Psychodynamic Treatment of Depression (Book Review)

Author:  Busch, Fredric N., Marie Ruddin and Theodore Shapiro
Publisher: Washington, DC: American Psychiatric Publishing, 2005
Reviewed By: Michelle D. Presniak and Michael Wm. MacGregor, Fall 2005, pp. 60-61

Psychodynamic Treatment of Depression is a clearly written book that is useful to all clinicians treating patients with depression. For the seasoned clinician, theory is interwoven into each chapter to help connect the authors’ ideas to those of other writers. For the novice clinician, clinical vignettes are used to elucidate difficult theoretical and conceptual ideas. Psychodynamic Treatment of Depression also offers an excellent way to introduce different dynamics to students learning psychodynamic therapy. The authors, Fredric Busch 1, Marie Rudden 2, and Theodore Shapiro 3, provide a focused psychodynamic approach to treatment that is both clear and practical, and that covers all stages of treatment. The book is divided into three sections: Introduction and Overview, Techniques in Psychodynamic Treatment of Depression, and Special Topics. This book is a must for any clinician treating depression.

In the three chapters included in the Introduction and Overview section the authors introduce the structure and purpose of the book, briefly review psychodynamic models of depression, and present an overview of psychodynamic psychotherapy for depression. In the first chapter the authors discuss the background training needed by clinicians intending to use their book, highlight indications for psychodynamic psychotherapy (e.g., good reality testing, ability to understand metaphors, etc.), discuss the length of treatment, and briefly explore the use of medication as an adjunct to psychotherapy. The authors then provide a discussion of a psychodynamic model of depression in the second chapter. This chapter is rich in theory and reviews various models of depression. The authors discuss Abraham and the role of anger projected onto others, Freud and perceived loss, Brenner and castration and disempowerment, and Bowlby and disruptions in attachment. They summarize the different models of depression in an excellent table. This use of summary tables is found throughout the book and is a definite strength. It allows for an easy to find and concise presentation of material. In this same chapter the authors provide a summary of the central dynamics found in depression (again along with a summary table), and then present a core dynamic formulation for depression (e.g., pages 26 & 27). The central dynamics presented in this chapter (e.g., guilt and shame, defenses, etc.) are discussed in greater detail in the second section of the book. The last chapter in this section briefly reviews the initial, middle, and terminations phases of treatment which are also explored in greater detail in section two. Once again, this chapter contains summary tables that help condense the material. For example, the authors highlight the ‘areas of focus’ and ‘expected responses’ for each of the three phases of treatment.

The authors state that their book is written for clinicians who are already experienced in psychotherapy, depression, and psychodynamics. This first section of the book, however, is written in a way that is accessible to both novice clinicians and to students learning psychodynamic psychotherapy. The authors provide an excellent overview of the psychodynamic conceptualization and treatment of depression.

In second section of the book, Techniques in Psychodynamic Treatment of Depression, the authors provide a more detailed discussion of the stages of treatment and the specific techniques utilized in the psychodynamic treatment of depression. The first chapter in this section discusses the beginning stage of treatment and emphasizes the barriers to engagement. Topics in this chapter include, establishing the therapeutic frame and an alliance, barriers to engagement, how to clarify the central psychodynamics for patients, and the role of psychoeducation the early stage of treatment. This is an excellent chapter. The authors discuss the dynamic conceptualization of engagement and resistance and provide technical suggestions to ameliorate or overcome resistance. They once again use summary tables to help condense the information. As well, the authors make ample use of clinical vignettes, which enhance the reader’s ability to understand the material. Some of the interpretations provided in the vignettes are sophisticated and complicated. It is with these complicated interpretations that the authors’ recommendation that readers have some background in psychodynamic theory becomes relevant. Even for a novice clinician or a student, however, the interpretations are useful to demonstrate how psychodynamic techniques can be used in treatment as they provide real life examples of the challenges that clinicians face on an ongoing basis.

The second chapter in this section provides an overview of the middle phase of treatment and is then followed by five chapters that deal with specific issues encountered in, or of seminal importance to, the middle phase of treatment. In their overview the authors explore topics such as how to work with central themes, techniques of psychodynamic therapy (e.g., clarification, confrontation, interpretation, etc.), how to monitor and work with countertransference, and the use of dreams. The five specific issues subsequently discussed in individual chapters are: Narcissistic vulnerability, angry reactions to narcissistic injury, the superego and guilt, idealization and devaluation, and defenses mechanisms.

In the chapter on narcissistic vulnerability the authors discuss how early experiences of helplessness, loss, and rejection are related to envy, blame, and feelings of vulnerability. Using four excellent examples they discuss how to recognize areas of narcissistic vulnerability. The authors, through the use of clinical vignettes, discuss distortions in self- and other-images and counterproductive reactions to narcissistic vulnerability. In this chapter the authors clearly use clinical vignettes to help illustrate the concept of narcissistic vulnerability.

After discussing narcissistic vulnerability the next chapter explores how to address angry reactions to narcissistic injury. The authors provide an excellent table (page 92) that summarizes areas of exploration when working with angry reactions to narcissistic injury (e.g., identifying specific fantasies, etc.) and anticipated responses to this exploration (e.g., diminished self-directed anger, etc.). Again through the use of clinical vignettes, the authors explore specific angry fantasies, guilty reactions to anger, expectations of punishment, competitiveness and aggression, becoming comfortable with assertiveness, and recognizing anger directed towards the self within the context of narcissistic injury.

The next two chapters, entitled The Severe Superego and Guilt and Idealization and Devaluation, explore the role of guilt and an excessively perfectionistic ego ideal respectively in depression. In The Severe Superego and Guilt the authors discuss the functions of the superego (e.g., judging, limiting, etc.) and then identify how in depressed patients the superego can become harsh and function to contribute to, and maintain, depressive symptoms. Through the use of six case examples the authors explore techniques to help patients recognize guilt and punishment, how to use guilt fantasies in treatment, and how anger, guilt, and self-punishment can become embedded in character (e.g., as in the case of masochism). This is followed by the chapter on Idealization and Devaluation that explores these two defenses in relation to the self, to others, and in the transference. Following their discussion of Idealization and Devaluation the authors devote a chapter to discussing other defense mechanisms typically encountered in depressed patients. This chapter is particularly strong in terms of integrating theory, research, and clinical examples. Defenses such as Denial, Projection, and Passive Aggression are discussed and research from authors such as Bloch (1993) and Jacobson (1971) is presented.

The authors conclude the second section of the book with a chapter on the termination phase of treatment. This is a nice conclusion to this section. The authors start with the initial and middles phases of treatment, turn to specific issues that are addressed in the middle phase of treatment, and then conclude by discussing the termination phase. In a sense, the reader almost gets to see how the therapeutic process unfolds and appreciates the struggles encountered in treatment. In The Termination Phase the process of termination, how to handle premature terminations, and countertransference reactions to termination are all explored. Once again, the authors make ample use of clinical vignettes to highlight specific issues such as resistance.

In the third and final section of the book, the authors focus on topics that are of special concern regarding psychodynamic treatment of depression including impasses and negative reactions to treatment, suicidal behaviour, and combining psychodynamic treatment with other treatment approaches. In the chapter on impasses and negative reactions the authors discuss specific conditions that disrupt therapy including impairments in basic trust, severe trauma, and acting out. The chapter on suicide explores the dynamics of suicide by discussing suicide as revenge, pathological mourning, self-punishment, impaired reality testing and ego integration, etc. While some of these dynamics may be known to clinicians of various orientations, others may not. The authors focus on the psychodynamic understanding of the dynamic and nicely illustrate the contribution that psychodynamic and psychoanalytic theory makes to our understanding of suicidal ideation. This chapter highlights the importance of understanding the meaning behind suicidal ideation rather than simply looking at the symptoms of suicidal behaviour.

The final chapter in this section, and the book, is devoted to a discussion of psychodynamic therapy in conjunction with other approaches. One of the most frequently used approaches to the treatment of depression is psychopharmacological. The authors discuss how a psychodynamic approach can be used with a pharmacological approach and highlight some of the dynamic issues that may come up in patients taking medication, such as shame. This chapter is well written and presents a balanced view of the benefits of different treatment approaches.

The authors state that Psychodynamic Treatment of Depression is aimed to provide an overview of the psychodynamic treatment of depression, and that is to be used by clinicians who are trained in psychotherapy and diagnosis of depression. Although the authors indicate that experience in dynamics is needed to fully understand the concepts introduced, this book provides a valuable resource for educating both new and experienced clinicians. This volume is an exceptional resource for clinicians and provides an excellent introduction for students learning psychodynamic psychotherapy

Footnotes

1 Fredric N. Busch, MD, is a Clinical Associate Professor of Psychiatry at Weill Medical College of Cornell University and a faculty member at Columbia University Centre for Psychoanalytic Training and Research.  [top] 
2 Marie Rudden, MD, is also a Clinical Associate Professor Psychiatry at Weill Medical College of Cornell University, a Training and Supervising Analyst at the Berkshire Psychoanalytic Institute, and a faculty member at the New York Psychoanalytic Institute.  [top]
3 Theodore Shapiro, MD, is a Professor Emeritus of Psychiatry in Paediatrics at Weill Medical College of Cornell University and a Training and Supervising Analyst at the New York Psychoanalytic Institute.  [top]

References

Bloch, A. L., Shear, M. K., Markowitz, J. C., Leon, A. C., & Perry, J. C. (1993). An empirical study of defense mechanisms in dysthymia. American Journal of Psychiatry, 150, 1194-1198.
Jacobson, E. (1971). Comparative Studies of Normal, Neurotic, and Psychotic Conditions. New York: International Universities Press.

Reviewers Note

Michelle D. Presniak is a doctoral candidate in clinical psychology at the University of Saskatchewan; Michael Wm. MacGregor is an associate professor at the University. Correspondence can be sent to: Michael Wm. MacGregor, PhD, Department of Psychology, University of Saskatchewan, 9 Campus Drive, Saskatoon, Saskatchewan, S7N 5A5. Telephone: (306) 966-2525. Fax: (306) 966-6630.

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