Working With Countertransference Feelings

The many strong affects experienced toward the therapist during treatment provoke numerous reactions on the clinician's part. These counter-transference reactions were initially thought to interfere with treatment. However, it was soon recognized that they could provide the therapist with a valuable resource for reflection about the meanings of interactions with patients (Gabbard 1995 Jacobs 1993 Makari and Shapiro 1993 Sandler 1976 Shapiro 2002). For example, Dr. L's contemptuous attacks often...

Role of Psychoeducation in the Early Treatment Phase

Dynamic therapists educate their patients about the biopsychosocial dimensions of depression throughout their treatment. This is a necessary aspect of any treatment endeavor, in that it encourages patients to take an active role in understanding and managing their illness. Further, it can help particularly during the early treatment phase, when depressed patients may struggle with their sense of shame and exposure. Mr. F was helped to engage in his treatment by a brief explanation of the...

Case Example 2

J, a 50-year-old lawyer, was chronically anxious and depressed and had recently recovered from a severe episode of major depression. Any sense of relief he obtained from the subsiding of his depressive symptoms, however, seemed to rapidly vanish as he became preoccupied by somatic complaints. He insisted that he was beset by angina, despite multiple, extensive negative cardiac workups, and could not seem to stop voicing these concerns. He seemed upset with his cardiologist, despite the fact...

Countertransference Reactions During the Termination Phase

Common countertransference feelings at the time of termination include guilt about ending the treatment, reflecting the patient's, and sometimes the therapist's, experience of it as an abandonment. Feelings of uncertainty and inadequacy about the therapy's effectiveness may also emerge, often reflecting the patient's renewed struggles with idealization and devalua tion under the pressure of a final assessment of accomplishments. It is important for the therapist to reflect on the origins and...

Exploring the Link Between Competitiveness and Aggression

Because depressed patients have a history of intensified aggression connected to their early narcissistic injuries, they often become sensitized to any aggressive impulses and work hard to inhibit them. Many depressed patients specifically link competitive wishes with their preexisting aggressive fantasies. Therefore, competitive feelings are prone to cause the same kind of guilt and self-recriminations as angry feelings and fantasies. Further, competitive fantasies are often linked with wishes...

Reaction Formation

Reaction formation is the defense mechanism employed when patients cope with a frightening or disavowed feeling by turning it into its opposite. Although the mechanism is possibly more commonly found in pa tients with panic disorder, patients with depression also use it (Busch et al. 1995). Typically, the therapist observes depressed patients turning anger into a positive or helpful feeling, but some patients may convert guilt-provoking loving feelings into hatred. Although reaction formation...

Case Example

C was an overweight, 45-year-old divorced accountant who presented for treatment with a history of several years of dysthymic symptoms and multiple episodes of superimposed major depression. During depressive episodes, her symptoms included very low energy and motivation, impaired concentration, increased appetite with weight gain, and middle and terminal insomnia. Ms. C viewed herself as worthless and not deserving of attention from other people at the same time that she was furious about...

Central Dynamics of Depression A Summary

Several core dynamics of depression have been identified by these theoreticians (Table 2-2). Despite their variations in focus, almost all psychoanalysts describing their patients with depression have emphasized narcissistic vulnerability as triggering susceptibility to this syndrome. The basis of this vulnerability varies, however, from disappointments in early relationships to fragile self-esteem based on factors such as childhood experiences of helplessness or reactive fantasies of...

Handling Premature Requests for Termination

If the therapist believes that a request for termination is premature, it is important to articulate what further work may remain. This may include addressing the patient's guilty reactions in greater depth, exploring further a persistent tendency to idealize and devalue with destructive consequences, or continuing work on problems the patient may have in managing feelings of sadness, rejection, or anger. If the therapist feels clear that it is too early to end the treatment, an exploration of...

Defense Mechanisms in Depression

Psychoanalytic theorists have considered the possibility that certain defenses (i.e., internal or behavioral means of averting painful feelings or threatening unconscious fantasies) either may be specifically mobilized by depressive affects or may predispose individuals to the development of depressive syndromes (Brenner 1975 Jacobson 1971). Bloch et. al (1993) described three possibilities in this regard 1) defenses may become structured in response to a chronic mood disturbance 2) maladaptive...

Case Example 2 Identifying Feelings ofParental Rejection

Q, an artist in her 30s, was referred for treatment by her internist when she presented to him with a major depression after an abortive romantic relationship. Her lover, Jim, a married man, had been erratically attentive for a year, then abruptly terminated the relationship in a brusque butjoking manner that she found especially painful. When asked to think about her reaction to this particular behavior, she immediately identified the sense of pain as connected to her relationship with her...

Suicide as a Function of Impaired Reality Testing and Ego Integration

Suicidal fantasies and behaviors frequently accompany an impairment in reality testing or a lack of ego integration. The patient's defenses are ineffective in managing the intense rage and grieving that triggers these thoughts and behaviors, leaving the feelings unintegrated with the rest of the patient's experience. Impairments in reality testing and ego integrative capacity may also be evidenced by a profound inability to recognize positive aspects of the self, with a focus on the self as...

Techniques Used in the Middle Phase

The term clarification refers to a technique in which patients' typical methods of thinking or feeling about themselves or others are pointed out, particularly as they relate to the depressive mood state (Stone 1981). Similar to interventions in cognitive-behavioral therapy, clarifications do not address patients' unconscious motivations or early contributions to their way of thinking about themselves. Rather, they are used to bring attention to certain self-defeating thought or behavior...

Addressing Angry Reactions to Narcissistic Injury

Typically, patients respond to narcissistic injury with angry reactions and fantasies (Jacobson 1971 Rado 1928 Stone 1986). They tend to have difficulty tolerating these aggressive feelings and may deny them. In attempting to approach the reactive anger, it is essential that the therapist take a nonjudgmental stance, as patients are often critical of these feelings and expect a negative reaction from others. It is important in treating depression psychodynamically to explore angry reactions to...

Core Dynamic Formulation for Depression

The literature, then, suggests two broad models of depression those involving aggression toward others that is ultimately directed toward the self, and those focusing on difficulties with self-esteem in patients whose expectations of themselves far exceed their capacity to live up to them. Finally, some theorists refer to links between the two models. Rudden et al. (2003) have attempted to integrate these factors into a core dynamic formulation for depression. In this formulation, narcissistic...

Identifying Anger Guilt and Self Punishment Embedded in Character

Some depressed patients can seem, even to their therapists, to experience recurrences out of the blue, apparently related to a biological susceptibility to that mood state. In such patients, reductions in medication can be a contributing factor to recurrences of their depressions. However, in our clinical experience, certain personality traits and vulnerabilities are also clearly implicated in a susceptibility to recurrences for most dysthymic and depressed patients. Even for patients who...

Idealization and Devaluation

A s discussed in Chapter 8, depressed patients can have scrupulously held moral standards. Additionally, their personal expectations of themselves in other realms of endeavor can be unrealistic. These attitudes are rooted in an excessively perfectionistic ego ideal. The ego ideal, considered to be another dimension of the superego, establishes goals to be met and attributes to be held for the person to consider the self praiseworthy or deserving of respect. Failures to meet excessive...

The Severe Superego and Guilt

Along with narcissistic vulnerability and related affects of shame, helplessness, or reactive anger, conscious or unconscious guilt often cripples depressed patients. Some patients reveal deep-seated feelings that they are bad or unworthy and are prone to attacking themselves through self-criticisms or punishments when they sense that they are behaving in an aggressive, competitive, or overly sexual manner. Examples of this are the cases of Ms. G in Chapters 4 (Getting Started With...

Addressing Narcissistic Vulnerability

Narcissistic vulnerability is the tendency to react to slights and disappointments with a significant loss of self-esteem (Kohut 1966 Rothstein 1984 Spezzano 1993). As noted in Chapter 1 (Introduction), narcissistic vulnerability has been viewed by generations of analysts as central to the development of depression. Because of its crucial role, it is important to help the patient become aware of this vulnerability and to collaboratively explore its dynamics. Narcissistic vulnerability is...

Case Example 6

DDD, a 52-year-old writer, had been successfully treated 3 years earlier for major depression by a psychopharmacologist after referral by his therapist. After approximately 2 years, the patient was doing quite well and his medication was tapered off. However, 1 year later, Mr. DDD's depression recurred when he was competing to be president of an academic organization. Mr. DDD contacted the psychopharmacologist, who was also a psychoanalyst, and went in for reevaluation. It was clear from...

Establishing the Therapeutic Alliance

The term therapeutic alliance (Greenson 1967 Stern et al. 1998) refers to the relationship between therapist and patient as they work together in partnership to understand the meaning of the patient's symptoms. As the therapist is seen as caring but dispassionate and dedicated to understanding the meaning of the patient's difficulties without taking sides or beingjudgmental or invasive, a relationship evolves in which the patient learns to trust the therapist with the most intimate fears and...

Case Example 1A

T was a 62-year-old salesman who presented with a major depression of moderate intensity, connected to his fears about aging. He was experiencing uncharacteristic difficulties with his job, having lost several of his accounts, and began to fear that his age was a factor in this decline. Many of Mr. T's previous sales contacts had retired or moved to other locations, and he was no longer afforded the respect or responsiveness he had received in the past. In addition, he worried that his...

Addressing Idealization and Devaluation of Others

In focused psychotherapy for depression, it is important to help patients identify tendencies to idealize or devalue selected others. Exploring this tendency often reveals that it is a strategy for ignoring painful feelings about loved ones or about the patients themselves. The resulting distortion in their perceptions of interpersonal reality may leave depressed patients confused and add to a sense of vulnerability. Further, cycles of idealization and disappointment may burden their...

Psychodynamic Models of Depression

C's depression can be explained by a variety of psychodynamic models, put forth by different psychoanalytic theorists (Table 2-1). Below, we apply each model to the case of Ms. C. We then use these theories to distill a set of psychodynamic factors central to the understanding and treatment of depression. Traumatic early experiences temperamental propensity toward aggressiveness, which becomes directed at others Anger projected onto others, who are then experienced as hostile. Patient...

Patients With More Severe Narcissistic Sensitivity

Although depressed patients frequently have narcissistic sensitivity, in some cases patients have particularly severe forms, bordering on paranoia. They may interpret benign statements as negative or have a gift for find ing a potential criticism or rejection in a statement meant to be helpful. If their sensitivity is severe enough, they may benefit from atypical antipsychotic agents if these feelings have not resolved with the use of antide-pressants. From the therapeutic standpoint,...