Depression Treatment: Psychodynamic Psychotherapy

Psychodynamic psychotherapy can be an effective psychotherapy for the treatment of depression.  To learn how psychodynamic therapists think about depression, it is important to first understand the difference between consciousness and unconsciousness.  Consciousness is the state of being aware of something, either inside or outside of ourselves.  Unconsciousness is the state of being unaware of something, either inside or outside of ourselves.  According to psychodynamic psychotherapy, people are aware of only a small portion of our inner lives and the remaining parts, of which we are mostly unaware, have a strong influence on our thoughts, emotions, and behavior.  The main goal of psychodynamic psychotherapy for depression is to increase awareness of unconscious processes that cause and maintain depression. 
How Does Psychodynamic Psychotherapy Work?
The basic idea in psychodynamic psychotherapy is that depression is caused and maintained by an unconscious process where:
1. The triggering event is a rejection or some other major loss which leads to—>
2. Feelings of anger towards others which leads to—>
3. Feelings of guilt and anger towards the self which leads to—>
4. Feelings of low self-esteem which leads to—>
5. Symptoms of depression
Each of these steps in the process set up a person to have an internal conflict between the Id (the part of the brain that creates impulses and urges) versus the Super Ego (the part of the brain that is moral and follows society’s rules).  To cope with these conflicts, people use “defense mechanisms” that provide some temporary relief, but prevent people from effectively dealing with these problems. For example, a common defense mechanism called “projection” involves shifting difficult feelings to something or someone other than the original source of the the difficult feelings—when a father snaps at his children for little to no reason because he had a bad day at work.  In this way, the father has an opportunity to express his frustration, but does not actually express the frustration in the appropriate venue toward the appropriate people.
What Does Psychodynamic Psychotherapy Look Like in Action?  
Although there is not a formal sequence for psychodynamic psychotherapy, treatment does follow a predictable pattern in most cases.  In the first phase of treatment, therapists and clients agree on the frequency and expectations for therapy sessions, begin developing a productive relationship, and review the basic ideas of psychodynamic therapy for depression as described above.   In the middle phase of treatment, therapists use a variety of techniques such as confrontations and interpretations to help clients increase awareness of unconscious conflicts that are operating outside of their awareness.  As clients become more comfortable with therapy, therapists begin to increase the intensity of the interpretations.  One way of doing this is to interpret reactions the client has towards the therapist (“transference”) and the reactions the therapist has towards the client (“countertransference”).  As clients begin to increase awareness of these unconscious processes, and how they play out in everyday settings and relationships, depressive symptoms begin to reduce and relationships begin to improve.  In the final phase of treatment, therapists and clients review important themes covered in therapy, what helped produce improvements in depression, and when therapy in the future might be a good idea.

• David Taylor. Psychoanalytic and psychodynamic therapies for depression: the evidence base. Advances in Psychiatric Treatment (2008), vol. 14, 401–413 doi: 10.1192/apt.bp.107.004382
• Abbass, A. A., Hancock, J. T., Henderson, J., et al (2006) Short­ term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews, issue 4, CD004687.