Psychodynamic Theories Psychodynamic theory was the dominant school of thought within psychiatry and much of clinical psychology

during the first part of the 20th century, at least with regard to ideas about how psychotherapy should be conducted. Early psychodynamic approaches focused on the interrelationship of the mind (or psyche) and mental, emotional, or motivational forces within the mind that interact to shape a personality. The famous Dr. Sigmund Freud, who is credited with inventing psychodynamic theory and psychoanalysis, influentially suggested that the unconscious mind is divided into multiple parts, including the irrational and impulsive Id (a representation of primal animal desires), the judgmental Super-ego (a representation of the rules and norms of society inside the mind), and the rational Ego (which serves as an attempt to bridge the other two parts). According to Freud, the conscious and unconscious parts of the mind can come into conflict with one another, producing a phenomena called repression (a state where you are unaware of having certain troubling motives, wishes or desires but they influence you negatively just the same). In general, psychodynamic theories suggest that a person must successfully resolve early developmental conflicts (e.g., gaining trust, affection, successful interpersonal relationships, mastering body functions, etc.). in order to overcome repression and achieve mental health. Mental illness, on the other hand, is a failure to resolve these conflicts. There are multiple explanations that fall under the psychodynamic "umbrella" that explain why a person develops depressive symptoms. Psychoanalysts historically believed that depression was caused by anger converted into self-hatred ("anger turned inward"). A typical scenario regarding how this transformation was thought to play out may be helpful is further explaining this theory. Neurotic parents who are inconsistent (both overindulgent and demanding), lacking in warmth, inconsiderate, angry, or driven by their own selfish needs create a unpredictable, hostile world for a child. As a result, the child feels alone, confused, helpless and ultimately, angry. However, the child also knows that the powerful parents are his or her only means of survival. So, out of fear, love, and guilt, the child represses anger toward the parents and turns it inwards so that it becomes an anger directed towards him or herself. A "despised" self-concept starts to form, and the child finds it comfortable to think thoughts along the lines of "I am an unlovable and bad person." At the same time, the child also strives to present a perfect, idealized (and therefore acceptable) facade to the parents as a means of compensating for perceived weaknesses that make him or her "unacceptable". Caught between the

belief that he or she is unacceptable, and the imperative to act perfectly to obtain parental love, the child becomes "neurotic" or prone to experiencing exaggerated anxiety and/or depression feelings. The child also feels a perpetual sense that he or she is not good enough, no matter how hard he or she tries.
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This neurotic need to please (and perpetual failure to do so) can easily spread beyond the situation in which it first appears, such that the child might start to feel a neurotic need to be loved by everyone, including all peers, all family members, co-workers, etc. The goal of a traditional psychodynamic psychotherapy might be to help the child (now an adult in therapy) to gain insight into the mistaken foundations of his or her belief in his or her badness and inadequacy so that the need to punish himself/herself and to be perfect decreases. Psychodynamic theory has evolved a fair amount over its long history, and many variations of the original theory are available today. One popular branch of modern psychodynamic theory, known as object relations theory, is concerned with how people understand and mentally represent their relationships with others. The "objects" in object relations theory are representations of people (how other people are experienced, represented and remembered by the person doing the objectification). According to object relations theory, people's moods and emotions (and many other aspects of their personalities) can only be properly understood against the backdrop of the relationships those people have experienced. It is a foundational assumption of object relations theory that early relationships tend to set the tone for later relationships. According to object relations theory, depression is caused by problems people have in developing representations of healthy relationships. Depression is a consequence of an ongoing struggle that depressed people endure in order to try and maintain emotional contact with desired objects. There are two basic ways that this process can play out: the anaclitic pattern, and the introjective pattern. Even though these terms are not currently used in the DSM, some therapists may still use them to label different types of depression. Anaclitic depression involves a person who feels dependent upon relationships with others and who essentially grieves over the threatened or actual loss of those relationships. Anaclitic depression is caused by the disruption of a caregiving relationship with a primary object and is characterized by feelings of helplessness

and weakness. A person with anaclitic depression experiences intense fears of abandonment and desperately struggles to maintain direct physical contact with the need-gratifying object. Introjective depression occurs when a person feels that they have failed to meet their own standards or the standards of important others and that therefore they are failures. Introjective depression arises from a harsh, unrelenting, highly critical superego that creates feelings of worthlessness, guilt and a sense of having failure. A person with introjective depression experiences intense fears of losing approval, recognition, and love from a desired object. Historically, psychodynamic theories were extensively criticized for their lack of empiricism (e.g., their disinterest in subjecting their theories to scientific testing). However, this resistance to putting psychodynamic concepts on a scientific footing has started to change recently. Another modern derivative of psychodynamic theory, Coyne's interpersonal theory of depression has been studied extensively, and forms the basis of a very effective treatment option known as Interpersonal Therapy or IPT. According to interpersonal theory a depressed person's negative interpersonal behaviors cause other people to reject them. In an escalating cycle, depressed people, who desperately want reassurance from others, start to make an increasing number of requests for reassurance, and the other people (to whom those requests are made) start to negatively evaluate, avoid, and reject the depressed people (or become depressed themselves).. Depressed people's symptoms then start to worsen as a result of other people's rejection and avoidance of them. IPT has been designed to help depressed people break out of this negative spiral. We'll have more to say about IPT in the treatment sections of this document. Behaviorism began as a form of research psychology. For the early part of the 20th century, the behaviorists were strictly scientists, working in universities on psychological research problems. They did not really start to think about mental illness and psychotherapy until the 1930s and 40s, well after the psychodynamic therapists had all but cornered the market. To the behaviorist, human behavior has nothing to do with internal unconscious conflicts, repression, or problems with object representations. Rather, a behavioral psychologist uses principles of learning theory to explain human behavior. According to behavioral theory, dysfunctional or unhelpful behavior such as

depression is learned. Because depression is learned, behavioral psychologists suggest that it can also be unlearned. In the mid 1970s, Peter Lewinsohn argued that depression is caused by a combination of stressors in a person's environment and a lack of personal skills. More specifically, the environmental stressors cause a person to receive a low rate of positive reinforcement. Positive reinforcement occurs when people do something they find pleasurable and rewarding. According to learning theory, receiving positive reinforcement increases the chances that people will repeat the sorts of actions they have taken that led them to receive that reinforcement. In other words, people will tend to repeat those behaviors that get reinforced. For example, many people show up at work on a regular basis in order to receive money or insurance benefits. Most academically-minded children study in order to help ensure that they will continue to receive good grades. In these examples, working and studying are behaviors that are motivated by money, benefits, and good grades, which are positive reinforcers.
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According to Lewinsohn, depressed people are precisely those people who do not know how to cope with the fact that they are no longer receiving positive reinforcements like they were before. For example, a child who has newly moved to a new home and has consequently lost touch with prior friends might not have the social skills necessary to easily make new friends and could become depressed. Similarly, a man who has been fired from his job and encounters difficulty finding a new job might become depressed. In addition, depressed people typically have a heightened state of self-awareness about their lack of coping skills that often leads them to self-criticize and withdraw from other people (e.g., depressed people may avoid social functions and get even less positive reinforcement than before). To make matters worse, some depressed people become positively reinforced for acting depressed when family members and social networks take pity on them and provide them with special support because they are "sick". For example, some spouses may take pity on their depressed partners and start to do their chores for them, while the depressed person lays in bed. If the depressed person was not thrilled to be doing those chores in the first place, remaining depressed so as to avoid having to do those chores might start to seem rewarding. Research suggests that Lewinsohn's theory explains the development of depression for some individuals, but not for all.

Traditionally, behaviorists did not pay much attention to people's thoughts, perceptions, evaluations or expectations and instead focused solely on their external and directly observable and measurable behavior. They did this not because they weren't aware of these internal feelings and thoughts, but because they thought them relatively irrelevant to the process of influencing behavior, and too difficult to measure with any accuracy. It turns out that this position was too extreme. More recently, research has shown that internal events such as perceptions, expectations, values, attitudes, personal evaluations of self and others, fears, desires, etc. do affect behavior, and are important to take into account when doing therapy. As a result, old-fashioned "strict" behavioral approaches to treating depression are not as popular today as they used to be. Cognitive theories rose to prominence in response to the early behaviorists' failure to take thoughts and feelings seriously. The cognitive movement did not reject behavioral principles, however. Rather, the idea behind the cognitive movement was to integrate mental events into the behavioral framework. Cognitive Behavioral theories (sometimes called "cognitive theories") are considered to be "cognitive" because they address mental events such as thinking and feeling. They are called "cognitive behavioral" because they address those mental events in the context of the learning theory that was the basis for the pure behavioral theory described above. The rise in popularity of cognitive behaviorism continues today; it forms the basis of the most dominant and well-research formed of psychotherapy available today: Cognitive-Behavioral Therapy, or CBT. Cognitive behavioral theorists suggest that depression results from maladaptive, faulty, or irrational cognitions taking the form of distorted thoughts and judgments. Depressive cognitions can be learned socially (observationally) as is the case when children in a dysfunctional family watch their parents fail to successfully cope with stressful experiences or traumatic events. Or, depressive cognitions can result from a lack of experiences that would facilitate the development of adaptive coping skills. According to cognitive behavioral theory, depressed people think differently than non-depressed people, and it is this difference in thinking that causes them to become depressed. For example, depressed people tend to view themselves, their environment, and the future in a negative, pessimistic light. As a result, depressed people tend to misinterpret facts in negative ways and blame themselves for any misfortune that occurs. This negative thinking and judgment style functions as a negative bias; it makes it easy for depressed people to see situations as being

much worse than they really are, and increases the risk that such people will develop depressive symptoms in response to stressful situations. Aaron Beck's Cognitive Theory of Depression Different cognitive behavioral theorists have developed their own unique twist on the Cognitive way of thinking. According to Dr. Aaron Beck, negative thoughts, generated by dysfunctional beliefs are typically the primary cause of depressive symptoms. A direct relationship occurs between the amount and severity of someone's negative thoughts and the severity of their depressive symptoms. In other words, the more negative thoughts you experience, the more depressed you will become.
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Beck also asserts that there are three main dysfunctional belief themes (or "schemas") that dominate depressed people's thinking: 1) I am defective or inadequate, 2) All of my experiences result in defeats or failures, and 3) The future is hopeless. Together, these three themes are described as the Negative Cognitive Triad. When these beliefs are present in someone's cognition, depression is very likely to occur (if it has not already occurred). An example of the negative cognitive triad themes will help illustrate how the process of becoming depressed works. Imagine that you have just been laid off from your work. If you are not in the grip of the negative cognitive triad, you might think that this event, while unfortunate, has more to do with the economic position of your employer than your own work performance. It might not occur to you at all to doubt yourself, or to think that this event means that you are washed up and might as well throw yourself down a well. If your thinking process was dominated by the negative cognitive triad, however, you would very likely conclude that your layoff was due to a personal failure; that you will always lose any job you might manage to get; and that your situation is hopeless. On the basis of these judgments, you will begin to feel depressed. In contrast, if you were not influenced by negative triad beliefs, you would not question your self-worth too much, and might respond to the lay off by dusting off your resume and initiating a job search. Beyond the negative content of dysfunctional thoughts, these beliefs can also warp and shape what someone pays attention to. Beck asserted that depressed people pay selective attention to aspects of their environments that confirm what they

already know and do so even when evidence to the contrary is right in front of their noses. This failure to pay attention properly is known as faulty information processing. Particular failures of information processing are very characteristic of the depressed mind. For example, depressed people will tend to demonstrate selective attention to information, which matches their negative expectations, and selective inattention to information that contradicts those expectations. Faced with a mostly positive performance review, depressed people will manage to find and focus in on the one negative comment that keeps the review from being perfect. They tend to magnify the importance and meaning placed on negative events, and minimize the importance and meaning of positive events. All of these maneuvers, which happen quite unconsciously, function to help maintain a depressed person's core negative schemas in the face of contradictory evidence, and allow them to remain feeling hopeless about the future even when the evidence suggests that things will get better Albert Ellis' Cognitive Theory of Depression Dr. Albert Ellis pointed out that depressed people's irrational beliefs tend to take the form of absolute statements. Ellis describes three main irrational beliefs typical of depressive thinking:
1. "I must be completely competent in everything I do, or I am worthless." 2. "Others must treat me considerately, or they are absolutely terrible." 3. "The world should always give me happiness, or I will die."

Because of these sorts of beliefs, depressed people make unqualified demands on others and/or convince themselves that they have overwhelming needs that must (simply must!) be fulfilled. Ellis, well known for his rather acid wit, referred to this tendency towards absolutism in depressive thinking as "Musterbation." Ellis also noted the presence of information processing biases in depressed people's cognitions. Like Beck he noted that depressed people tend to: ignore positive information, pay exaggerated attention to negative information, and to engage in overgeneralization, which occurs when people assume that because some local and isolated event has turned out badly, that this means that all events will turn out badly. For example, depressed people may refuse to see that they have at least a few friends, or that they have had some successes across their lifetime (ignoring

the positive). Or, they might dwell on and blow out of proportion the hurts they have suffered (exaggerating the negative). Other depressed people may convince themselves that nobody loves them or that they always mess up (overgeneralizing).
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Ellis' ideas led him to develop Rational Emotive Therapy (RET), which was later renamed Rational Emotive Behavior Therapy (REBT). We discuss REBT as well as Beck's CBT in more detail in the treatment sections of this document. Bandura's Social Cognitive Theory of Depression Psychologist Albert Bandura's Social Cognitive learning theory suggested that people are shaped by the interactions between their behaviors, thoughts, and environmental events. Each piece in the puzzle can and does affect the shape of the other pieces. Human behavior ends up being largely a product of learning, which may occur vicariously (e.g., by way of observation), as well as through direct experience. Bandura pointed out that depressed people's self-concepts are different from nondepressed people's self-concepts. Depressed people tend to hold themselves solely responsible for bad things in their lives and are full of self-recrimination and selfblame. In contrast, successes tend to get viewed as having been caused by external factors outside of the depressed person's control. In addition, depressed people tend to have low levels of self-efficacy (a person's belief that they are capable of influencing their situation). Because depressed people also have a flawed judgmental process, they tend to set their personal goals too high, and then fall short of reaching them. Repeated failure further reduces feelings of self-efficacy and leads to depression. An important psychological concept, which is closely related to Bandura's selfefficacy idea, is Julian Rotter's concept of locus of control. When people believe that they can affect and alter their situations, they may be said to have an internal locus of control and a relatively high sense of self-efficacy. When individuals feel that they are mostly at the mercy of the environment and cannot alter their situation, they have a external locus of control, and a relatively low sense of self-efficacy. To extend the above explanation, depressed people tend to have a external locus of control and a low sense of self-esteem.

Seligman's Learned Helplessness In early 1965, psychologist Martin Seligman and his colleagues" accidentally" discovered an unexpected phenomenon related to human depression while studying the relationship between fear and learning in dogs. Seligman's study involved watching what happened when a dog was allowed to escape an impending (and aversive but non-damaging) shock so long as they escaped from a designated area of their enclosure upon hearing a tone. During the first experiment, the researcher rang a bell immediately prior to administering a brief slightly unpleasant sensation to the dog. The idea was that the dog would learn to associate the tone with the shock. In the future, the dog would then feel fear when it heard the bell, and would run away or show some other fear-related behavior upon hearing the tone. During the next part of the experiments, the researchers put the conditioned dog (which had just learned that hearing the tone is a warning for an upcoming shock) into a box with two compartments divided by a low fence. Even though the dog could easily see over and jump over the fence, when the researchers rang the bell and administered the shock, nothing happened (the dog was expected to jump over the fence.) Similarly, when they shocked the conditioned dog without the bell, nothing happened. In both situations, the dog simply lay down. Interestingly, when the researchers put a normal dog into the same box contraption, it immediately jumped over the fence to the other side. Apparently, the conditioned dog had learned more than the connection between the tone and the shock. It has also learned that trying to escape from the shocks was futile. In other words, the dog learned to be "helpless." This research formed Seligman's subsequent theory of Learned Helplessness, which was then extended to human behavior as a model for explaining depression. According to Seligman, depressed people have learned to be helpless. In other words, depressed people feel that whatever they do will be futile, and that they have no control over their environments.
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Useful as it was for explaining why some people became depressed, the initial learned helplessness theory could not account for or explain why many people did not become depressed even after experiencing many unpleasant life events. With further study, Seligman modified the learned helplessness theory to incorporate a person's thinking style as a factor determining whether learned helplessness would

occur. He suggested that depressed people tended to use a more pessimistic explanatory style when thinking about stressful events than did non-depressed people, who tended to be more optimistic in nature. As a means of illustrating explanatory style, let's pretend that you fail an exam. In response, you could think: 1) I am stupid. 2) I'm not good in math. 3) I was unlucky, it was Friday the 13th. 4) The math teacher is prejudiced. 5) The math teacher grades hard. 6) I was feeling ill that day. 7) The math teacher gave a hard test this time. 8) I didn't have time to study. Individuals who tend to view the causes of negative events as internal, global, and stable (e.g., people who use explanations #1, #2) are said to have a pessimistic attributional style. Individuals who tend to view the causes of negative events as external, specific, and unstable (e.g., explanation #7) have an optimistic attributional style. Individuals who become depressed are more likely to have pessimistic attributional styles than optimistic attributional styles. According to the revised learned helplessness theory, a pessimistic attributional style increases the likelihood of developing learned helplessness. In addition, prolonged exposure to uncontrollable and inescapable events can lead people to develop a pessimistic attributional style, and to become apathetic, pessimistic, and unmotivated, even if they are not that way to start An adaptation of this theory argues that depression results not only from helplessness, but also from hopelessness. The hopelessness theory attributes depression to a pattern of negative thinking in which people blame themselves for negative life events, view the causes of those events as permanent, and overgeneralize specific weaknesses to many areas of their life (e.g., "I am not good at creative things, so I am therefore not a good mother, therefore my relationship with my child is undoubtedly doomed"). Other cognitive behavioral theorists suggest that people with "depressive" personality traits appear to be more vulnerable than others to depression. Examples of depressive personality traits include neuroticism, gloominess, introversion, self-criticism, excessive skepticism and criticism of others, deep feelings of inadequacy, and excessive brooding and worrying. In addition, people who regularly behave in dependent, hostile, and impulsive ways appear at greater risk for depression. The Effects of Culture

Culture and ethnicity are important aspects of health and illness. A new branch of medicine, known as ethnomedicine, focuses on the role of culture, perception, and context in shaping someone's physical and mental health. Previously, it was thought that depression primarily plagued people in developed "Western" nations and that non-Euro-American cultures did not suffer from this disorder. However, ethnomedical studies suggest that this perception may have more to do cultural perceptions of what symptoms become labeled as a depressive disorder, how occurrences of depression are recorded for statistical purposes, and how depression is thought of within particular cultures. For example, in India, a wide range of distress disorders are categorized as depressive disorders, whereas in Japan, the very idea of mental illness is unacceptable and few people will admit to having it. Obviously, without knowing the full story, someone might conclude that Indian people have very high rates of depression, or conversely, that Japanese people rarely develop this disorder. Even within the United States, prevalence rates (the numbers of people experiencing depression) can be influenced by cultural context. For example, black women have lower rates of depression than white women. In addition, recent immigrants to the U.S. tend to have lower rates of depression than their descendants, who are presumably more "Western" in attitudes and behavior. Ethnomedical research suggests that cultural differences in focusing on oneself and one's place within the social hierarchy are linked to the prevalence of depression. Some of this difference comes from the individualistic vs. collectivistic orientation of a particular culture. In Western cultures, individuals are ideally viewed as independent, autonomous entities striving for individual achievement and success. In contrast, other cultures view the family or society as being of more importance than the individual. Many times, personal happiness is sacrificed for the stability of the group at large in such cultures. Very little thought is given to particular individuals within such cultures. For example, in traditional Asian cultures it is common for one member of the family to work hard and share a paycheck with the entire extended family. Some authors suggest that because people from collectivistic cultures are not encouraged to place much importance on personal gratification, they do not spend time feeling frustrated about their failure to achieve personal success. As a result, the lack of focus on the self can lead to a decrease or absence of the development of depressive disorders. Our norms about our specific responsibilities and obligations (to our selves, to others, and to the institutions we live with) are also shaped by our culture. For

example, a person who comes from a culture where family obligations are demanding and non-negotiable may feel restricted, powerless, and limited. On the other hand, a person from the same culture may view family obligations as a way to feel needed, useful and competent. As mentioned in our discussion about cognitive theories, feelings and thoughts concerning powerlessness and usefulness shape people's self-concept and mood.
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Some cultures have rigid gender roles that define expected behavior. Men's lives exist primarily outside the home, while women's roles are specifically in the home. In these cultures, women may not even leave their homes unless escorted by a male family member; conversely, men never enter the kitchen. If someone from this type of culture encounters a social stressor which forces a change in roles or a challenge to the status quo (i.e., the death of a spouse), such stress can cause this person to become depressed. For instance, if a husband (from a culture with rigid gender roles) loses a wife, he will not know how to care for his children's day to day needs such as feeding, bathing, etc. Similarly, if a wife loses her husband, she will not know how to provide financial support for her family (and additionally, may be prevented from even trying). Both individuals may start to think of themselves as worthless or useless if they cannot meet the needs of their children. Cultural identity often influences the degree to which a particular individual shows somatic (physical) symptoms of depression. In other words, some cultures are more comfortable reporting depressive symptoms that are physical in nature rather than mental. For example, many depressed Chinese people complain of bodily discomfort, feelings of inner pressure, and symptoms of pain, dizziness, and fatigue. Similarly, depressed Japanese individuals often complain of abdominal, headache, and neck pain symptoms. Even within Western countries where depressive disorders are more "acceptable", researchers have theorized that some chronic conditions (chronic pain, fibromyalgia, chronic fatigue syndrome) may be more somatic (physical) forms of a mood disorder than actual physical problems. Some researchers have even suggested that fibromyalgia (a condition characterized by widespread pain, tenderness, and fatigue) should be characterized as a "depression spectrum disorder". Some cultures may view depressive symptoms as normal emotional responses to particular life events. For example, some cultures may expect the grief and bereavement process to last longer than the culturally-expected time period (about

one year) which is acceptable in the West. Individuals from such cultures might find it odd that a Western psychologist would think that 2 years spent mourning for a lost spouse was indicative of a mental health problem. Still other cultures may recognize that depressive symptoms are problematic, but attribute these symptoms to causes that don't make sense to observers or clinicians from other cultures. For instance, patients may reject explanations for symptoms that are commonly acceptable to treating clinicians in favor of explanations that are favored within the patient's culture. For instance, a patient from China seen in the United States might reject the idea that a biochemical imbalance is causing depressive symptoms in favor of an explanation in terms of energy flows or similar concepts drawn from traditional Chinese medicine. Such patients may respond best to mental health professionals who are able to use culturally-sensitive language to describe the cause of depressive symptoms and related suffering. Cultural differences in help-seeking behavior may influence the treatment of depression. For example, non-Western individuals frequently use indigenous (from their own culture) practitioners for treatment of "illness" and Western-trained physicians for treating "disease". If emotional disturbances are not considered within the realm of disease, depressed individuals might not readily seek out psychiatric or mental health care for depressive symptoms. Because the public discourse regarding depression is more prevalent in Western societies, it is more socially acceptable to have depression, and more people are willing to seek help. In contrast, mental illness is often more stigmatized in other cultures. As a result, people and their families may deny mental illness out of shame of being identified as "crazy". Others may find the label "depression" morally unacceptable, shameful, and experientially meaningless. Treatment for depression may be actively resisted by someone who comes out of this sort of culture. Cultures also vary in the degree to which they rely on or incorporate complementary and alternative medicine practices such as herbs, meditation, yoga, or other approaches into their prescribed treatments for depression. Individuals from some traditional cultures may reject Western antidepressant medications while embracing prescriptions for herbs, acupuncture or exercise. A person's cultural background can also influence their biological makeup. People from different parts of the world have different patterns of genes and, often, different patterns of disease to which they are vulnerable. Such genetic differences can influence whether people succumb to depression when stressed (Click here to

return to our discussion of the diathesis-stress model). Similarly, people's genetic background can influence their response to antidepressant medications.