Going Beneath The Surface: Psychodynamic Therapy For Depression
When we think of depression, we usually think of its external symptoms. They usually include sadness, fatigue, irritability, difficulty concentrating, or disrupted sleep or appetite. Most people experience a loss of pleasure, interest, and motivation, while others may also feel a sense of hopelessness.
These symptoms matter and can be debilitating. However, they are the manifestation of deeper patterns in our mind: much like a fever, depressive symptoms are indicative that there is something else going on. Psychodynamic depression therapy aims to address the underlying patterns and emotions, many of which are unconscious.
This approach does not assume that we “choose” to feel depressed or that understanding its origins will, on its own, make it disappear. It understands symptoms as expressing something about our emotional life and our inner world. By paying attention to these aspects, therapy can help us gain greater depth, compassion, and freedom.
Looking Beyond the Symptoms
When we are depressed, the world seems flat and small. We may feel that our future is foreclosed and our entire sense of self might feel empty, defective, burdensome, or inevitably alone. At times, this “flattening” serves a protective function.
Wanting less may reduce the risk of disappointment; withdrawing from relationships may protect us against rejection; emotional numbness may keep anger, grief, longing, or sadness away, protecting us from being overwhelmed by them.
Psychodynamic therapy helps make the connections between external symptoms and internal dynamics. While this kind of insight on its own may not be sufficient, it is necessary to understand what is going on in our mind. It is through this understanding and through greater access to the emotions underneath, that we can, over time, find ways to change and relate differently to ourselves and others.
Understanding the Inner Critic
Many people with depression live with a harsh internal voice that interprets mistakes, needs, and limitations as evidence of failure or inadequacy. Nobody is born feeling that way about themselves, so psychodynamic therapy aims to explore how this developed over time. A central part of the work involves understanding how and why we internalized expectations, criticisms, hopes, and fears from significant others in our life, and did our psyche manage them to shape the person we became.
Rather than just replacing “negative” thoughts with “positive” ones, in therapy you will likely examine why self-attack has become so convincing or necessary. Rather than simply “silencing” the inner critic, we may want to understand what it is trying to tell us, who in our life it is representing, and what role does it seems to play.
For example, many people with depression hold, even if unconsciously, a great deal of anger. Harsh self-criticism and self-punishment may represent how this anger was turned inwards rather than being directed at others, as a way to preserve our attachment to them. Recognizing this kind of function and the feelings underneath can loosen the critic’s authority and allow for more compassionate self-understanding.
Mourning What Was Lost
Working through depression in psychodynamic therapy frequently involves recognizing experiences of loss that have not been fully mourned. The loss may concern a person or a relationship that was once part of our life. The actual person might still be around, for example one of our parents, but part of our past experience of them, for example their unconditional love and support, may not.
At times the loss is less apparent, because it is not about something or someone we had in our life, but about something we sorely needed but never had. Those losses are more insidious and more likely to be minimized, but they can leave us with a sense of void or inadequacy that might later be experienced as depression.
The goal of psychodynamic therapy for depression is not to look at the past for its own sake, and certainly not to blame others for our present life, but to understand how the past shapes our present-day struggles. Therapy creates room to acknowledge these losses and absences, helps us surrender the hope that the past could be relived or repaired, without insisting that we should just “get over it.” This process is never easy, but mourning can gradually separate what was lost from the person’s identity, rather than continuing to live with a sense of void within.
Recognizing Relational Patterns
Depression is also relational, not only because it can impact our relationships, but because it is often rooted in a deep -even unconscious- anticipation or rejection or abandonment. If we expect rejection, we may tend to conceal needs and our feelings, withdrawing from relationships or just showing a façade before we feel hurt or disappointed. Or we may interpret uncertainty or ambiguity from others as confirmatory evidence that they don’t care or that we don’t matter.
When we struggle with depression, we tend to live in a world of certainty about our worth and about relationships. This certainty is protective as it helps us preserve emotional safety, yet it reinforces our experience by deepening our loneliness and disconnection.
In therapy, these patterns can be experienced and understood as they unfold. The therapist’s curiosity and willingness to remain present with difficult feelings can offer a different relational experience, one in which deep-seated fears can be spoken and do not need to be hidden. Over time, you might feel more open to expressing disappointment, anger, dependence, affection, and hope, without assuming these feelings will destroy the relationship or make you unacceptable.
Recovering Desire and Agency
Working through depression in psychodynamic therapy is more than just gaining skills, shifting thought patterns, or managing emotional symptoms better. It may involve shifting the relationship we hold with ourselves, recovering curiosity, desire, imagination, and a sense of agency and possibility.
Psychodynamic depression therapy is often gradual because it aims for more than temporary relief. It is not an easy path and it will not entirely get rid sadness, anger, or self-doubt, since those are experiences that make us human. However, by helping you understand what lies underneath depression, what those symptoms are trying to say, therapy can help you participate in relationships more freely and make choices that feel authentic and meaningful to yourself.
About the Author
Santiago Delboy, MBA, LCSW, is a psychotherapist, clinical supervisor, and founder of Fermata Psychotherapy, a psychodynamic therapy practice in Chicago. Fermata provides therapy for adults in-person and virtually. Santiago works with people navigating the aftermath of relational trauma and attachment issues, anxiety, depression, relationship and identity, self-esteem, men’s mental health, and cultural, professional, and life transitions. His approach is informed by psychoanalytic, relational, attachment, and trauma perspectives. He is Adjunct Clinical Faculty at the Chicago Center for Psychoanalysis, and has been a clinical consultant at the Institute for Clinical Social Work and Northwestern University.