Psychodynamic Psychotherapies: Negative Effects
Little information exists on possible negative effects of the dynamic psychotherapies on depressed patients. Indeed, in a survey of the literature, Hollon and Emerson (1985) were unable to identify a single study in which a treatment group of any kind fared worse than a no-treatment control group. Bergin and Lambert (1978) surveyed studies of therapist variables contributing to negative outcome in all psychotherapy studies and found that the results were inconclusive. Colson et al. (1985) reviewed data from the Menninger Foundation’s Psychotherapy Research Project to determine what factors influenced negative outcome in psychotherapy and psychoanalysis. Although the patients studied were not necessarily depressed, the authors’ findings may be applicable to certain instances of psychoanalytic or psychotherapeutic treatment of depression. For example, the authors noted that in cases with negative outcomes, therapists or analysts often did not recognize the patient’s limited capacity to use expressive techniques and failed to shift to a more supportive approach when needed. Hence, rigid adherence to highly exploratory technique despite the patient’s limitations may contribute to negative outcome. Some instances of therapeutic failure involved the therapist’s inability to recognize significant borderline pathology because of overestimation of the patient’s ego strength. Finally, failure to set limits on acting-out behaviors was also associated with poor outcomes.

Conclusions
Psychodynamic approaches to depression involve a particular way of thinking about the intrapsychic world of the patient and the interaction between the patient and the therapist. Concepts such as transference and countertransference are relevant to all treatments of depression. Although psychodynamic psychotherapy is separated from other modalities for the purposes of this text, clinicians must always keep in mind that the therapeutic modalities that are useful with depressed patients are by no means mutually exclusive. What is best for the patient must always be first and foremost in the clinician’s mind. Theoretical purity or adherence to a preferred school of thought should never be placed above the patient’s welfare.

When psychodynamic psychotherapy is the principal modality, the therapist must continually keep in mind that biological forces are at work in depression and may require pharmacotherapeutic interventions. Although suicidal ideation, for example, has specific unconscious meanings to the patient, changes in the chemistry of the brain may also contribute to such wishes. Whenever there is doubt about the relative contributions of psychological and biological factors, it is safest to err on the side of providing both forms of treatment and monitoring the results carefully. No data suggest that there is a negative interaction between psychotherapy and medication. The dynamic therapist should always regard the depressed patient as both a person with subjective psychological suffering and an organism with a diseased brain.

References