Psychodynamic Treatment of Depression

210 Pages·2004·4.38 MB·English

by  Fredric N. Busch

Psychodynamic
Treatment of
Depression
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Psychodynamic
Treatment of
Depression
Fredric N. Busch, M.D.
Clinical Associate Professor of Psychiatry,
Weill Medical College of Cornell University
Faculty, Columbia University Center for
Psychoanalytic Training and Research
New York, New York
Marie Rudden, M.D.
Clinical Assistant Professor of Psychiatry,
Weill Medical College of Cornell University
Training and Supervising Analyst,
Berkshire Psychoanalytic Institute
Faculty, New York Psychoanalytic Institute
New York, New York
Theodore Shapiro, M.D.
Emeritus Professor of Psychiatry in Pediatrics,
Weill Medical College of Cornell University
Training and Supervising Analyst,
New York Psychoanalytic Institute
New York, New York
Washington, DC
London, England
Contents
Part I
Introduction
and Overview
Chapter 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2
Development of a Psychodynamic Model of Depression. . . . . . . . 13
Chapter 3
Overview of Psychodynamic Psychotherapy for Depression. . . . . . 31
Part II
Techniques in Psychodynamic
Treatment of Depression
Chapter 4
Getting Started With Psychodynamic Treatment of Depression . . 39
Chapter 5
The Middle Phase of Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Chapter 6
Addressing Narcissistic Vulnerability . . . . . . . . . . . . . . . . . . . . . . . 75
Chapter 7
Addressing Angry Reactions to Narcissistic Injury . . . . . . . . . . . . . 91
Chapter 8
The Severe Superego andGuilt . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Chapter 9
Idealization and Devaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Chapter 10
Defense Mechanisms in Depressed Patients . . . . . . . . . . . . . . . . 139
Chapter 11
The Termination Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Part III
Special Topics
Chapter 12
Managing Impasses and Negative Reactions to Treatment . . . . . 161
Chapter 13
Psychodynamic Approaches to Suicidality. . . . . . . . . . . . . . . . . . 171
Chapter 14
Use of Psychodynamic Psychotherapy With Other
Treatment Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Part I
Introduction
and Overview
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Chapter 1
Introduction
T
he advent of multiple effective psychopharmacological interventions
and targeted psychotherapeutic treatments has led to remarkable progress
in the treatment of depression. Cognitive therapy, interpersonal psycho-
therapy, and psychopharmacological treatments have all been demon-
strated, in placebo-controlled studies, to be effective in treating major
depression (e.g., see the review of treatment studies by Gelder et al. [2000]).
Clinicians are aware, however, that treatment of depression often con-
tinues to be a struggle. Many patients’ depression does not respond fully
to these interventions, and some patients may have persistent social and
occupational deficits (Gelder et al. 2000). Chronic depression with pro-
longed episodes and persistent symptoms between episodes is common
(Judd et al. 1997; Keller et al. 1996; Kocsis and Klein 1995). Continuous
subsyndromal symptoms or symptoms of “minor” depression can cause
functional impairment and persistent suffering (Rapaport et al. 2002).
Therefore, there is increasing emphasis on the importance of patients’
recovery from depression (a return to baseline functioning) rather than re-
sponse to treatment (at least a 50% reduction of symptoms), which is usu-
ally used as the criterion in treatment studies for determining effectiveness
(Keller 2003; Thase 1999). It is important, then, to develop treatments or
combinations of treatments that address more fully the neurophysiolog-
ical and psychological vulnerabilities that may predispose patients to per-
sistent symptoms or recurrences of depression. Recently, Gabbard et al.
(2002) argued that psychodynamic psychotherapy should be considered
and investigated as an approach to reducing this vulnerability.
Clinicians tend to use combined approaches and attempt to determine
the most effective combinations of treatment for individual patients. In
fact, Keller et al. (2000) showed that the combination of medication and
psychotherapy is more efficacious than either psychotherapy or medication
alone. However, the presence of persistent and troubling side effects from
3
4 Psychodynamic Treatment of Depression
antidepressant medication often leads to a search for alternative antide-
pressant or psychotherapeutic interventions. Just as patients’ responses to
medications vary, responses to particular therapeutic interventions are
different in different patients. Psychodynamic psychotherapy explores
internal conflicts and unconscious issues that are often not addressed in
cognitive-behavioral, interpersonal, or medication treatments.
Psychodynamic psychotherapy has not been demonstrated in placebo-
controlled trials to be effective. Although there are many case reports of
successful treatments of depression employing this approach (Abraham
1911; Arieti and Bemporad 1978; Asch 1966; Jacobson 1971; Stone 1986),
diagnostic criteria and symptomatic improvement are not well docu-
mented. Nonetheless, some recent studies have attempted to systemati-
cally assess the impact of psychodynamic treatments for depression
(Gabbard 2000). Gallagher-Thompson and Steffen (1994), for instance,
found that psychodynamic psychotherapy was comparable to cognitive-
behavioral therapy in reducing depressive symptoms in the caregivers of
elderly family members. Shapiro et al. (1994, 1995) compared cognitive-
behavioral therapy with psychodynamic-interpersonal therapy in a ran-
domized, controlled trial for depression and found them to be equivalent
in efficacy. More recently, Burnand et al. (2002) compared psychodynamic
psychotherapy plus clomipramine with clomipramine alone in a random-
ized, controlled trial in patients with major depression. Combined treat-
ment was more cost-effective, and the combined-treatment group showed
less treatment failure and better functioning. Hilsenroth et al. (2003)
found a significant reduction in depressive symptoms with psychodynamic
treatment and a decrease in symptoms correlated with the use of psychody-
namic treatment techniques.
There is a major disparity between the widespread use of psychody-
namic psychotherapy in clinical practice and the few systematic studies
of this treatment. The Practice Guideline for the Treatment of Patients
With Major Depressive Disorder (American Psychiatric Association 2000b)
recommends the pursuit of systematic controlled trials of treatment of
depression by the use of psychodynamic psychotherapy.
Although this book is not a manual of psychodynamic treatment, it
does specify a particular focused dynamic approach to depression that
represents a step toward manualization: The psychodynamic approach
presented is adapted and molded to address the specific dynamisms that
we believe drive depressive symptoms and syndromes. The therapy out-
lined is applicable to the internal struggles that contribute to affective
disorders and that are complementary to the biological source of some
depressive illnesses. We therefore suggest that focused psychodynamic
psychotherapy can be a valuable adjunct for the treatment of depression,