Psychodynamic Therapy

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1 460 THE INTERNATIONAL ENCYCLOPEDIA OF DEPRESSION incongruent with conscious ideas about the self and would therefore be seen as unacceptable). Similar to other contemporary approaches to depression, a psychodynamic theory views depression as an interpersonally oriented problem and as resulting largely from cognitive-affective representations formed in the very earliest years of childhood and elaborated over a multitude of subsequent experiences. What is unique about a psychodynamic approach is that key aspects of these representations are believed to be out of one s immediate awareness and not easily accessible for consideration or introspection. Moreover, ambivalent feelings lead to an unconscious defensive push of thoughts or feelings from awareness. These out-of-awareness experiences, thoughts, and feelings are seen as important not only in the generation of pathological depressive affect, but also in its treatment. See also Kenneth N. Levy and Rachel H. Wasserman Anaclitic and Introjective Depression Psychodynamic Therapy References Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In P. Clayton & J. Barnett (Eds.), Treatment of depression: Old controversies and new approaches (pp ). New York: Raven Press. Bibring, E. (1953). The mechanism of depression. In P. Greenacre (Ed.), Affective disorders (pp ). New York: International Universities Press. Blatt, S. J. (1974). Levels of object representation in anaclitic and introjective depression. Psychoanalytic Study of the Child, 29, Freud, S. (1953). Mourning and melancholia. In J. E. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp ). London: Hogarth Press. (Original work published 1917) Kernberg, O. F. (1992). Psychopathic, paranoid, and depressive transferences. International Journal of Psychoanalysis, 73, Nemeroff, C. B. (1999). The pre-eminent role of early untoward experience on vulnerability to major psychiatry disorders: The nature-nurture controversy revisited and soon to be resolved. Molecular Psychiatry, 4, Sandler, J., and Joffe, W. G. (1965). Notes on childhood depression. International Journal of Psychoanalysis, 45, Psychodynamic Therapy Whereas systematic reflection on the treatment of depression dates back at least to the time of Hippocrates and Galen, psychodynamic approaches could be considered a watershed of modern psychological thought. The family of treatments known as the psychodynamic (also termed dynamic or psychoanalytic) therapies all share a common lineage, with Sigmund Freud ( ) as their intellectual forebear. Psychoanalysis, as both a psychological system and treatment approach, is remarkable for its scope, originality, ability to generate controversy, and also for the sheer number of its ideas that have become popular parlance (e.g., defense mechanisms, slips of the tongue). Most important for contemporary psychological thought, however, were Freud s discussions of the unconscious and, specifically, his insistence that unconscious motivations were ubiquitous in normal and pathological human life. Although systematic thinking about the unconscious certainly predates Freud (e.g., Schopenhauer and Nietzsche), his major contribution to the history of ideas was to systematize its study, thus making seemingly random events (e.g., dreams and forgetting) both meaningful and potentially comprehensible. Since their genesis, Freud s methods and ideas have been widely utilized, applied to other disciplines (e.g., philosophy and literary theory), and migrated far beyond their Viennese origins to take root in many parts of North America, Latin America, and Europe. In spite of the fact that Freud s conception of human nature involved strong hedonistic elements (namely, it was based on the so-called pleasure principle), a large portion of his voluminous body of work was devoted to charting human misery in all of its many shades and variations. Not surprisingly, the seemingly common human vicissitude of depression was an object of great interest to

2 Psychodynamic Therapy 461 him and those who followed. Freud s (1953) major work on the subject, Mourning and Melancholia, emphasized the similarities and differences between bereavement and depression. He saw the predisposition for depression as resulting from the real or imagined loss of loved ones in childhood. The image of the lost object, whom the child has ambivalent (namely, both loving and hateful) feelings for, is then internally reconstructed and taken into the child s psyche by a process known as introjection. The lost object then becomes part of the child s ego, and the ambivalent feelings are directed inward. A steady stream of anger, self-criticism, and reproach are thus directed at the self (instead of the lost object), and this is thought to result in depression. In general, dynamic understandings of depression have followed the development and evolution of psychodynamic thought itself, and theorists subsequent to Freud have amplified, subtly shifted focus on, or departed from his earlier ideas. This is perhaps reflective of variations in the causes or specific manifestations of depression across time or societies. For instance, Karl Abraham and Sandor Rado focused on the depressive consequences of early injuries to a child s selfesteem. Edward Bibring saw the origin of depression in a self-perceived gulf between who one is or what one has accomplished (i.e., the actual ego) and who one wished to be or what one hoped to achieve (i.e., the ego ideal). Marked discrepancies between the actual and the ideal were thought to lead to the incessant self-criticism and debasement so characteristic of depression. More recently, object relations theorists and self psychologists have sought the origins of depression in what could be termed a deficiency disease during the first few years of life wherein children either do not receive enough caregiving or do not receive it in an empathic and comfortable manner. Summarizing across these and other models (which is a precarious, if not impossible task), psychodynamic conceptions of depression tend to focus on such themes as real or perceived loss, narcissistic vulnerability, conflicted anger (often directed toward the self), disturbances in the self, early parental failures, guilt, shame, and interpersonal struggles. One way to introduce psychodynamic therapies for depression is to discuss what has been termed the psychoanalytic attitude or sensibility (e.g., McWilliams, 2004). In general, psychodynamic therapists value a particular type of honesty over the entire course of therapy. Self-examination and introspection are highly valued for both patients and therapists, and this includes a sustained investigation into aspects of oneself that may be disavowed or unknown, yet nonetheless highly influential. These aspects may include wishes, desires, dreams, and fantasies that serve as personal motivations. There is also an overriding respect for the complexity of the mind and the many layers and levels (e.g., conscious, unconscious) of thought, emotion, and behavior. This is epitomized in what have been termed the principles of overdetermination and multiple function (Wäelder, 1936). Overdetermination refers to the belief that every significant mental event is preceded by multiple causes (i.e., depression is not due to just one discrete cause). Similarly, the principle of multiple function holds that every action intended to solve one problem is simultaneously an attempt to solve other problems (e.g., depression may serve to punish oneself for perceived misdeeds, express hostility toward a partner, and emotionally connect with a depressed parent). Dynamic therapies attempt to clarify these causes and motivations. Similarly, all symptoms are understood not just as symptoms per se, but within the overarching context of the entire person and their historical development. Some specific approaches (especially time-limited therapies) spend relatively less time on past events, but all express unanimity on the contextual nature of psychopathology. Finally, psychodynamic therapists believe that pathology is linked to fundamental human processes and adaptations. Thus, given similar biological predispositions and environmental circumstances, anyone could fall victim to depression or other psychological disturbances, as

3 462 THE INTERNATIONAL ENCYCLOPEDIA OF DEPRESSION there is clearly a continuum between normal and pathological states. No one is immune to pathology, and psychodynamic therapists must be aware of and empathically utilize their own personal struggles in order to effectively help their patients. These various aspects of the psychodynamic sensibility may explain the tendency for most dynamic therapists to supplement standard symptom-based definitions of depression (e.g., the Diagnostic and Statistical Manual of Mental Disorders [ DSM- IV; American Psychiatric Association, 1994] and International Classification of Disease, tenth edition [ ICD-10, World Health Organization, 1992 ]) with more holistic models (e.g., Kernberg s [1975] structural diagnosis or the recent Psychodynamic Diagnostic Manual [PDM Task Force, 2006] ). There is a great deal of heterogeneity in the concept of psychodynamic psychotherapy. This plurality represents a strength of the dynamic approach, as it allows for responsiveness to a broad range of disorders (including depression), as well as different levels of disorder severity. When structuring a psychodynamic treatment, we have found it helpful to consider three different dimensions or continua. Using variations of these three dimensions, it is possible to meet the needs of patients with different treatment goals, degrees of suffering, and resources. The first dimension or continuum would be session frequency. At one pole of this dimension would be psychoanalysis proper, with a session frequency of four to five times per week. At the other end would be a purely supportive dynamic therapy (described below) in which sessions may occur on a twice-monthly basis. Between these two extremes would be so-called standard psychodynamic therapies with weekly or twice-weekly sessions. The second dimension would be length of treatment. A complete psychoanalysis, with its open-ended and exploratory nature, likely spans 4 years or more. At the other extreme are the time-limited or brief psychodynamic therapies. In these approaches (which are those most studied in treatment outcome research), patients typically receive a total of 12 to 40 weekly or twice-weekly sessions. The third dimension could be described as the expressive versus supportive continuum of techniques. In general, expressive or interpretative techniques are intended to uncover, understand, process, and emotionally attune patients to the origins of their problems and repetitive patterns. Therapist interpretations (in which observed thoughts, feelings, or behaviors are directly tied to the dynamic content that gives rise to them) would epitomize a more expressive approach, and they are also the primary tools used in psychoanalysis and intensive long-term psychodynamic therapies. In contrast, supportive techniques are utilized to make the patient feel more comfortable. The more supportive therapies often remain focused on the surface of a patient s life, spending less time on past events, and are intended to combat immediate distress as well as return the patient to his or her typical baseline level of functioning. Regression to earlier and distressing events is not encouraged, and supportive therapies instead rely upon the shoring up of adaptive defenses. These techniques are sometimes described as creating a holding environment for patients. One may wonder in what circumstances a depressed person would benefit from these different variations of dynamic therapy. There are many factors to consider, obviously, but we attempt here to provide some generalizations. Whereas some theorists have suggested in the past that all psychodynamic psychotherapies are inferior or baser alloys of the pure gold of psychoanalysis, most current therapists would disagree. They realize that not all people are appropriate for psychoanalysis and its many requirements. Most also believe that the approach taken must be adapted to the particular needs of the individual. Thus, in contrast to the early days of psychoanalysis when many patients were recommended for analysis, there is no longer a one-size-fits-all psychodynamic approach. However, there certainly are better and worse approaches, depending upon the idiosyncratic needs of a depressed patient. Patients needs can be grouped into goals, the degree of suffering, and resources. With

4 Psychodynamic Therapy 463 regard to goals, dynamic therapists take patient goals seriously and spend time revisiting them throughout the course of treatment. These goals can range widely. Some patients desire reduction of their depressive symptoms, while others hope to change their maladaptive interpersonal patterns and make significant modifications to their personality. Sometimes patients and therapists may disagree on goals, or even on what is driving the depression, and such a state of affairs requires continued clarification and discussion. Degree of suffering can range from a relatively mild first episode of depression, just barely interfering with a person s life, to a recurrent and severe major depression that causes widespread and global functional impairment. In some cases, patients in the darkest depths of depression may also experience problems with reality testing. Resources of the patient must be realistically considered as well. Whereas this includes such factors as money and time (both legitimate concerns), it also includes the patient s appropriateness for the demands of psychodynamic psychotherapy (i.e., his or her psychological resources). Over the course of the past 100 years, a great deal of speculation on these potential factors has taken place. In general, the closer that depressed patients approximate the prototypical good patient for psychoanalysis, the more appropriate they are for more expressive approaches. The further patients deviate from this template, the more likely they are to benefit from more supportive approaches. Unfortunately, the empirical validation of these concepts remains at the beginning stages. The prototypical patient should be suffering, curious about his or her problems, motivated to change, willing and able to think psychologically, capable of understanding metaphor, and able to acknowledge his or her emotional experiences. Sans these attributes, expressive techniques may be less effective (however, the empirical findings on this are mixed). Further, given the interpersonal focus of psychodynamic therapy and the importance of the therapeutic relationship, it is helpful if the patient has had at least one good relationship in the past (or present). Anecdotal evidence would also suggest that people with antisocial personalities tend to do poorly in psychodynamic therapy, but this may not be the case if they are concurrently depressed (Woody, McLellan, Luborsky, & O Brien, 1985). Presumably, profound interpersonal deficits would impede the formation of a good and authentic therapeutic alliance. Adequate reality testing is also a requirement of expressive work, and patients suffering from psychotic depressions are more likely to benefit from supportive treatments. Again, these are broad generalizations, but we have found them to be useful heuristics nonetheless. Psychodynamic authors (e.g., Busch, Rudden, & Shapiro, 2004) often describe hypothetical stages of therapy for depression. In the beginning stage, an extensive history of the patient s depression, overall development, and general functioning (e.g., work history, interpersonal life) is taken. This is important, as it reveals the dominant depression themes and yields insight into the development and maintenance of these problems. A history also consists of exploratory work to uncover the hidden or suppressed wishes, fears, impulses, and desires in the patient s inner life and also to understand the characteristic ways in which the patient deals with them. This work eventuates in the therapist forming a dynamic conceptualization of the patient s depression. For example, a depressed male patient may be understood as continually seeking out depressed women with unconscious wishes that he can save them from their depression (perhaps in a way that he could not save his mother) and also be recognized as good and masculine by them. These attempts ultimately fail due to his inability to connect with them beyond a superficial level, and these repeated failures leave him feeling inadequate and isolated. This conceptualization will then be used to help determine treatment goals and the general plan to reach these goals. However, the formation of a good therapeutic alliance, an essential achievement of this stage, is likely a precondition for treatment progress.

5 464 THE INTERNATIONAL ENCYCLOPEDIA OF DEPRESSION The middle phase of treatment is characterized by helping the patient thoroughly understand his or her depressive dynamics and the many ways in which these dynamics affect the patient s life and interpersonal relationships. Therapeutic work may involve the exploration of repetitive patterns of behavior as well as the patient s relationship with the therapist (e.g., in the transference). Using the example above, the patient at this stage begins to recognize and understand the emotional pull that depressed women seem to possess for him. He also begins to understand the problematic ways in which his neediness emerges in relationships with others, as it is simultaneously arising in the therapeutic relationship. It is important to note, however, that gaining insight is not held to be merely an intellectual process, but is an emotional one as well, and therapists work to link patients feelings to their experiences in a safe and moderated fashion. Distinctions are also made between feeling and acting, as some depressed patients may have difficulties with impulsive behavior (especially suicidal patients). Insight into the patient s depression and the working through of these insights into different areas of the patient s life often results in increased freedom from maladaptive patterns. Another primary goal at this stage is to inoculate the person from future depressions through eliminating vulnerabilities that would make this likely (e.g., by reducing unrealistic guilt, increasing understanding of underlying dynamics, or working toward a more realistic self-concept). The final phase of therapy includes the actual termination of the treatment and therapeutic relationship. Termination is often experienced as a recapitulation of earlier losses that may have served to elicit the patient s depression. This being the case, substantial time is devoted to exploring the patient s experiences of impending loss. Such time is necessary, as these feelings may be very confusing and conflicted for the patient (e.g., sadness over the loss combined with anger over abandonment). In general, exploration and discussion of the end of therapy is intended to ultimately provide a new experience or provide the possibility for separating in a manner different from the past. Successfully weathering a separation with a well-intended and responsive person may serve as both a model for other nondisruptive separations and as a preventative for future episodes of depression. Using our previous example, the patient at this stage has made progress in both his depressive symptoms and in the quality of his relationships. As termination nears, he begins to feel increasingly angry and fearful. In response, a great deal of time is spent resolving his ambivalent feelings toward the separation, and he is eventually able to move on and interact with people in a new and more flexible manner. We end by briefly reviewing empirical evidence for the efficacy of psychodynamic therapies for depression. When compared to other treatments for depression (e.g., cognitive therapy), there have been relatively few large trials of psychodynamic therapy. This paucity of research is likely due to several factors. First, the research tradition of psychodynamic therapists historically relied upon in-depth descriptions of individual case studies as opposed to large-scale controlled clinical trials. Second, some prominent scholars have expressed skepticism that dynamic therapy could be adequately operationalized into specific and detailed therapy manuals (a major requirement for randomized controlled trials) while simultaneously maintaining an individualistic approach to patient treatment. However, not everyone agrees with these assessments, and clinical research into brief psychodynamic therapy for depression has taken place. Comparisons of brief dynamic therapy to either cognitive therapy or behavior therapy indicate essentially equivalent effectiveness in treating depression (e.g., Leichsenring, Rabung, & Leibing, 2004). Similarly, two studies to date have compared brief dynamic therapy to antidepressant medication. Results did not indicate superiority for either approach. Unfortunately, no longterm follow-up studies were conducted for these medication trials, and it remains to be

6 seen whether dynamic therapy, like cognitive therapy, will demonstrate lower relapse rates than medication. In addition to these findings derived from clinical trials, research into the process of therapeutic change has been conducted. Specifically, investigations into nonspecific therapy factors (e.g., the therapeutic alliance) as well as psychodynamic-specific factors (accurate interpretations of patient s core dynamic difficulties and the competent delivery of interpretative techniques) have consistently been associated with positive treatment outcome. In summary, although psychodynamic therapy in existing trials appears to be as effective as other treatment approaches and possesses some level of empirical support for several mechanisms of change, more therapy process and outcome research is warranted. This is particularly the case for more intensive forms of psychodynamic therapy. See also Brian A. Sharpless and Jacques P. Barber Bereavement Psychodynamic Model of Depression References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Busch, F. N., Rudden, M., & Shapiro, T. (2004). Psychodynamic treatment of depression. Washington, DC: American Psychiatric Publishing. Freud, S. (1953). Mourning and melancholia. In J. E. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp ). London: Hogarth Press. (Originally published 1917) Kernberg, O. F. (1975). Borderline conditions and pathological narcissisim. New York: Jason Aronson. Leichsenring, F., Rabung, S., & Leibing, R. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61, McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner s guide. New York: Guilford Press. PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Wäelder, R. (1936). The principle of multiple function: Observations on over-determination. Psychoanalytic Quarterly, 5, Woody, G. E., McLellan, A. T., Luborsky, L., & O Brien, C. P. (1985). Sociopathy and psychotherapy outcome. Archives of General Psychiatry, 42, Psychophysiology of Depression 465 Psychophysiology of Depression As its name implies, psychophysiology is the study of mind-body relations. In particular, it examines relations between physiological and psychological variables, and especially how psychological constructs are reflected in patterns of physiological activity. Psychophysiological techniques are useful for the understanding of emotion, cognition, personality organization, and mental illness. Sweat gland activity, heart rate, blood pressure, muscle tension, brain activity, and other electrophysiological responses are commonly measured, as are stomach activity, breathing patterns, stress hormones, and immune system functioning. Emotional states tend to be reflected in such physiological activity, which makes physiological measurement an invaluable research and assessment tool. The literature in the area of relations of physiological response systems to emotional disorders is vast and diverse, and the study of each of these response systems is complex and technical. As such, this entry briefly discusses two common examples and their interpretation. The interested reader is referred to Santerre and Allen (2007) for a broader overview of the application of psychophysiological methods to psychopathology. Distinguishing Psychophysiology From Biological Psychiatry The predominant viewpoint in biological psychiatry tends to conceptualize mental illnesses as manifestations of various brain disorders. Researchers of this mind-set tend to interpret the results of their studies from the standpoint of general abnormalities in physiology and functional neuroanatomy, which are conceptualized as causing or contributing to psychopathology (Insel, 2007). These models can be quite intricate, focusing on subtypes of neurotransmitter receptors, complex brain circuitry, and feedback mechanisms between the brain and the endocrine system, for example. In contrast, psychophysiological perspectives take into account complex interconnections between the mind and the body. In

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