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Depression: A Literature Review on Diagnosis, Subtypes, Patterns of Recovery

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 Depression: A Literature Review on Diagnosis,
Subtypes, Patterns of Recovery, and
Psychotherapeutic Models
Mark Widdowson
Abstract
This article summarizes data on the preva-
lence and diagnosis of depression as well as
findings from research regarding recovery
and relapse from depression. It also offers a
summary of models of understanding depres-
sion from a range of psychotherapies that
are empirically supported for the treatment
of depression. Links are made betw een these
models and transactional analysis theory.
______
Prevalence
Figures in the fourth edition of the American
Psychiatric Association’s (1994) Diagnostic and
Statistical Manual of Mental Disorders (DSM-
IV) estimate that between 10% and 25% of
women and between 5% and 10% of men will
experience major depressive disorder (MDD)
during their lifetime.
The Office of National Statistics (2000) in
the United Kingdom reported that 9.2% of the
general population experienced mixed anxiety
and depression in the year 2000, with 2.8% of
the British population experiencing a depres-
sive episode (without anxiety symptoms). They
estimate that one in ten adults in Britain experi-
ence depression at some point during their life,
with one in six experiencing mental health prob-
lems at any one time.
Epidemiological studies in the United States
suggest that 9% of all adults will experience
major depressive disorder in any given year,
and approximately 16% will experience MDD
during their lifetime (Kessler et al., 2003). De-
pression accounted for 4.46% of total world-
wide disability adjusted life years (DALYs) in
the year 2000, and globally depression ac-
counted for 12% of the total number of years
lived with disability (YLD). It is estimated that
globally, depression is the fourth most common
Vol. 41, No. 4, October 2011
cause of disease burden in women and the sev-
enth most common cause in men (Moussavi et
al., 2007; Ustun et al., 2004)
Although there are mixed findings regarding
the prevalence of depression, according to demo-
graphic factors such as class and race, there is
some research suggesting that people with low-
er socioeconomic status are more likely to be
depressed and more persistently depressed than
people with higher socioeconomic status (Lor-
ant et al., 2003).
In addition to its prevalence and general im-
pact on health, major depressive disorder has a
high mortality rate, with up to 15% of people
with MDD committing suicide (American Psy-
chiatric Association, 1994). W hen we consider
that depression is such a widespread condition,
the figures relating to suicide risk for those
with depression become even more alarming.
Anecdotal evidence from informal conversa-
tions the author has had with psychotherapist
colleagues suggests that depression is the single
most common disorder for which people seek
therapy. Clearly, depression is a significant mental
health problem and given its prevalence is
likely to be one that all psychotherapists en-
counter regularly in clinical practice.
Despite this prevalence, depression has had
little specific coverage in the TA literature.
Depression: Diagnostic Features and
Symptoms
Depression is not just a form of extreme
sadness. It is a disorder that affects both
brain and body, including cognition, be-
havior, the immune system and peripheral
nervous system. Unlike a passing sad mood,
depression is considered a disorder because
it interferes with ordinary functioning in
work, school, or relationships. Unlike nor-
mal grief, which comes in waves, it is
351
MARK WIDDOWSON
constant and oppressive. Depression also
differs from ordinary mourning in that the
mourner experiences the world as empty
or bad, whereas clinically depressed indi-
viduals locate their sense of emptiness or
badness in the self. (PDM Task Force,
2006, p. 109)
Depression varies in intensity, from mild to
extremely severe, and its symptoms can range
from subtle to substantially disabling.
Types of Symptoms. Affective symptoms in-
clude loss of pleasure and interest in life or ac-
tivities the individual previously enjoyed (an-
hedonia); feelings of worthlessness, guilt, in-
feriority, inadequacy, helplessness, and weak-
ness; and an overwhelming sense of sadness,
despair, loss of hope, and self-hatred.
Cognitive symptoms include impaired con-
centration and memory, indecisiveness, ration-
alization of guilt, and sustained and intense self-
criticism. Suicidal ideation of varying intensity
is common in depressed individuals.
Somatic symptoms are common among peo-
ple with depression and can include fatigue,
lethargy, sleep disruption (hypersomnia or ins-
omnia), restlessness and agitation, headache,
muscular pain, back pain, weight loss or gain
(and associated appetite changes), and loss of
sexual desire. A greater number and severity of
somatic symptoms has been associated with
treatment-resistant depression (TRD) (Papa-
kostas et al., 2003).
The DSM-IV contains detailed information
regarding the diagnostic criteria for depression
and disorders that have dysphoric mood distur-
bance. It is strongly advised that all practition-
ers familiarize themselves with this diagnostic
framework. It is also worth noting that depressed
mood can be a feature of a number of medical
conditions as well as a side effect of a number
of medications. Therapists should be aware of
the potential for a patient’s depression to be
connected to an underlying and undiagnosed
medical condition or a result of medication and
to advise the patient to seek medical attention
when relevant. (A summary of DSM-IV diag-
nostic criteria, including specifiers and brief
information regarding a number of medical
conditions and drugs that may cause depressed
mood, is available on request from the author.)
352
Subtypes of Depression
Anaclitic and Introjective Depression Sub-
types. Sidney Blatt (1974) and a number of his
colleagues identified two subtypes of depres-
sion: anaclitic and introjective depression. Blatt’s
theories were based on a range of research into
depression rather than being focused on symp-
toms, as are standard diagnostic systems such
as the DSM. Instead, Blatt’s theories focused
on the internal experience, preoccupations, and
life experiences of individuals with depression.
They are primarily psychodynamic in nature,
but his conceptions of anaclitic and introjective
depression also correspond, respectively, to A.
T. Beck’s (1983) subtypes of sociotropic and
autonomous depression and are similar to Bowl-
by’s (1977, 1980, 1988) concepts of ambivalent
and anxious attachment patterns.
Anaclitic depression is characterized by
feelings of loneliness, helplessness, and
weakness; the individual has intense and
chronic fears of being abandoned and left
unprotected and uncared for. Thus, these
individuals have a desperate need to keep
in close physical contact with need-gratifying
others, and they experience deep longings
to be loved, cared for, nurtured, and pro-
tected. Others are valued primarily for the
care, comfort, and satisfaction they can
provide because there has been little inter-
nalization of the experiences of gratifi-
cation or of the qualities of the individuals
who provided satisfaction. These depen-
dent individuals rely intensely on others to
provide and maintain a sense of well-being,
and therefore they have great difficulty ex-
pressing anger for fear of losing the need
gratification others can provide. Separat-
ion from others and loss are sources of
considerable fear and apprehension, and
are often dealt with by primitive means
such as denial and/or a desperate search
for substitutes (Blatt, 1974). Introjective
depression, in contrast, is characterized by
self-criticism and feelings of unworthiness,
inferiority, failure, and guilt. These indi-
viduals engage in constant and harsh self-
scrutiny and evaluation and have a chronic
fear of being disapproved and criticized,
and of losing the approval and acceptance
Transactional Analysis Journal
 DEPRESSION: A LITERATURE REVIEW ON DIAGNOSIS, SUBTYPES, PATTERNS OF RECOVERY, MODELS
of significant others. They strive for exces-
sive achievement and perfection, are often
highly competitive and work hard, make
many demands on themselves, and often
achieve a great deal, but with little lasting
satisfaction. They can be critical and attack-
ing of others as well as themselves because
of their intense competitiveness. Through
overcompensation they strive to achieve and
maintain approval and acceptance (Blatt,
1974). (Blatt & Zuroff, 1992, p. 528)
Depressive Personality Disorder. Despite
being removed from the DSM-III, DSM-III-R,
DSM-IV, and DSM-IV-TR, there has been con-
tinued clinical interest among psychotherapists,
particularly psychoanalytic therapists, in the
existence of a depressive personality disorder.
Indeed, the Psychodynamic Diagnostic Manual
(PDM) retains a diagnostic category of depres-
sive personality disorder. Personality research
by Shedler and W esten (2004) confirmed what
many psychotherapists already know: that the
depressive personality disorder is “the most com-
mon type of personality structure encountered
clinically” (PDM Task Force, 2006, p. 44). The
depressive personality disorder is characterized
by chronic dysphoric affect combined with a
tendency toward feelings of guilt and/or shame.
Individuals with a depressive personality typi-
cally experience repetitive depressive person-
ality themes that intensify under stress and can
be influenced positively by psychotherapy but
not by medication.
The PDM draws heavily on Blatt’s theories
of anaclitic and introjective depression and states
that
introjectively depressive individuals look
inward to find the explanation for painful
experiences. . . . W hen mistreated,
rejected, or abandoned, they tend to be-
lieve that they are somehow at fault . . .
[and] attribute their suffering to their own
badness—something they can try to change.
Thus, introjectively inclined depressive
people work hard to be “good” but rarely
succeed to their own satisfaction. . . . Ana-
clitically depressive individuals are nota-
ble for their distress and disorganization in
the face of experiences of loss and separa-
tion. Their psychologies are organized
Vol. 41, No. 4, October 2011
around themes of relationship, affection,
trust, intimacy, warmth, and similar issues.
They feel empty, incomplete, lonely, help-
less, and weak rather than morally perfec-
tionistic and excessively self-critical. They
often complain of existential despair, the
feeling that life is empty and meaningless.
Individuals with depressive personality dis-
orders tend to strike therapists as likable,
even admirable. They are usually “nice”
people. It is vital when treating depressive
patients of the introjective type to elicit
their negative feelings, especially their hos-
tility and criticism, because they typically
idealize the therapist, try to be good pa-
tients, and interpret the therapist’s non-
critical acceptance as evidence that the
therapist has not yet noticed how bad they
really are. It is also important that they see
how they persist in believing that their
badness is the cause of whatever difficul-
ties and losses they encounter. (PDM Task
Force, 2006, pp. 45-46)
The PDM identifies the central personality
tension for people with depressive personality
as being focused on “goodness/ badness” or
“aloneness/relatedness of self.” Their central
affects are listed as sadness, guilt, and shame,
and their characteristic pathogenic belief about
self is that “there is something essentially bad
or incomplete about me.” Their characteristic
pathogenic belief about others is “people who
really get to know me will reject me” (PDM
Task Force, 2006, p. 46). The PDM lists cen-
tral tensions, affects, and pathogenic beliefs
about self and others for all the personality dis-
orders it identifies. From a transactional analy-
sis perspective, one can see that these tensions,
affects, and pathogenic beliefs can easily be
mapped onto the racket (script) system (Ers-
kine & Zalcman, 1979) and that the key per-
sonality themes, dynamics, and preoccupations
and their associated relational patterns can be
understood as a particularly toxic, inflexible,
and persistent script that is interpersonally
manifest in powerful games.
Depression: Patterns of Natural Course,
Relapse, and Recovery
Natural Course of Depression. It is difficult
353
MARK WIDDOWSON
to make accurate statements about the natural
course of depression because it is possible that
many people experience depression that, due to
factors such as embarrassment and underreport-
ing, are not identified in prevalence studies.
The course of depression and prognostic indi-
cators vary considerably according to type and
number of previous episodes.
Symptoms of M DD typically develop over a
period of between several days and a number
of weeks, although early indicators of an im-
pending depressive episode (prodromal symp-
toms) can occur several months before the on-
set of a depressive episode that meets DSM cri-
teria. The duration of a major depressive episode
(M DE) is variable, although in many cases it is
between 6 months and 2 years. Between 5-10%
of all individuals continue to meet criteria for
MDD for 2 or more years. Despite not meeting
diagnostic criteria for MDD, it is probable that
many people continue to experience depressive
symptoms for a prolonged period of time (Ameri-
can Psychiatric Association, 1994). Forty per-
cent of people will continue to meet diagnostic
criteria 1 year after diagnosis of MDD, 20%
will continue to have some symptoms without
meeting full diagnostic criteria (partial remis-
sion), and 40% will have no mood disorder.
Initial severity of the episode appears to be pre-
dictive of its persistence, with more severe epi-
sodes lasting longer.
DSM-IV criteria for recovery from MDD are
that the individual must not have met diagnos-
tic criteria (i.e., depressed mood or loss of in-
terest or pleasure plus four additional symp-
toms) for a period of 2 consecutive months.
Throughout this time, an individual may still
have a number of depressive symptoms, in
which case the individual is considered to be in
partial remission.
Relapse Rates. A study by Piccinelli and
W ilkinson (1994) found that 75% of people
with MDD would have at least one further epi-
sode of depression within 10 years. Ten percent
of patients in their study had experienced chronic
and persistent depression for a period of 10
years. The DSM-IV states that approximately
50%-60% of individuals who experience a sin-
gle MDE will go on to have a second episode.
Individuals who have had two episodes have a
354
70% chance of having a third, and individuals
who have had three episodes have a 90%
chance of having a fourth. Clearly, the number
of episodes is a predictor of the chance of re-
curring episodes of major depression.
There is a greater likelihood of an individual
experiencing another episode of depression
when there is only partial remission (i.e., some
symptoms remain). W hile psychosocial stres-
sors (such as relationship problems or bereave-
ment) are often associated with the first or sec-
ond episode, they are less often associated with
subsequent episodes.
People with dysthymia have a high probabili-
ty of eventually having an MDE, with estimates
as high as 79% of people with dysthymia going
on to develop an MDD during their lifetime.
People who have had an MDD and who have
an underlying dysthymic disorder will also have
a much higher rate of relapse for an MDD, with
62% experiencing an MDE within 2 years
(Keller, Lavori, Endicott, Coryell, & Klerman,
1983).
Patterns of Symptomatic Recovery and Re-
lapse in Psychotherapy. In their study on pat-
terns of symptomatic recovery in time-limited
(cognitive-behavioral or interpersonal) psycho-
therapy conducted with a sample of 212 de-
pressed patients, Barkham et al. (1996) found
that percentages of patients meeting criteria for
clinically significant change (measured by
change from a distressed/symptomatic score to
a nondistressed/asymptomatic score on each of
the 21 items of the Beck Depression Inventory;
see A. T . B eck, Steer, & Brown, 1996; A. T.
Beck, W ard, Mendelssohn, & Erbaugh, 1961)
ranged from 34% to 89% within 16 sessions of
therapy. In measurements of the 14 symptoms
(including guilt, crying, and pessimism) show-
ing the fastest and largest change, between 50%
and 89% of patients had achieved nondistressed/
asymptomatic scores on all items after 16 ses-
sions of psychotherapy.
Kopta, Howard, Lowry, and Beutler (1994)
examined patterns of symptomatic recovery
among a sample of 854 patients in ongoing (not
time-limited) outpatient psychotherapy meas-
ured using the Symptom Checklist-90 (SCL-
90-R) (Derogatis, 1983). The study identified
three categories of symptoms: acute, chronic,
Transactional Analysis Journal
 DEPRESSION: A LITERATURE REVIEW ON DIAGNOSIS, SUBTYPES, PATTERNS OF RECOVERY, MODELS
and characterological. As one might expect,
acute symptoms demonstrated the fastest aver-
age rate of response to treatment, followed by
chronic symptoms, then characterological symp-
toms. The mean ED50 (“effective dose” or
number of sessions needed for 50% of the sam-
ple to achieve clinically significant change) for
acute distress symptoms was 5 sessions. The
ED50 for chronic distress symptoms was 14
sessions, and the ED50 for characterological
symptoms was over 104 sessions. W ithin the
acute distress category, which listed 20 symp-
toms, the symptom dimension showing the
largest number of ED50 changes was depres-
sion (5 symptoms), followed by somatization (4
symptoms) and obsessive-compulsive (4 symp-
toms). W ithin the chronic distress symptoms
category, which listed 27 symptoms, depression
was again the symptom dimension showing the
largest number of ED50 changes (7 symptoms),
followed by interpersonal sensitivity (5 symp-
toms).
From these two studies, one can conclude that
50% of patients will achieve clinically signifi-
cant symptomatic relief of between 12 and 21
depressive symptoms within 16 sessions of
psychotherapy— an encouraging result for
those who practice shorter-term psychotherapy.
Nevertheless, this still leaves 50% of patients
who will require a greater number of sessions
to achieve symptomatic relief, and charactero-
logical symptoms (which from a transactional
analysis perspective would require script change)
may require therapy of at least 2 years duration.
Between 78-88% of clients who took part in
the National Institute of Mental Health (NIMH)
Treatment of Depression Collaborative Research
Program and who had short-term manualized
therapy had either relapsed or sought further
treatment by the 18-month follow-up (Morri-
son, Bradley, & W esten, 2003; Shea, W idiger,
& Klein, 1992). W esten and Morrison (2001)
also identified that by 2-year follow-up after
short-term manualized therapy, only 27% of
patients with depression had maintained their
improvement. One possible explanation for
such low levels of maintained recovery is that
manualized therapies used in research tend to
focus on a limited area of the client’s presenta-
tion, do not necessarily work with the client’s
Vol. 41, No. 4, October 2011
other presenting problems (comorbidity), do
not account for characterological problems, and/
or do not provide therapy of a sufficient length
to remedy such issues (Morrison et al., 2003).
From a transactional analysis perspective, it is
possible to understand that underlying and un-
resolved script issues may lead to relapse or a
return of symptoms.
Comorbidity, Recovery, and Natural Length
of Therapy. Morrison et al. (2003) conducted a
study on a sample of 242 therapists in the Uni-
ted States regarding cases in which both thera-
pist and client were satisfied with the outcome.
In their article, they state that it is widely ac-
cepted among therapists that a significant pro-
portion of clients present with comorbidity of
more than one Axis I disorder and that a signi-
ficant proportion of clients present with a co-
morbid Axis II disorder. It is also widely ac-
cepted that the presence of comorbidity com-
plicates the therapy and will require extending
the natural course of treatment to achieve clini-
cally significant change (i.e., change in which
the client is considered to have recovered from
the disorder). It is noteworthy that in their study,
Morrison et al. (2003) identified that 47.9% of
patients in their sample presenting with depres-
sion had comorbidity with another Axis I dis-
order and 46.3% had comorbidity with an Axis
II disorder. Comorbidity with characterological
issues (non-Axis II diagnosable) was as high at
76.9% of all clients, a finding that many thera-
pists can no doubt identify with based on their
clinical experience.
In their study, Morrison et al. (2003) identi-
fied that the median number of sessions for cli-
ents presenting with depression was 75, with
the first clinical changes being noticeable at
session 20 and relatively permanent change in-
dicating significant internal restructuring being
identified by session 50. The presence of co-
morbidity significantly lengthened treatment
duration, typically doubling it. Despite these
findings, which indicate longer treatment is the
norm in clinical practice, it is noteworthy that
without the presence of comorbidity, the medi-
an number of sessions for clients presenting for
cognitive-behavioral therapy (CBT) with de-
pression was 16 sessions, with a median for
clinically significant response at session 8.
355
MARK WIDDOWSON
M odels of Depression
Biological Models. Although biological psy-
chiatry has put forward a number of theories to
explain depression, at present none has provid-
ed a complete answer as to why some people
become depressed. It is clear that a number of
biochemical changes are present in people who
are depressed, although neither the causes nor
the mechanisms to address them are fully under-
stood. It is likely that there are many subtle and
as yet unidentified biological changes that take
place in individuals who are depressed. Further-
more, investigations to identify a genetic suscepti-
bility for these changes have so far failed to
find any clear genetic markers that could be
used to identify people who may be prone to
developing depression. W hile certain clear
changes are present in those who are depressed,
it is probable that the pattern of changes takes
place in a complex interactive matrix of bio-
logical cause-effect chains.
One theory about depression is that it is
caused by an imbalance in certain neurotrans-
mitters, particularly serotonin, norepinephrine
(noradrenaline), and dopamine. A full discus-
sion of the role, purposes, and interactions of
these neurotransmitters is beyond the scope of
this article, but it is believed that serotonin plays
a part in feelings of well-being, norepinephrine
is associated with fight-flight responses and
attention and focus, and dopamine is associated
with feelings of pleasure and reward. Most
antidepressants act on the systems of release,
absorption, or breakdown of one or more of
these neurotransmitters, increasing their levels
or activity within the brain to create the anti-
depressant effect (Barros, Calil, Guimarães,
Soares, & Andreatini, 2002).
In addition, a number of neuroendocrine hor-
monal changes that have an impact on the brain
have been identified in depression. Numerous
studies have demonstrated the hyperactivity of
the hypothalamus-pituitary-adrenal (HPA) axis
in people with depression (Pariante & Miller,
2001). T he HPA axis has a major role in the
physical response to stress and in the regulation
of a range of physiological processes. One out-
come of an overactive HPA axis in depression
is an increase in cortisol levels. Cortisol has a
range of physiological effects; with chronic
356
elevation, it can negatively impact metabolism
(leading to appetite and weight changes), the
immune system (causing immune suppression
leading to increased susceptibility to infection
and increased inflammation) (Leonard, 2001),
and through its actions on the hippocampus,
impairment in learning and memory. This hyper-
activity of the HPA axis and the concomitant
increase in cortisol levels may explain the in-
creased prevalence or worsening of certain ill-
nesses among depressed people.
Psychoanalytic Models. The psychoanalytic
understanding of depression originated with
Freud’s (1917/1957) paper “Mourning and
Melancholia.” In it, he examined the similari-
ties and differences between mourning and
melancholia (depressive states) and “observed
that the significant difference between the two
states is that in ordinary grief reactions the ex-
ternal world is experienced as diminished in
some important way (e.g., it has lost a valuable
person), whereas in depressive conditions, what
feels lost or damaged is a part of the self” (Mc-
W illiams, 1994, p. 228). Many psychoanalytic
writers have explored the experiences of an
early sense of loss and/ or experiences of re-
peated loss throughout childhood (Jacobson,
1971). The sense of loss does not necessarily
originate in death and bereavement and com-
monly is not; it is more likely a loss of some
aspect of the relationship with the child’s care-
giver(s) or a loss of a sense of love or nurtur-
ing. For example, it may involve the loss of the
primary caregiver’s attention when a younger
sibling is born or when a parent is struggling to
manage relationship/marital difficulties. The loss
may also be connected with premature weaning
or forced separation.
The aggression theory of psychoanalysis and
the theory of defense mechanisms also provide
insights into the inner experience of a depressed
person. In people with depressive tendencies,
anger is turned against the self rather than ex-
pressed. This repressed anger manifests as in-
tense self-criticism and a sense of guilt (Klein,
1975).
Introjection is also seen as a primary defense
mechanism among people with depression (Mc-
Williams, 1994). The person introjects and iden-
tifies with criticism and then replays it internally
Transactional Analysis Journal
 DEPRESSION: A LITERATURE REVIEW ON DIAGNOSIS, SUBTYPES, PATTERNS OF RECOVERY, MODELS
in the form of self-criticism. This internaliza-
tion of the criticism may be a means of main-
taining a sense of attachment to the original cri-
tic, often the child’s caregivers. The introjected
other may not necessarily have been overtly
critical or hostile, but there is a pervasive sense
of some aspects of disapproval or lack of nur-
turing from that person or a loss associated
with him or her (e.g., a sense of missing that
person’s love). The child concludes that the loss
of love (an experience of emotional abandon-
ment) must be his or her fault and that he or she
has somehow driven the lost person away (Mc-
W illiams, 1994). Self-blame originates from
this, and the anger that is then experienced is
directed toward the self rather than focused on
its original source. There then follows an in-
tense need to be good so as to prevent further
experiences of abandonment.
The fact that they felt rejected has been
converted into the unconscious conviction
that they deserved rejection, that their faults
provoked it, and that future rejection is
inevitable if anyone comes to know them
intimately. They try very hard to be “good,”
but they fear being exposed as sinful and
discarded as unworthy. (McWilliams, 1994,
p. 237)
Associated with this is the (usually implicit)
conclusion the child draws that his or her nor-
mal but not-so-pleasant wishes or urges (such
as anger, competitiveness, or greed) are bad
and that he or she is somehow inherently bad
for having such dreadful thoughts.
In psychoanalytic theory, defense mechan-
isms are primarily a means of managing anxie-
ty. Turning the anger against the self resolves
the anxiety by making meaning of the sense of
abandonment and giving the child a way to pre-
vent further abandonment. This, in turn, helps
the child to maintain a sense of control over his
or her emotional situation and to manage his or
her feelings of helplessness. T he child con-
cludes (unconsciously) that guilt is better than
despair.
It is possible that disruptions in the normal
separation-individuation processes (Mahler,
Pine, & Bergman, 1975) can generate depres-
sive dynamics “when the mother’s pain about
her child’s growth is so great that she either
Vol. 41, No. 4, October 2011
clings and induces guilt (‘I’ll be so lonely with-
out you’) or pushes the child away counter-
phobically (‘W hy can’t you play by your-
self?’)” (M cW illiams, 1994, p. 234). In both
these situations, one’s normal desires for either
independence or closeness are punished and
therefore are experienced as being bad, and the
self is experienced as bad for having them.
The family dynamics of a person with de-
pressive tendencies may involve denial of grief
or other painful feelings. In some instances, the
depressed person emotionally takes care of the
family and “takes on” the grief of everyone.
Experiences of being punished for expressing
feelings of hurt are common in such families,
with the depressed person having experiences
of having been mocked or punished for crying
and so forth. McWilliams (1994) described how
many of her depressed patients were often
the most emotionally astute person in their
family of origin. Their reactivity to situa-
tions whose emotional implications the
other family members were better at deny-
ing got them branded “hypersensitive” or
“overreactive,” labels they continued to
carry internally and to connect with their
general sense of inferiority. (p. 236)
W e see that in psychoanalytic theory, depres-
sion is viewed as having its origins in loss and
a thwarting of natural grief processes that would
normally lead to some resolution of the sense of
mourning. The expression of anger (and painful
feelings) is also repressed, and the individual
experiences the self as being inherently bad.
From a transactional analysis perspective, the
sense of being bad and inferior to others is
equivalent to an “I’m Not OK, You’re OK” life
position (Berne, 1972; Ernst, 1971). The sense
of being bad, worthless, and inferior forms a
key script decision, and the Child ego state be-
comes “confused” or fixated by repressing and
blocking the expression of anger and hurt. These
feelings underlie depressed racket feelings (Ers-
kine & Zalcman, 1979) and will need to be ex-
pressed through deconfusion as part of therapy.
Interpersonal Models. Unlike most models
of psychotherapy that grew out of clinical ob-
servation, interpersonal psychotherapy (IPT)
was originally developed as a manualized treat-
ment approach to be used in a study comparing
357
MARK WIDDOWSON
psychotherapy with medication. IPT was found
to be an effective treatment, and over time, its
theory and methods have been expanded and
repeatedly shown to be effective in the treat-
ment of depression. IPT is a structured, time-
limited, psychodynamically informed therapy
in that its theory is based on psychodynamic
authors such as Bowlby and Sullivan. How-
ever, unlike psychodynamic therapy, the trans-
ference relationship between the therapist and
client does not become a primary focus of
therapy. The emphasis in IPT is on the patient’s
current, particularly interpersonal, functioning
(W eissman, Markowitz, & Klerman, 2000).
IPT is based on the premise that inter-
personal distress is intimately connected
with psychological symptoms. Thus the
foci of treatment are two-fold. One focus
is the conflicts and transitions in relation-
ships in which the patient is engaged. The
aim is to help the patient either to improve
communication within those relationships,
or to change his or her expectations about
those relationships. The second focus is
helping the patient to build or better utilise
his or her extended social support network
so that he or she is better able to muster
the interpersonal support needed to deal
with these crises which precipitated the
distress. (Stuart & Robertson, 2003, p. 4)
IPT identifies four main problem areas that
contribute to the cause and maintenance of de-
pression.
1. Interpersonal disputes: This refers to inter-
personal conflicts the patient is experienc-
ing. These can be acute or chronic and may
be connected to unrealistic or mismatched
expectations or difficulties in communi-
cation.
2. Role transitions: Any changes in an indi-
vidual’s social roles or life-stage changes
are seen as a source of stress and some-
thing that require adjustment or a re-
negotiation of social support.
3. Grief and loss: This refers to both bereave-
ment issues as well as a more generalized
sense of loss such as might accompany
illness or the ending of a relationship.
4. Interpersonal sensitivity: An individual’s
pattern of relating to others may be some-
358
how problematic and may both result in
and maintain interpersonal problems. (Kler-
man, W eissman, Rounsaville, & Chevron,
1984; Stuart & Robertson, 2003).
In IPT, psychological problems are always
considered to be interpersonal in nature and
“are similar in that they are all derived from the
combination of an acute stressor combined with
a social support system that does not sufficient-
ly sustain the patient” (Stuart & Robertson,
2003, p. 41). IPT aims to address the problem
areas that appear to be the primary source of
the client’s present difficulties and to support
the client to develop sufficient levels of social
support.
Transactional analysis shares many features
with IPT, particularly the emphasis on promot-
ing satisfying relationships as a key component
of psychological health. Examining unhelpful
expectations about one’s self or others in rela-
tionships together with interpersonal sensitivi-
ties might occur in transactional analysis thera-
py through decontamination processes and chal-
lenging racket and script beliefs relating to self
and others. Transactional analysis therapists
understand problems in relationships as being
linked to games. The analysis and change of
transactional and stroking patterns that occur in
transactional analysis therapy all seek to en-
hance interpersonal relationships.
Blatt’s Models of Anaclitic and Introjective
Depression. Individuals with anaclitic tenden-
cies are more likely to experience depression
following some kind of relational disruption
that involves problems in relationship. They
tend to experience themselves as weak and help-
less and have intense wishes to be cared for,
protected, and loved. They are also often pre-
occupied with past, present, and anticipated fu-
ture disruptions in relationships and issues of
abandonment, rejection, and aloneness.
Individuals with introjective tendencies are
more likely to experience depression as a result
of events that activate their sense of self-criticism,
self-blame, and feelings of failure (although de-
pression may also follow from interpersonal
problems, especially those associated with inter-
personal problems where the individual experi-
ences guilt or criticism). Introjective depression
tends to be “characterized by intense feelings
Transactional Analysis Journal
 DEPRESSION: A LITERATURE REVIEW ON DIAGNOSIS, SUBTYPES, PATTERNS OF RECOVERY, MODELS
of inferiority, guilt, and worthlessness and by a
sense that one must struggle to compensate for
having failed to live up to expectations and
standards” (Blatt & Zuroff, 1992, p. 552).
These individuals often have difficulty resolv-
ing conflict, may be socially isolated, are heavily
focused on work and achievement, and may
consider themselves to be a failure personally
and socially.
Interpersonally, people with an anaclitic dis-
position tend toward pleasing others and avoid-
ing conflict to prevent experiences of abandon-
ment and rejection (which they fear), whereas
those with an introjective disposition are more
concerned with autonomy and gaining the re-
spect and approval of others and fear disapproval
and a sense of loss of control. They are inter-
personally more distant with lower levels of
emotional involvement, partly because their
sense of self-worth derives from senses of
achievement, autonomy, self-control, and self-
definition, all of which they consider to be
traits that will be approved of by others (Blatt
& Zuroff, 1992).
Data from . . . adults’ retrospective ac-
counts of their parents’ care-giving indi-
cate that parental lack of consistent care,
nurturance, or support and parental exer-
cise of excessive authority, control, criti-
cism, and disapproval are associated with
depression. These untoward behaviors of
parents create impaired and distorted men-
tal representations or internal working
models of caring relationships such that an
individual either constantly seeks reassur-
ance and support and has difficulty with
separation or continually anticipates rejec-
tion and/or criticism and censure and avoids
interpersonal involvement (Blatt & Ho-
mann, 1992). (Blatt & Zuroff, 1992, pp.
542-543)
Cognitive-Behavioral Models. The cognitive-
behavioral perspective on depression was large-
ly developed by Aaron Beck and his colleagues
in their 1979 book Cognitive Therapy of De-
pression (A. T. Beck, Rush, Emery, & Shaw,
1979). CBT examines the components of psy-
chological problems by exploring four domains:
cognitions, emotions, behaviors, and physical
aspects.
Vol. 41, No. 4, October 2011
Cognitions consist of memories, images
and beliefs as well as streams of unhelpful
automatic thoughts. These thoughts result
in emotions (such as guilt, shame and sad-
ness), which in turn impact upon our bio-
logy (such as reduced energy, poor con-
centration and insomnia), and affect our
behaviour (such as increased avoidance of
activity and use of alcohol). (Mulhern,
2010, p. 59)
These domains are mutually interactive, and a
change in one of them typically has an impact
on others.
It is perfectly consistent with the cognitive
model to recommend a client to engage in
exercise (a behaviour) as a way of reduc-
ing tension (physiology) which then re-
lieves depressed mood (emotion) which
may then lead to a less catastrophic appraisal
(cognition) of a current daily hassle. (Scott,
Stradling, & Dryden, 1995, pp. x-xi)
Beck’s theory of depression includes his for-
mulation method, which is used to generate an
individualized picture of the patient’s prob-
lems. The formulation involves examining pre-
disposing factors (the individual’s susceptibili-
ty to depression), precipitating factors (events
that triggered the depressive episode), and per-
petuating factors (what maintains the depres-
sion) (A. T. Beck et al., 1979).
Predisposing factors for depression include
a tendency to perceive things negatively or pes-
simistically. Research by Alloy et al. (2006),
which examined individuals’ cognitive style (a
tendency to interpret events negatively and dys-
functional attitudes) prospectively found that it
was possible to predict which individuals were
more likely to develop depression. This sup-
ported the theory about the important role an
individual’s tendencies toward perceiving and
interpreting events have in the development of
depression. Linked to this would be an indi-
vidual’s schema (J. S. Beck, 1995), which is an
inflexible and persistent set of core beliefs
about self, others, and the world. CBT views
schemas as having their origins in childhood,
and a negatively biased schema will predispose
an individual to depression. From a transac-
tional analysis perspective, the concept of sche-
ma has equivalence with a combination of the
359
MARK WIDDOWSON
racket (script) system (Erskine & Zalcman,
1979) and the frame of reference (Schiff, Schiff,
& Schiff, 1975). The schema, if it is negatively
biased, will influence how an individual per-
ceives and interprets the world and the actions
of others as well as his or her evaluation of his or
her self in ways that create a particular suscep-
tibility to depression.
Precipitating factors in depression tend to
focus on loss or stress. However, it is not the
event in itself that is considered to be causative
but how an individual perceives and attributes
meaning to that event. For instance, an indi-
vidual with schema core beliefs that he or she
is unlovable may interpret a relationship break-
up as evidence that he or she is, indeed, unlova-
ble. Someone with a schema focused around
beliefs such as “I always mess things up” may
well think that he or she is a failure, should
have known this would happen, and was stupid
not to anticipate it in the event of redundancy
rather than seeing the redundancy as a product
of economic downturn and accounting for the
large-scale redundancies that have taken place
in the economy and perhaps even in his or her
own company (M ulhern, 2010).
Once the individual’s predisposing factors
have interacted negatively with the precipita-
ting factors and resulted in depression, a range
of perpetuating factors maintain it. The depres-
sion leads to a tendency to view things nega-
tively in a pessimistic and self-critical way
(Abramson, Seligman, & Teasdale, 1978) and
to focus overly on negative aspects of a situa-
tion or to selectively remember only negative,
unpleasant memories. This then influences the
way the depressed person interacts with the
world and maintains a sense of hopelessness
about the future (Greenberger & Padedsky,
1995). Thus, the depression becomes self-
perpetuating. For example, frequently people
who are depressed start to avoid activities due
to their negative thought processes. In response
to an invitation to a social event, someone with
depression might think, “I can’t be bothered to
go. I won’t enjoy it anyway even if I do go, so
what’s the point?” Consequently, the individual
does not engage in a pleasurable activity and
the depressed state of being is maintained. This,
in turn, could lead the individual to feel guilty
360
for not attending the event, which may then
trigger a range of self-critical thoughts and re-
inforce the depression.
As described earlier, transactional analysis
theory has a number of concepts that are equiva-
lent to those used in CBT. For example, the rack-
et (script) system (Erskine & Zalcman, 1979)
and frame of reference (Schiff et al., 1975) cor-
respond to the CBT concept of schema, as does
the transactional analysis concept of life script
and an individual’s script beliefs (Berne, 1972).
Concepts such as contaminations (Berne, 1961)
and discounting (Mellor & Schiff, 1975) match
CBT concepts relating to attributional style and
precipitating and perpetuating factors in de-
pression.
Transactional Analysis Models of Depres-
sion. Transactional analysis psychotherapy has
a number of equivalent ways of understanding
the concepts from the psychotherapeutic ap-
proaches described earlier. Since those approach-
es have shown empirical support for their use in
treating depression, it is logical to hypothesize
that transactional analysis should also have
considerable validity for understanding depres-
sion and that transactional analysis therapy is
capable of producing comparable effects in
treating depression.
The theory of life positions developed by
Berne (1972) and Ernst (1971) is frequently the
starting point for transactional analysts in under-
standing depression. Berne drew on Klein’s
(1975) theory of the depressive position in de-
veloping his theory of life positions and linked
the depressive position with the “I’m Not OK,
You’re OK” life position. The depressed indi-
vidual has a pervasive sense of being not OK
and inferior to others who are considered to be
OK. A strong sense of being not OK leads indi-
viduals to conclude that they are somehow in-
herently bad.
Steiner (1974) put forward the theory that
depression is linked to stroke deprivation. In
his view, individuals with depression have a
powerful set of stroke economy rules that limit
seeking and experiencing positive strokes and
lives. Depressed persons live in an interper-
sonal world in which positive strokes either are
not forthcoming due to limited or unsatisfac-
tory relationships and/or are discounted by the
Transactional Analysis Journal
 DEPRESSION: A LITERATURE REVIEW ON DIAGNOSIS, SUBTYPES, PATTERNS OF RECOVERY, MODELS
individual, maintaining his or her low self-
esteem and sense of worthlessness. Patterns of
negative stroking are internalized in the indi-
vidual’s Parent ego state (Steiner identified this
as part of the individual’s P 1 ego state or “Pig
Parent,” to use his terminology). This results in
the negative strokes being internally replayed
through the internal ego state dialogue as self-
criticism, which reinforces the sense of the self
as being inherently bad. In addition to the
prevalence of negative, critical strokes, there is
an absence of positive, nurturing strokes, which
leads to an undeveloped internal Nurturing
Parent. Steiner (1974) saw this internalized strok-
ing pattern as a loveless script with a central
feeling of being unloved or unlovable. His
theories of stroking patterns in depression re-
ceived some support in the research of Fetsch
and Sprinkle (1982) who used a stroke theory
based short-term group intervention with a
group of depressed young men and found that
group participants experienced an improvement
in depressive symptoms when measured using
the Beck Depression Inventory (A. T. Beck,
Steer et al., 1996; A. T. Beck, Ward et al., 1961).
In another piece of research, Horowitz (1982)
found that as “positive stroke acquisition fre-
quency increases, self-reported symptom dis-
tress decreases” (p. 219) and that infrequent
acceptance of positive strokes was correlated
with higher levels of depression, obsessive-
compulsive behavior, anxiety, disordered think-
ing, and interpersonal alienation.
Goulding and Goulding (1979/1997) sug-
gested that depression is linked to the Don’t
Exist injunction and the presence of a suicidal
script decision. The depressed individual is seen
to have a type two impasse around the Don’t
Exist injunction and often also a type three im-
passe around issues of worthlessness. They also
supported Steiner’s view that people who have
depression also do not have a sufficient internal
Nurturing Parent.
W ithin transactional analysis theory, depres-
sion may be seen to be a repetitive and mala-
daptive coping strategy. “W e find that the [de-
pressed] person has often in the past reacted to
stress with depression, sadness, loss of self-
esteem, and feelings of being overwhelmed and
unable to cope” (Goulding & Goulding, 1979/
Vol. 41, No. 4, October 2011
1997, p. 182). The view that depression is a re-
petitive, maladaptive coping strategy is also
echoed in the theory of the racket system (Ers-
kine & Zalcman, 1979). The racket system is
used by many transactional analysis therapists
to compile a diagnosis of the internal dynamics
of an individual’s depression. The racket beliefs
about the self that a person with depression
experiences might include: “I am inherently
bad/worthless, unlovable/inadequate/inferior”;
“If things go wrong it is my fault. I won’t start
things because I will only mess them up. I am
a failure”; and “I am helpless.” Racket beliefs
about others might include: “Others are better
than me” and “Others will reject me.” Racket
beliefs relating to the world might include:
“The world is a cruel, unjust, and unfair place”
and “Life is pointless, meaningless, and hope-
less.” W ith regard to the racket system, the re-
ported internal experiences of individuals with
depression would include a number of their de-
pressive symptoms, and the observable behav-
iors would include withdrawal and avoidance
of activities. These individuals will have memo-
ries they can draw on as “evidence” for the ac-
curacy of such beliefs. The theory of the racket
system also acknowledges the central impor-
tance of identifying, understanding, and expres-
sing the underlying, repressed feeling to under-
standing and dismantling the racket system. In
depression, these underlying feelings are likely
to be feelings of anger and grief.
Although a number of depressive symptoms
and processes can be understood using transac-
tional analysis concepts of structural analysis,
several TA authors have used the functional
model to understand the process of a person
with depression. The harsh, self-critical process
that is a key feature of depression is believed to
be connected to a harsh, critical Parent ego state
that dominates the internal dialogue of the de-
pressed individual at the conscious, out-of-
awareness, and unconscious levels (Kapur, 1987;
Maggiora, 1987). This process is described by
both Kapur and Maggiora in functional analysis
terms as the presence of a strong, overdevel-
oped Critical Parent transacting internally with
the Adapted Child who, in turn, experiences
feelings of guilt, shame, despair, and a sense of
worthlessness. Additionally, the internal Nur-
361
MARK WIDDOWSON
turing Parent is seen as relatively weak, which
results in the individual being unable to sustain
any positive sense of self-esteem (Kapur, 1987;
Maggiora, 1987). As the accuracy of the Parent-
driven, self-critical dialogue and the “I am bad”
response of the Child ego state is accepted by
the depressed individual as the “truth,” the nega-
tive beliefs about self, others, and the world
also can be viewed as contaminations of the
Adult ego state.
Interpersonally, individuals with depression
may simultaneously seek to counteract their
sense of badness, prevent abandonment, and
treat others as having more value (“I’m Not
OK, You’re OK”) by transacting from a Nur-
turing Parent position or by Rescuing others
(Karpman, 1968; M aggiora, 1987). People with
depression with a sense of helplessness may
also present from a Victim position, inviting
the therapist and others to Rescue them (Kapur,
1987).
The detailed understanding of an individual’s
depression using transactional analysis theory
would involve a layering of multiple theoretical
concepts, which would, in turn, inform the thera-
pist’s treatment approach. This would provide
the therapist with a subtle and individualized
way of understanding how each patient experi-
ences depression, both intrapsychically and
interpersonally, and of understanding the eti-
ology and dynamics of the individual’s depres-
sion. As was discussed earlier, depression is
not a single, unified experience, and different
theories may or may not be appropriate for
understanding a particular patient’s experience.
Therapists are advised to consider how each of
these theories (or, indeed, any other transac-
tional analysis theory) either enhances their
conceptualization and understanding of the
patient’s experience of depression or can be
discarded as not being relevant for that indi-
vidual, thus tailoring the case formulation and
treatment plan to the needs of each patient.
Most of the studies that address treatment
effectiveness for depression rely on symptoma-
tic relief as a measurement of effectiveness.
Because transactional analysis considers symp-
tomatic relief to be only the second of Berne’s
(1961, 1966) four stages of cure, it is possible
that continuing therapy beyond this point may
362
have a substantial impact on reducing relapse
rates, although to date no research has been
conducted to support this. Nevertheless, with
patients who intend to terminate therapy at the
symptomatic relief stage, it may be advanta-
geous to help them identify prodromal indica-
tors (early symptoms indicating the onset of
disease or relapse) as a sign that additional thera-
py may be beneficial to prevent full relapse.
Furthermore, data from research on mainte-
nance therapy (occasional sessions to maintain
gains) from studies conducted on IPT suggest
that maintenance therapy is an effective strate-
gy for relapse prevention (Frank et al., 1990).
Conclusion
Depression is one of the problems most fre-
quently encountered by psychotherapists in
their clinical practice. It is important for thera-
pists to be aware of the symptoms and manifes-
tations of depression so as to facilitate the diag-
nostic process and ongoing monitoring of pa-
tients who have depression. An appreciation of
the factors that influence relapse and recovery
is also important to help the therapist present
factual, research-based information to patients
to help them enter therapy from a position of
informed consent. This, in turn, also helps thera-
pists to make a more accurate assessment of
their patients’ prognosis. Understanding the
internal dynamics and processes of depression
will also help therapists refine their treatment
planning so that their approach is tailored to
each patient and interventions are designed and
implemented in the most effective manner. Un-
fortunately, to date, the evidence base for trans-
actional analysis in the treatment of depression
remains poor. This is not due to the ineffective-
ness of transactional analysis but to a lack of
evidence from well-designed research studies.
Such studies are necessary if transactional analy-
sis is going to be in a position to compete
equally with other approaches. Only then will
transactional analysts be able to demonstrate
what they know well from their work: that trans-
actional analysis is an effective approach for
treating depression.
W hile this article describes several psycho-
therapy approaches and models for understand-
ing and working with depression, including
Transactional Analysis Journal
 DEPRESSION: A LITERATURE REVIEW ON DIAGNOSIS, SUBTYPES, PATTERNS OF RECOVERY, MODELS
some that have been tested and found valid, no
single approach can claim to be a universally
effective treatment for depression. This sug-
gests that each views depression from a slightly
different perspective, thus addressing certain
types or aspects of it. Learning from each ap-
proach and using a model that has substantial
theoretical equivalence with each approach, the
transactional analyst can draw on a powerful,
complex, and layered formulation of concepts
to understand and provide treatment for depres-
sion, one that could reasonably expect to pro-
vide results equivalent to those seen with other
therapies.
Mark Widdowson, M.Sc., ECP, FHEA, is a
Teaching and Supervising Transactional Ana-
lyst (psychotherapy) and the author of Transac-
tional Analysis: 100 Key Points and Tech-
niques (Routledge). He is a doctoral candidate
at the University of Leicester and has been
conducting research investigating the process
and outcome of transactional analysis psycho-
therapy for the treatment of depression. Mark
can be reached at 3 Crossview Place, Glasgow
G69 6JN, United Kingdom; e-mail: mark.
widdowson1@btinternet.com .
REFERENCES
Abramson, L. Y., Seligman, M. E. P., & Teasdale, J.
(1978). Learned helplessness in humans: Critique and
reformulation. Journal of Abnormal Psychology, 87,
49-74.
Alloy, L. B., Abramson, L. Y., Whitehouse, W. G., Hogan,
M. E., Panzarella, C., & Rose, D. T. (2006). Prospective
incidence of first onsets and recurrences of depression
in individuals at high and low cognitive risk for depres-
sion. Journal of Abnormal Psychology, 115, 145-156.
American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.). Wash-
ington, DC: Author.
Barkham, M., Rees, A., Stiles, W. B., Shapiro, D. A.,
Hardy, G. E., & Reynolds, S. (1996). Dose-effect rela-
tions in time-limited psychotherapy for depression.
Journal of Consulting and Clinical Psychology, 64(5),
927-935.
Barros, H. M. T., Calil, H. M., Guimarães, F. S., Soares, J.
C., & Andreatini, R. (2002). The brain decade in de-
bate: V-neurobiology of depression. Progress in Neuro-
Psychopharmacology & Biological Psychiatry, 26,
613-617.
Beck, A. T. (1983). Cognitive therapy of depression: New
perspectives. In P. J. Clayton & J. E. Barrett (Eds.),
Treatment of depression: Old controversies and new
approaches (pp. 265-290). New York, NY: Raven.
Vol. 41, No. 4, October 2011
Beck, A. T., Rush, A. J., Emery, G., & Shaw, B. (1979).
Cognitive therapy of depression. New York, NY:
Guilford Press.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual
for the Beck depression inventory-II. San Antonio, TX:
Psychological Corporation.
Beck, A. T., Ward, C. H., Mendelssohn, M. J., & Erbaugh,
J. (1961). An inventory for measuring depression. Ar-
chives of General Psychiatry, 4, 561-571.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond.
New York, NY: Guilford Press.
Berne, E. (1961). Transactional analysis in psychothera-
py: A systematic individual and social psychiatry. New
York, NY: Grove Press.
Berne, E. (1966). Principles of group treatment. New
York, NY: Grove Press.
Berne, E. (1972). What do you say after you say hello?:
The psychology of human destiny. New York, NY:
Grove Press.
Blatt, S. J. (1974). Levels of object representation in ana-
clitic and introjective depression. The Psychoanalytic
Study of the Child, 24, 107-157.
Blatt, S. J., & Zuroff, D. C. (1992). Interpersonal related-
ness and self-definition: Two prototypes for depression.
Clinical Psychology Review, 12, 527-562.
Bowlby, J. (1977). The making and breaking of affectional
bonds: 1. Etiology and psychopathology in light of
attachment theory. British Journal of Psychiatry, 130,
201-210.
Bowlby, J. (1980). Loss: Separation, and depression. Vol.
3 of Attachment and loss. New York, NY: Basic Books.
Bowlby, J. (1988). Developmental psychiatry comes of
age. American Journal of Psychiatry, 145, 1-10.
Derogatis, L. R. (1983). SCL-90-R: Administration, scor-
ing and procedural manual-II. Baltimore, MD: Clinical
Psychometric Research.
Ernst, F. H., Jr. (1971).The OK corral: The grid for get-on-
with. Transactional Analysis Journal, 1(4), 33-42.
Erskine, R. G., & Zalcman, M. J. (1979). The racket sys-
tem: A model for racket analysis. Transactional Analy-
sis Journal, 9, 51-59.
Fetsch, R. J., & Sprinkle, R. L. (1982). Stroking treatment
effects on depressed males. Transactional Analysis
Journal, 12, 213-217.
Frank, E., Kupfer, D. J., Perel, J. M., Cornes, C., Jarrett,
D. B., Mallinger, A. G., . . . Grochocinski, V. J. (1990).
Three-year outcomes for maintenance therapies in
recurrent depression. Archives of General Psychiatry,
47, 1093-1099.
Freud, S. (1957). Mourning and melancholia. In J. Strach-
ey (Ed. & Trans.), The standard edition of the collected
works of Sigmund Freud (Vol. 14, pp. 243-274). Lon-
don, England: Hogarth. (Original work published 1917)
Goulding, M. M., & Goulding, R. L. (1997). Changing
lives through redecision therapy. New York, NY:
Grove Press. (Original work published 1979)
Greenberger, D., & Padedsky, C. A. (1995). Mind over
mood. New York, NY: Guilford Press.
Horwitz, A. (1982). The relationship between positive
stroking and self-perceived symptoms of distress.
Transactional Analysis Journal, 12, 218-221.
Jacobson, E. (1971). Depression: Comparative studies of
363
 MARK WIDDOWSON
normal, neurotic and psychotic conditions. New York,
NY: International Universities Press.
Kapur, R. (1987). Depression: An integration of TA and
psychodynamic concepts. Transactional Analysis Jour-
nal, 17, 29-34.
Karpman, S. (1968). Script drama analysis. Transactional
Analysis Bulletin, 7(26), 39-43.
Keller, M. B., Lavori, P. W., Endicott, J., Coryell, W., &
Klerman, G. L. (1983). Double depression: Two-year
follow up. American Journal of Psychiatry, 140, 689-
694.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz,
D., Merikangas, K. R., . . . Wang, P. S. (2003). The
epidemiology of major depressive disorder: Results
from the national comorbidity survey replication (NCS-
R). Journal of the American Medical Association, 289,
3095-3105.
Klein, M. (1975). Envy and gratitude and other works
1946-1963. New York, NY: The Free Press.
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., &
Chevron, E. S. (1984). Interpersonal psychotherapy of
depression. New York, NY: Basic Books.
Kopta, S. M., Howard, K. I., Lowry, J. L., & Beutler, L. E.
(1994). Patterns of symptomatic recovery in psycho-
therapy. Journal of Consulting and Clinical Psycho-
logy, 62(5), 1009-1016.
Leonard, B. E. (2001). The immune system, depression
and the action of antidepressants. Progress in Neuro-
Psychopharmacology and Biological Psychiatry, 25,
767-780.
Lorant ,V., Deliege, D., Eaton, W., Robert, A., Philippot,
P., & Ansseau, M. (2003). Socioeconomic inequalities
in depression: A meta-analysis. American Journal of
Epidemiology, 157, 98-112.
Maggiora, A. R. (1987). A case of severe depression.
Transactional Analysis Journal, 17, 38-43.
Mahler, M. S., Pine, F., & Bergman, A. (1975). The psy-
chological birth of the human infant. New York, NY:
Basic Books.
McWilliams, N. (1994). Psychoanalytic diagnosis. New
York, NY: Guilford Press.
Mellor, K., & Schiff, E. (1975). Discounting. Transaction-
al Analysis Journal, 5(3), 295-302.
Morrison, K. H., Bradley, R., & Westen, D. (2003). The
external validity of controlled clinical trials of psycho-
therapy for depression and anxiety: A naturalistic study.
Psychology and Psychotherapy: Theory, Research and
Practice, 76, 109-132.
Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel,
V., & Ustun, B. J. (2007). Depression, chronic diseases,
and decrements in health: Results from the world health
surveys. Lancet, 370(9590), 851-858.
364
View publication stats
Mulhern, R. (2010). Depression. In A. Grant, M. Town-
send, R. Mulhern, & N. Short (Eds.), Cognitive behav-
ioural therapy in mental health care (pp. 55-73). Lon-
don, England: Sage.
Office of National Statistics. (2000). Psychiatric morbidity
among adults living in private households in Great
Britain. London, England: Author.
Papakostas, G. I., Petersen, T., Denninger, J., Sonawalla,
S. B., Mahal, Y., Alpert, J. E., Nierenberg, A. A., &
Fava, M. (2003). Somatic symptoms in treatment-
resistant depression. Psychiatry Research, 118, 39-45.
Pariante, C. M., & Miller, A. H. (2001). Glucocorticoid
receptors in major depression: Relevance to patho-
physiology and treatment. Biological Psychiatry, 49,
391-404.
PDM Task Force. (2006). Psychodynamic diagnostic
manual. Silver Spring, MD: Alliance of Psychoanalytic
Organizations.
Piccinelli, M., & Wilkinson, G. (1994). Outcome of de-
pression in psychiatric settings. The British Journal of
Psychiatry, 164, 297-304.
Schiff, J. L., Schiff, A., & Schiff, E. (1975). Frames of
reference. Transactional Analysis Journal, 5, 290-294.
Scott, M. S., Stradling, S. G., & Dryden, W. (1995). De-
veloping cognitive-behavioural counselling. London,
England: Sage.
Shea, M., Widiger, T., & Klein, M. (1992). Comorbidity
of personality disorders and depression: Implications for
treatment. Journal of Clinical and Consulting Psy-
chology, 60, 857-868.
Shedler, J., & Westen, D. (2004). Refining personality
disorder diagnoses: Integrating science and practice.
American Journal of Psychiatry,161, 1350-1365.
Steiner, C. (1974). Scripts people live: Transactional
analysis of life scripts. New York, NY: Grove Press.
Stuart, S., & Robertson, M. (2003). Interpersonal psycho-
therapy: A clinician’s guide. London, England: Hodder-
Arnold.
Ustun, T. B., Ayuso-Mateos, J. L., Chatterji, S., Mathers,
C., & Murray, C. J. (2004). Global burden of depressive
disorders in the year 2000. British Journal of Psychia-
try, 184, 386-392.
Weissman, M. M., Markowitz, J. C., & Klerman, G. L.
(2000). A comprehensive guide to interpersonal psy-
chotherapy. New York, NY: Basic Books.
Westen, D., & Morrison, K. (2001). A multidimensional
meta-analysis of treatments for depression, panic, and
generalized anxiety disorder: An empirical examination
of the status of empirically supported therapies. Journal
of Consulting and Clinical Psychology, 69(6), 875-899.
Transactional Analysis Journal