Psychodynamic Psychotherapies

Introduction

Glen O. Gabbard, M.D.

Psychodynamic therapies of depression have been studied less rigorously than cognitive-behavioral therapy and interpersonal psychotherapy. Nevertheless, both brief and extended psychodynamic psychotherapies, and in some cases psychoanalysis, have a significant role to play in the treatment of depressed patients. A wealth of clinical experience has demonstrated that certain patients require in-depth exploration of unconscious conflicts, depleted self-esteem, and problematic internal object relations to obtain relief from their depression. Moreover, psychodynamic thinking may be extremely useful in understanding transference, countertransference, and resistance issues that arise in other forms of treatment, such as pharmacotherapy, cognitive-behavioral therapy, and interpersonal psychotherapy.

Indications
Empirical research available to date is of only limited assistance in predicting which patients are likely to respond preferentially to the psychodynamic therapies. One study shed some light on the question of which depressed outpatients are most likely to respond to brief psychodynamic therapy. The results of this investigation suggested—retrospectively, not predictively—that the elderly patients with major depressive disorder who responded best to brief dynamic therapy had lower expectations for treatment and better interpersonal relationships at the end of treatment. In a more recent investigation, depressed caregivers of elderly family members were randomly assigned to either brief psychodynamic therapy or cognitive-behavioral therapy. After 20 sessions, 71% of the caregivers were no longer clinically depressed. Overall, no differences were found between the two treatment groups. Symptom-oriented measures suggested that those who had been caregivers for more than 3.5 years improved more with cognitive-behavioral therapy, whereas those who had been caregivers for shorter periods of time showed more improvement from brief psychodynamic therapy. Beyond research data, however, clinicians must take patients' preferences into account. Certain patients view their depression as growing out of a psychological matrix that requires understanding and mastery. Patients sometimes refuse medications because they harbor consciously or unconsciously held negative attitudes about taking antidepressants or because medications are imbued with specific unconscious meanings.

Psychodynamic Psychotherapies Introduction Indications Efficacy

• Evidence for Acute-Phase Efficacy