Psychodynamic Psychotherapies: Treatment Principles
Although psychodynamic approaches to depression are lumped together in the design of this present volume, they may vary considerably in their technical strategies. The actual interventions used in dynamic psychotherapies and psychoanalysis can be conceptualized as residing on an expressive-supportive continuum (Gabbard 2000). At the expressive end of the continuum, one finds the interventions most associated with exploratory and uncovering strategies. These include interpretation, confrontation, and clarification. As one moves toward the supportive end of the continuum, one encounters interventions such as advice, praise, empathic validation, encouragement to elaborate, and affirmation. These latter strategies are used for patients who have greater fragility and require support from the therapist. Whereas expressive psychotherapy is geared toward exploring and uncovering unconscious aspects of defensive operations, supportive therapy attempts to bolster adaptive defenses to improve the patient’s functioning. In actual practice, most dynamic psychotherapies move across the expressive-supportive continuum, using interventions from both ends of the continuum (Wallerstein 1986). Indeed, dynamic therapy is often referred to as supportive-expressive psychotherapy.
In general, dynamic therapists will use a more expressive emphasis in the psychotherapy for patients who are psychologically minded, motivated to understand themselves, and capable of abstract thinking. A more supportive emphasis will be used with patients who lack those capacities and have fewer ego strengths. In his long-term follow-up of 42 patients studied in the Menninger Foundation’s Psychotherapy Research Project, Wallerstein (1986) found that supportive approaches produced intrapsychic changes that are just as durable and extensive as those produced by expressive approaches.
The most expressive forms of dynamic psychotherapy, such as psychoanalysis, are not directly aimed at symptom removal to the extent that reeducative psychotherapies and psychopharmacological approaches are. Instead, they are geared toward uncovering the relevant psychodynamic themes that underlie the depression so that the patient achieves mastery and understanding of the psychological origins of the depression. Ultimately, of course, this understanding leads to improvement in symptoms. The transference-countertransference developments are regarded as a laboratory in which the patient’s significant conflicts and internalized relationship patterns are recapitulated in vivo so that they can be examined by the therapist and patient in a collaborative effort to understand their meaning. Although some of the same conflicts and internalized relationship patterns are elicited in supportive dynamic therapy, they are handled differently. The supportive dynamic therapist has a more educative role and gives more advice while strengthening adaptive defenses. In this regard, dynamically informed supportive therapy and interpersonal psychotherapy have much in common.
In psychoanalysis the analyst and patient meet four to five times a week in an effort to intensify the transference themes and examine them in great depth. Extended dynamic psychotherapy that is primarily expressive in orientation may involve sessions from one to three times a week and entails a more focused, less comprehensive analysis of the transference issues. Brief dynamic therapy, whether predominantly expressive or supportive, occurs one to two times a week over a period of several weeks or months. The more expressive variants are focused on one or two primary psychodynamic themes and their transference analogs. Whereas psychoanalysis is generally conducted with the patient lying supine on a couch, most forms of psychotherapy are conducted face to face with the patient sitting up. The usual duration of a session in both processes is 45 or 50 minutes.
The dynamic therapist must not impose psychodynamic formulations on the patient. Instead, the therapy should be conducted in such a way that the patient leads the therapist to the relevant psychological themes. To facilitate this process, the therapist must first simply listen and empathize with the patient’s perspective in the service of establishing a solid therapeutic alliance. Dynamic psychotherapy is often counterintuitive in the sense that interventions that might intuitively seem helpful are not. For example, when encountering someone who is in the depths of depression, family members and friends often assume that the person needs to be cheered up. They may offer encouraging comments such as “Things aren’t as bad as they seem. They could be much worse. You have so much to live for.” Unfortunately, these comments are often interpreted by the depressed patient as reflecting a lack of understanding and empathy on the part of his or her friends and family. Therapists may feel like making similar comments, but these remarks have the opposite of the intended effect. Instead of building rapport, such comments may result in the patient’s feeling as if the therapist is one more person who does not understand.
A more productive course is for the therapist to acknowledge and empathize with the extent of the patient’s depression and convey a sense that there are indeed reasons for the patient’s feelings that can be understood in the course of the treatment. Rather than trying to interpret the causes or meanings of the patient’s depression, the therapist should first enlist the patient’s assistance in a collaborative search for the pertinent psychological themes.
The nature and meaning of the particular stressors involved in the depressive episode are a good starting point. Twin studies (Bierut et al. 1999; Kendler et al. 1993, 1995, 1999) suggest that stressful life events may be the most influential predictor of a depressive episode. Depression appears to be a model of an illness with a genetic diathesis activated by environmental stressors. Genetic factors seem to alter the sensitivity of the individual to the depression-inducing effects of stressful life events (Kendler et al. 1995). There is also considerable evidence that early experiences of abuse, neglect, or separation may create a neurobiological sensitivity that predisposes one to respond to stressors in adulthood with the development of a major depressive episode. Kendler et al. (1992) documented an increased risk for major depression in women who had experienced maternal or paternal separation in childhood or adolescence.
Heim et al. (2000) recruited four groups of female subjects between the ages of 18 and 45 years. Twelve subjects had no history of childhood abuse or psychiatric disorder and served as a control group. A second group of 13 subjects had a diagnosis of current major depression and also a history of sexual or physical abuse in childhood. A third group of 14 subjects also had a childhood history of sexual or physical abuse but no current major depression. The fourth group, 10 subjects, had a diagnosis of current major depression but no history of abuse in childhood.
When the groups were compared, the women with the history of childhood abuse exhibited increased pituitary-adrenal and autonomic responses to stress compared with controls. This effect was particularly dramatic in women who had current symptoms of depression and anxiety. When women had both a current major depression diagnosis and a history of childhood abuse, they had a sixfold greater adrenocorticotropic hormone (ACTH) response to stress than age-matched controls.
The investigators concluded that adverse experiences in childhood may result in persistent sensitization of the hypothalamic-pituitary-adrenal axis to mild stress in adulthood. Moreover, this increased response to stress, presumably due to corticotropin-releasing factor (CRF) hypersecretion, suggests that early childhood abuse may contribute to a diathesis for adult psychiatric disorders, such as depression. A genetic substrate might serve to diminish monoamine levels in synapses or to increase reactivity of the hypothalamic-pituitary-adrenal axis to stress. If there is no serious stress on the individual, the genetically determined threshold is not necessarily sufficient to induce depression.
A prospective study from the United Kingdom (Bifulco et al. 1998) found that women with a history of childhood abuse or neglect were twice as likely to have negative relationships and low self-esteem in adulthood. Those abused or neglected women who have these negative relationships and low self-esteem in adulthood were then 10 times more likely to experience depression. Weiss et al. (1999) examined studies of childhood sexual abuse and found a clear relationship to adult-onset depression. These authors suggested that gonadal steroids may play a key role in the modulation of the hypothalamic-pituitary-adrenal axis and may therefore contribute to the higher sensitivity of that axis to stress in women. This sexual dimorphism may help explain the higher prevalence of depression in women. One of the clinical implications of these findings is that exploration of the impact of childhood trauma or neglect may be crucial in the psychodynamic therapy of depressed patients.
These early stressors of childhood separation, neglect, or abuse appear to make one more vulnerable to adult stressors that may lead to depression. However, from a psychodynamic perspective, the clinician must always consider the meaning of a particular stressor: What may seem like a relatively mild stressor to an outside observer may have powerful conscious or unconscious meanings to the patient that greatly amplify the impact. As Hammen (1995) noted, “The field has reached considerable consensus that it is not the mere occurrence of a negative life event but rather the person’s interpretation of the meaning of the event and its significance in the context of its occurrence” that cause depression (p. 98). In her longitudinal study of the link between depressive reactions and stressors, she and her colleagues found that stressors whose content matched the patient’s area of self-definition were particularly likely to precipitate depressive episodes (Hammen et al. 1985). In other words, in someone whose sense of self is partly defined by social connectedness, loss of significant interpersonal contacts may precipitate major depression. A current stressor may reactivate a stressor from childhood, as in the following example:
Mr. B, a 48-year-old executive who had been diagnosed as having major depressive disorder, sought psychotherapy because he felt that he was no longer getting the gratification out of life that he once did. In the course of the psychotherapy, Mr. B talked about many aspects of his life but was unable to identify any clear psychosocial stressors that may have triggered the depression. Finally, one day, in passing he mentioned that his wife, who had spent most of her adult life as a homemaker, had recently finished an advanced degree and was enthusiastically pursuing a career that provided her with a substantial income and a source of professional satisfaction.
Mr. B’s therapist asked him if his wife’s success was bothering him. He initially protested that, on the contrary, he was happy for his wife. After a moment’s reflection, however, he told his therapist that maybe his knee-jerk response did not really capture his feelings. He went on to say that he was envious of his wife’s excitement and enthusiasm, and he felt that she was more interested in her job than in him.
As Mr. B continued to talk, he became increasingly aware of his resentment toward her, and his therapist asked if the situation reminded him of anything from his past. Mr. B said that his mother started working when he entered the first grade and that he felt she changed from that moment on. Specifically, he said that he had always felt like “the center of the universe” to his mother until she started working. Something shifted at that point so that he felt peripheral in his mother’s life. The therapist helped him see that his wife’s entrance into the workplace had recapitulated an important developmental experience and triggered feelings of depression and hopelessness about ever getting his emotional needs met.
As the therapist gets to know the patient and listens to the emerging psychodynamic themes, initial hypotheses can be formed. Is there a dominant other in the patient’s life? Is there a discrepancy between the patient’s ideals and the realities of his or her life? Are there feelings of guilt and remorse connected with fantasies of hurting others? These hypotheses may be bolstered by the developments in the transference. For example, if the therapist observes that his or her approval and affection have become more important to the patient than the understanding of the patient’s psychological problems, it is possible that the therapist has become a “dominant other” for the patient. The therapist, in such circumstances, can begin to interpret these patterns to the patient so that the dominant ideology is clarified and alternatives are sought. In many cases, a mourning process needs to be facilitated so that the patient can give up the unattainable goals and find new sources of gratification in life.
When attempting to use an exploratory or a predominantly expressive approach with a depressed patient, the therapist must keep in mind that the patient’s self-esteem may be particularly fragile as a result of the depressive illness. This heightened narcissistic vulnerability may result in the patient’s experiencing the therapist’s attempts at insight as pointed criticisms. An interpretive strategy may need to be postponed until the patient has made sufficient improvement so that the therapist’s observations are experienced less painfully. The therapist must also be attuned to the possibility that the patient may misuse the therapist’s insight in a pathologically self-punitive manner that promotes self-blame. Whereas nondepressed patients often disavow personal responsibility for their difficulties, depressed patients may take on an excessive burden of responsibility and use dynamic therapy to discover new ways to blame themselves for their problems.
Careful examination of transference-countertransference enactments may provide a window into critically important relational patterns that are embedded in the patient’s character and instrumental to the perpetuation of the depression. Dynamic therapists and analysts carefully study their own emerging emotional reactions to the patient and regard these reactions as a valuable source of information about the patient’s internal world (Gabbard 2000; Gabbard and Wilkinson 1994). When the therapist begins to feel “stuck,” for example, one hypothesis that should be entertained is the possibility that the same “stuck” feeling exists in the depressed patient’s relationship with family members or other significant persons.
Mr. C, a 60-year-old clergyman, was admitted to a psychiatric hospital for major depression and suicidal ideation. In the course of psychotherapeutic work with him, his hospital psychiatrist noted that Mr. C talked on at great length about his suffering, his transgressions, and his hopelessness about changing anything, but he rarely showed any interest in treatment. Moreover, his therapist noted that whenever he tried to get a word in edgewise with Mr. C, the patient raised his voice and talked over him so that the patient conveyed a sense that he was not interested in hearing anything his therapist had to say.
Periodically, Mr. C’s therapist would assert himself sufficiently to make a few comments. While he spoke to Mr. C, he noticed that the patient subtly shook his head from side to side and, almost inaudibly, muttered, “Yeah, yeah, yeah, yeah.” At first, Mr. C’s therapist was not sure he was hearing the patient correctly, and he simply continued to talk. However, as he continued to treat Mr. C, he soon realized that every observation he made was greeted with this same mocking chant.
After enduring several sessions of this pattern, Mr. C’s therapist made the following comment: “I’ve noticed that each time I say something, you don’t seem to be listening. Instead, you say ‘Yeah, yeah, yeah, yeah’ over and over again. Are you aware that you do that?” Mr. C responded, “Yeah, yeah, yeah, yeah, yeah, yeah.” His therapist noted the intense countertransference irritation this produced in him related to a feeling that Mr. C had utter contempt for any help he, the therapist, might offer. Rather than expressing the anger, the therapist processed it silently and wondered what it might say about the patient’s other relationships.
In a meeting on the hospital unit with Mr. C’s wife, the therapist reported his observation to her about Mr. C’s mocking chant. She immediately responded to his observation by reporting that she experienced exactly the same thing when she tried to offer helpful comments to her husband. She added, “It makes me so angry I could scream!” This meeting seemed to be a breakthrough in the treatment of Mr. C because his wife and his therapist both confronted him with the hostility and contempt that he was disavowing. His life as a clergyman had been characterized by reaction formation against any feelings of anger or aggression. To keep his negative feelings outside his awareness, he constantly ministered to others and took care of their needs. The resentment that had built up over the years regarding his self-sacrificing characterological stance had finally surfaced in the context of his depression. When he recognized how he was producing such anger in others, he became more reflective about his behavior and was able to engage in a psychotherapeutic process more productively while also being treated with fluoxetine.
Revision date: June 22, 2011
Last revised: by Jorge P. Ribeiro, MD