P s y c h o d y n a m i c Ps y c h o t h e r a p y a s

Tre a t m e n t f o r D e p re s s i o n i n
Adolescence
Nick Midgley, MSc, PsychD*, Simon Cregeen, MPsychPsych,
Carol Hughes, BA (Psych), Margaret Rustin, BA Hons

KEYWORDS
 Depression  Adolescence  Psychotherapy  Psychoanalytic  Psychodynamic
 IMPACT Study

KEY POINTS
 Encouraging indications from research studies are that short-term psychodynamic
psychotherapy (STPP) may be effective for the treatment of internalizing disorders and,
in particular, child and adolescent depression.
 Psychodynamic therapy may be the treatment of choice for depressed teenagers with
complex, chronic difficulties and comorbidities, whereby the emphasis is on supporting
the developmental process more broadly rather than focusing exclusively on a reduction
of symptoms.
 Attentiveness to unconscious phenomena is specific to psychodynamic psychotherapy, is
related to the theoretical importance attributed to these deep layers of the mind, and is
closely linked to the techniques used by the therapist.
 Both therapist and young person need to be wary of the omnipotent fantasy of the “total
cure” and be able to work toward a more realistic sense of a “good enough” ending.

Josie had just turned 15 when she began her psychotherapy. She was brought to
her first appointment by her father and sister, who stayed in the room with Josie
throughout the meeting. Once seated Josie was almost silent, except for saying
quietly “I don’t know how I got to be here.” Later in the session, once her family
had told the story of how Josie had become depressed and taken an overdose,
the therapist was able to draw her out on this. Josie said “I was a little girl and
then one day I was a teenager. I don’t know how I got to be here. It’s like I’m in
a faraway country. I am lost. I don’t know where to go or what to do.”

INTRODUCTION: DEPRESSION IN ADOLESCENCE

According to a report funded by the World Bank and the World Health Organization,1
depression is the leading cause of disability in the world, with over half of mental

Anna Freud Centre, 21 Maresfield Gardens, London NW3 2HX, UK

* Corresponding author.
E-mail address: [email protected]

Child Adolesc Psychiatric Clin N Am 22 (2013) 67–82

http://dx.doi.org/10.1016/j.chc.2012.08.004 childpsych.theclinics.com
1056-4993/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
68 Midgley et al

Key Abbreviations: ADOLESCENT DEPRESSION

CBT Cognitive-behavioral therapy
IMPACT Improving Mood with Psychoanalytic and Cognitive-Behavioural Therapy study
LTPP Long-term psychodynamic psychotherapy
NICE National Institute for Health and Clinical Excellence
STPP Short-term psychodynamic psychotherapy

health costs in Europe each year going toward the treatment of people suffering from
anxiety and depression. Among those suffering from clinical depression, more than
60% report that they first suffered from depression during their teenage years. The
outcomes for those who become depressed as adolescents are not encouraging,
with a high risk of a range of illnesses in later life, including increased rates of self
harm, suicide, and other mental and physical health problems, compared with other
adolescents.2,3 It is therefore vital that effective interventions are developed that not
only offer support when young people first experience depression but also help to
promote the kind of resilience that will prevent long-term mental health problems
from developing. Treatments such as cognitive-behavioral therapy (CBT) have
been shown to be effective, at least in the short term, for those with mild to moderate
depression. But the evidence for the long-term effectiveness of CBT, especially for
more severe depression, is mixed.4 In the authors’ view psychodynamic psycho-
therapy, when seen as part of a multidisciplinary intervention, has a significant contri-
bution to make as a treatment option for young people with depression.

PSYCHODYNAMIC PSYCHOTHERAPY AS A TREATMENT OPTION FOR DEPRESSION IN

ADOLESCENCE

Compared with some other therapies, psychodynamic treatment has lagged in devel-
oping a robust evidence base, but the pace of research is now accelerating.a In
a recent systematic review of the evidence base, Midgley and Kennedy5 identified
35 distinct research studies, including 9 randomized controlled trials, which evaluated
the effectiveness or efficacy of psychodynamic work with children and young people.
The review suggested that there is a small, but growing, body of evidence in support of
the effectiveness of child and adolescent psychodynamic psychotherapy, with espe-
cially encouraging indications that short-term psychodynamic psychotherapy (STPP)
may be effective for the treatment of internalizing disorders6,7 and, in particular, child
and adolescent depression.8–10 The study by Trowell and colleagues10,11 is important
because it demonstrated that although young people engaged in short-term psycho-
dynamic psychotherapy showed slower initial rates of improvement than those
receiving systemic family therapy, by the end of treatment both therapies were effec-
tive. Moreover, the gains made by those young people receiving psychodynamic
therapy were maintained and even increased during a 1-year follow-up period.
The evidence for both long-term psychodynamic psychotherapy and STPP in
the treatment of adults is more substantial, with several studies focusing on the
psychodynamic treatment of depression.12–15 Clinical practice guidelines for the
treatment of depression in adults identified STPP as demonstrating effectiveness

a
The term “psychodynamic psychotherapy” is used here as a generic term for a range of treatments
informed by psychoanalytic principles. In the United Kingdom, child and adolescent psychotherapists
are seen as providing psychoanalytic therapy; they are trained to provide both intensive psychoana-
lytic therapy and a range of other work, including assessment, brief interventions, work with parents,
supervision, and consultation to other professionals.
 Psychodynamic Treatment of Adolescent Depression 69

comparable with that of other psychological therapies and medication.16 There are
some indications that for major depression, combined treatment (psychodynamic
and medication) is more effective than either one alone.17 Moreover, a recent
meta-analysis suggested that there was clear evidence for effectiveness, superiority
over controls, and comparability with other therapies in follow-up, but marginal infe-
riority in some measures in immediate follow-up.18 The investigators concluded that
more and higher-quality studies of STPP were needed if it is to meet criteria for an
empirically supported treatment; this holds equally true for STPP with both adults
and children.
Improving Mood with Psychoanalytic and Cognitive-Behavioural Therapy Study
As part of developing such an evidence base, the authors of this article are members
of the STPP steering group for a large-scale clinical trial currently under way in the
United Kingdom, the Improving Mood with Psychoanalytic and Cognitive-
Behavioural Therapy Study (IMPACT) (Midgley N, Cregeen S, Hughes C, et al.
Short-term psychoanalytic psychotherapy (STPP) for adolescents with moderate to
severe depression. A treatment manual. 2010. Version 1. Submitted for publication).4
This randomized controlled trial aims to investigate the role of psychological therapies
in reducing relapse for adolescents with moderate to severe depression. The findings
of this study, the largest clinical trial to examine psychodynamic work with young
people ever performed, are likely to go a long way toward establishing more confi-
dently whether short-term psychodynamic therapy can be considered an evidence-
based treatment for adolescent depression. In the meantime, this article sets out
a psychodynamic approach to both understanding and treating adolescent depres-
sion. This approach is based largely on the manual for STPP for adolescents (11–17
years old) with moderate to severe depression, developed for the IMPACT study
(Midgley N, Cregeen S, Hughes C, et al. Short-term psychoanalytic psychotherapy
(STPP) for adolescents with moderate to severe depression. A treatment manual.
2010. Version 1. Submitted for publication). Although this article makes reference to
longer-term psychodynamic treatments, the 28-session model (plus 7 sessions of
parent/carer work) used in the IMPACT study informs the psychodynamic approach
presented here.

A PSYCHOANALYTIC UNDERSTANDING OF THE DEVELOPMENT OF DEPRESSION IN

ADOLESCENCE

Josie lives with her birth parents, Mr and Mrs B, and her younger brother Kenny
(5 years old). Josie has an older sister Rebecca (19) who recently became
engaged and moved in with her fiancé. Mrs B has long-standing mental health
difficulties which have affected her capacity to care for her children. Rebecca
had been a major caregiver for her younger siblings, a role that Josie was ex-
pected to take on for her brother, Kenny, when her older sister started work
and became engaged. Josie has a difficult relationship with her mother, by
whom she is both verbally and emotionally attacked with threats and criticism.
Josie is an intelligent young woman, who was an academic high achiever. It
seemed that her sister’s engagement precipitated the depressive breakdown.
Until that point Rebecca had been a protective factor in Josie’s life. Alongside
this, the developmental challenges of the move into puberty and adolescence
proved too much for Josie. She attempted to deal with these challenges through
a premature (asexual) romantic relationship with a boy from school, which con-
tained within it a fantasy of oneness (denying the need to develop her own sepa-
rate identity). With the loss of this relationship (and the defensive fantasy) as well
as the “loss” of her sister, Josie collapsed into depression, feeling hopeless,
70 Midgley et al

defeated, and unable to face the future. It was at this point that she tried to take
her own life.

TWO PSYCHOANALYTIC FORMULATIONS OF DEPRESSION

Rooted in the work of Freud,19 Abraham,20 and Klein,21 early psychoanalysts offered
an understanding of depression as related to loss, guilt and a sense of responsibility
for having attacked and damaged the ambivalently loved or lost object. “Object” is
a term in psychoanalysis that refers both to significant external figures (particularly
parental), and to internal representations of those figures. These internal representa-
tions are developed on the basis of lived experiences (especially early in life) with
carers and parents, and through the individual’s own emotional attitude toward, and
toleration of, such lived experiences. Internal objects both reflect directly the reality
of external figures and are significantly shaped by the individual’s own projective
and introjective processes. The world of internal objects is a dynamic conception
and, hence, forever in movement and subject to change. The outcome of such guilt
was understood to be a sense of the self as worthless, bad, and potentially destruc-
tive, and the typical depressive symptoms, such as self-criticism and the wish to die,
were understood as the behavioral manifestation of these underlying dynamics.
Since the 1970s there has been an increasing interest among psychoanalysts in
issues related to narcissistic vulnerability and “narcissistic depression.”22 Kernberg,23
for example, writes of a certain type of depression “which has more of the quality of
impotent rage, or of helplessness-hopelessness in connection with the breakdown of
an idealized self-concept.” A chronic sense of emptiness, often a result of failures in
empathic parenting, was described by Kohut24 as the core depressive feature in
some narcissistic patients. Alongside the emphasis on guilt owing to a sense of having
damaged the object, in this type of depression, according to Kohut, there is a greater
focus on the subject’s own sense of narcissistic fragility, with subsequent feelings of
shame and humiliation. The empirical research literature provides some support for
the idea that these 2 formulations capture different subtypes of depression, at least
for adults, each one describing a group of depressed individuals with differing presen-
tations and differing vulnerabilities, and with potentially differing responses to therapy.25
Depression Formulated as a Developmental Crisis
For young people, any understanding of depressive dynamics has to be put in the
context of normal developmental processes.26 Psychoanalysts writing about adoles-
cence have stressed its importance as the time during which the young person
consolidates his or her own independent identity. Whereas investigators such as Erik-
son27 and Blos28 have emphasized the achievement of autonomy, others such as the
Laufers29 have focused on the impact of developing a sexual body. The emotional-
developmental tasks of adolescence inevitably involve the reemergence of Oedipal
anxieties, feelings, and conflicts that were first met and wrestled with in toddlerhood.21
For many adolescents the active mobilization of Oedipal dynamics can be a startling
and confusing experience. Adolescence presents an opportunity to rework Oedipal
matters (now in the context of a sexually maturing body) and eventually establish
a secure young adult sexual and relational identity. However, the task can also be
felt to be too much—even threatening—and lead to developmental retreat, a turning
away, or manic and promiscuous activity.30 Vulnerable youngsters with limited, inflex-
ible, or primitive defenses and an insecurely established ego (sense of self) often find
adolescent developmental tasks overwhelming. In this sense, adolescent depression
can be viewed as a developmental crisis. In turn, the hopeless withdrawal that is
 Psychodynamic Treatment of Adolescent Depression 71

characteristic of depression means that the young person cannot engage in the activ-
ities and relationships of his or her peers, so that a vicious circle may be set in motion.
The challenges of adolescence are more pronounced for those young people who
have had significant histories of difficulties in the parent-infant or early parent-child
relationships.31 It seems that if these difficulties involved closeness or enmeshment,
then youngsters may demonstrate considerable difficulties in individuating in adoles-
cence. By contrast, if the early relationships were marked by distance, quite often
adolescents seem to hurtle into adolescent relationships, sometimes into promis-
cuous sexuality and risk-taking behavior such as drug or alcohol abuse (Hughes
and colleagues, unpublished data, 2012). These young people may be seeking
emotional closeness, not necessarily sexual gratification, although the two are often
conflated in a confused way. The expectations of these relationships are unrealistic,
with a wish for “oneness” and a fantasy of all emotional needs being met. Such expec-
tations are fragile and often result in relationship breakdown, which triggers further
loss and a sense of abandonment and evokes depressive symptoms. In Josie’s
case, at the age of 14 she developed an intense relationship with a boy who lived
nearby, in which the two of them “felt like we were one person, we always knew
what the other one was thinking.” The breakup of this relationship clearly precipitated
her depression, although it was only with a second loss (when her sister left the family
home) that Josie broke down more overtly. In the authors’ clinical experience, many
adolescent suicide attempts are in the context of such losses. For such young people,
it may be that the move into an adolescent state of mind is experienced as the total
loss of a psychic “home.” For others, it may lead to a despairing realization of the
fragility of their link with good and sustaining internal and external objects.
Such a fragile sense of a “core self” has been noted as a common feature of
depressed adolescents in the clinical literature.32 Rhode33 speaks of depressed chil-
dren and adolescents with profound annihilation anxieties, who in treatment
expressed the belief that they were living in a “black hole”: that they did not feel
they existed, or had the right to exist.33 For example, once Josie’s mood lifted she
described how being depressed had felt as if she were liquid: “I felt sorta like water,
liquid, just draining away. In fact, I wanted to soak away, just not to be anymore.
Now I am not depressed I feel kind of solid. The wind can blow, I am solid—I am here.”

Depression Formulated as “Conflicted Anger”

Clinical experience suggests that many depressed youngsters also present with what
Busch and colleagues34 have called conflicted anger. Because such anger is felt to be
unacceptable, it may be split off and denied and/or consequently break through in
aggressive outbursts, which can leave them and their families distressed. Josie, for
example, would on rare occasions have sudden outbursts of anger, during which
she would smash some of her favorite possessions in her room, in a way that left
her parents feeling that this behavior had “appeared out of nowhere.” Afterward she
would be left feeling guilty and confused, bereft at having damaged objects that she
cared about and unable to explain why she had been so angry.
Integrated aggression, in the form of appropriate assertiveness and testing out of
intellectual strength and personal passions in the service of the development of the
personality, is rare among depressed teenagers. For some, the parent is perceived
as being too fragile to survive and so is protected by an internalization of the anger,
turning it onto the adolescent self. This process can take the form of self hatred and
reproach as well as physical attacks of the self through cutting or self harm. Some
depressed youngsters feel, in an unrealistic, omnipotent way, that their anger and
aggression is too dangerous and that is has somehow caused their parents’ mental
72 Midgley et al

illness or fragility. When this is the case it has important implications for treatment, as
at some stage it is likely that this disavowed anger and aggression is likely to reappear
in the treatment, focused on the relationship with the therapist (the transference).
When it does so, there is a high risk of treatment breakdown or of acting out behavior,
unless the anger can be addressed directly and the young person made to feel safe
enough to explore in the context of a containing relationship with the therapist. As
Josie put it quite late on in her therapy (after several difficult sessions, during which
she had been very challenging to her therapist): “at times I really hated you; but I
always knew that you were on my side.”

INDICATIONS FOR REFERRAL FOR PSYCHODYNAMIC PSYCHOTHERAPY FOR

ADOLESCENT DEPRESSION

The child psychiatrist who met Josie and her parents immediately after she had
taken an overdose concluded that Josie was not at immediate risk of further
self harm, but he did think that Josie needed further help. He discussed medica-
tion but, based on his assessment, the psychiatrist considered that they should
“watch and wait” before deciding whether to go ahead with a course of fluoxetine.
Instead he suggested that Josie might be helped by CBT. However, Josie’s
parents said to the psychiatrist that Josie had already been offered CBT at school
a few months earlier, and hadn’t been able to manage the cognitive tasks that
were set for her. Josie agreed that she didn’t want to try this again. In speaking
to Josie alone, the psychiatrist wondered whether she might benefit from a less
structured setting than CBT, where she could use her interest in drawing to
express what she was feeling. He suggested that Josie meet with a child and
adolescent psychotherapist in the team instead, and Josie agreed to this. Soon
after, an assessment for psychodynamic therapy was begun.

In the United Kingdom, the present guidance provided by the National Institute for
Health and Clinical Excellence suggests a stepped-care approach to the treatment of
child and adolescent depression, with time-limited psychodynamic psychotherapy (up
to 30 sessions) considered only for those patients not responsive to standard psycho-
educational support and family work, or to brief cognitive-behavioral input.35 This
guidance also suggests that some types of antidepressant medication should be
considered alongside psychotherapy, especially for more severe depression if clini-
cally appropriate. The guidance also stresses that the “best available evidence”
should be considered alongside the professional judgment of the clinician, taking
into account the preferences of the service user. So in Josie’s case, a referral to
psychodynamic therapy took place directly following her initial assessment with a child
psychiatrist.
There is not yet enough empirical research to say with confidence which depressed
young people are most likely to benefit from psychodynamic interventions, although
the IMPACT study4 described earlier should provide some data on this matter.
However, clinical experience suggests that psychodynamic therapy is often the treat-
ment of choice for depressed teenagers with complex, chronic difficulties and comor-
bidities, whereby the emphasis may be on supporting the developmental process
more broadly rather than focusing exclusively on a reduction of symptoms.36
Even in time-limited (and focused) treatment, psychodynamic psychotherapists
address the whole personality of the patient and the whole nexus of object relation-
ships, both internalized and current. Using the terms of Luyten and Blatt,37 the treat-
ment is person-centered, not disorder-centered. As most depressed young people
referred to child and adolescent mental health services have a range of other difficul-
ties and diagnoses (eg, anxiety, compromised attachment, obsessional symptoms, or
 Psychodynamic Treatment of Adolescent Depression 73

conduct disorders), the wide perspective of psychodynamic therapy addresses both

the depressive phenomena and other significant personality factors or disorders that
are likely to be interacting with the depression. The treatment may be particularly suit-
able when there has been a long history of difficulties and where there are intergener-
ational continuities (eg, a history of parental depression) and entanglements.
Dependence on a highly rigid defensive system would be a contraindication for treat-
ment. Psychodynamic therapy is also not recommended when there are child protec-
tion issues that have not yet been adequately addressed.

DEVELOPING A PSYCHOANALYTIC FORMULATION TO GUIDE TREATMENT

The initial meetings between Josie and her psychotherapist established that she
was a bright, high-achieving girl, whose previously “warm” personality had
changed about 6 months before her referral. At the time of the referral, Josie
met the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic
criteria for Major Depression (moderate). Although she was no longer actively
suicidal at the time of the therapy assessment, she continued to be depressed,
had thoughts about self harm, and was not attending school. She was said by
her parents to have gone from being a girl with a full life with plans for her future
to lying on her bed, tearful and apathetic.
As well as assessing her symptoms, the therapist was interested to get a picture
of Josie’s “internal world” and to develop some initial hypotheses about what had
gone wrong with Josie’s development. During one of the initial meetings, Josie
described throwing herself into an intense asexual romantic relationship with
a boy of her age. “We were like one person. We didn’t even need to say
anything—we just knew what we each felt or thought.” When this relationship
broke down she tipped into severe depression and tried to take her life through
an overdose. The therapist understood this as a collapse in the face of the unbear-
able loss she experienced as she faced separation and individuation. Paradoxi-
cally she tried to “find herself” through psychic merger with this boy, and
experienced the subsequent loss as a loss of her own sense of self. Josie tried
to defend herself against unwanted feelings in several ways. She located the
need for care in her brother (compulsive caregiving); she avoided family tensions
by withdrawing and thereby disowning her own anger (until it occasionally broke
out in unmanageable ways); and finally, all capacity for separation and having
one’s own voice was located in other people. This left her emptied of parts of
herself and ego capacities, and she collapsed emotionally. She retreated from
a seemingly threatening external world and stopped going to school. As such
a range of psychosomatic illnesses provided Josie with a form of escapism, as
she could take to her bed and be left “undisturbed” by the rest of the family. It
seemed that Josie was afraid that her aggression would damage an already fragile
object (a parent with a mental illness), and so she turned it on herself.

A “case formulation”, such as the (abbreviated) one given here, is an important

element in framing psychoanalytic work, especially short-term or time-limited psycho-
therapy. In addition to data gathered from the initial meetings with the young person,
this assessment draws on family information derived from the parent worker, any initial
assessment meetings with the other child and adolescent mental health service clini-
cians, plus demographic and psychiatric data made available to the clinician from
formal assessments that may be used. As well as the standard information about
the referral, developmental history, and a statement regarding protective and risk
factors, a psychodynamic formulation would include a statement outlining the
therapist’s initial hypotheses about central psychodynamic features and how they
maintain the young person’s depression and/or make the young person vulnerable
74 Midgley et al

to depressive moods, within a dynamic developmental context. Busch and col-

leagues34 present an integrated psychodynamic formulation for depression in adults
that is based around an assessment of 5 key areas, which the authors have found
helpful. This formulation is presented in Box 1 (with some adaptations to take into
account the differences between adults and adolescents).
Without focusing treatment too narrowly on any one particular element of the pre-
senting problems, a preliminary formulation helps to define the field of attention for
the therapeutic work by concentrating on underlying psychodynamic issues. This
approach may be especially important in STPP, where it is essential that treatment
focuses on identified dynamics, defenses, and issues that have been spoken about
in a meaningful way with the adolescent.38

THE AIMS OF PSYCHODYNAMIC TREATMENT FOR DEPRESSED ADOLESCENTS

At first Josie couldn’t manage without her father or a friend in the therapy room,
feeling she didn’t know what she felt or how to describe what was happening to
her. Only later in the therapy did she feel able to come into the room on her own.
Over time she and her therapist came to understand how the onset of adoles-
cence took her unawares, despite her physical maturation. She was not emotion-
ally ready to be a teenager. Now that she was in therapy, she spoke of wanting to
find “her old self” again, and to discover ways that would help her cope if she ever
felt so depressed that she wanted to die again. She began to see that her depres-
sion was a “marker” that things weren’t right in how she felt about herself as
a person, and she wanted to try and change that “before it is too late.”

Especially when working with time-limited psychodynamic psychotherapy, the clini-

cian needs to bear in mind Winnicott’s39 point, that one may not be asking “how much

Box 1
Five elements commonly found in a psychodynamic formulation of depression

1. Narcissistic vulnerability; that is, an insecure sense of a separate self and a heightened
sensitivity to perceived or actual losses and rejections leading to a lowering of self esteem,
which in turn triggers depressive affects, existential angst, and rage in response to
narcissistic injury.
2. Conflicted anger; that is, anger, blame, and envy directed toward others leads to disruptions
in interpersonal relationships, confusion over responsibility and to self-directed anger and
subsequent depressive affects.
3. Severe superego, experience of guilt and shame; that is, feelings and wishes seen as bad and/
or wrong, with doubt about whether the young person’s love outweighs aggression, leads
to negative self-perceptions and self-criticism, and in some cases confusion between reality
and fantasy.
4. Idealized and devalued expectations of self/others; that is, high self-expectations and/or
idealization of others, often switching to sudden de-idealization and devaluation, may lead
to disappointment, anger at self and others, and subsequent lowering of self esteem.
5. Characteristic means of defending against painful affects; that is, use of defenses typical to
depression such as denial, projection, passive aggression, and reaction formations leading
to increased depression because either the world is seen as hostile or the self is attacked.
Splitting, as a characteristic defense against aggression, blocks assertive/aggressive efforts
from integration in the service of personality development.

Data from Busch F, Rudden M, Shapiro T, editors. Psychodynamic treatment of depression.

Washington, DC: American Psychiatric Publishing; 2004.
 Psychodynamic Treatment of Adolescent Depression 75

can one do?”, but rather “what is the least that needs to be done?” Both therapist and
young person need to be wary of the omnipotent fantasy of the “total cure,” and be
able to work toward a more realistic sense of a “good enough” ending.40
When the main features of the central depression dynamic are addressed success-
fully, outcomes of the treatment may include the following (see Busch and
colleagues34):
 The young person can manage depressive feelings and aggression better
 The young person is less prone to guilt and self devaluation
 The young person can make more realistic assessments of his or her own
behavior and motivation, and that of others
 The young person has a better developed sense of agency
 The young person has a better capacity to be thoughtful rather than to “act out”
 The young person has a more realistic view of what he or she is responsible for,
and of the difference between fantasy and reality
 The young person is less vulnerable to depression in the face of loss, disappoint-
ment, and criticism
In Josie’s case, the therapist and Josie’s family were able to agree that they hoped
to see her not only wanting to live and better able to attend school, but to recognize
that this would depend on her being able to manage depressive feelings better and
building up a greater resilience. The therapist had a hypothesis that helping Josie to
become more aware of her aggressive feelings would be an important focus, but at
the time of starting therapy this was not explicitly shared by the therapist, as it seemed
important to allow Josie to begin treatment and find things out for herself.

THE TECHNIQUE OF PSYCHODYNAMIC PSYCHOTHERAPY WITH DEPRESSED YOUNG

PEOPLE

Much of Josie’s early therapy was conducted in silence. She chose to draw, her
drawings being dark and forbidding. There were disturbing scenes of death:
decaying cadavers, bloody skulls transfixed by daggers, and wounded bodies
with bleeding gashes. Josie seemed absorbed in these images as well as in the
process of image making. She seemed to “attack” the paper with pencil and black
pens. Her therapist found herself watching and thinking intently, mirroring the
intensity of Josie’s preoccupation.
The ending of sessions was difficult. Josie found it hard to leave, often weeping,
saying she couldn’t face going. The therapist found herself terribly afraid that
Josie would die before they met again, so she found herself extending the length
of sessions—but they were never long enough. With the help of supervision, the
therapist realized that Josie was not actively suicidal, but that she was allowing the
therapist to get a sense of what Bion called a “nameless dread”41 that Josie,
herself, was protecting against through “projective identification.”41–43 Once the
therapist was aware of this it was possible to manage her own anxiety, help Josie
to feel that her anxieties could be thought about, and so end the sessions on time
rather than “acting out in the countertransference” by prolonging the
sessions.44,45 (Supervision within psychodynamic psychotherapy has a vital role
to play, dealing as we are, with unconscious processes, transference and coun-
tertransference phenomena. Consequently, within the IMPACT study STPP
psychotherapists are required to attend regular supervision. The authors have
manualized the process of psychotherapy supervision as a subsection of the
STPP IMPACT manual. [Midgley N, Cregeen S, Hughes C, et al. Short-term
psychoanalytic psychotherapy (STPP) for adolescents with moderate to severe
depression. A treatment manual. 2010. Version 1. Submitted for publication.])
76 Midgley et al

Josie’s transference feelings toward her therapist were especially difficult in

sessions before a break or in the whole period leading up to the end of therapy.
By working through the ups and downs of her relationship with her therapist, Josie
became better able to manage her anxieties about separation. As treatment
entered the “middle phase,” the therapist noticed a shift both in Josie and in
her own countertransference. Although the actions seemed the same, the
emotional tone changed from terror to anger. The therapist judged that Josie’s
internal object was now more robust and could withstand Josie’s anger. She
drew the rage into the transference by helping Josie to voice the rarely expressed
feelings of anger and irritation toward her therapist. In doing so the therapist was
allowing Josie an experience of being angry with the therapist and the therapist
surviving. The therapist did not retaliate but remained a thinking person who could
validate, process, and understand Josie’s feelings. At this point Josie herself
suddenly demanded to return to school, as if she had re-discovered a sense of
assertion, a positive aggression, which allowed her to feel more potent and less
terrified of the consequences of her anger. “I want to get on with my life,” she
told her therapist, “not be at the beck and call of my family.”

Establishing a Psychodynamic Frame for the Therapy

The techniques of psychodynamic psychotherapy are primarily based on close and
detailed observation of the relationship the young person makes with the therapist,
and the theoretical assumption that the young person’s free play, drawings, and
conversation can be seen as equivalent to “free association.” A suitable consulting
room is required. Sessions take place in this same room and at the same time each
week for ongoing therapy. The therapist introduces the context to the young person
as one for understanding feelings and difficulties in his or her life. Undirected play,
art activities, and talking are the fundamental sources of the relevant “clinical facts.”46
The therapist’s stance is nonjudgmental and enquiring, and conveys the value of
words. The aim is to put into words the therapist’s understanding of what the young
person communicates through play, behavior, and verbal expression; this will include
conscious and unconscious thoughts and feelings. Ritvo36 proposes that the tech-
niques used in psychodynamic treatment lie on a continuum, “from those that are
most supportive of the patient’s strengths and current adaptations to those which
lead to expression of deeper feelings and bring the patient’s inner conflicts and issues
into the discussion.”36(p15) In her actions and words, the therapist attempts to convey
openness to all forms of psychic experience (current preoccupations, memories,
daydreams, fantasies, and dreams) but will be attuned specifically to evidence of
unconscious fantasies that underlie the young person’s relationship to self and others.
This attentiveness to unconscious phenomena is specific to psychodynamic psycho-
therapy, is related to the theoretical importance attributed to these deep layers of the
mind, and is closely linked to the techniques used by the therapist.
These principles underlie the focus on the transference relationship made to the
therapist, that is, the relationship made not in response to “real” aspects of the ther-
apist’s person and behavior, but arising from characteristics of the figures of the child
or young person’s internal world. These aspects are then believed to be present in the
therapist, as a consequence of the externalization of the young person’s picture of the
world. Systematic observation of these transference elements allows for clarification
of the young person’s fundamental assumptions about the external world. The anxi-
eties that underlie these beliefs can be analyzed and discussed, thus enabling the
young person to begin to differentiate psychic from external reality. As a result, the
adolescent may become more able to test out reality, and establish a fruitful relation-
ship with it. Such an idea bears some similarity to Bowlby’s concept of “internal
 Psychodynamic Treatment of Adolescent Depression 77

working models” of attachment,47–49 based on early experiences with our primary

caregivers, but which may prove maladaptive in a new environment. Being able to
develop new representations and expectations of others is an important part of ther-
apeutic change, but is a slow process, requiring testing and retesting in the “here and
now” of the therapeutic relationship.

Working with the Transference and the Countertransference

A central source of information to the therapist in expanding his or her understanding
are the emotional responses evoked in him or her by the young person. These
responses are broadly referred to as countertransference phenomena.47 Such
phenomena can include personal factors that intrude and distort the therapist’s
capacity for objective understanding, but also many responses arising from primitive
nonverbal forms of communication, projective identifications, which the therapist
becomes aware of. These are similar to the ways in which infants can communicate
with their caretakers before the development of language, and depend on emotional
availability and space for “reverie” in the therapist.41 These primitive modes of rela-
tionship can be used to control anxiety by ridding oneself of it and pushing it outside
rather than using it for communicative purposes. The distinction between benign
(communicative) and malign (destructive, eg, to cause confusion) forms of projection
is vital in clinical work. At times, for example, the anxiety that Josie’s therapist felt
about her safety was an important way that she could become alert to fragile states
of mind that Josie herself was denying. At other times, in a more destructive way,
the therapist would be left feeling so stupid and worthless at the end of a meeting
with Josie that she just “couldn’t think,” and in those cases supervision became vital
in helping her to see what painful feelings Josie herself was defending herself against
by means of such malign projections.
With all adolescents, most particularly those with environmentally compromised
early experiences, there is a need for the therapist to be in a state of mind characterized
by availability to the reception of projected contents (anxieties, affects, uncertainties) of
the adolescent’s mind. These contents are often of a primitive nature and are not always
known to the adolescents themselves. The patient’s experience of the therapist
receiving, holding in mind, and thinking about this projected material is a central feature
of the work. Bion50 describes how the placement and residence of toxic, primitive states
of mind in the therapist’s mind can lead to their detoxification. Previously unthinkable
anxieties and emotions can then become thinkable, and in due course “returned” to
the patient. Patients thereby gain ownership of a previously disowned part of them-
selves, and are strengthened by identification with an object experienced in this way.

PSYCHODYNAMIC TREATMENT IN A MULTIMODAL TREATMENT PLAN

Josie’s parents (Michelle and David) were offered a space to meet a “parent
worker” separately from Josie’s meetings with her therapist. Concerns about
the emotional environment in the family and Michelle’s own mental health, and
consequent multiagency involvement, helped gather and heighten the parents’
awareness of the imperative for them to engage in some work themselves. Michel-
le’s initial wariness, fear, and unfamiliarity with emotions being “thinkable about”
and put into words, soon gave way to some relief that this was possible, given the
right relational conditions. This process was an extremely painful one, as it led to
realizations of how, as a parent to Josie, she had dealt with her own childhood
experiences of being subject to parental cruelty and abandonment by behaving
in the same way toward her daughter. Through this, Josie had been left as the
one to feel helpless, criticized, despairing, and emotionally unplaced.
78 Midgley et al

David attended the parent work sessions less frequently to begin with, but
thanks to the clinician’s persistence, David and Michelle eventually began
attending parent work sessions together. The clinician was able to begin to help
them think, as a parental couple, about Josie, and to see how David’s fear of
his own aggression was part of the reason why he was unable to protect his chil-
dren adequately against Michelle’s explosive rages. This joint work was an oppor-
tunity to strengthen the positive aspects of their relationship. The parents were
also helped to see how their own painful, early experiences had made it more diffi-
cult for them to bring Josie up without exposing her to similar experiences,
despite their active wish to avoid this. Although painful for them, this awareness
was an important step in allowing the parents to do things differently, in the
way they had always hoped.
Importance of a Multidisciplinary Team
Psychodynamic treatment with severely depressed adolescents needs to be consid-
ered in relation to the various contexts of the young people’s lives, and within a multi-
disciplinary team framework. This notion reflects the fact that adolescent depression
is in most cases multiply determined,51 and as such needs to be treated in an inte-
grated way. We need no longer see genetics and environmental factors, physiology,
and psychology as “either/or,” but can see the “both/and” in the complex interplay
of these factors. Goodyer,52 for example, points to the complexity of brain, hormonal,
and family factors, and life events, which interact in adolescent depression. The
psychotherapist and/or parent worker requires alertness to the need, at times, for
active communication and liaison with other significant individuals and agencies in
the adolescent’s life. This liaison may include external agencies such as school/
college, youth and social services, and mental health colleagues, most particularly
child and adolescent psychiatrists (if the therapist is not one him or herself), especially
when there are issues about risk and a possible need for medication or hospitalization.

Parent Work
Therapeutic work with parents or carers offered concurrently and in parallel with an
adolescent’s psychodynamic psychotherapy (by different clinicians) is a well-
established practice in the work of most psychodynamic child and adolescent thera-
pists in the United Kingdom,53–55 and there is some evidence that psychodynamic
therapy is more effective when offered alongside parent work.5 In relation to their
son’s or daughter’s depressive difficulties, parents may be struggling in several
ways: for instance, under the pressures of living with them (“I can’t bear it”), under
the pressure of parental guilt (“is this because of me?”) or fear (“what might they
do?”), or under the pressure of identification (“I was like this at their age” or “I am still
like this at 40”) and despair (“nothing has helped”). In addition to engaging the parents
in the treatment process, the therapeutic relationship with the parent worker aims to
help contain parental anxieties, and gives space to think about their relationship to
their son or daughter. An associated task is to help the parents create space in their
minds to re-imagine their child in fresh and previously unknown ways, to foster their
capacity for reflective functioning.56
As a model of change, if parental anxieties are emotionally contained, they are better
placed to think about their experience as a parent, which includes emotions and anxi-
eties aroused within them by their depressed son or daughter. Parent work can enable
the parents to think anew, or more freely, about adolescent development and how to
support this. Being less anxiously invaded by the adolescent’s depression and every-
thing associated with this, parents are more able to be in touch with their son’s or daugh-
ter’s distress and struggles, and better able to act effectively and in a considered way.
 Psychodynamic Treatment of Adolescent Depression 79

LOOKING TO THE FUTURE IN THE TREATMENT OF DEPRESSION IN ADOLESCENTS

Josie made good use of therapy, and by the end of the 28 sessions of therapy she
no longer met diagnostic criteria for depression. Her scores on the Mood and
Feelings Questionnaire57 had changed from 41 (well above the clinical cutoff
point) to 26 (just below it). She was more optimistic about life and had plans for
the future.
Josie seemed relieved to find containment in her relationship with her thera-
pist—someone who could reflect, make sense of nonverbal communication,
and really hear and validate her emotional experiences. As her mood improved
she found her own voice and became able to come to therapy alone. Toward
the end of therapy Josie started to wear bright and then later feminine clothes,
which suggested the beginning of adopting a more sexual feminine identity.
She developed deeper same-sex friendships, although she still expressed fear
about intimate relationships and a fear of abandonment. A similar fear was also
expressed in her relationship with her therapist during the ending period of treat-
ment. During the last phase of therapy, Josie was able to see the effect of her
mother’s past on her mother. As she did so she gained some emotional distance
(“it’s about her life, not about me”) and individuation began. She also started to
see school as a possible place for her development and future, although she
needed a lot of support from the adults around her to return, and when treatment
ended her school attendance was still erratic.
For Josie’s parents, Michelle and David, the parent work enabled some
emotional containment of their pain, and some differentiation of their own needs
from those of Josie and her siblings. This process led to a lessening of their
propensity to project unbearable anxieties, needs, and conflicts onto their chil-
dren, and a greater capacity to support Josie with her own development.

Future Directions for Research on the Psychodynamic Treatment of Depression in

Adolescence
As the authors have tried to illustrate in this article, psychodynamic psychotherapy can
be a powerful intervention for depressed young people, especially those for whom
depression is a marker of broader difficulties in negotiating the adolescent process.
Although outcomes research in child and adolescent psychodynamic psychotherapy
is still in its infancy, there is a growing body of empirical evidence to show the effec-
tiveness of such an approach,5 and there are several ongoing studies that also aim to
throw more light on the elements of psychodynamic therapy with adolescents that
may promote change (eg, Slonim and colleagues58).
The work by Blatt and colleagues25,37 on adult depression is important because it
not only begins to provide empirical support for certain subtypes of depression related
to key psychodynamic features, it also relates these to therapeutic mechanisms that
may help us as clinicians to know what kind of help is needed by different people with
different kinds of psychological vulnerability to depression. Within the IMPACT study,
psychodynamic patterns specific to adolescents suffering from depression will be
systematically investigated to deepen our understanding of adolescent depression
itself, and increase our understanding of how psychodynamic treatment can be
most effective. The authors plan to use the Adolescent Psychotherapy Q-Set,59 for
example, to investigate the patterns of therapeutic interaction that emerge in different
treatments, so that one can begin to relate certain psychodynamic patterns with ther-
apeutic processes.
There is still a great deal to learn about adolescent depression, and much that can
be learned about what are the most effective interventions to promote long-term
recovery. We need to understand in more complex terms the multifaceted nature
80 Midgley et al

of adolescent depression, so as to unravel how those complex dynamics interact

with particular therapeutic interactions and techniques. It is anticipated that the
ongoing IMPACT study4 will provide further opportunity to empirically investigate
the mechanisms of change in psychodynamic psychotherapy with depressed
adolescents, as well as an opportunity to investigate the experience of young
people and their families receiving psychodynamic therapy (Midgley N, Target M.
IMPACT: my experience—overcoming depression: Young peoples’ experience of
psychotherapy. 2011. Submitted for publication). Such studies will help us to
develop a greater understanding of how psychodynamic therapy can help young
people like Josie, and make a real contribution to the emotional well-being of
depressed adolescents.

REFERENCES

1. World Health Organization. World health report. Geneva (Switzerland): World

Health Organization; 2000.
2. Rudolph K, Klein D. Exploring depressive personality traits in youth: origins,
correlates and developmental consequences. Dev Psychopathol 2009;21:
1155–80.
3. Jonsson U, Bohman H, von Knorring L, et al. Mental health outcome of long-term
and episodic adolescent depression: 15-year follow-up of a community sample.
J Affect Disord 2010;130(3):395–404.
4. Goodyer I, Tsancheva S, Byford S, et al. Improving mood with psychoanalytic and
cognitive behavioural therapies (IMPACT): a pragmatic effectiveness superiority
trial to investigate whether specialised psychological treatment reduces the risk
for relapse in adolescents with moderate to severe unipolar depression: study
protocol for a randomised controlled trial. Trials 2011;12(1):175.
5. Midgley N, Kennedy E. Psychodynamic psychotherapy for children and adoles-
cents: a critical review of the evidence base. J Child Psychother 2011;37(3):
1–29.
6. Muratori F, Picchi L, Casella C, et al. Efficacy of brief dynamic psychotherapy
for children with emotional disorders. Psychother Psychosom 2002;71(1):
28–38.
7. Muratori F, Picchi L, Bruni G, et al. A two-year follow-up of psychodynamic
psychotherapy for internalizing disorders in children. J Am Acad Child Adolesc
Psychiatry 2003;42(3):331–9.
8. Target M, Fonagy P. The efficacy of psycho-analysis for children with emotional
disorders. J Am Acad Child Adolesc Psychiatry 1994;33(3):361–71.
9. Horn H, Geiser-Elze A, Reck C, et al. Efficacy of short term psychotherapy for
children and adolescents with depression. Prax Kinderpsychol Kinderpsychiatr
2005;54(7):578–97.
10. Trowell J, Joffe I, Campbell J, et al. Childhood depression: a place for psycho-
therapy. An outcome study comparing individual psychodynamic psychotherapy
and family therapy. Eur Child Adolesc Psychiatry 2007;16:157–67.
11. Trowell J, Miles G, editors. Childhood depression: a place for psychotherapy.
London: Karnac; 2011.
12. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic
psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen
Psychiatry 2004;61:1208–16.
13. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psycho-
therapy. JAMA 2008;300(13):1551–65.
 Psychodynamic Treatment of Adolescent Depression 81

14. de Maat S, de Jonghe F, Schoevers R, et al. The effectiveness of long-term

psychoanalytic therapy: a systematic review of empirical studies. Harv Rev
Psychiatry 2009;17(1):1–23.
15. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol 2010;
65(2):98–109.
16. Malhi G, Adams D, Porter R, et al. Clinical practice recommendations for depres-
sion. Acta Psychiatr Scand 2009;119(Suppl 439):8–26.
17. de Maat S, Dekker J, Schoevers R, et al. Short term psychodynamic supportive
psychotherapy, antidepressants, and their combination in the treatment of major
depression: a mega-analysis based on three randomized clinical trials. Depress
Anxiety 2008;25:565–74.
18. Abbass A, Town J, Driessen E. The efficacy of short-term psychodynamic
psychotherapy for depressive disorders with comorbid personality disorders.
Psychiatry 2011;74(1):61–74.
19. Freud S. Mourning and melancholia. In: Strachey J, editor. The standard edition
of the complete psychological works of Sigmund Freud, vol. 14. London: Hogarth
Press; 1917. p. 237–58.
20. Abraham K. A short study of the development of the libido, viewed in the light of
the mental disorders. In: Abraham K, editor. Selected papers on psychoanalysis.
London: Hogarth Press; 1927. p. 418–501.
21. Klein M. Mourning and its relation to manic-depressive states 1940. In: Klein M,
editor. The writings of Melanie Klein, vol. 1. London: Hogarth; 1975. p. 344–69.
22. Bleichmar H. Some sub-types of depression and their implications for psychoan-
alytic treatment. Int J Psychoanal 1996;77:935–61.
23. Kernberg O. Borderline conditions and pathological narcissism. New York: Jason
Aronson; 1975.
24. Kohut H. The restoration of the self. New York: Int Univ Press; 1977.
25. Blatt S. Contribution of psychoanalysis to the understanding and treatment of
depression. J Am Psychoanal Assoc 1998;46:722–52.
26. Freud A. Normality and pathology in childhood: assessments of development.
London: Karnac Books; 1996.
27. Erikson E. Childhood and Society. New York: W.W. Norton & Co; 1950.
28. Blos P. The second individuation process of adolescence. Psychoanal Study
Child 1967;22:162–86.
29. Laufer M, Laufer E. Adolescent disturbance and breakdown. Harmondsworth
(London): Penguin; 1975.
30. Rustin M. The psychology of depression in young adolescents: a psychoanalytic
view of origins, inner workings and implications. Psychoanal Psychother 2009;23:3.
31. Bifulco A, Brown G, Harris T. Childhood loss of parent, lack of adequate parental
care and adult depression: a replication. J Affect Disord 1987;12:115–28.
32. Gretton A. The wake-up call of adolescence: time-limited clinical work with three
young people. In: Trowell J, Miles G, editors. Childhood depression: a place for
psychotherapy. London: Karnac; 2011. p. 33–56.
33. Rhode M. Some reflections on the individual therapy: themes and interventions.
In: Trowell J, Miles G, editors. Childhood depression: a place for psychotherapy.
London: Karnac; 2011. p. 25–136.
34. Busch F, Rudden M, Shapiro T, editors. Psychodynamic treatment of depression.
Washington, DC: American Psychiatric Publishing; 2004.
35. NICE. Depression in children and young people: identification and management
in primary, community and secondary care. London: National Institute for Health
and Clinical Excellence; 2005.
82 Midgley et al

36. Ritvo RZ. Dynamic psychotherapy for the treatment of depression in youth. In:
Rey JM, Birmaher B, editors. Treating child and adolescent depression. Philadel-
phia: Lippincott Williams & Wilkins; 2009. p. 140–50.
37. Luyten P, Blatt S. Psychodynamic treatment of depression. Psychiatr Clin North
Am 2012;35(1):111–29.
38. Christogiorgos S, Stavrou E, Widdershoven-Zerkavi M, et al. Brief psychody-
namic psychotherapy in adolescent depression: two case studies. In: Trowell J,
Miles G, editors. Childhood depression: a place for psychotherapy. London: Kar-
nac; 2011. p. 89–109.
39. Winnicott DW. Therapeutic consultations in child psychiatry. London: Hogarth
and Institute of Psychoanalysis; 1972.
40. Lanyado M. Brief psychotherapy and therapeutic consultations: how much
therapy is ‘good enough’? In: Lanyado M, Horne A, editors. Handbook of child
and adolescent psychotherapy. London: Routledge; 1999. p. 233–46.
41. Bion WR. A theory of thinking. Int J Psychoanal 1962;43:328–32.
42. Klein M. Notes on some schizoid mechanisms. Int J Psychoanal 1946;27:99–110.
43. Ogden T. Projective identification and psychotherapeutic technique. New York:
Jason Aronson; 1982.
44. Pick IB. Working through in the countertransference. Int J Psychoanal 1985;66:
157–66.
45. Casement P. On learning from the patient. London: Routledge; 1985.
46. O’Shaughnessy E. What is a clinical fact? Int J Psychoanal 1994;75:939–47.
47. Heimann P. On countertransference. Int J Psychoanal 1950;31:81–4.
48. Bowlby J. The nature of the child’s tie to his mother. Int J Psychoanal 1958;39:350.
49. Bowlby J. Attachment. In: Attachment and loss, vol. 1. New York: Basic Books;
1982 (Original work published 1969).
50. Bion WR. Elements of psychoanalysis. London: Heinemann; 1963.
51. Graham P, Hughes C. So young, so sad, so listen. London: Gaskell, Royal
College of Psychiatrists; 2005.
52. Goodyer IM. The depressed child and adolescent. United Kingdom: Cambridge:
Cambridge University Press; 2000.
53. Rustin M. Dialogues with parents. J Child Psychother 1998;24(2):233–52.
54. Tsintias J, Boethious S, Hallerfors B, et al, editors. Work with parents: psychoan-
alytic psychotherapy with children and adolescents. London: Karnac; 2000.
55. Miles G. The work with the parents alongside individual therapy with the children/
young people: present and absent parents. In: Trowell J, Miles G, editors. Child-
hood depression: a place for psychotherapy. London: Karnac; 2011. p. 110–24.
56. Slade A. Parental reflective functioning: an introduction. Attach Hum Dev 2005;
7(3):269–81.
57. Daviss WB, Birmaher B, Melhem NA, et al. Criterion validity of the Mood and Feel-
ings Questionnaire for depressive episodes in clinic and non-clinic subjects.
J Child Psychol Psychiatry 2006;47(9):927–34.
58. Slonim DA, Shefler G, Gvirsman SD, et al. Changes in rigidity and symptoms
among adolescents in psychodynamic psychotherapy. Psychother Res 2011;
21(6):685697.
59. Bychkova T, Hillman S, Midgley N, et al. The psychotherapy process with adoles-
cents: preliminary comparisons between different therapeutic modalities using
the Adolescent Psychotherapy Q-Set. J Child Psychother 2011;37(3):327–48.