Psychodynamic Therapy for Depression

What depression feels like

Depression affects people in different ways. Common experiences include a persistent low mood, a loss of interest in things that used to matter, tiredness, broken sleep, poor concentration, and a harsh, critical attitude towards yourself. Many people describe a flatness or emptiness rather than obvious sadness, and a sense of going through the motions. If any of this is familiar, it is worth knowing that depression is a recognised and treatable difficulty, and that there are usually good reasons why it has developed.

Why depression develops

Psychodynamic therapy treats depression as something that has developed for a reason, rather than a simple chemical fault or a personal failing. It does not deny that biology plays a part. What it adds is attention to meaning: what a loss or setback means to you, and what is happening to the feelings underneath (Gabbard, 2014).

One long-standing idea, from Freud (1917), is that depression can involve anger and disappointment turned against the self instead of felt towards others. When something important is lost, or a close relationship disappoints us, it is natural to feel angry as well as sad. If that anger feels too dangerous to feel directly, the mind can turn it inwards, into self-criticism, guilt, and a sense of worthlessness. This does not mean depression is your fault. It means some of the feelings underneath may not yet have been felt or understood.

A second idea, from Edward Bibring (1953), is that depression can come from a gap between how you feel you ought to be and how you feel you are. Wishes to be worthy and loved, to be capable, and to be good are held up as standards, and when you cannot meet them the result can be helplessness and a collapse in self-worth. A fragile sense of self-esteem is often at the centre of depression (Gabbard, 2014). It can also follow bereavement, a major change, or no obvious cause at all.

The triangle of conflict

A useful way to understand this comes from David Malan (1979), who described the triangle of conflict. At the base is a hidden feeling, such as grief, anger, or longing. When it begins to surface it can produce anxiety, a sense that the feeling is risky to have. To manage the anxiety, we use defences: the methods, usually outside our awareness, by which we keep a feeling at bay. In depression, common defences include withdrawing, going quiet, turning critical, or going numb. These bring relief in the short term, but over time they keep the underlying feelings stuck and maintain the low mood (Gabbard, 2014). For example, a person who is angry with someone they rely on may, without deciding to, turn that anger on themselves and conclude they are at fault, and the self-criticism can feel like the plain truth about them even though it keeps the anger out of awareness.

Early attachment relationships

Much of the time these patterns begin in our earliest relationships. As children we take in how the people around us responded, and form inner templates of how closeness, need, and feeling work. In psychodynamic terms these are sometimes called internal objects, and we carry them into adult life and repeat them without realising it. A child who was repeatedly criticised may grow up carrying a critical figure inside and treating themselves as that figure once did. A child whose needs were not reliably met may grow up expecting loss, and may carry a sense of a self that is somehow unworthy, set against an inner figure that criticises or abandons (Gabbard, 2014).  These patterns can also appear in the relationship with the therapist, which is one reason it is so useful to look at, because the pattern can be noticed as it happens.

The inner critic, guilt and shame

A common thread in depression is a harsh inner critic. In psychodynamic terms this is linked to the superego, the part of the mind that holds our standards and judges us against them. In depression this inner judge can become relentless, expecting more than anyone could deliver and condemning every shortfall (Gabbard, 2014). Some psychodynamic writers describe it as a kind of internal saboteur that takes the moral high ground and hands out punishment, while working against you rather than for you (Britton, 2003). It often forms early, partly out of feelings such as anger turned back against the self, and partly out of early experiences in which distress was met with criticism or went unsoothed.

Two feelings often sit underneath low mood; guilt and shame. Guilt is the sense of having done something wrong, and it can bring a wish to put things right. Shame is the sense of being bad or unworthy at one's core. Shame is harder to see and to talk about, and it drives both the self-criticism and the urge to hide. There is an important difference between a guilt you can take responsibility for and make amends, which is bearable, and a relentless sense of simply being bad and deserving punishment, which is not (Britton, 2003). Part of the work is moving from the second towards the first. Depression also tends to take a recognisable shape: for some it centres on relationships and a fear of being alone, and for others on a standard that can never be met. Many people feel both (Gabbard, 2014).

Psychodynamic therapy for depression

The aim of therapy is to help you feel and make sense of the feelings that have been kept out of awareness, so that they no longer have to be turned into low mood, self-attack, or numbness. This usually involves several things, which go on together. The first is reaching the feelings underneath, such as anger, grief, and disappointment, and putting them into words rather than turning them against yourself. In the safety of the therapy relationship these feelings can be felt and named, often without the criticism or punishment that may have followed them earlier in life (McCullough Vaillant, 1997). The second is easing the guilt, shame, and anxiety that have made those feelings seem too risky to have. The third is loosening the defences, the habits of withdrawing, going quiet, or turning critical, that keep the feelings at bay (Malan, 1979).

In learning to step back and face one's inner critic, rather than taking its verdict as the truth about you, you can reclaim the right to question and assess it instead of being ruled by it (Britton, 2003). The other is building what is sometimes called ego strength: the capacity to bear difficult feelings without being overwhelmed. Where someone has lived with a harsh inner critic, the steady, accepting stance of the therapist can itself begin to change how they treat themselves (Gabbard, 2014). Understanding why you feel as you do tends to bring relief, and relationships often become easier.

What psychodynamic therapy involves in practice

In practical terms, therapy usually means meeting weekly for sessions of about fifty minutes. You are invited to talk freely, and there is no need to prepare. Over time, patterns come into view: the situations that bring on low mood, the feelings that are hard to allow, and the ways you turn against yourself. Some come for a focused piece of work over several months, and others stay longer to understand themselves more deeply.

Does psychodynamic therapy work?

There is good evidence that psychodynamic therapy helps with depression. In a large head-to-head trial it worked about as well as cognitive behavioural therapy, a well-established treatment (Driessen et al., 2013). Reviews that pool many studies reach the same conclusion, and find that the benefits tend to last, and sometimes keep developing, after therapy has finished (Shedler, 2010; Driessen et al., 2010; Cuijpers et al., 2021).

Sessions are available in central London and online.

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Sources

• Bibring, E. (1953) 'The mechanism of depression', in P. Greenacre (ed.) Affective Disorders: Psychoanalytic Contributions to Their Study. New York: International Universities Press, pp. 13-48.

• Britton, R. (2003) Sex, Death, and the Superego: Experiences in Psychoanalysis. London: Karnac Books.

• Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A. and Furukawa, T.A. (2021) 'Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types', World Psychiatry, 20(2), pp. 283-293.

• Driessen, E., Cuijpers, P., de Maat, S.C.M., Abbass, A.A., de Jonghe, F. and Dekker, J.J.M. (2010) 'The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis', Clinical Psychology Review, 30(1), pp. 25-36.

• Driessen, E., Van, H.L., Don, F.J., Peen, J., Kool, S., Westra, D., Hendriksen, M., Schoevers, R.A., Cuijpers, P., Twisk, J.W.R. and Dekker, J.J.M. (2013) 'The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial', American Journal of Psychiatry, 170(9), pp. 1041-1050.

• Freud, S. (1917) 'Mourning and melancholia', in J. Strachey (ed. and trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 14. London: Hogarth Press, pp. 237-258.

• Gabbard, G.O. (2014) Psychodynamic Psychiatry in Clinical Practice. 5th edn. Washington, DC: American Psychiatric Publishing.

• Malan, D.H. (1979) Individual Psychotherapy and the Science of Psychodynamics. London: Butterworths.

• McCullough Vaillant, L. (1997) Changing Character: Short-Term Anxiety-Regulating Psychotherapy for Restructuring Defenses, Affects and Attachment. New York: Basic Books.

• Shedler, J. (2010) 'The efficacy of psychodynamic psychotherapy', American Psychologist, 65(2), pp. 98-109.