Psychotherapy of Severe Depression



VOLUME 17, #1, SPRING, 1980


Swarthmore College, Pennsylvania
University of California at San Francisco

ABSTRACT: In the ward program described in a previous article (Deikman &
Whitaker, 1979) there were many opportunities to try psychological treatment
approaches with severely depressed, suicidal and "untreatable" patients.
Three case illustrations are presented here, showing particularly the
collaborative efforts of patients and staff in group psychotherapy. In
these cases, many assumptions about "untreatable' patients were critically
examined and rejected. Psychological approaches were designed which
successfully reached the bases of conflict by reinstituting traumatic
situations and providing ways of developing corrective emotional experiences. Psychological theories helpful in such basic psychotherapeutic work are discussed.
   The authors do not identify their approach with one particular theoretical
school or type of psychotherapy. They feel that the problem with most
current approaches to treatment of severe depression is that our
understanding of the psychodynamics of depression is not really put to use in
designing treatment programs.
   In this article certain approaches to the psychological treatment of
severe incapacitating depression and psychosis are described. Illustrative
cases are discussed particularly in relation to group psychotherapy within
the ward milieu, and with reference to treatment outcomes.Severe, incapacitating depression is usually treated by electroshock or
anti-depressant drugs. Both of these treatments have certain advantages in
terms of economics and expediency. Neither costs much money initially or
takes much time to administer and each may alleviate depressive
symptomatology, at least in the short run. Furthermore, it is thought there
exists no viable treatment alternative.
   During the course of a year during which the authors were developing an
experimental psychiatric was at a university teaching hospital, there were
many opportunities to try psychological treatment approaches with severely
depressed patients. Ordinarily theses patients would have received somatic
treatment and/or have been sent to a state hospital for long-term
institutionalization. Most had been treated unsuccessfully for months or
even years with anti-depressants, an, in some cases, electroshock before we
made our psychological treatment attempts. Each of our illustrative cases
was declared "untreatable" by consensus of the staff before we made our
treatment attempts.
   It seemed to us that there were some important disadvantages to the
somatic treatment methods and that a psychological approach would promote
better understanding of severe depression. Somatic treatments do not by
themselves aid in the patient's learning what his or her depression is all
about nor in developing different emotional,, cognitive and behavioral
responses which would avert future depressions and lead to a more satisfying
productive life. Furthermore, we were struck by the impersonality and
avoidance of interpersonal closeness between patient and staff in these cases particularly. The patients' characteristic withdrawal seemed reinforced by staff, who were threatened and made anxious by the patients, as if the
patients' despair and self-destructiveness might be catching. Prescribing
drugs often seemed motivated by the need to disidentify with patients.
Most importantly, we felt that there was evidence that psychological
treatment would be effective and that there existed adequate theoretical
rationales for its effectiveness. We wondered whether the suicidal crises
couldn't become psychologically creative events in the lives of our patients,
our thinking have some similarity to Tabachnich's (1973) concept of "Creative
Suicidal Crises." The case to be presented first will illustrate some of
these points.

*Requests for reprints should be sent to Leighton C. Whitaker, Director.
Psychological Services, Parrish Hall, Swarthmore College, Swarthmore, Pa.

The case of Mrs. H.
Prior to starting the new, experimental ward, one of the authors (Dr. W.)
had opportunity to work with a fifty-year-pld woman who had thoroughly
convinced ward staff that she would commit suicide upon release from the
hospital despite several weeks of treatment.
The circumstances of admission and chief complaint are quoted here as
reported by her psychiatric resident but with names deleted:
"Patient was transferred to Psychiatric Hospital from General Hospital
following a serious suicidal attempt in which she almost died. This included
a cardiac arrest in the ambulance between an outlying hospital and General.
She required a tracheostomy and maintenance on a respirator for a four day
period, but was saved essentially without noticeable brain damage through
heroic medical efforts."

Her psychological history was replete with evidence that she would be most
difficult treatment case. The resident reported:

"....a long standing history of fairly severe hysterical character disorder in which the patient had been extremely narcissistic, used to having her
own way at a very early age." It was said, her...characteristic was of
handling painful situations is massive denial and repression until the
reality becomes overwhelming, unable to avoid any long (sic), at which point
she feels overwhelmed, betrayed and helpless. This has occurred repeatedly
in her life, the most recent time being when she felt betrayed and
overwhelmed by her friend criticizing her as well as her husband divorcing
her, and attempted suicide."

   In addition to her sever characterological problems and her highly
stressful life situation, the patient had suffered diabetes mellitus for two
years, for which she was taking forty insulin units per day. Both her
parents had diabetes and her mother committed suicide by overdosing with
sleeping pills when the patient was age nineteen. The dire implications of
this history were not relieved by any evidence that the patient would
cooperate with treatment efforts. Her clinical course in both the general
and psychiatric hospitals was described as "stormy." Having spent several
days in the general hospital she was then place on a ward of the psychiatric
hospital where her psychiatric resident reported the "...the patient was a
rather haughty, imperious lady who tended to alienate, at times, both
patients and staff from her, and seemed to be extremely narcissistic and
demanding during much of her stay here." Nevertheless, this patient's
treatment outcome was quite favorable following a psychological treatment
approach of about one week toward the end of her six weeks stay on the
psychiatric ward.
   At a ward conference on her case, about four weeks after her psychiatric
admission, it was predicted by ward staff that, unless carefully guarded, the
patient would take every opportunity to escape the hospital and follow
through on her suicide plans. Staff were unanimous in their opinion that
further treatment attempts, including her ongoing individual and group
therapy, would be ineffective. Dr. W. then obtained permission to try a
short-term approach that he thought might work. The primary setting for this
approach was group therapy where Dr. W. and a psychology postdoctoral fellow (Dr.P.), who had been trained in psychodrama, were cotherapists.
   The treatment was based on the premise that the patient had denied her
rage at her husband and was directing it at herself. We enacted the original
rage-producing situation. Dr. P. played the husband while Dr. W. and the
other group members encouraged the patient to express her rage at her
surrogate husband, Dr. P. It was anticipated that her initial response to
our provocations would be to try to avoid the group therapy sessions and when forced to attend, would try to escape the room by the window or the door. Accordingly, precautions were taken to ensure her attendance and one of the cotherapists stood ready by the window while another blocked the door. Other patients in the group were fully informed of the treatment plan and gave
their support.
   The enactment was based as faithfully as possible on the actual
circumstance in which her husband had informed her of his leaving. Instead
of actually leaving, however, the "husband" was to stay in the room. It was
hoped that the patient, finding her exits blocked, would find no other outlet
for her feelings than to attack him. The "husband, " a strong young man, was
prepared to encourage and accept her attack, using a sofa cushion to protect
himself from the full force of her blows. The other patients were prepared
to tell the patient at the right time that her "husband" was a cruel deserter
and to encourage her to attack him.
   This treatment procedure required three consecutive daily sessions. Arriving
at the first session, not knowing what was planned, the patient appeared to
be withdrawn, depressed, sullen and prepared, as usual, to avoid listening,
talking, or in any way participating constructively in the session. She was
then told that Dr. P. had something to tell her and that he was her husband.
Dr. P. then enacted the actual leave-taking scene that preceded her suicide
attempt. The patient quickly got up from her seat and tried to leave by the
door. Blocked at the door, the then tried the window, she next tried to
avoid the enactment by closing her eyes and covering her ears with her
hands. Dr. P. then held her hands, preventing her from covering her ears
and told her that what he had to say was important, and that he was leaving
her for a very attractive woman he had met. He said he would be going to
Sweden with this woman and he wouldn't have his job or any income there so
he had no money to leave for her (his wife). The scene was reenacted several
times during the first two sessions. Gradually Mrs. H. began to make
sporadic attacks on her "cruel husband," and with each attack was supported
vocally by everyone else in the room. By the end of the second session the
patient was attacking her "husband" with unrestrained murderous intensity,
and Dr. P. had to rely on hiss protective cushion as she tried to beat him
with her fists.
   In the third session, Mrs. H. announced that she was feeling much better
and she appeared interested in talking. The group then discussed how it is
that so many people, including this patient and other patients in the group,
got thinking of suicide because "they've been angry" and couldn't or wouldn't
express it to the person they felt the anger toward. Mrs. H., both in this
session and on the ward, condemned her own "stupid,"self-destructive behavior
and talked about the things she yet wanted to do in life and about her pride
in her children and her desire to visit them in their out-of-state homes.
After the session, she continued in the daily group therapy sessions for a
few more days but was no longer the group's major focus of concern. During
this time, the patient stated spontaneously and convincingly that she would
never attempt suicide again because she now experienced her life as
worthwhile. She was discharged from the hospital shortly thereafter and
obtained the kind of office secretarial work she had done successfully many
years before. No formal follow-up was planned except that she would come in
occasionally for sessions with her individual therapist, a psychiatric
resident. Two weeks after discharge she stopped by Dr. W.'s office for a few
minutes, telling him about a book she had enjoyed reading and how it might
interest him. She also said enthusiastically that she was feeling good and
liked her job. Two months after discharge, she stopped by again, cheerfully
relating how she had made friends and was enjoying personal relations with
people at the office where she was working.
   The experience with Mrs. H. suggested that other severely suicidal and
depressed patients, who did not respond to the usual somatic treatments,
might be helped by intensive, though not necessarily lengthy, psychological
treatment. During the year in which the authors were developing the
experimental ward, it was possible both to work with several such patients
and to plan more systematic outcome evaluations for some who lived in the
metropolitan area. Only one of these cases will be presented in detail in
this paper because of space limitations. However, the next case to be
described does represent the type of work done with fairly chronic cases and
the average outcome for this treatment. The chronic case which had the least
favorable outcome will be discussed briefly later.

The case of Elizabeth

The patient was a seventeen-year-old girl admitted to our ward a couple of
months before the change in ward policy and leadership. Chronically and
severely depressed. Elizabeth had made repeated suicide attempts, had many
hypochondriacal complaints and hallucinated on several occasions. She was
from a family of several children, most of whom were older than she and who
had left home in their early teens. All attempts to work with the parents
had failed and consulting psychiatrist said the family presented the worst
prospects for family therapy of nay he had ever seen. Consequently, the
treatment plan had consisted of phenothiazines and attempts to place the
patient in a foster home, but foster placement was strongly opposed by her
family as well as the patient. At the time of the changeover in ward
leadership. Elizabeth was about to be discharged to a state hospital
because the treatment had been unsuccessful.
    The staff was unanimous in predicting that she would become a chronic state
hospital patient if she did not kill herself first.
The authors decided not to discharge Elizabeth but, instead, to initiate a
program of intensive psychological treatment. Six months after the new
treatment began, an interview was held which we present here to indicate how
the experimental program was experienced by the patient. The interview is
quoted verbatim:
Dr. D: "...when you came into the h hospital ....Describe how thins were
Elizabeth: "Very confused."
Dr. : "What was confused?"
Elizabeth: " My mind. I rally couldn't think through anything. The only
thing in my mind was this. I thought I had to die...the only way out.
Dr. D: "You had to die?Why?"
Elizabeth: "Yes, I felt like I didn't have anything to live fork nobody
wanted me to live, nobody loved me, so why should I live. I was just
destined to die. My thoughts all went to the negative side of things. I
felt as though everything I had to do led up to kind of my dying. I couldn't
look at myself because I was a terrible person...I had evil thoughts about
Dr. D: : "What kind of thoughts seemed so evil?"
Elizabeth: " I can remember thinking one certain thought about a person I
had been in contact with that was a good friend of mine. I can remember
thinking that 'Why is she --I can't stand that. She must be bad.' I
remember that silly thought that I should die for that thought right there.
I hated people. I had this thing, I had to strive to love everybody and
before that excluded anger. There was no anger at all, I couldn't feel it, I
didn't want the feeling."

   At the beginning of her new treatment Elizabeth was restricted to the
ward, and her parents agree not to see her for two to three months. No phone
calls or visits from friends were allowed. In this way we hoped that the
patient would depend on her parents less and the ward community more.
A particular feature of the ward was the assignment of all patients to a
special form of group psychotherapy in addition to individual psychotherapy
three or four times per week. Each of the groups met four times a week; they
were composed of about six patients plus the supervising psychologist, a
psychiatric resident and a psychology-fellow. The trainees and supervisor
met by themselves on the fifth day of each week for an hour of supervision.
In Elizabeth's case, it was decided to act on the hypothesis that he
psychotic and suicidal behavior were a way of dealing with intense, denied
anger originally felt toward her parents. As in the case of Mrs. H.,
psychodrama vignettes were employed in the group therapy sessions. A
psychodrama scene was enacted by either Dr.P. or Dr. W., faithfully modeled
after a detailed account the patient had given of some typical antagonistic
and frightening interactions with her father, who was played by one of the
two therapists in any given session. In addition, the ward nursing staff was
assigned the job of repeatedly confronting the patient with her anger in any
ward situation in which they felt sue that anger was present.

   Elizabeth: "People drove at me all the time, saying 'You appear to be a
little angry. You're angry you're angry, please admit it. You're angry at
your father, you're angry at you mother,' and I wouldn't admit these things.
Then after they threw them at me, I can remember two doctors here, acting out
the psychodrama, and this is when it all started. Dr. P. played my father,
and I played myself. And I can remember the feeling just escaping inside me
and coming out and running over and just trying to strangle Dr. P....just had
my hands around him, trying to squeeze his neck...I was so angry I could kill
him, and that is when it really got bad, when I felt angry that day."
Dr. D: "What made it so bad?"
Elizabeth: "Well it was hard. I had never experience anything so hard.
It's like I had shut myself off form all these kinds of emotions, and I can
actually say that they may have been there, but I didn't feel them."
Dr. D: "You didn't feel the anger at all?"
Elizabeth: "Yeah, I didn't feel anything. I mean that day, just these
overwhelming feelings came upon me. I felt hot, and I felt rushed; I felt
like I could just scream at him, and I could just choke him and 15,000 things
at once. I didn't know what to do, and I was scared...I thought I was going
crazy for sure."
   In the case of Elizabeth, the intensive group focus on her was carried on
for about a week, but then the attention of the group shifted to another
patient, and Elizabeth managed to suppress the anger toward her father that
had surfaced. The ward confrontation continues, however, and about a month
later her feelings erupted once more.

Elizabeth: "About two days after that, I succeeded to suppress all those
feelings, and a month later I got very ill. I couldn't figure out why I was
ill. I was suffering a loss, you know, I had lost somebody who had really
meant a lot to me, and I couldn't -- and I went through this shaking and
screaming at the top of my lungs, and I couldn't control any of it. And then
I just decided, 'I'm angry because I'm screaming,' and I'm saying things I've
never said in my whole life, and I couldn't stop it, and this went on for
three solid days, just screaming at the top of my lungs. Just all kinds of
things like, 'I hate you,' talking about my father and saying, 'I didn't do
this, you're a bastard because you did this to me' and admitting feelings
that people didn't know I had in me."

   Under the old ward policy, the screaming would not have been tolerate.
Elizabeth would have been "medicate" with sufficient phenothiazines to render
her quiet. In case, however, the ward staff behave differently.

Elizabeth: "...At that time I thought they were driving crazy."
Dr. D: "Pressure on you?"
Elizabeth: "Yes, you know. 'Go ahead Elizabeth, scream Elizabeth, it's
okay, go ahead.' And this was how they are coming across to me. I can
remember one of the nurses say, 'Scram, go head, it's all right. Don't be
ashamed.' And I can remember saying, 'Your're trying to drive me craze,' but
yet I can remember saying, 'Don;t leave me alone, please.' I remember
wanting the staff to be with me at all times during those few days because I
was so scared, but I really was very close to them, but yet in another way
it's really bad because I felt 'Well, maybe they're trying to drive me
crazy's remember a one-to-one basis with the attendant, and I can remember
not liking him at all. But I really believe he taught me how to express my
feelings, and he kept talking to me every single night that I was here for
six months. We had sessions that lasted from an hour to two hours, and I
really began to trust him. That was one of my most important experiences

   The patient screamed, and she was encouraged to do so, for the treatment
plan was to try to make her anger conscious, to get her to express her
feeling instead of suppressing them. At the same time, she was provided with
personal support by the nursing staff. One attendant, as she indicated,
spent a great deal of time with her.
During this period she became "worse" in that she was hallucinating.

Elizabeth: " I remember when I became kind of psychotic that night,
hallucinating really bad. The third night just before it was over with I
remember an attendant on the ward with me, and I started screaming. I said,
'Get away from me!' and he kept saying, 'Well, what's going on?' to me his
face had become completely different. He was my father. I had lost touch
with everybody."

Elizabeth had also hallucinated her grandfather.

Elizabeth: " it was strange because I went to bed the third day that night,
and I'm lying there thinking, 'Will, it will be better tomorrow. I won't be grandfather will come and take me away. I won't have to stay
here any longer. He promised he's calm in the morning. And I can remember
waking up and the shaking was gone. I wasn't shaking anymore. And I can
remember looking out the window and saying to myself, 'It's 10:30 , and he's
not here.' And this was the first time in my whole life that I could actual
say, 'You know, I angry. It was hard. I guess I threw it out of my thoughts
so I couldn't thing about it anymore. It was strange because no more
shaking: I could very calmly talk about things compared to the way I was
with the shaking and screaming. It was just strange the way it happened. I
just kept admitting to myself that I was angry, to get it over with and to
talk about everything I was angry about. And then when it was all over,
there was no more to talk about..."

   For the next month, from time to time, she would see her father's face in
different objects or pictures, and she would hear voices saying: "You'll
never get away with it. You'll pay for everything you've done, you'll never
get away with it."

Elizabeth: "I was feeling guilty about being angry, and I can actually say
I felt worse afterwards about a fey things, but they weren't as intensified
as they had been. When I decided to finally look at it and work on it, my
doctor said, 'Well, these voices mean something to you,' and it scared me.
I didn't want to hear them any more. And after that I didn't hear them any

    The patient's reports of hearing voices helped us and the patient to under
stand why she had the need to punish herself. Ordinarily, such reports would
have led to medicating a patient, thereby obliterating an opportunity for
Elizabeth began, at this point, to make much better use of her individual
psychotherapy sessions. Her suicidal preoccupation decreased markedly, she had no further hallucinations or delusions, and he individual psychotherapy focused on working out problems of dependence and independence in her relationship with family. At this point the patient began attending high school classes outside the Hospital and participated in family conferences.
    Three months later there were no signs of psychotic functioning or suicidal
threat and she was doing well in school. Consequently she was discharged
from the hospital to out patient psychotherapy.
The interview repeated below was conducted shortly before discharge.

DR.D: "What kind of things have you come to understand about how things got
so bad...What kind of a jam did you get into?"
Elizabeth: "I think the whole story is that making my family all I wanted
and all I have and also with whatever they said was true, no matter what it
was. This was the whole thing because it was like they'd say, 'Little doll,
you do this, do it, and then jump on your shelf.' "
Dr. D: "Why did you try to do that?"
Elizabeth: "Because I didn't want them to reject me in any way because I
felt they were my whole world, and I had nobody else."
Dr. D: "So it was to hang on to them?"
Elizabeth" "Oh yeah, not knowing how I felt about anything and not getting
angry at them to their faces so they would never get angry at me."
Dr. DL "Do you have any problems now,"
Elizabeth "Oh yeah."
Dr.D: What kind?
Elizabeth: "I think they're typical teenage problems, you know,but are so
much milder, just like -- with my parents over things I want to do and they
don't want me to do."
Dr. D: "Like what?"
Elizabeth "My parents aren't very liberal, and I find myself to be very
liberal now, and maybe it concerns going to this person's house and my
parents don;t k like them because hey are hippies. This thing with whom my
friends should be, and I don't want them to pick my friends. I think picking
my friends is my job."
Dr. D: "Do you think about the future? How does it look to yo for
Elizabeth: "I like to look at the future. I think the most important
thing...I'm going to be myself and not what anybody else wants me to do,
whatever the means. I also feel as though whatever it takes to make
Elizabeth happy, for once I'm going to do it. If it means yelling at people,
then if that makes my happy, I'm going to do it. I look at the future as
being very bright, leaving home and having a like of my own, never ending up
in a psychiatric hospital."

   The treatment program produced far more than merely banishing Elizabeth's
overt psychotic symptoms. Her view of herself and her family became more
appropriate and realistic. Prior to treatment, her thoughts had been turned
backward, clinging and holding to her parents. After this period of
treatment, she was actively thinking and planning in terms of her life ahead.
Elizabeth made successful social adjustments at school where there had been none previously, and she dealt with subsequent problems of loss and
transition with appropriate affect and without recourse to suicidal thoughts
or activities. She left the hospital with significantly increased ego
strength, including better ability to think, to plan ahead, and to control
her own behavior. Elizabeth was in general more nature than before her
decompensation. The risk of recurrence had been reduced and the scope and quality of her like experience had changed to something more open, alive, and forward-looking.
   Following her discharge from the Hospital Elizabeth stayed with her family
for a short time. She then took an apartment, got a job, and for four months
following discharge was in outpatient psychotherapy with the same woman
psychiatric resident who had been her inpatient individual therapist.
Two and a half years after her discharge, the patient and her husband of
two years contacted Dr. W. because they were interested in further outpatient
psychotherapy for her. Both described their marriage as "pretty
successful" though it had been somewhat "downhill" for the past five m
onths.l Her husband, also a former Hospital patient, had done well in his
follow-up outpatient psychotherapy and had started college while Elizabeth
worked as an order clerk for a hardware company. Though claiming that she
didn't resent supporting her husband, she said she wanted a college education for herself also, and she wanted to finish what she had started in
psychotherapy but didn't want a woman therapist again. Elizabeth also
expressed fear of her husband's abandoning her, but said that she realized
she was irrational in always interpreting his anger as rejection.
The second issue, which one can confront only to the degree that the first is
resolved is that of treatment effectiveness. There can by no meaningful
measures of treatment effectiveness unless various approaches to treatment
exist and can be compared. Unfortunately, studies of primarily psychological
treatment approaches to extreme depression are rare. There is a body f
literature, however, that strongly suggests the workability of psychological
approaches with such patients and which helps to explain the results we

   As Fenichel (1945) has stated succinctly, "Freud explained the depressive
self-reproaches as accusations directed against the introjected
object...Abraham added that often complaints appear to come counterwise from the introjected object actually made against the patient" (p. 398). While
this classic dynamic explanation of depression may not fit all cases, it
certainly seemed to fit the cases we treated. It would help to explain the
patients withdrawal and avoidance, which may be furthered by others'
complicity in avoidance. Confirming Freud's ideas, Scholz (1973) found that
suicidal patients showed more turning against the self as a defensive
procedure than nonsuicidal patients. Scholz concluded "critical to the
management and therapy of the suicidal individuals, then, is not merely the
easing over of a particular crisis, but furthering the development of new
means of coping with similar stress in the future" (p.2). Whereas Tabachnk
(1973) says that some suicidal patients may have "creative suicidal crises:
we believed that many suicidal crises could be made creative if "new means of coping with similar stress "could be developed during an "in vivo" experience in which powerful group influence could play a major reconstructive role.
   The specific psychotherapeutic approach we took in these cases may be
thought of as reinstitution the original (basic) genetic event or transaction
and then providing a corrective process Since group influence, originally in
the family group, is important in the development of severe depressive and
suicidal behavior, it makes sense to marshall group corrective emotional
experiences and thus we emphasized group therapy and the ward milieu.
Some authors, such as Bemporad (1970) question the classical
psychoanalytic theory of depression. Bemporad emphasizes "dependency on a dominant other" but his concept does not necessarily conflict with Freud's.
Rather it seems to point up, correctly, one of the major outcomes of the
depressive's training, i.e., continuing to yield to the irrational authority
of another person in ways that are self-destructive and depressing. Our
enactment's of harsh authoritarian oppression served not only to simulate
the original kinds of "training" situations but reflected current situations
for the patient also. Bempoard adds that the depressive's inability to
express anger is related possible to not being able to achieve autonomy and
independence. The solution, then, would seem to be in eliciting a daringly
independent, angry assertiveness on the part of the patient, in an
objectively safe environment which encourages this appropriate assertiveness.
   This method would restore, as it were, the individual's instinctive
response to oppression and relive him or her of having to introject the anger.
   The psychological treatment we employed can be reduced essentially to
these steps.
1. Formulation of the conflict situation to which the patient originally
responded with depression and suicidal inclinations.
2. Reenactment of the conflict situation.
3. Provision of corrective group influence, i.e., encouragement of
assertiveness against the oppressive "authority."
4. Group approval (social reinforcement) of the new coping response.
5. Repeated sequences like the above, with repeated reenactment and
later, verbal review of the process and further social reinforcement of the
new response.
This process is consistent with what Yalom (1975) had delineated as
critical incidents in psychotherapy (;;;. 25-29) providing corrective
emotional experiences in group psychotherapy.
We do not identify our approach with any one school of psychology or
psychotherapy. Psychodrama, psychoanalysis, and behavior modification were certainly in our minds at the time, though we were not "choosing a theory" so much as using what ideas were available. The problem is that, in general, none of these valuable theoretical models seem to get much use in determining the actual treatment of severe, incapacitating depression.
   Our treatment results suggest that this approach can be quite effective.
Our standard of effectiveness was "greatly increased ability to function
productively in the real world, " not just symptomatic relief. We do not
endorse a standard such as "dischargeability" or "symptom relief" by
themselves, because these criteria beg the question of real improvement and
can mislead professionals and the public into emphasizing suppression
instead of improvement.
   The varieties of treatment outcomes suggested to us that the factor of
acute vs. chronic was important but that even quite chronically depressed
persons could benefit, in terms of our improvement criteria. The fact that
none of our several depressed patients, who were deemed hopeless cases when we started, have committed suicide or required rehospitalization has been encouraging. We emphasize, however, that hospital treatment of this type needs to be followed by good quality outpatient psychotherapy. Effective
hospital treatment can give the patient a real developmental opportunity.


BEMPORAD, J.R. New views on the psychodynamics of the depressive character.
In S. Arieti (Ed.), The
world biennial of psychiatry and psychotherapy, Vol. 1. New York: Basic
Books, pp. 219-243, 1970.
DEIKMAN, A. & WHITAKER, L. Humanizing a Psychiatric Ward: Changing from Drugs
to Psychotherapy.
Psychotherapy: Theory, Research & Practice, 16(2), 204-214, 1979.
FENICHEL, O. the psychoanalytic theory of neurosis. New York: Norton, 1945
SCHOLZ, J.A. Defense styles in suicide attempters. J. Consult. Psychol. 41,
70 - 73, 1973.
TABACHNICK, N. Creative suicidal crises, Arch. Gen. Psychiatry, 29, 258-263,
YALOM, I.D. The Theory and Practice of Group Psychotherapy, 2nd Ed. New
York: Basic Books, 1975.

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