Transactional Analysis Journal

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Depression: An Integration of TA and Psychodynamic Concepts

Raman Kapur
Transactional Analysis Journal 1987 17: 29
DOI: 10.1177/036215378701700206

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 Depression: An Integration of TA
and Psychodynamic Concepts
Raman Kapur
Abstract
This article integrates TA and psychody-
namic concepts in order to provide a fuller
understanding of depression. The major
issues in treating mild and severe depression
are reviewed, and a longitudinal view of the
psychotherapeutic treatment of depression is
presented.
Introduction
Depression is one of the most common forms
of psychopathology; its treatment encompasses
traditional pharmacological interventions as
well as psychotherapeutic approaches. This
paper focuses on the latter by integrating con-
cepts from TA, psychodynamic psychotherapy,
and Arieti and Bemporads' (1978) model of
severe and mild depression in order to arrive
at a clinically oriented model of depression.
The Dynamics of Depression
I'm trying to be someone else
To fit in where I can
I've done this for so many years
I don't know who I am.
This poem by a client highlights the dynamic
of the dominant other identified by Arieti and
Bemporad (1976) in which depressed in-
dividuals live, not for themselves but for others,
most often a spouse, less frequently a mother,
a lover, an adult child, a sister, or a father.
(Although this pattern predominates, other
depressed persons live for an inaccessible aim
called the dominant goal.) As children, these
I wish to thank Charles Hand, Gill Ingram, and Chris
Hodkinson of the Student Counselling Centre. University
of Ulster, North Ireland. for providing me with opportunities
to develop my interests in TA and psychodynamic
psychotherapy.
Vol. 17. No.2. April 1987
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people were encouraged to seek gratjfication
through using the dominant other as an in-
termediary to reward any activity (Bemporad,
1977). For example, impressive educational
achievements are hotly pursued to gain ap-
proval from the dominant other. This parent-
child interaction has been called a bargain rela-
tionship; depressed persons deny themselves
autonomous gratification in return for accep-
tance by the dominant other. Later they often
attempt to reestablish this pattern with unwit-
ting transference objects, including therapists.
Upon closer examination, the personality
structure of depressed persons reveals the
underlying passivity characteristic of their day-
to-day functioning (Brown, 1977; Cameron,
1963). Semrad (Rako & Mazer, 1980)
describes this as "getting someone else to do
something they're not doing ... " (p. 151).
From a TA perspective, a structural analysis
reveals several characteristics. The Parent ego
states of depressed individuals exhibit several
fundamental flaws (Loomis & Landsman,
1980, 1981). Their high external Critical Parent
allows them to externalize responsibility for
distress. This occurs through criticizing signifi-
cant others and perceiving them as betraying
the depressed person's trust. For example, a
40-year-old mildly depressed nurse often
remarked that it was pointless to trust others
since they constantly disappointed her. This
dysfunctional Parent ego state is further im-
paired by a high internal Critical Parent which
ensures that unreasonable personal standards
and expectations are firmly established. Thus,
each time the person fails, he or she feels guil-
ty and more depressed. This feature of the
Parent ego state is often referred to by
psychoanalytic theorists as the harsh or severe
superego (Bellak, 1981).
29
 JACK BIRNBAUM
The imbalance in depressed persons' Nurtur-
ing Parent ego states ensures that they take care
of others to their own neglect, a relationship
strategy with an often masochistic flavor. They
feel unable to love and take care of themselves,
and the self-image is of being all-bad.
The depressed person's dysfunctional Adult
promotes considerable ambivalence (Benedek,
1975) and conveys a feeling of frustration to
the therapist, who is often invited to cathect his
or her own Adult to defuse this ambivalence.
The Child ego state performs functions im-
portant for maintaining the painful status quo.
In particular, the intensity of the helpless
Adapted Child invites rescuing from others,
and the therapist often ends up enacting roles
in the Drama Triangle (Karpman, 1968).
Depressed persons who are unable to find
authentic ways of dealing with relationships
often resort to powerful Adapted Child
maneuvers when venturing out of their fragile
shells. The Adapted Child is used as a way of
hurting back those perceived to be the cause
of the person's distress. There is rarely a
healthy expression of Free Child energy; the
predominant emotion of anger tends to be turn-
ed both inward and outward in an unhealthy
way (Birnbaum, 1976), the latter being dis-
placed on to significant others. The Free Child
remains neglected and starved for strokes.
To deal with the inevitable rejection and
damaged self-esteem that results from these
maladaptive relationship strategies, depressed
people tend to become dependent on others and
to use these relationships as sources of nar-
cissistic nutrients; that is, they demand love and
reassurance from others (Bellak, 1981). Denial,
the primary defense mechanism used by
depressed people to manage anxiety (Bellak,
1981), prevents premature exploration of the
more unconscious reasons behind the person's
distress.
In terms of differential diagnosis, the inten-
sification of one or more behaviors in a client
may lead the clinician to question the diagnosis
of depression. It is important to note that mak-
ing a clear differentiation between depression
and borderline states is required to ensure suc-
cessful treatment, and failing to do so can lead
to considerable resistance (Weiner, 1982). The
psychoanalytic work of Kernberg (1975, 1980)
covers in greater detail the assessment of
borderline conditions.
30
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The following sections of this paper outline
a longitudinal view of the treatment of clinical
depression in which traditional TA and psycho-
dynamic concepts are integrated into the
"dominant other" model of depression.
Initial Phase of Treatment
Effective psychotherapy depends on the
therapist making successful contact with clients.
The foundations laid during this initial stage
often dictate the strength and structure of the
emotional growth which occurs at later stages.
Depressed clients are often reluctant to make
therapeutic contact, and initial therapist trans-
actions need to contain what Loomis and
Landsman term realistic Nurturing Parent
(1981). However, the negative effect of offer-
ing a heavy Nurturing Parent with no Adult
messages is that depressed clients may feel that
the ideal and fantasied dependency now exists.
Arieti (1978) suggests similar transactions in
which the therapist is compassionate, although
not in such a manner that clients can interpret
it as an acknowledgment of their helplessness.
Arieti suggests the therapist initiate by saying,
"Most probably you do not know why you are
depressed. But in my professional work I have
found without exception that there are reasons
for every depression. The depression does not
come out of the blue. The anguish and suffer-
ing stem from sources that a person like you,
at a certain period of his life, cannot find out
himself. He needs help." (p. 37-38)
Cathexis of some degree of Adult from
clients allows the therapist to formulate a
therapeutic contract. All escape hatches
(Holloway, 1977) must be closed by a thorough
examination of the contract since clients are in-
evitably apprehensive about proposed changes.
However, contract agreement is often pragma-
tically dictated by the intensity of the depres-
sion; severely depressed clients will be very
passive in the face of any commitment. As with
all aspects of treatment planning, evaluation is
required on an individual basis.
One of the primary unconscious aims of
depressed clients during this initial stage of
treatment is to maintain a high level of depen-
dence on the therapist, with little or no change
in how they see themselves or significant
others. At this point the Schiff model of sym-
biosis (Schiff & Schiff, 1971) is useful for clari-
fying the mechanisms clients use to maintain
Transactional Analysis Journal
 A REPLACEMENT THERAPY FOR THE HISTRIONIC PERSONALITY DISORDER
this dependency. Using Arieti and Bemporad' s
terminology, the therapist now becomes the
dominant third in addition to the client and the
dominant other. As the therapeutic relationship
develops, clients come to rely on the therapist's
Parent and Adult to take care of and think for
. them, thus looking after their Child needs.
As the therapeutic relationship progresses,
transference develops in which the therapist is
perceived as another authority figure in the
client's life. Defenses and resistances may be
activated to combat what clients see as further
intrusion and penetration into their lives. Since
their previous experience with authority figures
has been inevitably characterized by hurt and
disappointment, depressed clients go through
a period of resistance while they assess the risk
in trusting yet another authority figure.
Resistance is a defense expressed in the trans-
ference (Singer, 1970; Watchel, 1982), and
consequently the therapist must be sensitive to
the individual anxieties of depressed individuals
as well as to any potentially unhealthy coun-
tertransference.
Resistance in depressed clients is character-
ized by the games "Yes But," "Kick Me,"
and "Wooden Leg" among others (Birnbaum,
1976; Breen, 1977; Kemp, 1977). Clients resist
change because it involves taking significant
risks, and they have usually made an internal
decision based on previous experience: "Once
bitten, twice shy." They exhibit what Schmale
and Engel (1975) term the conservation-
withdrawal reaction, i.e., they become inac-
tive and disengage from an environment that
they perceive as no longer providing the needed
nutrients, security, or comfort. As one client
wrote:
But I speak not only with anger and
pain
But with a passion and joy and a
mind that is sane
I speak to tell you it's not only bad
It brings love and tenderness and
emotions are glad
Love is a window filled with gleam-
ing glass
It's also a chamber filled with a dead-
ly gas.
Thus, overall the first phase of treatment is
characterized by a healthy Nurturing Parent
from the therapist along with a focus on resist-
ance to change. Verbal analysis of the resist-
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ance reveals the games these clients use. They
attempt to maintain their passivity by function-
ing only from Child. Their apparent unwill-
ingness to trust the therapist can be understood
within the context of the total therapeutic rela-
tionship, i.e., the transference and counter-
transference (Chessick, 1977). In the face of
this resistance, no attempt is made at this stage
of treatment to explore the reasons behind their
distress; rather the goal is developing a thera-
peutic alliance (Bugental, 1978).
Middle Phase of Treatment
This phase of the work can be called-the work
phase because during it clients begin to under-
stand the reasons behind their distress. Its
length depends on the severity of the depres-
sion, and can range from six months in mild
cases to three years in more severe ones. The
following paragraphs outline the major themes
at this stage of treatment, focusing on the
transference, the easing of resistance, therapeu-
tic technique, countertransference issues, fac-
tors influencing outcome, and the fundamen-
tal shift depressed clients must make before
they can begin taking care of themselves.
During the first phase of treatment, depressed
clients see the therapist as possessing the
features of the real-life dominant other. The
therapist's task is to shift to maintain a more
flexible position than the real-life dominant
other so that the original transference can be
resolved. The therapist becomes what Arieti
and Bemporad call the significant third (1978),
a person who is able to share experiences with
clients without aiming for control or domina-
tion. In relation to symbiotic processes, clients
shift from the passive role to cathecting Parent
and Adult with simultaneous disengagement of
Adapted Child maneuvers. However, this con-
tinues to be a delicate stage for these clients,
and the therapist needs to allow them time to
develop their full resources under the emotional
umbrella of the therapist's Parent and Adult.
A potent therapist who provides permission and
protection is important at this stage (Crossman,
1966).
Resistance is considerably dissolved during
this middle stage of treatment; games lessen and
discounts and redefinitions become minimal.
The duration and intensity of temporary resist-
ances are dictated by the emotional issues under
consideration. Clients are allowed to under-
31
JACK BIRNBAUM
stand themselves at a mutually agreeable pace.
This phase is characterized by what Fried
(1980) calls the backward pulls and forward
pushes of psychotherapy.
The therapist is now in a strategic position
to search for the reasons why clients are dis-
tressed. Early script issues surround the ''I'm
Not OK" basic position are explored, and in-
junctions are carefully examined. Goulding and
Goulding (1979) identified several injunctions
common to depressed patients, including Don't
Be, Don't Be Close, Don't Trust, Don't Be
You, Don't Feel, and Don't Make It. The focus
of the therapy thus becomes encouraging clients
to make new decisions about how they see
themselves based on new information available
to their Adult ego states.
The type of therapeutic technique used to
facilitate these new internal decisions depends
on the severity of the presenting depression.
The redecision techniques developed by the
Gouldings (1978, 1979) are more appropriate
for mildly depressed clients who maintain
relatively good psychological functioning.
Since their cognitive functioning is not
significantly impaired, they can become active
and interested in understanding themselves. In
contrast, severely depressed clients suffer from
marked cognitive impairment with associated
low psychological functioning. They are less
motivated to change, and thus require an in-
tervention that gently encourages them to make
new decisions about how they see themselves
(Kapur, Ramage, & Walker, 1986). With these
clients, Steiner's (1974) suggestion of break-
ing down the existing stroke economy to allow
them to receive and give strokes is effective in
dissolving their destructive injunctions. The
most useful therapeutic tools with this popula-
tion are positive stroking in conjunction with
interpretations about why they have such
unhealthy self-concepts.
With both mild and severely depressed
clients, the most crucial feeling for the therapist
to deal with is his or her response to the client's
suicidal tendencies. The therapist must be alert
to his or her own rational and irrational coun-
tertransference and use such material maximal-
ly to resolve the situation. When faced with
suicidal behavior, the therapist should transfuse
clients with hope and possibilities for change
(Lesse, 1975). As these clients are encouraged
to come out of their fragile but safe emotional
32
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shells, any change, regardless of how small,
requires reinforcement from the therapist.
To overcome an immediate suicide crisis at
this stage of treatment, a no-suicide contract
(Goulding & Goulding, 1978; Steiner, 1974)
is made with the depressed client and residen-
tial facilities are offered if that is practical.
However, even with these precautions, there
are instances in which a severely depressed
client will perform the final script payoff and
take his or her own life. Therefore, the therapist
must be clear about issues of personal respon-
sibility; this requires an ongoing review of the
therapist's own grandiose rescue fantasies and
a realization that he or she cannot rescue all
clients (Pfeffer, 1984).
The two factors that have most bearing on
the severity of a depression relate to the client's
early childhood experience and the previous
treatment history. Clients suffering from severe
parental rejection and abuse in childhood tend
to reject therapeutic parenting because it is ex-
perienced as intrusive and harmful. In addition,
the type and length of prior treatment can
significantly impact the success of current
therapy. Pilkonis, Imber, Lewis, and Rubin-
sky (1984) demonstrate that a long history of
treatment and an increased duration of the
presenting problem are reliable indicators of
poor outcome for psychotherapy.
During the middle phase of therapy clients
often question the validity of self-love and ex-
press the fear that concern for themselves could
be interpreted as selfishness. Eric Fromm
(1967) discusses this issue in detail: A lack of
self-love and an exaggerated concern for others
often implies a devaluation of oneself. Giving
clients permission to love and take care of
themselves is often one of the most important
and significant moves in therapy with depressed
clients. As a transferential parent the therapist
should encourage clients to make this radical
shift because it forms the basis for future emo-
tional growth. As Fromm (1967) writes, "The
affirmation of one's own life, happiness, free-
dom is rooted in one's capacity to love, i.e.,
in care, respect, responsibility, and knowledge.
If an individual is able to love productively, he
loves himself too; if he can love only others,
he cannot love at all." (p. 130)
In summary, the main work at this stage of
therapy is exploring the historical reasons for
the client's distress. Parental injunctions are
Transactional Analysis Journal
 A REPLACEMENT THERAPY FOR THE HISTRIONIC PERSONALITY DISORDER
examined and new decisions made about how
clients see themselves and others. As a
transferential parent in the significantthird rela-
tionship the therapist encourages clients to look
after themselves and gives them permission to
deal with relationships differently. As this hap-
pens the transference is dissolved and clients
perceive the therapist without distortions from
the past.
Final Phase of Treatment
A major goal in treating depressed clients is
to foster awareness of those past events that
crippled them emotionally and thus restricted
their options for dealing with relationships.
This requires an optimally functioning Adult
with a nurturing and permission-giving Parent.
Clients are encouraged to deal with relation-
ships in ways that allow their Child needs to
be met, not abused.
One of the most significant changes de-
pressed clients experience is in their ability to
listen to themselves to find out what they real-
ly want from relationships. The internal Nur-
turing Parent and Free Child now work
together, the former taking care of the latter's
needs for warmth, security, and emotional
comfort. A new channel of communication ex-
ists between these ego states. Clients no longer
need to engage in potentially masochistic rela-
tionships with others in order to receive
gratification. Rather, they can function in-
dependently and obtain pleasure through their
own efforts.
Often, when clients reach the final stage of
treatment they radically reverse previous pat-
terns of dealing with relationships, i.e., by
moving from submissive to dominant. This can
create many difficulties, and they need support
for finding a balance in how they deal with rela-
tionships. Careful Adult appraisal of the situa-
tion and refined decision making are required
in order to arrive at what could be described
as the middle way of relationships. This balance
is similar to ideas found in traditional Buddhism
(Humphreys, 1959) in which there is constant
pursuit of the right balance between the
countless opposites in human relationships.
Other characteristics of the final phase of
therapy with depressed clients are a less strict
internal Critical Parent and an Adapted Child
that is less prominent and does not use
helplessness as a primary way of dealing with
Vol. 17, No.2, April 1987
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relationships. They no longer adhere to
unrealistic expectations and can relinquish the
power of their previous helpless behavior.
Conclusion
Psychotherapeutic treatment of depressed
clients requires a radical change in their
psychological make-up. There must be a shift
in their assumptions about themselves and the
world in which they live (Frank, 1974). This
involves new decisions about their perceptions
of themsleves and others and accepting respon-
sibility and authority for their own lives.
Krishnamurti (1971) describes this eloquently
when he writes on suffering:
The shedding of the past all the time
when you see yourself is the freedom
from the past. Sorrow ends only when
there is the light of understanding,
and this light is not only lit by one
experience or by one flash of
understanding; this understanding is
lighting itself all the time .. . . The
understanding of yourself is the end-
ing of sorrow. (p. 109)
The message inherent in the psychotherapy
of depression is that life is worth living. As
therapists, our concern is for how our clients
can best recover from past and currently in-
flicted emotional injuries. By offering an in-
tegration of concepts from various therapeutic
models, the author echoes Krishnamurti's state-
ment that' 'truth is a pathless land, and you can-
not approach it by any path whatsoever, by any
religion, by any sect" (public comment, August
3, 1929, Ommen, Holland). In the therapeutic
endeavor, "cure" can be viewed as a pathless
land which cannot be approached along any
specific or predetermined path. Through offer-
ing our clients different instruments to heal their
wounds, we respect their individuality and in-
crease the chances of success in psychotherapy.
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