Psychoanalytic psychotherapy and difficult-to-treat depression: towards an integrative model

Abstracts

A depressão envolve um grupo heterogêneo de situações, sendo que algumas se apresentam como de difícil tratamento. A psicoterapia psicanalítica e suas formulações teóricas têm sido muito úteis na compreensão e no tratamento da depressão. Este artigo propõe que isso é particularmente verdadeiro para os casos difíceis, quando uma perspectiva integradora pode melhorar a resposta clínica. É feita uma revisão da literatura sobre psicoterapia psicanalítica na depressão.

Depressão; transtorno depressivo; psicanálise; terapia psicanalítica; psicoterapia

REVIEW ARTICLE

Psychoanalytic psychotherapy and difficult-to-treat depression: towards an integrative model

La psicoterapia psicoanalítica y la depresión de difícil tratamiento: búsqueda por un modelo integrador

Júlia Trevisan

Psychiatrist, Department of Psychiatry and Legal Medicine, School of Medicine, Hospital de Clínicas de Porto Alegre, Brazil

^{Correspondence}

ABSTRACT

Depression is associated with a heterogeneous group of situations, some of which may be difficult to treat. Psychoanalytic psychotherapy and its theoretical formulations have been extremely useful in the understanding and treatment of depression. The author suggests that this is particularly true in difficult-to-treat cases, when an integrative perspective may improve clinical response. The article reviews the literature on psychoanalytic psychotherapy in the treatment of depression.

Keywords: Depression, depressive disorder, psychoanalysis, psychoanalytic therapy, psychotherapy.

RESUMEN

La depresión abarca un grupo heterogéneo de situaciones, habiendo algunas que se presentan como siendo de más difícil tratamiento. La psicoterapia psicoanalítica y sus formulaciones teóricas han sido muy útiles para la comprensión y el tratamiento de la depresión. El siguiente artículo propone que eso es particularmente verdadero para los casos más difíciles, cuando una perspectiva integradora puede mejorar la respuesta clínica. Se hace una revisión de la literatura sobre psicoterapia psicoanalítica en la depresión.

Palabras clave: Depresión, trastorno depresivo, psicoanálisis, terapia psicoanalítica, psicoterapia.

INTRODUCTION

Psychiatric thought has been trying to understand human beings and their suffering for a very long time. It is possible that the complexity of understanding mental disease is related to just how difficult it is for humanity to articulate the concepts of mind and brain. Science advances in line with its paradigms, but the common ground, that which unites us definitively, is clinical experience.

The task of the mental health professional is to identify their patients' problems and attempt to offer them relief, but this can be extremely difficult. Both during diagnostic evaluation and therapeutic conduct, the professional is faced with a wide range of possibilities, all worthy of attention and study. The reference point when taking decisions is scientific, but it is the possibility of thinking critically about their science and their understanding of human beings that brings quality and richness to a professional's work. The diagnostic task, for example, indispensable to good practice, possibly involves something much more complex than what we have so far been able to systematize. Consequently, the same can be said of the therapeutic task.

The depressive disorders, while well defined from a phenomenological viewpoint, are an example of how heterogenous a group of complaints can be. In practice, a case can become problematic, not simply in function of the severity of the episode, but also as a result of the presence of other biological, psychological or even social factors.

Research into the efficacy of dynamically oriented psychotherapy in depression, while returning many positive results, is non-specific. We continue to ask ourselves, "For this specific individual, with this problem, what type of treatment, administrated by who, at what point in time and under which conditions will lead to how great an extent of benefit in over how long a period?"¹ While we ask ourselves this question, psychoanalytic theory continues to offer, as it has since Freud, its contribution.

The present text raises certain considerations on the relationship between analysis-oriented psychotherapy and the approach to cases of "difficult-to-treat depression", reviewing certain psychoanalytic contributions to the subject and proposing that another point-of-view, in addition to the biological one, be tried in these cases. Difficult-to-treat depression can be each and every situation that results in an unsatisfactory response to treatment. This is an exercise built upon a non-systematic bibliographic review of a given practical situation, and the expression "difficult-to-treat depression", which, while vague, non-specific and unfamiliar to current classifications, is the best way that the current author has found to describe the situation. A clinical example is described and commented on based on contributions found in the psychoanalytic literature on depression.

SCIENCE AND PSYCHOTHERAPY

The scientific question must be faced in psychotherapy. This, however, is not an easy task. Furthermore, certain assumptions must be made in order to achieve clinical applicability in our current, but not eternal, "scientific truths" While psychiatrists, we are much more clinicians than we are scientists and we must apply a humanist focus to our work that takes into account the scientific knowledge of several different areas, but which goes beyond this and constitutes an art.²

In psychotherapy research is becoming a serious scientific field, but certain obstacles that have already been overcome by the biological sciences have not been overcome in the field of psychotherapy. Although the value of case histories is being reaffirmed,¹ it is no longer enough to confirm form colleague to colleague that someone is performing good therapeutic work. There are many difficulties, including the fact that we cannot achieve homogenous samples (if such are possible), we do not have placebo and do not even have a common language.

According to Thomas Kuhn,³ the first stages of development of the majority of sciences have been characterized by continuous competition between a number of different concepts of a distinct nature, each one of the partially derives and all of them only approximately compatible with the dictates of observation and the scientific method. What differentiated these different schools was not one or other failure of the method — they were all scientific — but that which we call the incommensurability of their ways of looking at the world and of practicing science within that world.

In psychiatry, we are still talking about lines of thought, we are still at the pre-paradigmatic stage or, as Drob puts it,⁴ multiparadigmatic. While this may be discouraging, it is better than prematurely establishing a truth, a dogma, as a defense against uncertainty.^4,5

Lipowsky² warns us of the problems of reductionism in psychiatry and states that no focus that does not take into account the mind nor one that ignores the brain can do justice to the complexity of mental disease.² Eclecticism is a necessity in psychiatry. Eclecticism is understood to mean, not that which is described as a pragmatic posture in which the therapist uses whatever they think will help the patient, something ingenuous and without criticism, but the integrative sense, in which theoretical purity can be preserved and differences respected.^5,6 Eizirik⁷ suggests that one adopt a certain neutrality in relation to the theories that support our practice, which implies the acceptance of possible value, utility or complementarity in other theories or authors and also signifies the presence of a certain sense of humor that derives from the capacity to recognize and smile at one's own pretensions and convictions and admit their limits including the explanatory range of theory.

Wallerstein⁸ postulates that, in order to be as effective as possible, every approach must be matched to the patient for which it is most appropriate. According to Yager,⁹ the eclectic focus involves approaching every clinical situation by way of multiple theoretical perspectives and establishing that which is most in accordance with what the patient wants and needs, without discarding the best available information. For this author eclecticism is necessary due to the properties of our cognitive and perceptive apparatus, because of the manner subject to errors with which we organize our reality. He states that a theoretical perspective, at the same time as it organizes inquiries, observations and understanding, also limits the field of vision and that the two elements are necessary because without an appreciation system data becomes confused. He observes that we, psychiatrists, process "reality" via our own prejudices in order to see things that correspond to our usual form of appreciating human behavior and disease, including depression.⁹

SCIENTIFIC CONTRIBUTIONS TO ANALYSIS-ORIENTED PSYCHOTHERAPY ON THE HETEROGENOUS GROUP OF DEPRESSIVE DISORDERS

Although depression has been described phenomenologically in a very clear manner within the current classifications, it presents in the most varied range of psychological, biological and social contexts. There are thousands of situations in which depression may be difficult to treat. Examples would be conditions that fulfill the criteria for resistant depression, cases of refraction to initial treatment, cases in which compliance is difficult, in which comorbidity or syndromal groups on axes I or II interfere with treatment, or, even in situations in which there is a risk of suicide. Furthermore, a variety of atypical living conditions and an infinity of situations which, in general, we attempt to include within the biopsychosocial model may also interfere with treatment.

In a study of patients with mental disease who had not exhibited a response to 6 months' routine treatment, and of whom 75.5% had been diagnosed with depression, and were making use of health services, Guthrie et al.¹⁰ found positive results for psychotherapeutic intervention. The study, focused on the cost/benefit ratio of psychodynamic interpersonal psychotherapy, concluded that this is an efficient alternative for patients with enduring, non-psychotic symptoms who were not responding to conventional psychiatric treatment.

The United States' National Institute of Mental Health¹¹ conducted a wide-ranging study of two different forms of treatment for depression (NIMH's Treatment of Depression Collaborative Research Program). Of the 250 patients selected, 239 enrolled on the study and were given one of four different treatment methods: interpersonal psychotherapy (IPP); psychocognitive-behavioral therapy (PCB); imipramine and clinical management (IMI-CMC); and placebo and with clinical management (PLA-CM). The IPP method was based of the interpersonal psychoanalysis school of Sullivan, on studies of mourning by Freud and the attachment theory of Bowlby; PCB was represented by the ideas of Beck.¹² When the entire sample was analyzed, without taking the initial disease severity into account, no evidence was found that one type of psychotherapy was more effective than another, and the same was true of the standard treatment with imipramine. When compared with placebo, there was limited evidence of the performance of IPP and no evidence for PCB.

When an exploratory assessment was made of severity, it was observed that, for more severely depressed patients there was some evidence for the efficacy of IPP and strong evidence for IMI-CMC. Furthermore, in an observation on compliance, the author, interested in the clinical significance of the findings, commented that more patients on IPP than on PLA-CM remained in treatment long enough to achieve improvement.¹³

Among the conclusions of the authors, is the statement that, overall, the final judgment on the effectiveness of psychotherapy for the most depressed patients should be withheld and that, perhaps, if the patients were studied for a greater period of time and other characteristics of the sample were evaluated (for example, factors such as personality), the result would be different.¹¹ Another important observation is that none of the therapies studied produced consistent effects in the measurements related to their theoretical origins, indicating the low specificity of the results of these approaches.¹³

Scott et al.,¹⁴ studying chronic depression, reported that this is a very heterogenous group of patients, in which a number of different factors contribute to the cause, but that the role of events as precipitants or maintaining factors of the conditions indicates the importance of the psychological factor in the development of chronicity. Scott,¹⁵ reviewing psychological treatments for depression, observed that the attitude of the patient, by believing in the treatment model and the possibility of improvement, would significantly improve the clinical response. Furthermore, the aptitude of the therapist in a given treatment model may correspond to more than 30% of the variation in results.

Kendler et al.,¹⁶ seeking etiologic models for depression, suggested four primary risk factors in interaction: traumatic experiences, genetic factors, temperament and interpersonal relations. The authors observed that a recent stressor event was, in isolation, the factor of greatest risk for the development of the condition. Furthermore, the authors called attention to the multiplicity of possible interactions between factors, with an additive effect, such as the existence of certain characteristics that could predispose to a stressor, in addition, naturally, to "bad luck".

Zavaschi et al.,¹⁷ reviewing the literature on the relation between losses and depression, found a significant association between trauma due to lost affective connections during childhood and depression in adult life. In this review, the authors observe that some have attributed non-response to treatment of depressed patients to sequelae from psychological traumas that occurred during childhood (Kaplan & Klinetob apud Zavaschi).¹⁸ In an original study on the theme, Zavaschi¹⁸ did not found a positive relationship between childhood losses and depression, but that there was a relationship with other traumatic events, despite the majority of other studies claiming that the relationship does exist.

The occurrence of depression in parallel with other axis I or II diagnoses appears to be more the rule than the exception.¹⁹ Different personality structures and certain subsyndromes, even though they don't constitute a comorbidity, also influence the evaluation and results of treatment and may make it problematic. Schestatsky,²⁰ studying depression and comorbidity, state that the presence of an associated personality disorder increases the probability of suicide, reduces the response to treatment, reduces the number of remissions and interferes with social readaptation. Marcus²¹ proposes that, depending on the personality structure, depression has diverse presentations and should be approached technically with this in mind.

Grote & Frank,¹⁹ among others,^20,22 considered the role of psychotherapy to be crucial to the approach to patients in specific psychosocial contexts and with comorbidity. These authors studied the participation of certain circumstances in difficult-to-treat depression and concluded that there is a need for individualized approaches. The circumstances studied included pregnancy, motherhood and possible subsyndromes of panic, social phobia and posttraumatic stress that influence presentation and response to the treatment.

For Hendin,²³ psychotherapy also contributes to the approach to patient at risk of suicide. The author alerts to the fact that the therapist should not reduce treatment to simple management and control of the patient, but should also understand the extent to which the patient is using their potential death as part of their adaptation, avoiding countertransferential traps and working psychodynamically. Situations that might occur, for example, are the therapist's avoidance of getting closer to the patient in order to reduce guilt in the face of a possible suicide or concern at having their competence checked. Furthermore, the therapist may see themselves imprisoned narcissistically, in their desire to get to know and to cure everyone, while the patient may have chosen them as executioner and not savior. The author²³ concludes that the best chance of helping the patient lies in understanding and helping with the problems that make them suicidal, including the way in which they are using the threat of death, because it is only through psychotherapy that the nature of suicidal involvement becomes apparent.

Summing up, studies demonstrate, although with limitations with respect of specificity, that psychotherapy is an essential component in the response to treatment for depression and that the combined approach, for example, pharmaceuticals with psychotherapy is a common and positive practice,²⁴ in particular for patients with the more chronic and complex forms of the disease.²⁰

THE CONTRIBUTIONS MADE BY PSYCHOANALYTIC THEORY TO UNDERSTANDING DEPRESSIVE STATES

In Mourning and melancholia, Freud²⁵ compares melancholy to mourning, describing a sensation of painful sadness resulting from an objective loss. He said that the distinctive mental traces of melancholy are a discouragement that is profoundly painful, an end to interest in the outside world, the loss of capacity to love, the inhibition of all and every activity and a reduction in feelings of self-esteem to the point of finding expression in self-recrimination and self-vilification, culminating in a deluded expectation of punishment.²⁵ Overall, in melancholy the loss of the object is of an ideal nature. In addition to sharing certain characteristics with mourning, melancholy involves a regression to the oral, still narcissistic phase of the libido, when an identification with the lost object occurs, Freud also said that in mourning it is the world that becomes worthless and empty; in melancholy it is the ego. In relation to the regressive identification he said that the shadow of the object falls over the ego.²⁵ The liberated libido, product of the object-cathexis, is withdrawn to the ego and returns to establish an identification of the ego with the object. Since it is judged as if it were an object, part of the ego places itself against the other, judging it critically. The self-recriminations seen clinically are recriminations made of a loved object that have been displaced. Object and ego succumb to the judgment, the so-called, 'critical agent'.²⁵ It is worth observing that in mourning, this perturbation of the self-esteem is absent.

Freud also highlights ambivalence as a predisposing factor to the condition, where the relation between the object is characterized by love and hate. The self torture that is seen clinically is explained by means of tendencies towards sadisms and hate related to the object and which return on the "I" of the individual. Here there is a correction of the earlier assumption about the destiny of the object-cathexis, in other words it is only a part of the object-cathexis that is displaced to identification. The other part, due to the ambivalence, finds itself in sadism. Suicide also harbors murderous impulses towards others. The ego can only kill itself if, as a result of a return to the object-cathexis, it can treat itself as an object.²⁵

According to Abraham,²⁶ in a consideration of the libidinal development phases proposed by Freud, the unconscious sees the loss of an object as an anal process, and the introjection of one like an oral process. On the sadistic-anal phase of the libido, the author discourses on the instinctive component of sadism, showing two tendencies opposed to in action. One of these is to destroy the object (or the external world); the other is to control it. While referring to melancholy and neurosis in a single chapter, Abraham proposes that the sadistic-anal phase should be analyzed in two stages. At the posterior level, conservative tendencies predominate, to retain and control, and at the more ancient level are the tendencies more hostile to the object, to destroy or lose it. The obsessive neurotic regresses to the posterior of these two planes and is capable to maintain contact with its object. The melancholic, however, as soon as the ego enters into conflict with the love object, abandons relations with this object, acting on the tendencies of the more ancient level.

Abraham²⁶ postulates on the importance of the oral phase to melancholy. He considers an especial fixation of the libido in the oral phase as one of the factors implicated in the etiology of the disease. The process of introjection in the melancholic, the representative of the oral phase, rests on a severe conflict of ambivalent sentiments. Other factors implicated in the etiology, according to this author, are the occurrence of the first disappointment with the love object before the oedipal desires are overcome and a repetition of this first disappointment in later life, in addition to a great injury to infantile narcissism. On the subject of the psychogenesis of melancholy, Abraham²⁶ reminds us that melancholic patients are inaccessible to any criticism of their mode of thinking. In them can be seen the narcissistic character of thought and disregard for people who confront them with reality.

Summing up, Abraham says that when melancholic people suffer an unbearable disillusionment caused by their love object, they tend to expel this object as though it were feces, and destroy it. Soon after they will perform the act of introjection and devouring it, as act which is a specifically melancholic form of narcissistic identification. Their sadistic thirst for vengeance then finds satisfaction, tormenting the ego, an activity which, partly, gives pleasure".²⁶

Melanie Klein²⁷ postulates that depressed individuals do not establish good internal objects and do not feel safe in their internal world as a result of the external loss. In 1934,²⁷ with A contribution to the psychogenesis of manic depressive states, the author develops the concept of the depressive position, defined as a phase of development in which a baby recognizes an entire object and relates to it. Here, she observes that new sentiments appear, of lack of and desire for the good object which, in the fantasy, was destroyed and lost, in common with the guilt resulting from this. In the 1940 work Mourning and its relation to manic depressive states,²⁸ less is said about oral regression and more focus is given to the concept of the depressive position as an event that modifies development and through which the changes necessary to adaptation occur. It is as though the child passes through something similar to mourning, and that the satisfactory negotiation of this moment, with the establishment of good internal objects, determines the future course of mental disease and, in particular, vulnerability to depression in the face of future losses. The essence of the concept of the depressive position is to contain the start of the process of internalization of good internal objects, something that never ends, staying with the individual throughout life.²⁸ If concern with the object predominates, guilt will lead to an attempt at repair. If narcissism predominates, the psychic mechanisms will not take the object into account and will go in search of increased self value.²⁹

Edith Jacobson, apud Lund,³⁰ describes her vision of psychotic depression pointing out that, among other issues, with depressive moods, the predominance of derivatives of aggressive impulses are differentiated. There is fusion of the self and of the object representation within the ego and superego, calling forth attack from an extremely pathological, sadistic and idealized superego on a fused and highly devalued self. The capacity for sadness is absent because the object and its representation are devalued and united with the devalued representation of self. Jacobson confirms the predominance of oral-sadistic conflicts and an intense dependence on loved, hated and idealized objects, and proposes that the primary anxieties and conflicts in depression are the fear of abandonment of the object and of the consequences of the aggression directed at it.³⁰

Brenner,³¹ on the other hand, believes that there are two types of displeasure, a anxiety and depressive affect, which can result from situations such as loss of the object, loss of the object's love, castration or punishment. In the case of anxiety, the situation is only feared and in depressive affect, it is an event that has occurred. The position of this author is that what is important is to understand the nature of the formation of the subjacent commitment and conflict. For him, suffering or depressive affect are not necessarily loss of the object or aggression directed at the ego by means of identification, or synonymous with accepting that the predominance of these conflicts are from the oral phase, based on pre-oedipal traumas. He postulates that depressive affect plays the same role in the psychopathology that anxiety does, being an inevitable part of mental life, working like a trigger for defenses and conflicts, and may or may not be conscious in a given formation of commitment.³¹

Bleichmar²⁹ defines the essence of depressive disorders as a sensation of impotence and despair in ever realizing a desire on which the subject is intensely fixed. This sensation colors the entire self-depiction and the self sees itself as inferior, incapable, weak, impotent and threatened.

Assumptions about pathological narcissism are included among the attempts to systematize knowledge of the psychopathology of depressive states. In this case, a depressive state always appears whenever there is deception, either on the part of the ideal ego, direct heir to narcissism or from the ideal of the ego (idealized parental imago). The individual feels themselves in a permanent state of alarm in the face of the possibility of not corresponding to the demands originating from within or without themselves.^32,33

With respect of self-esteem, Pedder³⁴ reminds us that this is the sensation of the self being esteemed and valued by their internal objects, whether they are termed "critical agent", superego or parental imago. The expression refers to an internal object relation, the esteem that one part of the self has for another. For Marcus,²¹ the self-esteem system has a central role in vulnerability to depression, and the degree to which depression affects self-esteem does not just on the severity of the disease, but also on the structure of the premorbid personality.

More recently, other authors have been trying to differentiate two types of depression, basing themselves in part on the writings of Freud on the processes of oral incorporation and superego formation, and considering that it would not be fruitful to integrate these two mechanisms from such distinct phases of psychic development.³⁵ They postulate that there is one type of depression, called anaclitic , that is focused on interpersonal issues such as dependence, abandonment, sensations of loss and abandonment, and another, called introjective, derived from a punitive and cruel superego, focused on issued of self-criticism, concerns with personal value and feelings of guilt and failure.³⁵

Anaclitic, or dependent, depression is characterized by sentiments of loneliness and abandonment and by the search for someone who will fill the vacuum of the original mother.³³ For such an individual, who deeply desires caring and love, the separation from or loss of the object brings fear, apprehension and primitive defense mechanisms. Introjective, or self-critical, depression is characterized by feelings of worthlessness, inferiority, failure and guilt. The individual is constantly judging themselves in a cruel manner and has a chronic fear of external criticism or disapproval. They are demanding, competitive, seek approval and recognition and, generally, achieve good results, obtaining, however, little satisfaction.

It is interesting to observe that response to treatment is different for the two groups. The self-critical group responds better to psychodynamically oriented interventions than to brief interventions.³⁵ These individuals are at greater risk of serious suicide attempts, their feelings of guilt are satisfied by the illness, being able to deny themselves the right to improve and present the so-called negative therapeutic reaction.^33,36

CLINICAL VIGNETTE

Ana, 38 years old

Ana was referred for clinical and psychotherapeutic outpatients follow-up four months ago, after her third hospital admission due to attempted suicide. At that time she presented with altered weight and appetite, insomnia, despair, worthlessness, cunning affect, sad and irritable mood, the sensation of being lost in the world, alone, saying that, despite not being how it had been, thinking of killing herself, she could not see any other future for herself than dying. She said that she was incapable of thinking, adding that sometimes she would feel airy, as though anaesthetized, and sometimes a despair would come over her, an intense suffering that brought thoughts of death. She did indeed appear distant and incapable of making contact with her own feelings or talk about the circumstances of her life. In recent years she said she had been incapable of being with her family. She said that her conjugal relationship wore her out, that she couldn't stand the difficulties of caring for children aged 4, 9 and 16 and that her parents were intrusive and critical. She also saw herself as incapable of assuming her professional responsibilities.

The depressive symptoms had taken form after the birth of her youngest child, She had been going through a wearing period of higher education and physical disease which had caused her serious problems due to complications resulting from the use of corticoids, when she got pregnant, itself unplanned and with her marriage already in conflict. She tells how, at the time, with her children more grown up, she had intended to live her own life, get more satisfaction from relationships etc. Her puerpurium had been complicated, the baby had clinical problems that made feeding and sleeping difficult. She felt overloaded and incapable of dealing with the tasks of motherhood. She had tried a number of different pharmaceuticals to treat the depressive symptoms and had been hospitalized at services of known technical and academic prowess. At the time of presentation she was taking venlafaxine.

Her family, professional and social lives were all in total disorder, she was living apart from her family and was on leave from work. She had been living away from home for the previous 2 years, living with a female cousin and was involved in an extramarital relationship, which she considered to be her only good moments. Her hospital admissions coincided with this period. Her husband traveled for his job, her adolescent son remained at home trying to look after himself and the two younger children were being cared for by relatives.

Initially we combined a detailed evaluation, which was prolonged due to the chaotic characteristics of her family and support context. Precautions were necessary in order to establish resources in cases of risk and arrangements were made to ensure the treatment was maintained, including help to organize a limitation to her financial resources, which demanded the presence of a relative from outside of the primary group, but available. During this period, Ana showed herself to be determined to be treated, appearing to believe in the treatment proposal and, despite her difficulties, collaborated with the organization of the therapeutic contract. The medication was maintained in the belief that this was a suitable prescription, taking into account the previous attempts, focusing at this point of the treatment on the psychodynamic issues.

As treatment progressed, Ana began to bring up material relating to her interpersonal relations and life history, describing her mother as someone extremely invasive and her father as cold, distant and highly critical. Her aggressive sentiments with relation to her family members became evident, to their expectations of attention and care and her sense of being drained and uncomfortable with the demands of the maternal function and her recriminatory worries.

COMMENTS

Ana's depression already long-term and seriously prejudicial to her familiar, social and professional functioning, presented only limited improvement, characterizing a difficult to treat case. The presence of psychological factors influencing her progress suggested the psychodynamic approach.

Among the variety of different factors that were possibly involved in the case of Ana, some became more evident at the start of the process. Her inability to think, the result of a kidnap, was perhaps a defensive strategy to abolish the mental function, since the realization of her desire could not be achieved. The desire in this case may be only an ideal, an abstraction that remains in the place of an object. Her ego, identified with the absent object, became impoverished and empty. There is evidence of devaluation and impotence in the face of the unattainable. Perhaps a repetition of the unattainable desire for the love of her father, a figure she describes as cold and extremely critical.

Her aggressive sentiments, her hostility, her anger at everything and everyone are noteworthy and remind us why it is that many authors hold aggression to be an essential component of depressive cases — in this case perhaps innate, perhaps in response to a lost object, or both. Her thoughts of death represent the desire to kill her object. The sadism is here represented both in the aggression directed at the introjected object and in the impact that the suicidal attitudes have on her family members. Ana abandons relations with her object and feels lost in the world, as she put it. In fact she has expectations of attention and care and seeks a substitute for this in the figure of the lover. She recriminates herself for abandoning her children, but, more than anything else, perhaps she recriminates herself, questioned by her superego, for the intensity of her aggressive feelings, which make her feel guilty.

As she progresses, Ana still mentions themes of death, but less frequently. As the work progresses, she appears less cognitively prejudiced, more capable of self-observation, recovering parts of herself that had been inhibited defensively, and this appears to alleviate her. She has been speaking of how she misses her children, of how she does not feel capable of returning to her life and, as she puts it, face the blame of her parents and husband. She is better, although partially, with respect of her depressive symptoms, thinking that she should change her sessions to alternate days so that she can be with her children more often. She remains on the same antidepressive medication.

The referral of this patient for combined treatment appears to have resulted in a more all-embracing view of her disease. Although multiple factors that have not yet been understood may be involved in the psychopathology of this patient, the task continues to be the possibility of remaining alert to this amplitude of vectors, both within psychoanalytic theory and with respect of the concepts of clinical psychiatry.

CONCLUSIONS

With respect of psychotherapy and depression, it is worth repeating Freud's²⁵ warning that melancholy is not a homogenous group of conditions and that it probably involves more than one etiology, in order to then take advantage of psychoanalytic theory, amplifying our view of depressive states.

While biological concepts and pharmacological approaches to difficult-to-treat depression are essential, we must think about the disease in a more open manner, with a more individualized focus.¹⁹ Science is based upon our capacity to ask questions, including about science itself, and should be used as a means to widen — and not fence in — knowledge. This is a good principle for guiding our clinical practice in the face of the heterogenous group of patients with depression. It is possible that the benefits of eclecticism may be better demonstrated in the management of difficult cases, i.e. those that do not respond to the initial treatment strategy, when an ability to rethink a problem, change the conceptual system and find new means of tackling a problem can theoretically increase the probability of an effective result. Indeed, if the psychiatrist lacks the flexibility to change their theoretical perspective or, even, sufficient knowledge of the alternatives, a patient may be unnecessarily treated with an inappropriate method or prematurely labeled "refractive".⁹

Despite the limitations of our science, it is evident that psychoanalytic theory is rich in contributions to the theme, and that analysis-oriented psychotherapy can be extremely useful in dealing with cases of difficult-to-treat depression. The author believes that the patient, more than anything else, is the arbiter of what makes sense.

Acknowledgement

Thanks to Dr. Cláudio Laks Eizirik, for the support given.

REFERENCES

Received on August 27, 2004.

Revised on September 27, 2004.

Approved on November 3, 2004.

Final paper, Graduate Program in Analytic Psychotherapy, 2003.

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Publication Dates

• Publication in this collection
  14 Sept 2005
• Date of issue
  Dec 2004

History

• Reviewed
  27 Sept 2004
• Received
  27 Aug 2004
• Accepted
  03 Nov 2004