Psychodynamic Treatment of Depression

In an uncommonly lucid introduction, the authors summarize the existing choices of treatment for depression, the value of combined treatments, and the assets that psychodynamic psychotherapy brings to bear on treating depression. The authors point out that in spite of the fact that there are no placebo-controlled studies demonstrating superiority of the psychodynamic approach, there is good reason to believe that its principles are important and that for selected patients it has great utility. In addition, many of its main beliefs and techniques lend themselves to use in other therapies.

In the introduction, the authors write about a focused treatment, not an open-ended exploration. They describe the patients for whom it is most likely to be helpful and the topics that should be explored with the patient to determine suitability for treatment. The book begins with a review of the different ideas underlying a dynamic explanation of depression and a statement of fundamental principles behind psychodynamic treatment. The last introductory chapter presents a demystified overview of psychodynamic treatment that is exemplary in its clarity and freedom from jargon.

The dominant middle section of the book consists of a series of chapters on the techniques used to treat depression. The approach emphasizes clarity, and the authors are consistent and organized. A chapter on starting treatment includes an excellent discussion of forming a therapeutic alliance as well as barriers to engaging depressed patients. Subsequent chapters expand on the topics introduced earlier in the book, so there are chapters on narcissistic vulnerability and injury, harsh self-judgment and guilt, idealization and devaluation, and the defenses used by depressed people. The chapter on defenses is unusually good. The authors abundantly illustrate their points with cases, which are very helpful and constitute a strong point of the book. Occasionally it seems as if there is an overreliance on cases in situations where more discussion and explanation of what the therapist does might have been in order. There also should have been a few cases of clear-cut treatment failure followed by appropriate discussion, and the case mix tends heavily toward the urban, bright, and talented, but these are minor points.

This section ends with a chapter on termination that contains fairly standard advice. However, the examples are of rather lengthy terminations, sometimes longer than the entire course of many therapies using short-term dynamic approaches. Support for extended termination is not as well presented as the authors’ other recommendations.

The book includes a few special topics, including approaches to suicidal behavior and a chapter on the use of psychodynamic psychotherapy with other treatment approaches. This last chapter would be best read with the introductory chapters.

Treating depression will remain a mainstay of psychiatric practice. No treatment fits everyone no matter how skillfully applied. Anything as complicated and pervasive as depression, which, as we know, appears as a universal symptom as well as specific syndromes, can only be seen as having multiple contributing variables. Explanatory models include evolutionary ones in addition to the those we regularly think about in the spheres of endowment and experience. When it comes to treating disorders like depression, there will always be people who need to understand who they are in the present in terms of the experiences they have had in the past. For many such people, treatment that is too formulaic or ritualized does not make sense to them and does not work. For most patients, open-ended exploration of origins of problems leads nowhere. Psychodynamic therapy applied in a focused fashion, combined, if necessary, with other approaches including medication, offers many patients the opportunity to put demons to rest. Success in treatment often hinges on a good fit of patient, psychiatrist, and treatment approach. Having flexibility in choosing and applying the treatment that best meets the patient’s needs is ideal.

Although this book deals specifically with the treatment of depression, it actually is an excellent introduction to psychodynamic theory and practice. As such, it would have particular utility in residency training. Residency accreditation requirements include didactic material in psychodynamic theory and clinical experience using such an approach. This book should be ideal in helping meet these requirements.

There are many experienced therapists who would find the focus of this book on depression useful; it has great practical utility either as a modern, clearly explained review of an approach or as a fresh introduction to a way of looking at patients. I tried to imagine reading this book lacking any background in psychodynamic theory and practice. I believe it would still work well because of the lucid, organized approach that remains clinically focused and mercifully free of old-fashioned theory and jargon. The one exception is the traditional psychoanalytic use of the term “genetic.” It is time to part ways with using this term in its confusing archaic sense, which has nothing to do with genes. In every situation I can think of, the word “developmental” could be substituted and would represent current, commonly accepted use.