Ms. J. was a 58-year-old manager in a large corporation. She’d had several depressions, requiring time off from work while she was being treated. Unhappiness with her marriage led her to seek psychotherapy, where it soon became evident that Ms. J. was very sensitive and easily felt hurt by the people around her. She reacted to these perceived slights with great anger, about which she then experienced guilt — “I shouldn’t feel like this.” Intense self-criticism unleashed cycles of feeling increasingly worthless and depressed.

Talk it out in therapy

Difficulties with anger have long been known to trigger depression or to maintain it. Patients with these psychologic dynamics have great difficulty in accepting or tolerating their feelings of anger towards others. They tend to deny them or turn “against the self,” which results in intense self-criticism or guilt, with attendant feelings of sadness and emptiness. At other times, the anger is displaced outwards, i.e. subjects react as if others are irritated with them, leading to exhausting states of persecutory anxiety.

Ms. J. recalled that her mother had been extremely critical of her, tolerated no expressions of anger and had spanked her frequently for the slightest misbehaviour. Her father was much kinder, but was away from home for much of her childhood. She thought her mother barely tolerated her and internalized a sense of being defective and wrong that left her oversensitive to any disapproval from others. At work, she struggled to be fair to her employees. If anyone was displeased with her decisions, she could become very upset and feel inadequate as a manager.

Therapy helped Ms. J. to see how angry she actually was in these circumstances. She also became aware of how much she felt like her critical, demanding mother when she was irate. Here was another clincher — she wanted to avoid any identification with her mother, whom she believed to have been cruel and rejecting. Ms. J. was full of unexpressed anger going far back into her life and she had developed a conviction that to express any irritability would be enormously destructive. In treatment, she was encouraged to talk about her angry feelings. Slowly, the clinician taught her to use them as an indication that she needed to be assertive about issues in her life, instead of responding with internalized rage.

The same dynamic had also come into her medication treatment. When her doctor was late several times, she felt deeply offended despite apologies and so, she “forgot” to take her medication. Again, encouraging the patient to talk about feelings of anger helped to establish more constructive patterns of reacting.

Common pattern

This is one of 4 common, powerful psychologic patterns that serve to maintain recurring states of low mood in many depressed patients (see Fredric Busch et al. Psychodynamic Treatment of Depression, 2004). Growing up with fragile self-esteem makes them feel easily affronted as adults, known as “narcissistic vulnerability.” Work and ordinary experiences with people become very stressful. Perceived slights trigger anger that they direct back in the form of self-criticism. Psychotherapy helps them learn to disrupt this cycle.