The perceptions of patients (n=25) and their therapists about psychodynamic psychotherapy for depression were assessed during the first treatment year using 23 scales. Patients and therapists independently evaluated the impact of depression on the therapeutic experience of the patients. The estimations of the impact of depression by the patients and therapists were concordant in the majority of the subjects, reflecting mutual tuning and a working alliance. The roles of affects and frustrating subjects in the treatment relationship were evaluated as significantly different by the patients and the therapists. The results highlight the importance of working on the expression of affects in the psychotherapy of depression.
KEYWORDS: psychodynamic psychotherapy, process, depression, patient-therapist interaction
The specific mode of action of the two available evidence-based treatments for depression, antidepressive medication and psychotherapy, are not fully known (Cipriani et al., 2009; Antonuccio, Danton, & DeNeIsky, 1995). Recent studies that compared psychopharmacological treatment to psychotherapy with regard to action on brain function revealed that psychopharmacological and psychotherapeutic treatment have some similar and some different modes of action on brain activity of patients with depression (Nemeroff et al., 2003). Modern brain research shows that psychotherapy seems to have specific features not shared by the effects of psychopharmacological treatment (Martin et al., 2001; Nemeroff et al., 2003). Despite these interesting findings, the core clinical features that make psychotherapy effective in depression are unknown.
Depression is a widespread, debilitating illness with far-reaching personal and economic implications for individuals, their families, and society (Hirschfeld et al., 2000). Major depressive disorder is associated with significant psychosocial disability that often exceeds those noted in common medical illnesses (Judd et al., 2000). The impact of depression extends beyond the core symptoms, such as depressed mood and loss of energy, and it affects quality of Ufe, including the ability to function socially and to maintain and enjoy relationships and work (Hirschfeld et al., 2000). Feelings oí disappointment, love, anger, criticism, neglect, or undermining destructiveness are turned inward, causing suffering or perceived victimhood. This can be seen in the depressed person's ways of communicating, relating, and thinking.
Narcissistic vulnerability in depression triggers depressive affects, such as worthlessness and shame, resentment, and even rage in response to negative experiences (Busch, Rudden, & Shapiro, 2004). Anger leads to disruption and withdrawal in interpersonal relationships. This leads to a cycle of restricted interaction with social objects, an inability to grasp his or her behaviour, or in the total absence of the object of anger, a tendency to turn resentment toward the self, lowering of self-esteem. Guilt, fear of punishment and the devalued self-image further tax self-esteem and sensitize the individual to negative self -perceptions and criticism by others (Bush et al., 2004). Ineffective ability to deal with anger, and the concomitant painful affects of depression, increase the tendency to low mood through anger directed at the self or though a vision of the world as hostile, menacing, uncaring, or defeating (Bush et al., 2004). Also common are feelings of love and hate or ambivalence directed towards the same person (Morgan & Taylor, 2005). In the social sphere, current life stress and dysfunctional interpersonal relationships often accompany depression (Keller, Neale, & Kendler, 2007; Kendler, Kuhn, & Prescott, 2004; Kendler, Thornton, & Prescott, 2001; Luyten, Blatt, Van Houdenhove, & Corveleyn, 2006). In addition to negative affects and their psychological and social consequences, moderate or severe depression is connected to functional impairment of the personality and interference with social and/or occupational functioning (Karasu et al. …