activity, in a way of relating—for example, by being subtly reproachful and angry, or alternatively appealing, or distressed, or by active biases in a way of understanding the therapist's communications, will all affect the way the therapist can function. For example, the therapist may be nudged into becoming moralistic, judgmental, or sometimes excessively sympathetic.
One of the therapist's most important tasks is to monitor the effect the patient is having on his or her way of thinking and relating in order to understand what this may indicate about the patient's way of operating. Where therapists are inexperienced or in training, supervision is essential. Experienced therapists and analysts should continue the discipline of reflective practice through regular case presentation with colleagues.
The focus upon depressive symptoms, which may have been the patient's first, or ostensible, occasion for seeking help, tends to recede once therapy has become established. While sometimes it is important to work out just how the conflicts and difficulties may have led to particular symptoms, this focus may lose meaning for the patient. Instead patients become more concerned with their lives, and the working over of significant feelings, events, and relationships that are tacitly understood as having provided the ground out of which depressive symptoms have developed. The emphasis on symptoms may return, or new symptoms develop, because of external stresses, breaks in therapy, some failure of understanding, in reaction to the opening up of previously unexplored areas, or as the ending of therapy comes into sight.
Excessive mental pain is characteristic of depression. However, having a normal capacity to suffer mental pain is as important in the personal sphere as being able to feel physical pain is for bodily self-preservation. It is for this reason that when mental pain is present in the depressed patient the therapist tries to bring it and its causes into the open, rather than to smooth it away or deny it. At the same time, however, the therapist will try to moderate excessive pain through giving the pain its proper proportion and by understanding its nature and origin.
As we have seen the pain of object loss is a common element and some melancholia's are based upon the extreme painfulness of relinquishing a lost object. As the object is felt to be dead this means that to maintain the connection with the love object the patient must feel dead too. Significant loss of an object or belief system disrupts the relationship with the internal good object, which as described above, is central to the ego's stability. As already described, the therapist with their comments and interpretations tracks the inner feelings connected with these states and this ameliorates mental pain.
Some of the painful mental suffering characteristic of depression arises from the sado-masochistic nature of those internal object relations associated with a punishing super-ego. They can involve cycles of punishing the self and the object. Some depressed patients by taking up positions of martyrdom or victimhood achieve a hidden gratification by making others seem to inflict pain or reject them. The therapist need to be able to identify and describe these positions so that ultimately the patient will be able to also.
Sometimes causing oneself to suffer pain masochistically may obscure a more deeply feared pain originally felt at the hands of others and this needs to be understood.
In patients with chronic forms of depression, the capacity to suffer painful conflicts may be numbed to defend against these underlying pains. This leads the person to avoid any change or growth because of the danger that it is felt to represent. In chronic depressions, states of dulled, partial breakdown are clung to because they offer some functioning and equilibrium, albeit at the cost of restricted capacities and continued disability. No matter how unresponsive, stuck, or chronic the patient's adjustment may appear to be, it is important to recollect that it may be based upon a precarious internal situation.
An important step in the consolidation of these changes is based upon the patient's internalization of the therapist's consistent attitude towards life experiences and the mental states associated with them. Some internalizing of this kind of functioning may be seen in the patient while therapy is ongoing but it is only consolidated after the ending of therapy.
The ending of the therapy can provoke a crisis in which the belief in the goodness of the object is once more called into question. The successful working through of the loss represented by the ending of therapy involves a mourning process that, if it is successfully negotiated, will be succeeded by the more stable internalization of the therapist's function as a dynamic element in the patient's own personality.
Therapists may find themselves in situations with depressed patients where they urgently need to enable the patient to recover their interest in staying alive. Through interpretive understanding they need to alleviate, first-aid fashion, those mental processes (especially super-ego processes) that are most powerfully causing suffering. Interpretation is also needed to support those capacities that enable the patient to begin to think about what has happened in their life and inner world. Therapists treating seriously depressed patients need not feel that they must rely upon interpretation alone. They should feel authorized to take emergency action and to seek help as clinically appropriate.
As indicated already there is some research evidence supporting the value of combining medication with psychodynamic psychotherapy. This should be used when the depression is life-threatening.
While there may be few situations in psychodynamic psychotherapy where antidepressants are actively contraindicated, many patients feel that medication diminishes their contact with themselves, or in other ways alters their mental functioning in ways that they dislike. The UK Committee on the Safety of Medicines (2003) recently advised that several SSRIs should not be used with young people because of the reports of increased suicidal and aggressive feelings.
Negative reactions to improvement are characteristic in depressive states and working them through is an important part of the therapeutic process. These reactions have many origins. Most frequently, there is a part of the patient's mind, often taking the form of a destructive super-ego formation, which retaliates as if it had been left out or as had found its dominance threatened when things seem to get a bit better. These parts of the mind need recognition and understanding just as much as any other.
However, the therapist will need to be alert to these reactions, to be able to accept them, and understand the dynamics that may be operating. There may be deep-seated masochistic trends in the personality that require illumination before improvement can be regarded as at all stable. At other times, the desire to reverse the child–parent relation, to get power over the parents (the therapist) and to triumph over them gives rise to deep-seated guilt feelings and cripples any of the patient's endeavors. Stupor-like states may express as well as defend against the more violent of these reactions.
As described above for some patients a compromise within a psychic retreat permits a kind of limited life at the price of accepting a level of disability. This is equivalent to paying protection money: ‘consenting to be robbed so as not to be murdered’. The sacrificing of resourcefulness it exacts leads to an emotional version of the disability benefits trap.
In the treatment of the seriously depressed it is not uncommon for dangerous suicidal states to follow periods of improvement. These dangerous reactions, customarily explained in terms of a release of the previous condition of inhibition, may take the form of direct urges to murder or attack others. Other times the patient feels urges towards self-murder. Both of these can be very frightening to the patient, as well as potentially dangerous. Obviously, following improvement the therapist needs to be alert to the possibility of reactions of this sort.
Patients may sense something aggressive or explosive developing within them. The therapist may be able to anticipate the signs of anxiety and concern about these incipient developments and use interpretation to modify the way they emerge.
Mr C a depressed borderline man tended to pick rows with petty officials when he would go into loud tirades full of violent imagery. As he became more isolated and desperate, the violence increased; he began to pick arguments with the police and to risk arrest. The therapist understood this as the patient's only way of communicating that his violence was getting out of hand. He suggested that the patient was choosing to do battle with someone who he was sure could protect themselves and perhaps might protect him also. This interpretation, along with realism about the aggressivity of the disputes, served as a point of contact for the patient. Gradually, as he was able to extend the depth of his meaningful communication with the therapist his circumstances improved but his inner poverty became more difficult to hide from. He brought a dream in which he was hanging below the arch of a bridge over some black and icy waters (he lived near a river). This dream alerted the therapist to the risk of a suicidal depression developing in Mr C. He interpreted that the patient had been able to find a bridge between himself and the therapist, a bridge towards a better life. However, he might feel that it wasn't recognized that this meant contact with an inner life which felt like icy waters not an easy feeling of security.
The therapist's ability to judge when the patient feels their impulses are getting out of control is of great value. Sometimes speaking of this will enable a discussion between the therapist and the patient about the correct course of action. In these situations the patient is often very split and the sane part of the patient can be an ally in estimating the severity and in the management of the situation. For example,
It seems to me that you have enough from today's session to get through to next week but it may be this isn't so. What do you think?… You can always phone, should things get more difficult…. Perhaps, you feel that you need more help in managing this and we need to recognize this?
It can be seen from the above how part of the therapist's appraisal of the risk will be an assessment of the patient's contact with him or her, and the reliability of the understanding between them. When the patient is secretively or openly in the grip of a dangerously destructive part of themselves the therapist may need to intervene, or ask colleagues to intervene, to detain the patient compulsorily.
Of course, it is important for those involved in this work to face the fact that the patient's complete safety cannot be guaranteed whatever steps are taken. Regrettably suicides or homicides occur. They create anger, deep-seated guilt, and blame, which have a major psychological impact on those involved. Tactful, supportive, and understanding discussion is—after a while—helpful.
As patients with depression often have difficulties with handling aggressive or hostile feelings they behave in ways that evoke these in others. The patient's consistent seeking of the passive role, the martyred saint or the victim can stir up guilt, or rage, in those who want to be helpful. This dynamic may operate powerfully in those with ‘treatment-resistant’ depression. Other depressed patients subtly invite a somewhat critical or moralizing stance. This may be to confirm the illusion that all that is lacking in the patient is more of an effort.
Depressed patients can stir up wishes to rescue and cure. They can also stir-up powerful feelings of despair, hopelessness, and rejection. In suicidal patients the therapist commonly experiences a wish to keep them alive, however, the therapist may sometimes wish that the patient would end it all. It is important to think about both these feelings. A part of the patient that wishes to live and prosper may be evoked in the therapist or when despair and hatred is evoked the patient may be at risk of suicide.
Much can be learnt from these, to some degree, inevitable reactions. As indicated above therapeutic processes are greatly improved by seeking supervision from a more experienced and knowledgeable colleague or by clinical presentations and discussions in general. If countertransference reactions are beginning to deform the work, then case supervision can make the difference between success and failure.
It has been estimated that between 14% and 37% of patients with major depressive disorder have panic attacks (Pini et al., 1997; Fava et al., 2000), whereas 40–70% of patients with panic disorder at some point will meet the criteria for major depressive disorder. Rudden et al. (2003) in a series of psychodynamic treatment studies have examined the co-occurrence of these conditions and were able to make valuable recommendations about what needs to be understood and interpreted. This sort of understanding equips the therapist to work out strategies for responding to phobic patients who, for instance, are unable to attend their sessions when this means venturing out in the dark.
There is a connection between dependence disorders and depression. Alcohol dependence and other substance misuse often overlies significant depression as well as other disturbance. Their treatment presents particular challenges. A small proportion of patients diagnosed with depression are defending against some underlying psychotic or borderline decompensation. This may emerge as the patient becomes more known in therapy. It may take the form of ‘nothing happening’ in the therapy. These eventualities need to be recognized and responded to accordingly.
In most instances, the threatened drop-out needs to be responded to by understanding what is going on and in a spirit of confident thoughtfulness and persistence, through interpretation. Some kind of ‘therapist testing crisis’ often seems to need to happen, and to be surmounted, if the treatment of patients with significant depression is to be successful. The testing may employ destructive despair, phobia, noncontact, nonresponse, increase of depression, or suicidality. In these situations the therapist's ‘not taking the patient's “no” for an answer’ requires great clinical judgement and expertise, to be able to distinguish when it is necessary and when it is neither indicated nor appropriate. The patient's consent is a sine qua non for psychotherapeutic treatment. A small number of patients make a decision that this form of therapeutic probing and disturbing is not for them, and the decision needs to be respected.
From the dynamic point of view much remains to be discovered about the etiology, prevention, and treatment of depressive disorders. The findings and ideas of the future cannot be fully anticipated. However, it is possible to guess about future directions by extrapolating on the basis of existing trends. These include:
The nature of the disability in depressive disorders. Discussions of the burden of depressive disorder have concentrated upon the impact of symptoms, distress, social or occupational malfunctioning, hospitalization, increased mortality, and suicide. These are important, but a more penetrating conceptualization of personal functioning leading up to depression as well as that following from it is needed. Better recognition of key psychological functions such as the ability to form life projects and core relationships might lead to more measures based upon functional capacity rather than symptoms. Such instruments would be valuable in the further study of depression and its treatment.
The disease entity approach to depressive syndromes. The study of depressive disorders is organized around the use of diagnoses based on symptom pictures. Developmental perspectives, and dynamic psychopathological approaches based upon the study of personality functioning and object relations, may be able to contribute more to our understanding of the factors determining prognosis and the degree of treatment responsiveness or resistance.
Within the framework of the nosological approach a more adequate dynamic classification of depression is needed. Blatt (1974) and Bleichmar (1996) have made helpful contributions. The current authors are developing a dynamic dimensional model to be based upon the experience of treating long-term depressed patients with a degree of treatment resistance.
Gene–environment expression. First identifying and then tracking the development of the psychological, temperamental phenotype expressions as outcomes of gene–environment interaction, and their role in the genesis of depression, will be of great potential value in working out ways of preventing depressive disorders.
Treatment studies. The psychoanalytic understanding of those elements contributing to chronicity, and resistance to treatment, are more deeply understood now than they were a century ago. As a result of clinical psychoanalytic research, we may now have sufficient understanding to improve the outlook for those who suffer from the more damaging and intractable forms of depression. This possibility needs to be tested.