Short-term Psychoanalytic Psychotherapy for Adolescents with Depression

A Treatment Manual

Simon Cregeen, Jocelyn Catty, Carol Hughes, Nick Midgley, Maria Rhode, Margaret Rustin

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367103743
• eBook ISBN: 9780429919169
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Short-term Psychoanalytic Psychotherapy (STPP) is a manualised, time-limited model of psychoanalytic psychotherapy comprising twenty-eight weekly sessions for the adolescent patient and seven sessions for parents or carers, designed so that it can be delivered within a public mental health system, such as Child and Adolescent Mental Health Services in the UK. It has its origins in psychoanalytic theoretical principles, clinical experience, and empirical research suggesting that psychoanalytic treatment of this duration can be effective for a range of disorders, including depression, in children and young people. The manual explicitly focuses on the treatment of moderate to severe depression, both by detailing the psychoanalytic understanding of depression in young people and through careful consideration of clinical work with this group. It is the first treatment manual to describe psychoanalytic psychotherapy for adolescents with depression.

CHAPTER ONE

Psychoanalytic views of adolescent depression

Psychiatric definitions of depression, such as the ones provided in the DSM-5 (APA, 2013) and the International Classification of Diseases (ICD-10; WHO, 2010), are primarily based on manifest symptoms. In psychoanalytic psychotherapy, however, the focus is primarily on underlying psychodynamic and developmental issues, rather than on the manifest symptoms of depression. This is in line with research suggesting that depressive symptoms may well be a component of many different disorders, given the high levels of co-morbidity with other Axis I disorders (such as anxiety) and with Axis II disorders such as personality disorders (Fava et al., 1996). It is also in line with a study of depression in young people (Trowell et al., 2007) which reported high levels of co-morbidity with other conditions, particularly anxiety. These findings have important implications for both treatment and research, as different treatments may turn out to be differentially beneficial for different types of depression (Corveleyn, Luyten, & Blatt, 2005).

In therapeutic terms, psychoanalytic treatment aims to address the underlying dynamics of the disorder first and foremost, not just the symptoms per se. In focusing on such underlying dynamics, this form of therapy thus focuses on some of the vulnerabilities to depression, thereby offering not only symptomatic improvement but also the possibility of fostering greater resilience against the recurrence of depression. An effective theory of depression needs to encompass the many different forms that depression may take, including the various possible changes in cognition, mood, and other symptoms. In order to be clinically relevant, the theory needs also to speak meaningfully to the considerable co-morbidity with other types of disturbance, especially during adolescence, as well as both the internalizing and externalizing types of depression (Trowell et al., 2007).

This chapter begins by describing a range of psychoanalytic theories of depression. It then goes on to consider the importance of looking at depression in the context of adolescent development. It ends by offering a psychoanalytic formulation of some of the underlying psychodynamic processes and factors that are likely to make some adolescents vulnerable to depression and to suffer ongoing depression. These processes, which reflect the key theoretical concepts on which STPP is based, underpin the approach to treatment described in the following chapters.

Psychoanalytic theories of depression

The role of unconscious conflict and aggression

Conflict is inherent to human existence but is particularly intense during adolescence, especially with respect to adult authority figures, and often linked to depressive symptoms. Unconscious conflict may be particularly powerful in relation to feelings of aggression and hostility. Psychoanalytic authors, beginning with Freud in “Mourning and Melancholia” (1917e), are in agreement that depression is associated with fears about the consequences of aggression and the patient’s conscious or unconscious fear of being unable to manage it appropriately. When such fears become overwhelming, the result may be guilt (Rado, 1928), hopelessness, and despair. In depression, there is a tendency to turn aggression against the self and a consequent failure to elaborate issues of identity in a satisfactory manner.

The focus on aggression in psychoanalytic theories of depression has been especially important in helping to make sense of the severe levels of self-reproach and self-criticism that can be found in many depressed patients, although there are ongoing debates within psychoanalysis about the role that aggression plays in the genesis of depression (Bleichmar, 1996). Bleichmar (1996) identifies four broad perspectives on the interaction between aggression and depression within psychoanalytic theory:

» aggression as a necessary universal feature and a fundamental causal agent present in every depression (e.g., Abraham, 1924; Klein, 1935);

» aggression as a causal agent of depression but as part of a larger process involving the frustration of particular desires and wishes, which leads to aggression being directed towards the self (e.g., Jacobson, 1972);

» aggression being present in certain cases but the central dynamic of depression being related more specifically to experiences of helplessness and loss of self-esteem (e.g., Bibring, 1953);

» aggression as a secondary phenomenon in depression understood as a response to failures of the object which leads to narcissistic rage (e.g., Kohut, 1977).

Early relationships

Abraham (1924) was the first psychoanalyst to highlight the particular importance in the vulnerability to depression of hostile elements in the early relationship to the mother, based either on temperament or on early experience. Drawing on his clinical experience with depressed adults, Abraham suggested that an experience of interpersonal loss or disappointment in adult life (especially in a love relationship) was experienced by some people as an unconscious repetition of an early childhood state of being wounded narcissistically (i.e., an injury to the sense of integrity of the self), thus evoking powerful feelings of hostility and aggression. In some cases, such aggressive feelings are experienced as unacceptable, and they evoke unmanageable feelings of guilt. The aggression may then be repressed and turned against the self, leading to merciless attacks on the patient’s own self as well as feelings of guilt and lack of self-worth.

Abraham’s focus on the connection between depression and the earliest mother–infant relationship was developed by Melanie Klein (1935, 1940), whose ideas helped to identify some of the typical anxieties and defence mechanisms found in the depressed patient. Klein (1946) proposed that the first months of life, for all infants, were characterized by the “paranoid-schizoid” defences against anxiety, in which the prime concern is for the survival of the self. Splitting of good and bad is necessary to overcome confusion but, when taken to extremes, can lead to an excessively black-and-white world view and an impoverishment of the personality. In the depressive position, which follows developmentally, good and bad aspects of the self and of significant others begin to be integrated, and this can lead to guilt about any hostility towards loved people. The main concern is for the survival of loved figures, both externally and internally, so that someone who has not overcome the anxieties of the depressive position may be preoccupied with loss and be frightened of forming attachments. These “depressive anxieties” (which are not the same as a state of depression) are resolved by making reparation during the “working-through” (Freud, 1914g) of the depressive position. This process is repeated throughout life, especially when external events arouse anxiety about loved ones.

When the adult patient has a depressive breakdown, Klein understood this in terms of an inability to tolerate (normal) depressive anxieties, especially those concerned with a sense of having irreparably damaged a loved person. Someone for whom guilt is intolerable may regress to the paranoid-schizoid position or adopt a “psychic retreat” (Steiner, 1993). The defences that are mobilized to manage the persecutory anxieties may limit the patient’s capacities, especially to manage guilty feelings, which may become overwhelming. For the depressed patient struggling to maintain the depressive position, guilt and self-reproach are powerful. Equally, these patients lack confidence in their capacity to “repair” the situation and restore loved internal figures. This links with the sense of hopelessness and helplessness discussed by other psychoanalytic writers such as Bibring (1953).

The role of loss

The role of “object loss” in the aetiology of depression has been central to many psychoanalytic theories, alongside aggression. Freud (1917e) distinguished between “melancholia” (depression) and normal mourning, while suggesting that both could be understood as the ego’s reaction to the loss of an important “object” (either an actual person or, for example, a political ideal). In mourning, a period of intense sadness and withdrawal from normal interests gradually leads to the bereaved person’s acknowledgement that the loss he or she has suffered is irreversible, and that the loved person will not return. As an outcome of this mourning process, the lost, loved person becomes more securely established as an inner presence with whom the bereaved person can identify, so that his or her sense of self becomes enriched.

Freud contrasted this situation with that in pathological mourning, or “melancholia”, where he noticed that the depressed person’s feeling of worthlessness and self-reproaches were typically voiced in a way that sounded as though they were being addressed to another person. He posited that the melancholic person’s internal situation reflected the way in which he or she had dealt with the loss of an emotionally important figure (generally a parent) towards whom profoundly ambivalent feelings were held. In Freud’s striking phrase, the loss (either real or perceived) of such a relationship had a profound consequence: “the shadow of the object fell upon the ego” (1917e, p. 249). The aggression and reproaches originally aimed at the ambivalently loved object were now turned against the melancholic’s own self. This notion of what was later termed the “ego-destructive super-ego” was elaborated by other authors (e.g., Bion, 1959; O’Shaughnessy, 1999) in relation to difficulties other than depression and has continued to be central to the way psychoanalysts have understood certain key aspects of the experience of depression. Recently, Green (2013), revisiting “Mourning and Melancholia”, has argued that in melancholia the psyche rigidifies into inflexible postures. In some young people this seems marked, whereas for others it is an additional component in the background.

While Freud’s ideas helped to make links between experiences of loss, self-directed aggression, and depression, it was clear that not all depression was precipitated by loss and that not all experiences of loss led to depression. Freud’s work had offered a powerful account of the dynamics at play in depression, but it did not sufficiently address the question of why certain individuals appeared to be more susceptible to reacting to loss in a melancholic way, whereas others were able to pass through a period of more “healthy” mourning. For psychoanalysts, it was necessary to get a clearer idea of the particular vulnerabilities that certain individuals had that would make them more susceptible to a depressive reaction.

While the work of Freud, Abraham, and Klein helped to elucidate some of the mechanisms that lead to feelings of guilt and self-hatred in depression, other psychoanalytic thinkers have focused more on the sense of helplessness and powerlessness that is characteristic of some forms of depression. Bibring (1953) was one of the first psychoanalytic thinkers to see depression as a primary affect that could be evoked in certain threatening situations. As Lazar (1997) puts it, “he viewed rage turned against the self as less important than a sense of helplessness in the face of a loss of ideals and self-esteem” (p. 52).

More specifically, Bibring suggested that a loss of self-esteem and depressed feelings were a direct response when the ego was faced by frustration. While experiences of loss were common among Bibring’s depressed patients, what defined the depression was a sense of the self as unable to attain certain goals, leading to a profound sense of impotence and helplessness (see also Haynal, 1977). As Bemporad, Ratey, and Hallowell (1986) put it, “what the depressive has lost was not necessarily a love object but also a set of aspirations or a view of one’s self” (p. 168).

Bibring’s ideas were elaborated by Sandler and Joffe (1965) in their extensive review of the case notes of children with depression seen for psychoanalytic treatment at the Anna Freud Centre in London in the post-war years. Sandler and Joffe agreed with Bibring that depression could be thought of as a basic emotion that was evoked when children were faced by the loss of something or someone whom they felt was central to their core sense of well-being. They emphasized that the significant thing was not the lost person per se, but, rather, the loss of a previous sense of self, a self whose well-being was associated with maintaining a link to a particular person. These children felt unable to do anything to repair this loss, leading to a self-representation as helpless and powerless that in turn was associated with a sense of apathy, inhibition, and hopelessness characteristic of depression. It is interesting to note the convergence of this idea with Klein’s emphasis on the centrality of reparation (Klein, 1937).

There are certain similarities between Bibring’s conceptualization and that of Bowlby (1960), who also saw depression as one stage in a natural sequence of responses to any experience of loss or separation from an important attachment figure. Sandler and Joffe (1965) hypothesized that some children were more vulnerable to depression than others because of pre-morbid personality characteristics, which one might hypothesize could be linked to Bowlby’s ideas about the effect of different patterns of attachment on the way children manage separation and loss. Bowlby’s work on the importance of secure attachment for the child’s emotional development shows obvious parallels with psychoanalytic ideas concerning the importance of the balance between love and hostility: the defining characteristic of securely attached toddlers is the capacity to protest when left by their mothers, but then to allow themselves to be comforted. In insecurely attached toddlers, this balance cannot be attained or maintained. One might hypothesize that such an insecure attachment would make the developing child more vulnerable to depression, a hypothesis that is supported by recent longitudinal research (Halligan, Herbert, Goodyer, & Murray, 2004).

The psychoanalytic thinking of Bibring, Sandler and Joffe, Bowlby, and Haynal is useful in understanding the well-established link between traumatic experiences and depression. Certain traumatic experiences, including physical and emotional abuse or physical illness, may leave people feeling a profound sense that they are unable to influence their world in any meaningful way. This is consistent with Brown and Harris’s (1978) finding that when traumatic experiences are identified in the histories of depressed adults, they tend to threaten profoundly that person’s sense of identity and worth.

The death instinct

Primary aggression and destructiveness is a contested notion within psychoanalysis. Freud first proposed (1920g) and then developed (1930a, 1937c) the existence of a conflict between a life instinct and a death instinct, following clinical observations and based on his ideas regarding biology and philosophy. Central to his thinking was the idea that there is a primary destructiveness which involves a fusion of the life and death instincts. Although there have been many views on this idea, and indeed objections to it, it is an idea that has survived and been developed by subsequent thinkers and so needs consideration.

Freud’s thinking was subsequently taken up by Klein, whose ideas were rooted in her clinical experience. She made a conceptual link between the death instinct and the development of a harsh superego (Klein, 1933), and she later considered that primitive envy was the most destructive manifestation of the death instinct (Klein, 1957), thus presenting a significant impediment to development. Klein linked the life instinct with feelings of love, and the death instinct with those of hate and destructiveness. She considered that the fear of annihilation was the primary anxiety: “Since the struggle between the life and death instincts persists throughout life, this source of anxiety is never eliminated and enters as a perpetual factor into all anxiety-situations” (Klein, 1948, p. 29).

As her thinking developed, Klein increasingly saw the manifestations of love and hate as being less derived from instincts and more associated with the interplay of object relations and thus subject to being projected into external and internal objects. Subsequent post-Kleinian psychoanalysts have developed thinking on the life and death instincts, especially in relation to narcissism, most notably Meltzer (1968), Rosenfeld (1971), Segal (1997a), and Feldman (2009).

In clinical work with depressed patients, we often see the conjunction of an identification with a lost object (Freud, 1917e) and persecution by a harsh superego. O’Shaughnessy describes the formation of this constellation:

Freud described how in a melancholia, destructiveness is felt to be concentrated in the superego …, and four years later in 1927, Melanie Klein showed that the extreme and unreal destructiveness of the early superego is the result of the projection into it of the child’s savage impulses. [O’Shaughnessy, 1986/2015, p. 88]

With patients who are in a state of melancholia, the identification with the lost and hated object is a narcissistic one and may include states of envy, grievance, possessiveness, and tyranny felt towards the object (Sodre, 2005). In melancholia, the dynamic combination of a severe superego and the narcissistic identification could be thought of as associated with the workings of the death instinct.

In her summary review of developments in Kleinian thought, Bott Spillius (1994) suggests that there are two, not mutually exclusive ideas in relation to the death instinct that are still prevalent in post-Kleinian thinking. One is that of a “strong tendency toward inherent destructiveness and self-destructiveness” which can lead the individual to “attack or turn away from potentially life giving relationships”, with the associated wish to “oblate any awareness of desire that would impinge on their static and apparently selfsufficient state” (p. 341). The second idea is “what Rosenfeld [1987], following Freud, calls ‘the silent pull of the death instinct”’ (Bott Spillius, 1994, p. 341). In this, the individual is inexorably drawn towards “a nirvana-like state of freedom from desire, disturbance, and dependence” (p. 341). She suggests that it is “a false opposition” to try to determine whether such tendencies are “innate or acquired, inherent or defensive” and that, clinically, “what one can tell is how deep-rooted the patient’s negative tendencies are in the present analytic situation” (p. 341).

Clinical work with some depressed patients reveals phantasies (which are sometimes made explicit) that suicide will bring about a relief from the pain of living and a belief that this peaceful state will be experienced, known, and enjoyed by them, albeit post-death. Such a state of mind also may include a sense of triumph over the object (and the world of the living) associated with ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• ABOUT THE EDITOR AND AUTHORS
• ACKNOWLEDGEMENTS
• SERIES EDITORS’ PREFACE
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Psychoanalytic views of adolescent depression
• CHAPTER TWO Psychoanalytic child psychotherapy: principles and evidence
• CHAPTER THREE Short-Term Psychoanalytic Psychotherapy for adolescent depression: framework and process
• CHAPTER FOUR The stages of treatment in Short-Term Psychoanalytic Psychotherapy
• CHAPTER FIVE Work with parents and carers
• CHAPTER SIX Supervision of Short-Term Psychoanalytic Psychotherapy
• CHAPTER SEVEN Short-Term Psychoanalytic Psychotherapy in clinical practice
• AFTERWORD
• ABOUT THE ASSOCIATION OF CHILD PSYCHOTHERAPISTS
• REFERENCES
• INDEX