روان درمانی روانپویشی و درمان افسردگی

Psychodynamic psychotherapy and the treatment of depression

Neil Morgan
David Taylor

Depression is a common yet complex disorder. Clinical experience, together with longitudinal studies of depressed people, shows that it can often be a chronic, lifelong, relapsing condition, rather than a ‘one-off’ illness.1 The psychological burdens of depression are not only symptoms of an illness, but have a quality which is in some form familiar to everyone. In this way, depression can be seen as involving a personal, ongoing struggle with the universal life challenges of sadness, disappointed hopes and the mental pains of grief and guilt (see, for example, the Book of Job, c. 450 BC). Put simply, our struggles with depression are part of what it is to be human.

The psychodynamic explanation of depression is that it has its origins in infancy and in childhood experience. In this model, the unique make-up and early experiences of an individual can lead to vulnerability, which, in interaction with life events, culminates in adult depression. Although the mainstay of medical treatment of depression has been pharmacological, surveys show that patients are overwhelmingly interested in talking treatments as well. Certainly, the subjective experience of depression, as described above, is central to the condition. Dynamic psychotherapy, in its way of engaging with the patient, reflects on the problems of living and relating, which are the focal point of concern for many patients.

This contribution gives an account of the main themes of the foremost psychoanalytic/psychodynamic accounts of the nature and origins of depression, followed by a review of the evidence for the efficacy of such treatment.

The psychoanalytic model of depression

Freud’s canonical Mourning and Melancholia2 compared and contrasted the mental processes involved in mourning with those in depression. He postulated that mourning and depression are different types of reaction pattern to the same sort of event – namely loss. The common basis of both states of mind explains why they have a family resemblance. The depressed person sometimes can

Neil Morgan is Consultant Psychiatrist in Psychotherapy at the Royal London Hospital, London, UK.

David Taylor is Medical Director of the Tavistock and Portman NHS Trust, London, UK, where he is also the clinical lead of an outcome study evaluating the use of psychoanalytic psychotherapy in the treatment of chronic depression and treatment-resistant depression.
find no conscious reason for his distress but he exhibits some similar features to a person who is mourning.

Freud postulated that in depression the loss is unconscious but the patient is unable to retrieve or acknowledge it, whereas in mourning the person is in no doubt about what or whom they have lost. Freud also noted a key difference: in mourning the world is felt to have lost meaning; in depression it is the self that is experienced as reduced.

Identification

The explanation of this key difference rests on the psychological concept of identification. Freud argued that part of the self had undergone a change in depression through its becoming identified with (becoming the same as) the lost object (object is the psychoanalytic term for a person). Depression arises from the inner (but unconscious) antagonism and complaints between one part of the self and another, which is identified with the lost, and therefore disappointing object. In this identification, ‘the shadow of the object falls upon the ego’ (i.e. the Self), which is a composite of identifications, is felt to contain a negatively identified aspect – and therefore to be ‘bad’.2 If I am ‘like’ my father, then this makes me ‘bad’ like him.

Ambivalence

Freud stressed the role of heightened ambivalence in depression; that is, feelings of love and hate directed towards the same person. In mourning, anger towards the lost object is overcome by feelings of sadness, longing and love, while in depression we encounter a higher level of anger and destructiveness.The balance is tipped so that love does not ‘win out’, which would lead to the acceptance of loss, as happens over the time course of mourning.

The ability to mourn is an adaptive capacity. It is both a product of mental health and resilience, and a component of them. In depression, on the other hand, there is no relinquishment (letting go of what has been lost) but identification and as a consequence there can be no adaptive alteration. The inability to relinquish – becoming stuck in identification, in grievance, and being unable to forgive in reaction to early disappointment and loss – becomes internalized, sometimes expressed directly as character traits and sometimes more as a susceptibility to depressive disorder in adult life (see Figure 1).

The superego

Alongside the ambivalent identification process, Freud also pointed out the increased severity of moral judgement that occurs in depression (‘I’m so bad, I don’t deserve to be happy’). He was concerned to understand how this happened. He described the setting up of a ‘critical agency’ within the ego, as part of child development, which ‘henceforth will judge the ego’. This is the superego, and Freud suggested that ‘the relationships between the ego and the superego becomes completely intelligible if they are carried back to the child’s attitude towards his parents’. The superego is coloured by the child’s own hostile and rivalrous feelings, so that ‘the more a child controls his aggression towards another, the more tyrannical does his superego subsequently become’.3

The superego covers a wider range of conscious and unconscious operations than the notion of conscience to which it is clearly related. In healthy development the superego may take on, over time, a benign guiding role, but in those with a predisposition to depression, the superego acts in a spoiling, superior and sadistic way, becoming hyper-moral and tyrannical towards the ego. The tension between the ego and the superego is manifested as a sense of guilt and worthlessness. When very severe, it has the power to degrade the ego’s capacity through murderous impulses directed at the self, sometimes culminating in suicide.

The role of aggression in depression – further developments in the dynamic theory of depression

Karl Abraham influenced thinking on the causes of depression by highlighting the role of aggression and destructiveness (Figure 2).4 When treating seriously depressed patients, he observed that the patient’s capacity for love was being overwhelmed by feelings of hatred and that they were profoundly upset by this. Melanie Klein, who analysed children, was impressed by the role of an innate destructiveness and aggression in depression, which could be much increased by adverse experiences.5 In the USA, Edith Jacobson also emphasized aggression and its role in depression, but she tended to view it much more as a reactive phenomenon rather than one with primary roots.6

Other psychodynamic approaches emphasize different aspects of the depressive constellation. Kohut viewed depression as coming

Case study 1

Mr A’s marriage was spoiled by powerful feelings of anger and hostility for which he could not account. When these feelings got out of control he feared they were destroying his marriage, leaving him feeling depressed, abandoned and bleak. The patient felt that his wife, N, was ‘addicted’ to her family; in particular he hated the attention his wife gave her sister, who was still breastfeeding her son. Mr A felt his quarrelling to be compulsive. ‘I cannot stop having a go at her about her sister,’ he said. N had got angry, calling him an ‘inquisitor’. He had smashed a valuable bowl during one row. That night he had the following dream.

‘There was only a flat sandy island with water all around. There had been a nuclear explosion. The ground was contaminated by radioactive fall-out. Everything was finished. There was no chance of escape for me and the other people there. N was amongst them and she had decided to leave me. I was crying, “Do you really like hurting me? You were doing this because I have put all my hope with you.”’

The analyst saw this dream as illustrating Mr A’s internal world. In the conflict of love and hate, the nuclear explosion represented the patient’s anger and the radioactivity the emotional fall-out of this explosion. The atmosphere is that of a nuclear winter. Nothing good in Mr A’s inner world is felt to survive his rage. No sense of life, nor good, nor hope in the future seems possible. The prevailing sense of the internal world centres around warfare and the infliction of hurt. The patient experiences himself as abandoned to a desolate fate. In this way the complex affect of depression can be seen to arise meaningfully out of Mr A’s powerful feelings of infantile need.

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from a lack of good experiences with what he termed the mirroring self-object, such as having interested and involved parents;7 this results in problems with self-esteem regulation. Margaret Mahler located the problem within separation and individuation from the earliest caregiver.9 John Bowlby and others thought depression resulted from a failure of secure attachment early in life.10

There are clear points of contact between the attachment perspective and some psychodynamic ideas. One of Melanie Klein’s hypotheses was that the reaction to loss occurring later in the life cycle will be influenced by revived aspects of losses experienced at the earliest stages in development.5 The early loss of the maternal object – notably weaning – may result in depression later in life if the infant has not yet been able to establish a representation of a loved object securely within itself. Major traumatic events, such as early maternal death or extended separations, influence whether deep-seated and passionate infantile wishes can be relinquished. When the individual continues to nurse unrealistic hopes based on compensatory exaggerations of unsatisfied wishes and needs, this lays down a vulnerability to depressive illness because these are unsustainable in adulthood. There are clear parallels between this formulation and the idea of maladaptive internal working models of attachment in Bowlby’s thinking about early loss and depression.

Each of the theories described probably has a contribution to make to the overall picture especially when we recollect that depression is a complex rather than a unitary phenomenon. For example, Blatt distinguished between at least two major types of depression: anaclitic (i.e. other-oriented) and introjective (i.e. self-oriented). In the former, the focus is more on the feelings of aloneness and helplessness, wanting to be dependent on others. In the latter, the focus of the depression is weighted more towards guilt feelings, failure to meet expectations and feelings of failure and self-criticism.

Common to all these theories is their invoking of the crucial role of the infantile phase of development. Each of them asserts that problems in the trajectory to eventual adulthood commence in early childhood and can constitute a vulnerability to depression (Figure 3).

Evidence for the value of the psychodynamic approach in treating depression

Evidence for the value of a psychotherapeutic approach to depression comes from two main directions:

• empirical and observational studies

• direct outcome research into the efficacy of psychotherapy treatment.

Empirical and observational studies

A large number of empirical studies over the last 50 years have tended to support what has been postulated from the clinical investigations of the inner world, gathered from patients in the consulting room.

In 1946, René Spitz published his research on institutionalized infants and ‘anaclitic’ depression.11 He observed many disturbances in institutionalized infants who had been separated from their mothers shortly after birth and who had experienced sub-optimal human interaction in hospitals and other institutions. They became unresponsive and withdrawn, with a marked reduction in motor activity, highly reminiscent of what in an adult might be taken for depression. In the Second World War, Anna Freud and Dorothy Burlingham observed a similar syndrome in young children evacuated from large urban centres during the Blitz.

In the 1950s and 1960s, John Bowlby wrote a series of papers on the predisposition to adult depression.10 He described a series of attachment and protest behaviours which, if not responded to, would proceed to a state of despair in infants and finally to states of detachment. Some features of these events were captured very poignantly on film by his colleagues James and Joyce Robertson. The films were influential in bringing to a wider audience the important effects that separation had on children, and in influen- cing hospital care and visiting policies in the 1960s (they are still available and well worth watching.)

This work has burgeoned into the field now known as attachment research. To summarize this extensive body of research very briefly, we now know that the capacity to develop close and loving relationships in adulthood protects against depression and that this is influenced by the attachment patterns developed in childhood. We also know that these patterns are transmitted

The relationship between aggression and depression according to various psychodynamic theories of depression

• Aggression is secondary –a response to the failure of e.g. parents, generating pain and rage in the person7

• Aggression while present is an epiphenomenon: the main cause is a decrease of self-esteem, arising out of early experiences of helplessness8

• Aggression is part of a larger process of frustration, and hostile attempts to gain gratification. When this is not attained aggression is turned towards the self, with loss of self-esteem6

• Aggression is a fundamental causal feature, present in every case of depression.4 As the subject internally attacks the object, the latter loses its value and inner buoyancy, and feelings of guilt ensue.5

Themes in ideas about the origins of depression

• Lack of good experiences with mirroring parents who support the regulation of self-esteem7

• Environmental failure in early life11

• Temperamental issues with innate destructiveness4,5

• Problems in separation, and individuation9

• Failure to achieve secure attachment relationships early in life10

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directly from parents and early caregivers to infants and toddlers, and are remarkably stable over time.12

These empirical studies complete a circle, prefigured by Freud, that connect an interior subjective world of thought and phantasy with early-life constitution and experiences, going on to subsequent relationship difficulties, and the development of adult depression.

Outcome evaluation research

The generic efficacy of psychotherapy compared to no treatment is long established. Many studies and meta-analyses have empirically validated psychotherapy as an effective treatment.13 The growth of evidence-based medicine, and the claim that dynamic psychotherapy may be suitable for chronic depression not amenable to treatment by other methods, has focused interest on outcome, especially in publicly funded health services, including the NHS.

A number of issues are important in evaluating the outcome of treatment. As noted above, the natural history of depression means that treatment effectiveness cannot be assessed properly from the management of a single episode. Roth and Fonagy14 recommend follow-up periods of at least 2 years to give a result that is not confounded by the natural history of the disorder. Notwithstanding, the follow-up periods of randomized control trials (RCTs) included in guidelines for the treatment of depression are, on average, no more than a few months. Other limitations of the currently available evidence base derive from the highly selected nature of patient profiles in research populations, which are usually very unlike clinical populations, for example in terms of comorbidity.

One RCT, the Sheffield Psychotherapy Project, found good evidence for the effectiveness of a 16-session intervention based on dynamic principles in the treatment of major depression. There is a paucity of research on the effect of longer-term psychotherapeutic treatment of chronic depression. (One such randomized controlled trial is presently being conducted at the Tavistock Clinic in London.)

There is evidence from longitudinal effectiveness studies to confirm psychotherapists’ clinical impression that improvement of patients may continue long after psychodynamic psychotherapy ends. This contrasts with other types of treatment, in which initially satisfactory response to treatment, in terms of symptom reduction falls off with increasing length of follow-up. A study in Scandinavia demonstrated patients gaining in strength and capacity after treatment ended.15 At follow-up, patients were doing better in terms of days off work than the population norm. This study documented different patterns of change in different personality types who found various ways of managing their thoughts and feelings. These changes included the emergence of reflective functioning.

However, further good-quality RCT evidence will be needed to convince service planners of the value of psychodynamic psycho- therapy for depression. Such research will need to be based on clinically representative patient groups, using detailed and sophisticated measures of change and long periods of follow-up.

Conclusion

Considerable conceptual difficulties will remain when trying to integrate fundamentally different categories of data. Bringing together the subjective world of meaning and interiority derived from clinical psychotherapy contacts and the objective view of the world based on observable measures, which are mostly averaged over groups, is never going to be an easy task. However, it has many benefits in terms of the quality of the clinical services available for this common and important condition. .

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3 Freud S. The Ego and the Id (1923). In: Strachey J, ed. Standard Edition of the Works of Sigmund Freud. London: Hogarth, 1961.

4 Abraham K. A short study of the development of the libido, viewed in the light of mental disorders (1924). Selected Papers on Psychoanalysis. London: Hogarth, 1949.

5 Klein M. Mourning and its relation to manic-depressive states. In: Contributions to Psycho-Analysis, 1921–1945. London: Hogarth, 1948.

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9 Mahler M. On Human Symbiosis and the Vicissitudes of Individuation. New York: International Universities Press, 1968.

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11 Spitz R. Anaclitic depression. Psychoanal Study Child 1946; 2: 313–41.

12 Steele H, Steele M, Fonagy P. Associations amongst attachment classification of mothers, fathers and their infants. Evidence for a relationship specific perspective. Child Dev 1996; 67: 451–5.

13 Lambert M J, Burgin A E. The effectiveness of psychotherapy. In: Burgin A E, Garfield S L, eds. Handbook of Psychotherapy and Behavioral Change. 4th edition. New York: Wiley, 1994.

14 Roth A, Fonagy P. What Works for Whom? New York: Guilford, 1996.

15 Sandell. Effect of psychoanalysis and long-term psychotherapy in outcome of psychoanalytic treatment. In: Leuzinger-Bohleber M, Target M, eds. Outcome of Psychoanalytic Treatment. London: Whurr, 2002.

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