Using the case of Anna Thompson, an analysis is made of presenting symptoms that, supported by a differential diagnosis, identifies major depressive disorder. The recommended course of treatment is Jungian psychodynamic therapy. It is first contrasted to Freudian psychoanalysis, and then specific Jungian techniques are highlighted that demonstrate its potential effectiveness in the treatment of an adolescent girl with major depressive disorder who may have been sexually assaulted. The main disadvantages of this form of therapy are reviewed, and the conclusion is offered of its sustained pre-eminence.
There are two parts to determining a mental disorder. First is using a variety of tools such as self-reported symptoms, observation, and written testing to see if the patient meets the criteria requirements laid out in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Second is conducting a differential diagnosis to eliminate other possible disorders that might better account for symptoms and testing results. In the case of Anna Thompson, major depressive disorder is indicated. There are nine criteria for this disorder in the DSM IV, of which five have to be met within the same two week period. Symptoms of the first or second criterion must be present.
Anna shows symptoms of the first criterion by demonstrating a depressed mood and loneliness after enrolling in a new school after her parents’ divorce where she has difficulty making friends. Exacerbating this, her mother’s work duties keep her away from Anna more than was previously the case. Additionally, Anna has been separated from her father and brother, with whom she got along well, for reasons she does not clearly understand. She is particularly sad about not being allowed to spend upcoming Thanksgiving with them.
With reference to the second criterion, Anna shows diminishing interest in normal activity by her recent non-attendance at school. While she had previously missed about a third of her school days since enrollment, she has not attended at all in the last two weeks. Coincidentally, her mother’s work has kept her away from home for the previous three weekends.
While Anna has always struggled with being overweight, and believes her classmates reject her partially for this reason, there has been a marked increase in her overeating in the past two weeks. During this same period, she has also kept herself more or less housebound, spending much of her time oversleeping.
There do not appear to be any symptoms of psychomotor agitation or retardation. While she is more sedentary than usual, she is also capable of chatting on the internet which suggests her psychomotor skills are functioning at normal speeds. Again, her withdrawal into the house with little activity or interaction suggests a lethargy which could be interpreted as fatigue or loss of energy.
Anna’s inability to make friends is symptomatic of feelings of worthlessness. Not only does she believe her difficulty with her weight diminishes her in the eyes of her peers, but so does her status as a racial minority. Mrs. Deetz, the school counselor, insists Anna is mistaken in seeing rejection because of her race, but she nevertheless appears to feel that there is nothing about her that could be a source of positive curiosity and interest to her classmates. In putting down to her race, she attributes it to a factor over which she has no control.
There is no indication that she has a diminished ability to concentrate. When not oversleeping, she watches television and chats with others on the internet, both of which require a basic level of focus.
Finally, Anna appears to demonstrate recurrent suicidal ideation. While she insists her self-mutilation, triggering her admittance into short-term psychiatric care, was not a serious attempt at suicide, she reports that her thoughts at the time were about family reactions if she committed suicide and who would attend the funeral. Mrs. Deetz also reports that, during an unhappy episode at school, Anna voiced a wish to be dead. In isolation, this could be put down to adolescent drama, but Anna admits to the doctor interviewing her that suicide sometimes seems preferable to living, which implies that she has given it repeated thought.
In terms of a differential diagnosis, two additional disorders might be considered: dysthymia, and bipolar disorder. Dysthymia is a milder, but more chronic form of depression. However, the acute symptoms Anna has demonstrated in the previous two weeks take her condition beyond the criteria for dysthymia. The key feature of bipolar disorder is manic episodes sometimes alternating with depressive episodes. Symptoms of mania include abnormally high energy levels, and euphoria or irritability. While Anna has shown irritability, she does not demonstrate other indicators of mania. Further, there is no suggestion of substance abuse, underlying medical conditions, or bereavement as causes for her symptoms.
Only two of the nine criteria for MDD can be clearly eliminated: psychomotor agitation or retardation, and diminished ability to concentrate. Two more criteria are borderline, with insufficient information to determine whether Anna meets them: significant weight gain, and fatigue or loss of energy. Nevertheless, indications of both are strongly suggested. That leaves five criteria that Anna meets, which is sufficient to satisfy the requirements for MDD by the DSM IV.
Besides drug therapy, Jungian psychodynamic therapy is the recommended course of treatment. Given the etiology of Anna’s depressive disorder, she could benefit from this therapy in two major areas: with relationship-building, and with investigating Mrs. Thompson’s suspicion that her daughter was sexually abused by the father.
This is an insight-oriented therapy, which recognizes that past experiences can influence current thoughts, feelings and behaviors negatively. While other therapies aim to address and relieve the symptoms causing difficulty in normal functioning, insight therapies work from the premise that gaining deeply felt insights in the root causes of the trouble will result in the symptoms abating (Kosslyn & Rosenberg, 2006, p. 485).
Psychodynamic theory holds that various aspects of the personality have competing demands, driven from the unconscious. Since, by definition, humans are unaware of the workings of the unconscious, any resulting maladaptive thoughts and behaviors are influenced by invisible motivating forces and are, as a consequence, beyond a person’s ability to change. The key idea behind the theory is to address not just the symptoms negatively impacting someone’s ability to function, but by accessing unconscious thought and bringing it to consciousness, find the causes of their maladaptive thoughts and behaviors. (Kosslyn & Rosenberg, 2006, p. 482).
Two schools dominate this theory: the first, originating with Freud, holds that the unconscious is populated with the competing demands of fundamental urges in a helpless pursuit of pleasure, and Freudian therapy (psychoanalysis) focuses on the most fundamental of those, sexual and aggressive. Freud believed they are influenced by early experiences with caregivers. Since it is the parts we reject about ourselves that are split off into the unconscious, the goal of therapy is to face up to these rejected parts in order to drain away their hidden power over our thoughts, feelings, and behaviors. The second school, which grew out of and diverged from psychoanalysis, was developed by Jung and others, and focuses more on relational experiences. This psychodynamic therapy centers on correcting poorly formed early experiences of relationships using the symbols, myths, and dreams of the wider culture, which Jung believed made up the content of the unconscious, and which he called the collective unconscious. This process is termed individuation, where the goal is to shape the personality by unifying fragmented pieces in the collective unconscious to create a whole.
A significant difference in therapeutic approach between the two schools lies in the relationship between the analyst and analysand. The Freudian analyst strives to remain detached. In this way, he or she can reach for an accurate reading and explanation of the patient’s unconscious drives and motivations. To benefit from this therapy, therefore, the patient first has to accept the therapist’s analysis, and then in a left-brain-driven exercise, be able to process it cognitively. Moreover, while it is to be expected that the patient will transfer feelings onto the analyst, reciprocation in the form of countertransference is considered a flaw in the Freudian analyst, who is then believed to have unanalyzed issues interfering with the therapeutic process that need to be resolved (Knox, 2009, p. 6).
The Jungian analyst, by contrast, accepts that a relationship involves the participation of two parties, and willingly agrees to accompany the patient on a journey into the unconscious (Knox, p. as Virgil accompanies Dante in Divine Comedy. Any feelings on the part of the analyst generated through transference and countertransference are considered not only unavoidable, but acceptable. In fact, not only are they acceptable, they are actively leveraged to get a read on issues important to the patient, as well as for guidance on how best to communicate in a way that will elicit the highest level of responsiveness in the patient.
Allan Schore goes even further, stating that these “affective transactions . . . co-create an intersubjective context that allows for the structural expansion of the patient’s orbito-frontal system and its cortical and subcortical connections” (Schore, 2003, p. 264). In other words, research indicates that these transference-countertransference phenomena can create an environment where the patient’s neural network can physically grow in parts of the brain where the regulation of affect can be assisted.
“From the beginning, the development of mind is dependent on experience of relating to others” (Wilkinson, 2005, p. 485), and thus the Jungian view is that relationship should be central to the cure. Anna has suffered significant losses over the previous year: she has been irreversibly separated from loved members of her family, moved to a new state, and a new school where few students resemble her, and even her mother, with whom she has historically had good relations, is growing more emotionally and physically unavailable. For these reasons, the therapy proposed here concentrates on the latter approach to psychodynamic therapy which builds and nurtures relationships.
Margaret Wilkinson (2005) describes the larger process as one in which the therapist creates a safe and empathic place for the patient to spill out “affect of unbearable experience” (p. 491). Over time, seeing that this does not destroy the relationship with the analyst, the patient learns to regulate it. As a consequence, the patient acquires the capacity to reflect on and “mentalize” the experience, bringing mental and emotional elements to relationships, not just knee-jerk behaviors and their sometimes manipulative consequences (Knox, 2009, p. 12). Then interpretation of the patient’s experience can bring about conscious awareness of the causes of troubling symptoms (Wilkinson, 2005, p. 491-492). Timing, however, is important. “When the patient’s emotions are out of control, consciousness becomes flooded with inchoate emotions and bodily experiences, and at this moment the analyst’s attempt to create a process of self-reflection through interpretation . . . will be unlikely to succeed” (Knox, 2009, p.10).
In contrast to reaching for Freudian accuracy, there is more emphasis on the analyst using “narrative competence to help the patient shape the story [of what happened to her] into a more coherent pattern” (Holmes, 2001, p. 86), a skill which the patient acquires to “fashion a new narrative about her self and her world” (Holmes., p. 85). Anna can learn to reshape her external world into one where, for example, there might be room for racial minority to be a reason to trigger friendships rather than avoid them.
Another important element to this therapy is contributed from attachment theory, where the therapist introduces the patient to a cycle of relational breakdown and repair. First, the therapist shows a tolerance for witnessing strong feelings in another person. However, when inevitable misunderstandings and disagreements ensue between therapist and patient, an equally important function for the therapist is to demonstrate that relationships can be restored. Sue Gerhard “describes the cycle of rupture and repair as the key to secure relationships, thus putting reparation at the heart of relating” (Wilkinson, 2005, p. 497). Anna has been beleaguered with relationship problems in the last year, resulting in self-alienation. Part of her recovery from major depressive disorder and maintenance of future mental health must include a support network. Learning to build and regain trust in relationships would be a critical skill for her to master.
Studies in neuroscience on how the mind-brain processes, encodes, and retrieves experiences demonstrate that two memory systems develop independently, storing and retrieving content in unique ways. Wilkinson summarizes them as follows:
The earliest memory form is implicit, unconscious, emotional and inaccessible, arising out of right hemisphere processing of information, and is on line from birth . . . . Later memory is explicit, conscious, informational and accessible, arising from predominantly left hemispheric process; it comes on line by the time a child is about three years of age. (Wilkinson, p. 487)
She goes on to explain that, in the event of trauma, functions such as sensation, behavior, and image become dissociated from one another, impairing the full formation of conscious memories. Instead, the event is “encoded implicitly in the emotional brain and in the body to remind and warn when similar danger should threaten again” (Wilkinson, p. 487). Lenore Terr takes this further, stating “traumatized children may also dissociate, teaching themselves to self-hypnotize and to enter places of consciousness in which they fail to take in and register full memories of their traumas” (Terr, 1996, p. 76), mentally absenting themselves as the trauma is taking place.
Evidence suggests that defense mechanisms, such as denial and repression, can cause victims of child sexual assault to function normally with no apparent symptoms, only to have dysfunctions emerge in adulthood (Green, 2008, p. 105). Thus, while there is only suspicion that Anna was subjected to sexual assault by her father, her denial cannot be taken at face value. Further, Wilkinson describes the same experience in World War I and Vietnam veterans, of traumatic events remaining in implicit memory while disappearing from the conscious mind. The fact that Mrs. Thompson’s suspicion was triggered by a scene she witnessed relatively recently does not discount a memory “lapse” on Anna’s part. What Eric Green describes as “sleeper effects” are not an age-specific phenomenon, and Anna may genuinely have no recall of recent sexual assault.
Green champions a form of therapy called Jung Analytic Play Therapy (JAPT), as opposed to the cognitive-behavioral therapies which tend to be routinely utilized in these cases. He explains that children who use denial to insulate themselves from trauma are protecting fragile egos. As such, they “may not have the ego strength to cognitively resolve traumatic events” (p. 105).
JAPT, on the other hand, uses indirect techniques, such as serial drawing (a series of drawings created over time during sessions) and picture journaling (combining journal writing with art, created between sessions) to sidestep the cognitive mind and access mental artifacts through symbolic meaning. Jung believed that “the collaboration of the unconscious is intelligent and purposive, and even when it acts in opposition to consciousness its expression is still compensatory in an intelligent way, as if it were trying to restore a lost balance” (Jung, 1939, p. 282). He implies a psychic equivalent to the physiological function of homeostasis.
As these symbols appear, they signal critical issues that the therapist can to address with more direct, carefully chosen techniques, creatively finding ways to proceed with the analytical tasks outlined above of reflection and interpretation. Because the emphasis is to “stay at the child’s feeling level” (Green, p. 107), the patient is not pushed prematurely to deal cognitively with the issues that arise. If Anna’s denial of sexual misconduct is motivated by a desire to protect an absent parent whom she loves and misses, and moreover, one whom she is now free to romanticize since she is no longer exposed daily to his human flaws, these techniques offer an opportunity to bypass her defenses.
An integral part of Green’s treatment plan is to include “non-offending caretakers . . . and other significant adults . . . in consultation and collaboration” (Green, p. 115). Regular family therapy sessions would benefit not only Anna, but also Mrs. Thompson in a supportive process of feeling heard and validated. Meanwhile, the collaboration would extend to an evaluation of all Anna’s potential supports, from mental health professionals to the school’s teaching, administrative, counseling, and medical staff in order to put in place a multidisciplinary team to support her and her mother through and after therapy. The resources and opportunities offered by Mrs. Deetz, the school guidance counselor, can be put to good use.
There are, however, several disadvantages to psychodynamic therapy. One is resistance. This occurs when the patient refuses to cooperate with the therapist. However, the development of indirect techniques, including JAPT, is specifically designed to overcome these types of defenses. Another weakness is its subjective nature. Since progress through insight therapies cannot be objectively measured, not much research exists to validate it. Growing contributions from research in other areas and disciplines, however, such as attachment theory, dissociative theory, and neuroscience, are adding to a body of support for its success. Finally, one of the biggest shortcomings of insight therapies is the cost and long-term nature of the process. Classical psychodynamic theory has no “game plan” and requires several sessions per week lasting for years, allowing what emerges about the patient to appear in its own time. However, recent developments and adaptations in setting specific goals for therapy and improved therapeutic techniques have resulted in documented success with shorter therapies, even with only one session per week. Nevertheless, success depends on the readiness of the patient to deal with unpalatable truths about their experiences and, therefore, timing cannot be predetermined. This alone threatens to put this form of analysis outside the resources of many patients, no matter how beneficial it might be therapeutically.
Financial restrictions aside, insights could bring relief to Anna’s symptoms in many ways. For example, as she learns to trust in relationships, she will feel more inclined to reach out to other students. With some success she might become more adventurous in joining in with activities her friends pursue, and then activities that appeal to her whether or not her friends are interested.
With increased activity, she will have less time to sit around and fall prey to negative thoughts, or try to fill a sense of emptiness with unneeded food. Meanwhile, with her new narrative competence, she can reframe any rebuffed attempts to build relationships in terms of factors outside her control, so any failure is not her fault, thus short-circuiting any derailment of her journey back to mental wellness.
As she learns to fill her life with satisfying relationships and starts to take care of her own emotional needs, her mother will also benefit by feeling relieved of the responsibility of being the sole source of comfort for her daughter. As a result, since they have enjoyed good relations in the past, she may resume her role as a central and effective protective factor in Anna’s life, adding to and strengthening the cycle of mental health.
In summary, the primary advantage of Jungian psychodynamic therapy over most other perspectives is its documented success with young people through the use of indirect techniques in play therapy. Also, if Anna was subjected to sexual assault, these techniques offer excellent opportunities to get around her defenses; and if she was not, they would still raise critical issues that have been contributing to her major depressive disorder. By accessing the unconscious and making the invisible visible, Anna could start healing deep wounds, but more spectacularly, research indicates the relationship itself with the therapist can cause her brain to adapt and grow. It is only the economic implications of its long-term nature that might create financial barriers to full treatment, and stand in the way of significant potential therapeutic benefits.
Green, E. (2008). Reenvisioning Jungian analytical play therapy with child sexual assault survivors. International Journal of Play Therapy, 17(2), 102-121.
Holmes, J. (2001). The search for the secure base. London and New York: Brunner-Routledge.
Jung, C. G. (1939). Conscious, unconscious and individuation. Collected Works 9i, 275-289. London: Routledge and Kegan Paul.
Knox, J. (2009). The analytic relationship: Integrating Jungian, attachment theory and developmental perspectives. British Journal of Psychotherapy, 25(1), 5-23.
Kosslyn, S. M. & Rosenberg, R. S. (2006). Psychology in context (3rd ed.) Pearson Education, Inc: Allyn and Bacon.
Schore, A. (2003). Affect regulation and the repair of the self. New York, NY, and London: Norton.
Terr, L. (1996). True memories of childhood trauma: Flaws, absences, and returns. The recovered memory/false memory debate (pp. 69-80). San Diego, CA US: Academic Press.
Wilkinson, M. (2005). Undoing dissociation. Affective neuroscience: A contemporary Jungian clinical perspective. The Journal of Analytical Psychology, 50(4), 483-501.