How does treatment for self-blaming depression differ from treatment of 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 opposites.3 Some cases remit without treatment, and others require lifelong management with psychotherapy, pharmacotherapy, or physical treatments like electroconvulsive therapy. Given this wide variability in presentation, severity, and course, the idea that all depressed patients are suffering from the same disorder seems unlikely.
While the DSM diagnostic system classifies all depressions as major depressive disorder or persistent depressive disorder (dysthymia), psychodynamic theorists have historically divided depression into various subtypes based on proposed etiology and manifest symptoms. Some of these types include endogenous or metabolic depression; exogenous or reactive depression; anaclitic depression; introjective depression; claiming depression; self-blaming depression; depressive personality; and others.
Identifying subtypes of depression helps us select appropriate treatment and can inform long-term prognosis. It also allows us to become particularly attuned to the psychological mechanisms underlying the patient’s depressive symptoms. In this article, I will briefly review the concept of self-blaming depression and its psychotherapeutic treatment, which differs in important ways from the treatment of other forms of depression.
Mrs Jones is a 60-year-old female who has struggled with depressive symptoms off-and-on throughout her adult life. Her most recent depression occurred following the death of her cat, who developed an injection-site sarcoma after a vaccination for feline leukemia. Upon evaluation, Mrs Jones states, “It is all my fault. I should have never had my cat vaccinated. I should have done my homework before taking her to the vet.” Prior depressions occurred similarly following events attributed by Mrs Jones to her own personal failings. In psychotherapy, she only becomes more depressed by words of hopeful encouragement, stating, “I do not deserve to feel any better. I am a failure.” Every life disappointment is interpreted as punishment for her badness and guilty deeds.
Psychoanalytic and psychodynamic theories have historically considered depression a reaction to loss.4 Something has happened in the life of the patient—the loss of a loved one; a job or position; a status; a concept of ourselves; an ideal—that leads to the onset of the depressive symptoms. Depression is thus a reaction to the loss of a key ingredient in our normal mental life. Like physical pain, depression, or psychic pain, has only one purpose: to be removed.5
In the very early lives of individuals who go on to become depressed, there is often a period of intense gratification of needs followed by a period of relative deprivation. This change from a near-paradisal situation to an environment of unmet expectations sets the stage for the later onset of depression in response to loss. The child reacts to the change by working harder to reclaim the lost paradise. If he or she fails, it is because the child is at fault. The child must atone or work harder. Eventually, the child realizes that no matter what is done, the paradise will not be recaptured. It is this realization that brings about the depressed feeling.6
In the self-blaming type of depression, this pattern is replayed in symbolic form. Some loss has been sustained, and the patient feels that his or her way of living has caused such a loss. This produces the manifest depressive symptoms. Arieti6 writes that in self-blaming depression, “the message the patient relays is not ‘help me,’ but ‘I do not deserve any help, any pity.’” He continues, “When suicidal ideas exist, 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 are too good to do it.’”
My experience has been that self-blaming depressed patients are deemed more difficult to work with and are thus more quickly referred for biological treatment than those with other types of depression. Yet, psychotherapy can be particularly effective for these patients, especially those with mild or moderate cases and those not complicated by comorbid mental disorder. The psychotherapeutic approach to self-blaming depression differs in significant ways from that used with other depressed patients, which I will discuss below.
In self-blaming depression, the patient comes to translate well-meaning, encouraging statements through a filter of self-accusation and guilt. Thus, for these patients, the therapist cannot assume the role of benevolent helper as they might in other cases. When offered kind reassurance and expressions of hope, self-blaming patients characteristically feel worse and more guilty, and reject the help. It is as if the patient says to the therapist, “I am unworthy 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 their depressive patients’ self-esteem are either ignored or received paradoxically. Supportive comments to a person immersed in self-loathing may provoke increased depression via the internal transformation: “Anyone who really knew me could not possibly say such positive things.”
Other misinterpretations made by self-blaming patients, described by Frances,7 include some variation of: 1) “How nice you are; how terrible I must be”; 2) “How awful I am to fool you into saying nice things about me”; 3) “You would hate me too if you only knew how hateful I am”; and 4) “How dare you be hopeful when there is no hope.”
If the therapist is not supposed to offer hopeful or supportive statements, at least during the acute phase of the illness, then what is he or she to do? Arieti6 describes that an investigation of the family or relationship situation often reveals dynamics that increase the patient’s feelings of duty or guilt. For instance, a spouse may say to the patient, “You are too sick to do the housework now” or “For many years, you took care of me; now it is my turn to take care of you.” These statements are interpreted by the patient as criticism and only worsen the guilt feeling.
Eventually, it will become possible to point out to the patient that the losses and disappointments which have led to the depression are actually symbolic of earlier, greater losses and disappointments, and that the patient has come unconsciously to repeat these patterns in his or her adult life. Thus, interpretation of the meaning and symbolism of the depressive symptoms is of chief importance in the treatment of these patients—perhaps even more so than in other forms of depressive illness.
As treatment proceeds, the therapist must remain attuned to the ups and downs of the patient’s life, for any setback may trigger the state of sadness and guilt. For instance, the patient may get depressed over the fact that he or she becomes so easily depressed. At times, when the depression has improved, a relapse may occur if the patient is allowed to feel guilty for the allegedly undeserved improvement. At this point, the patient may become so discouraged by the relapse that he or she may abruptly discontinue therapy.6
Throughout the treatment, the therapist must remind the patient that the minor disappointments of life—those to which the patient reacts so intensely—symbolize a much larger disappointment in early life, and that he or she is in actuality responding to an early loss of much greater and much more significant proportions. If this is not done—if the meaning of the symptoms remains uninterpreted and the focus of the treatment is solely on correcting cognitions—then the depression will be perpetuated.
Self-blaming depression reflects a unique subtype of depressive illness characterized by self-accusation, guilt, and an exaggerated sense of self-responsibility. Given its psychodynamic mechanisms, psychotherapeutic treatment of patients with self-blaming depression proceeds along different lines from treatment of other depressed patients. In particular, the therapist must be very carefully attuned to the patient’s tendency to interpret supportive statements as criticism and to the symbolic transformation of the early loss into present-day losses and disappointments. Psychotherapeutic treatment is possible and often effective in these cases.
Dr Ruffalo is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando, and an adjunct instructor 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.” World Psychiatry. 2011;10(3):226-228.
2. Paris J. The mistreatment 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 Publishing; 2013.
4. McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure 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-blaming patients misinterpret well meaning reassurance: 1) How nice she is=How terrible I am 2) How awful of me to fool him into saying nice things about me 3) You would hate me too if only you knew how hateful I am 4) How dare you be hopeful when there's no hope. https://twitter.com/AllenFrancesMD/status/1430564200888168450. Posted August 25, 2021.