How does treating self-blame depression differ from treating other types of depression?
Depression is a heterogeneous disorder.1.2 The DSM diagnosis of major depression is made when the patient meets at least 5 of 9 criteria, some of which are opposite.3 Some cases resolve without treatment, and others require lifelong management with psychotherapy, drug therapy, or physical treatments like electroconvulsive therapy. Given this wide variability in presentation, severity and course, the idea that all depressed patients suffer from the same disorder seems unlikely.
While the DSM diagnostic system classifies all depression as major depressive disorder or persistent depressive disorder (dysthymia), psychodynamic theorists have historically divided depression into various subtypes based on proposed etiology and symptoms. manifestos. Some of these types include endogenous or metabolic depression; exogenous or reactive depression; anaclitic depression; introjective depression; alleging depression; self-blaming depression; depressed personality; and others.
Identifying the subtypes of depression helps us choose the appropriate treatment and can shed light on long-term prognosis. It also allows us to be particularly sensitive to the psychological mechanisms underlying the patient’s depressive symptoms. In this article, I will briefly review the concept of self-blame depression and its psychotherapeutic treatment, which differs in important ways from the treatment of other forms of depression.
Ms. Jones is a 60-year-old woman who has struggled with depressive symptoms on and off throughout her adult life. Her most recent depression came after the death of her cat, which developed injection site sarcoma after a feline leukemia vaccination. After evaluation, Mrs. Jones declares: “It’s all my fault. I should never have had my cat vaccinated. I should have done my homework before taking him to the vet. Previous depressions have similarly occurred following events attributed by Ms Jones to her own personal failures. In psychotherapy, she only becomes more depressed with hopeful words of encouragement, declaring, “I don’t deserve to feel better. I am a failure.” Every disappointment in life is interpreted as punishment for one’s wickedness and sinful deeds.
Psychoanalytic and psychodynamic theories have historically viewed depression as a reaction to loss.4 Something happened in the patient’s life: the loss of a loved one; a job or position; a status ; a concept of ourselves; an ideal – which leads to the appearance of depressive symptoms. Depression is therefore a reaction to the loss of a key ingredient of our normal mental life. Like physical pain, depression, or psychic pain, has only one goal: to be suppressed.5
Early in life for individuals who become depressed, there is often a period of intense need satisfaction followed by a period of relative deprivation. This shift from a near-paradise situation to an environment of unmet expectations sets the stage for the later onset of depression in response to the loss. The child responds to change by working harder to reclaim the lost paradise. If he fails, the child is at fault. The child must atone or work harder. Eventually, the child realizes that no matter what is done, paradise will not be taken back. It is this awareness that causes the depressive feeling.6
In the self-blaming type of depression, this pattern is replayed in symbolic form. Some loss has been suffered and the patient feels that his way of life has caused such loss. This produces the overt depressive symptoms. Arieti6 writes that in self-blaming depression, “the message the patient conveys is not ‘help me,’ but ‘I deserve no help, no pity’.” He continues, “When suicidal ideation exists, the message is not, you should prevent my death”, but “I deserve to die; I should do to myself what you should do to me, but you’re too good to do it.
In my experience, self-blaming depressed patients are considered more difficult to treat and are therefore more quickly referred to biological treatment than those with other types of depression. Still, psychotherapy can be particularly effective for these patients, especially those with mild or moderate cases and those uncomplicated by a comorbid mental disorder. The psychotherapeutic approach to self-blaming depression differs significantly from that used with other depressed patients, which I will discuss below.
In self-blame depression, the patient comes to translate well-meaning and encouraging statements through a filter of self-blame and guilt. Thus, for these patients, the therapist cannot assume the role of benevolent helper as he could in other cases. When offered loving reassurance and expressions of hope, self-blaming patients usually feel worse and more guilty and reject help. It is as if the patient were saying to the therapist, “I am not worthy of your help. Why can’t you see it? McWilliams4 writes this about these types of patients:
Therapists often find that their efforts to improve the self-esteem of their depressive patients are either ignored or received paradoxically. Supportive comments to a person immersed in self-loathing can cause increased depression via internal transformation: “Anyone who really I knew I couldn’t say such positive things.
Other misinterpretations made by self-blaming patients, described by Frances,seven include some variations of: 1) “How nice you are; how terrible I must be”; 2) “How horrible I am to deceive you by saying nice things about me”; 3) “You would hate me too if you knew how hateful I am”; and 4) “How dare you hope when there is no hope.”
If the therapist is not expected to offer statements of hope or support, at least during the acute phase of illness, then what is he to do? Arieti6 describes that inquiry into the family or relationship situation often reveals dynamics that increase the patient’s feelings of duty or guilt. For example, a spouse may say to the patient, “You are too sick to do housework now” or “For many years you took care of me; now it’s my turn to take care of you. These statements are interpreted by the patient as criticism and only aggravate the feeling of guilt.
Eventually, it will become possible to point out to the patient that the losses and disappointments that led to the depression are actually symbolic of larger, earlier losses and disappointments, and that the patient has unconsciously come to repeat these patterns in his adult. life. Thus, the interpretation of the meaning and symbolism of depressive symptoms is of paramount importance in the treatment of these patients, perhaps even more so than in other forms of depressive illness.
As the treatment progresses, the therapist must remain in tune with the ups and downs of the patient’s life, as any failure can trigger a state of sadness and guilt. For example, the patient may be depressed by the fact that he becomes depressed so easily. Sometimes, when the depression has improved, a relapse can occur if the patient is allowed to feel guilty about the supposedly undeserved improvement. At this point, the patient may be so discouraged by the relapse that he may abruptly discontinue treatment.6
Throughout treatment, the therapist should remind the patient that the minor disappointments in life – those to which the patient reacts so intensely – symbolize a much greater disappointment early in life, and that he or she is actually reacting to an early loss of much larger and much more significant proportions. If this is not done – if the meaning of the symptoms remains uninterpreted and the treatment focuses only on correcting the cognitions – then the depression will perpetuate itself.
Self-blame depression reflects a unique subtype of depressive illness characterized by self-blame, guilt, and an exaggerated sense of personal responsibility. Given its psychodynamic mechanisms, the psychotherapeutic treatment of patients with self-blaming depression proceeds differently from the treatment of other depressed patients. In particular, the therapist must be very attentive to the patient’s tendency to interpret statements of support as criticism and to the symbolic transformation of early loss into current losses and disappointments. Psychotherapeutic treatment is possible and often effective in these cases.
Dr. Ruffalo is Professor of Psychiatry at the University of Central Florida College of Medicine in Orlando and Adjunct Professor of Psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is a psychoanalytic psychotherapist in private practice in Tampa.
1.Goldberg D. The heterogeneity of “major depression”. Global Psychiatry. 2011;10(3):226-228.
2. Paris J. The abuse of major depressive disorder. Can J Psychiatry. 2014;59(3):148-151.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Edition; 2013.
4.McWilliams N. Psychoanalytic diagnosis: understanding the structure of personality in the clinical process. 2nd ed. Guilford Press; 2011.
5. Ostow M. The Psychic Function of Depression: A Study in Energetics. Psychoanal Q. 1960;29:355-394.
6. Arieti S. The psychotherapeutic approach to depression. Am J Psychother. 1962;16:397-406.
7. @AllenFrancesMD. Other ways some self-accusing patients misinterpret wellness: 1) How nice she is = How terrible I am 2) How horrible I am to trick him into saying nice things about me 3) You would hate me too if you only knew how hateful I am 4) How dare you hope when there is no hope. https://twitter.com/AllenFrancesMD/status/1430564200888168450. Posted August 25, 2021.