Psychodynamic Psychotherapies: Applications and Procedures
The psychodynamic clinician approaches all clinical situations from a particular perspective. Psychodynamic psychiatry is fundamentally a way of thinking. More specifically, it is “an approach to diagnosis and treatment characterized by a way of thinking about both patient and clinician that includes unconscious conflict, deficits and distortions of intrapsychic structures, and internal object relations and that integrates those elements with contemporary findings from the neurosciences”.

Within this broad definition one can conceptualize the approach as an overarching one that is useful whether the clinician is prescribing medication or doing any other form of psychotherapy. Indeed, the “Practice Guideline for Major Depressive Disorder in Adults” reflects the central role of psychotherapeutic management in any form of depression treatment. Because compliance with pharmacotherapy is a central problem in the treatment of many patients, dynamic pharmacotherapy or dynamic clinical management is essential in many cases to ensure that the patient takes the medication as prescribed.

Dynamic Pharmacotherapy/Dynamic Clinical Management
The core psychodynamic principles of transference, countertransference, and resistance apply to the prescribing of medication in much the same way as they do to psychotherapy (Gabbard 2000). Transference involves the patient’s attribution to the doctor of qualities that belong to a person in the patient’s past. For example, the prescribing psychiatrist may unconsciously be viewed as an authoritarian parent telling the patient what to do. The psychiatrist may also be regarded as a competitor who is trying to “show up” the patient with his or her superior knowledge. In either case, the patient may rebel against this transference figure by refusing to take the medication. An exploration with the patient of the doctor-patient interaction and of the medication itself may be extraordinarily useful in elucidating the patient’s reluctance to comply.

Conversely, a doctor, when prescribing medication, may unconsciously experience the patient as representing significant persons from the doctor’s past (i.e., countertransference). For example, the doctor may demand compliance because he or she perceives the patient’s request for information as rebelliousness. Similarly, because of various countertransference reactions to the patient, the doctor may underprescribe or overprescribe if he or she is not attuned to the reemergence of an important past-object relationship from his or her internal world. There is no fundamental qualitative difference between transference and countertransference; doctors may also be vulnerable to distortions in the doctor-patient relationship. The clinician’s careful monitoring of his or her own emotional reactions to the patient may provide clues to the enactment of unconscious feelings.

The notion of resistance is a central concept in psychodynamic theory. Many patients are highly ambivalent about getting better. Despite the intense suffering of depression, some patients are convinced that they deserve to be punished for their perceived sins and transgressions. The medication may mean a form of liberation from the suffering of which the patient does not feel deserving. Other forms of resistance relate specifically to the doctor, who may unconsciously represent someone from the patient’s past. The doctor may be perceived as controlling, intrusive, or domineering. The medication may also be a specific target of resistance. In addition to manifesting the resistance by noncompliance with the prescribed agent, some patients may have a negative reaction to the biological improvement induced by the medication and show some degree of psychological deterioration as a way of undermining that improvement. Still other patients may resist being treated with an appropriate psychopharmacological agent because it has special meaning to them, as the following case example illustrates:

Ms. A, a 31-year-old homemaker, came to psychiatric attention because she could no longer get through the day without crying. After being diagnosed with a major depressive episode, she was given desipramine in gradually increasing doses until she was taking 250 mg daily. As she still was having no response to the medication, her psychiatrist obtained a measurement of the blood level of the medication. The blood level was in the therapeutic range, so the psychiatrist added lithium carbonate as an adjunct.

When giving Ms. A the prescription for lithium, her psychiatrist noticed that she hesitated in taking it. Nevertheless, she said she would get the prescription filled and try it. When she returned for her next appointment, her psychiatrist told her that they would need to monitor her blood level of lithium. Ms. A blushed a bit and confided that she was not actually taking the lithium. Without getting punitive or critical, her psychiatrist simply asked her to elaborate on why she was reluctant to take it. Ms. A became tearful and in an emotion-choked voice said, “I will not be genetically tied to my mother!” She went on to explain that her mother had been diagnosed with bipolar illness and treated with lithium. Ultimately, the mother had committed suicide.

Although the patient’s statement about her insistence that she not be genetically tied to her mother was absurd at one level, her psychiatrist immediately knew the basis of her resistance. He said to her, “It sounds like you’re worried that taking the lithium somehow means that you have the same disease your mother had and that you’ll end up as a suicide.” Ms. A acknowledged that she did harbor such fears, and she began to sob as she talked about her wish to make her life different from her mother’s. With further support and exploration from her psychiatrist, including a discussion of lithium as an augmentation of desipramine, she eventually agreed to take the lithium because she felt both understood and reassured.

Adjustment of medication dosage may also be facilitated by a psychodynamic approach. Loeb and Loeb (1987) reported on a series of bipolar patients who were treated with a combination of lithium carbonate and either psychoanalysis or psychodynamic psychotherapy. Through the intensive therapeutic work, the patients became consciously aware of the emergence of sexual wishes and fantasies before a manic episode. These previously unconscious thoughts provided both patient and doctor with a signal that an increase in the lithium dose was necessary. Recently, there has been increasing recognition of the limitations of lithium prophylaxis on the one hand and the role of stressful life events in relapse on the other. The pharmacotherapeutic management of bipolar patients requires a keen awareness of psychosocial stressors and of their intrapsychic meaning to the patient.

Psychodynamic Themes in the Psychotherapy and Psychoanalysis of Depressed Patients
Whether the treatment is brief dynamic therapy, extended dynamic therapy, or psychoanalysis, the clinician’s primary goal is to elicit and, in some cases, explore the central psychodynamic issues related to the patient’s depression. A survey of commonly observed themes that underlie depression may be of assistance to the clinician who is struggling to understand the depressed patient’s inner experience.

Freud (1917/1963) originally characterized depression by differentiating it from grief. Whereas the melancholic or depressed person experiences profound self-depreciation associated with self-reproach and guilt, the bereaved person generally does not undergo a significant loss of self-esteem. Freud understood the self-reproach and depression as stemming from anger turned inward. He postulated that the depressed patient identifies with a significant lost object, and therefore the internally directed rage is unconsciously directed at someone else who has been internalized. As his thinking progressed, Freud observed that introjection may be the only way one can give up a lost object, and he further explicated that depressed patients have a harsh superego (or conscience) related to guilt feelings stemming from anger toward persons they love.

Melanie Klein, expanding on Freud’s view, regarded depressed patients as being overly concerned that they might have destroyed internalized representations of loving parents as a consequence of their own destructiveness and greed. Moreover, they worry that they have transformed the “good” internalized parents into hate-filled and persecuting “bad” internal objects that wish to retaliate. Klein viewed the melancholic person as longing for the restoration of the lost good parents while being persecuted by the bad internalized parents. She observed the development of manic defenses, including contempt, denial, omnipotence, and idealization, which are used in an effort to disavow the bad internalized objects, rescue and restore the lost good parents, and deny the sense of extreme dependency on others for love. Clinical manifestations of these manic defenses include a contemptuous attitude toward those persons who arouse dependency in the patient, an inappropriately euphoric state of mind in the context of adversity, a thoroughgoing denial of any anger or hatred toward others, and a grossly exaggerated idealization of certain persons in the patient’s life.

The defensive function of mania becomes apparent when depression breaks through a manic episode in the dysphoric manic patient and a resurgence of manic denial is necessary. Although mania clearly has biological determinants, it has psychological functions that operate in parallel with the biochemical changes in the brain. A sense of triumph may also be part of a manic defensive posture linked to an unconscious sense that the patient has triumphed over his or her parents. This feeling may in turn activate further guilt and depression. Despite these psychological dimensions, psychotherapy should not be used as the primary treatment for acute mania.

As psychodynamic knowledge of depression has grown, clinicians have recognized that anger and aggression are not always central to depression. Bibring (1953) postulated a tension between ideals and reality as the core conflict in the depressed person. Three particular aspirations, in Bibring’s view, become fixed internal ideals or standards of conduct: to be strong or superior, to be good and loving, and to be worthy and loved. Depressed patients often feel that they cannot possibly measure up to these extraordinary ideals and as a result feel powerless and helpless. This tension within the patient’s ego results in a devastating impact on the patient’s self-esteem because of the failure to achieve these unreachable aspirations. Similar psychodynamic issues are often involved in suicidal ideation. Hopelessness, which is generally a better predictor of suicide risk than is depression per se, is frequently connected with a highly idealized view of the self that is rigidly held and incapable of being altered. Suicidal patients, acutely aware of the discrepancy between what they feel they should be and what they actually are, may view suicide as the only solution because they are convinced that they cannot lower their expectations or compromise in any way (Gabbard 2000).

An object-relations perspective on depression was brought to bear by Edith Jacobson (1971), who noted that in depression the self is experienced as a worthless bad object that is eventually transformed into a sadistic superego. The patient’s ego then becomes victimized by this cruel superego in a manner analogous to a helpless child’s being tortured by a powerful and harsh mother. Hence, the patient’s internal experience is often one of an internal object relationship in which a tormenting bad object persecutes a bad and worthless self. These dynamics are often found in suicidal patients who feel that a “hidden executioner” (Asch 1980) is tormenting them and driving them to suicide. Submitting to this tormentor or executioner ultimately may be regarded as the only possible outcome and may lead to suicide (Meissner 1986).

Arieti (1977) observed another important psychodynamic theme in the intensive psychotherapy of severely depressed patients who are refractory to somatic interventions. He noted that many depressed patients had a preexisting ideology that involved living for someone else rather than for oneself. He referred to this other person as the “dominant other,” who is generally the spouse but might also be an organization that serves the same function. In addition, an ideology or worldview might also take the place of the dominant other. These depressed patients rigidly adhere to the belief that their lives have no meaning if they cannot influence the dominant other to respond to them in a particular way or achieve an impossible goal. Although they recognize that living their lives for someone else or for an unachievable goal has not worked out in the way they had planned, they feel unable to change their pursuit and cannot imagine any viable alternatives. These patients may also develop suicidal ideation because of the hopelessness about shifting their expectations of the dominant other or their feeling that they are incapable of changing their life plan.

Heinz Kohut (1971) linked depression to the failure of parents and other significant objects to provide the patient’s self with responses necessary for growth. Known as self psychology, Kohut’s theory rests on the assumption that parents must provide admiration, validation, and affirmation for the child’s phase-appropriate developmental needs. In the absence of such responses, the child will not develop a cohesive self that can weather adverse life experiences. Depression may set in when significant others in the person’s life fail to provide such affirming responses and the patient experiences a sense of self-fragmentation and despair. Self psychology regards all pathology as being related to these failures. In this regard, it differs from the other psychodynamic formulations discussed previously, which are specific to depression.

Blatt (1998) suggested that from a psychoanalytic perspective, all of these various theoretical views represent two underlying types of depression. Anaclitic depression is characterized by feelings of helplessness, loneliness, and weakness related to chronic fears of being abandoned and unprotected. These individuals have longings to be nurtured, protected, and loved. Introjective depression, on the other hand, is characterized by feelings of unworthiness, failure, inferiority, and guilt. These individuals are also highly self-critical and have a chronic fear of criticism and disapproval from others. They are highly perfectionistic and competitive and have an excessive drivenness to achieve in work and school. The former type of depression is characterized by a vulnerability to having interpersonal relationships disrupted, and the depression is primarily manifested as dysphoric feelings of abandonment, loss, and loneliness. The latter type involves vulnerability to disruptions of a positive and effective sense of self and is manifested primarily by dysphoric feelings of guilt, failure, and worthlessness and by a sense that one’s autonomy and control have been lost.