Effectiveness of Intensive Short-Term Dynamic Psychotherapy on Object Relations, Anger, and Guilt in Women with Major Depressive Disorder

Sarlaki, Abolfazl; Farokhzad, Mona; Khanzadeh, Fatemeh; Younesi Sinaki, Mahsa; Razavi Mahdiian, Seyedeh Zahra; Tayyar Parvin, Mojtaba

doi:10.22055/psy.2024.44694.3112

Effectiveness of Intensive Short-Term Dynamic Psychotherapy on Object Relations, Anger, and Guilt in Women with Major Depressive Disorder

Document Type : Research Article

Authors

Abolfazl Sarlaki ¹

Mona Farokhzad ²

Fatemeh Khanzadeh ³

Mahsa Younesi sinaki ⁴

Seyedeh Zahra Razavi Mahdiian ⁵

Mojtaba Tayyar Parvin ⁶

¹  M.Sc. Graduate in Child and Adolescent Clinical Psychology, Department of Psychology, Faculty of Educational Sciences and Psychology, Shahid Beheshti University, Tehran, Iran

² M.A. student in clinical psychology, Department of Psychology, Faculty of Medical Sciences, Garmsar Branch, Islamic Azad University, Iran.

³ M.A. Graduate in Clinical Psychology, Department of Psychology, Faculty of Humanities, West Tehran Branch, Islamic Azad University, Iran.

⁴ M.A. student in General Psychology, Department of Psychology, Faculty of Educational Sciences and Psychology, Roudehen Branch, Islamic Azad University, Iran.

⁵ M.A. student in General Psychology, Department of Psychology, Faculty of Psychology and Educational Sciences, Kharzmi University, Tehran, Iran.

⁶ M.Sc. Student in Clinical Psychology, Department of Clinical Psychology, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran.

10.22055/psy.2024.44694.3112

Abstract

According to the psychodynamic theory, major depressive disorder (MDD) is caused by a perceived real loss in relationships, leading to anger and guilt towards the other person. Short-term intensive dynamic psychotherapy aims to help patients bring their unconscious emotions to the conscious level, known as "Unlocking the Unconscious". This study aimed to determine the effectiveness of short-term intensive dynamic psychotherapy on objective relationships, anger, and guilt in women with MDD. Regarding the purpose, the present study was of applied type, and in terms of methodology, it was semi-experimental with pre-test - post-test - 3-month follow-up design with a control group. The statistical population consisted of all women with MDD who were referred to counseling centers and psychological services in Isfahan in the spring of 2023. A total of 32 women with MDD were selected via available sampling and randomly assigned to the experimental group (16 people) and the control group (16 people). Dovanloo's (1995) ISTDP protocol was performed only for the experimental group along 8 sessions of 90 minutes weekly, while the control group was placed on the waiting list. Subjects were evaluated in 3 stages (pre-test, post-test, and 3-month follow-up) through Bell's Object Relation Inventory (BORI), State-Trait Anger Expression Inventory 2 (STAXI-2), kugler and Jones Guilty Feelings ‘S Questionnaire (KJGFQ), and Beck Depression Inventory-II (BDI-II). Data analysis was undertaken via repeated measures analysis of variance and the Bonferroni post hoc test using SPSS-28 software. According to the results, ISTDP was effective on alienation, insecure attachment, the total score of subjective relationships, internal occurrence of anger, internal control of anger, trait guilt, as well as the total score of guilt and depression symptoms, and up to 3 months after the intervention was stable (p>0/05). ISTDP had the greatest impact on depression symptoms (ηp²=0.543), anger internalization ‌(ηp²=0.436), and anger internal control (ηp²=0.412). ISTDP enables patients with depression to access and re-experience repressed anger toward attachment figures. Through this process, along with therapeutic pressure to confront guilt, patients can amend their object relations, reduce guilt, and alleviate depressive symptoms.

Keywords

dynamic psychotherapy

object relations

anger

feel guilty

depression

Abbass, A., Lumley, M. A., Town, J., Holmes, H., Luyten, P., Cooper, A., ... & Kisely, S. (2021). Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects. Journal of Psychosomatic Research, 145, 110473. https://doi.org/10.1016/j.jpsychores.2021.110473

Abbass A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Seven leaves press.

Abbass, A., Town, J., Ogrodniczuk, J., Joffres, M., & Lilliengren, P. (2017). Intensive short-term dynamic psychotherapy trial therapy: Effectiveness and role of “unlocking the unconscious”. The Journal of Nervous and Mental Disease, 205(6), 453-457. https://doi.org/10.1097/NMD.0000000000000684

Abraham, K. (1942). A short study of the development of the libido viewed in the light of mental disorders. Selected papers on psychoanalysis.

Ahmadi, F., Goodarzi, M., & Kazemi rezaei, S. A. (2021). the Effectiveness of Intensive Short-Term Dynamic Psychotherapy in dissociative experiences, object relations and delayed reward discounting in patients with substance use disorders and addiction, Journal of Clinical Psychology, 13(1), 65-78. https://doi.org/10.22075/JCP.2021.21041.1931 [Persian]

Ahmadi, F., Vatankhah Amjad, F., Kazemi Rezaei, A., & Mohammadi, S. (2021). The Effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP (in symptoms depression, anxiety, posttraumatic stress and guilt felling in Bereaved people from the disease COVID-19, Nursing Management, 10(3), 69-81. [Persian]

American Psychiatric Association. (2015). Depressive disorders: DSM-5® selections. American Psychiatric Pub.

Asgari, P., Hedari, A., & Khorami, N. S. (2021). The effects of acceptance-commitment therapy on behavior impulsivity, alexithymia and disappointment in depressed patients. Journal of Psychological Achievements, 28(2), 201–218. https://doi.org/10.22055/psy.2021.36514.2664 [Persian]

Asghari Moghadam, M. A., Moghadasin, M., & Dibagnia, P. (2011). The Reliability and Criterion Validity of a Farsi Version of the State-Trait Anger Expression Inventory-2 (STAXI-2) in a Clinical Sample. Clinical Psychology and Personality, 9(2), 75-94. [Persian]

Bagheri, J., Birashk, B., Dehghani, M., & Asgharnejad A. A. (2019). The Relationship Between Object Relations and the Severity of Depression Symptoms: The Mediating Role of Self-Compassion. IJPCP; 25(3), 328-343. https://doi.org/10.32598/ijpcp.25.3.328 [Persian]

Basile, B., & Mancini, F. (2011). Eliciting guilty feelings: A preliminary study differentiating deontological and altruistic guilt. Psychology, 29; 2(02), 98. https://doi.org/10.4236/psych.2011.2201

Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck depression inventory–II. Psychological assessment. https://doi.org/10.1037/t00742-000

Bell, M., Billington, R., & Becker, B. (1986). A scale for the assessment of object relations: Reliability, validity, and factorial invariance. Journal of Clinical Psychology, 42(5), 733-741. https://doi.org/10.1002/1097-4679(198609)42:5<733::AID-JCLP2270420509>3.0.CO;2-C

Bianchi, R., Schonfeld, IS., & Laurent, E. (2015). Burnout–depression overlap: A review. Clinical Psychology Review, 36, 28-41. https://doi.org/10.1016/j.cpr.2015.01.004

Borgmann, L., Schuurmans, L., Göritz, A. S., Reininger, K. M., & Moritz, S. (2026). Interpersonal ambivalence in depression: a psychodynamic perspective on the role of prosocial attitudes and latent aggression. Cogent Psychology, 13(1), 2651541. https://doi.org/10.1080/23311908.2026.2651541

Busch, F. (2009). Anger and depression. Advances in Psychiatric Treatment, 15(4), 271-27. https://doi.org/10.1192/apt.bp.107.004937

Caldiroli, A., Capuzzi, E., Riva, I., Russo, S., Clerici, M., Roustayan, C., ... & Buoli, M. (2020). Efficacy of intensive short-term dynamic psychotherapy in mood disorders: a critical review. Journal of Affective Disorders, 273, 375-379. https://doi.org/10.1016/j.jad.2020.04.002

Davanloo, H. (2001). Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. John Wiley & Sons.

Davanloo, H. (1995). Unlocking the Unconcious: Selected Papers of Habib Davanloo, MD. Wiley.

Erritzoe, D., Barba, T., Benway, T., Joel, Z., Good, M., Layzell, M., ... & James, E. (2026). A short-acting psychedelic intervention for major depressive disorder: a phase IIa randomized placebo-controlled trial. Nature Medicine, 1-8. https://doi.org/10.1038/s41591-025-03668-w

First, M. B. (2014). Structured clinical interview for the DSM (SCID). The encyclopedia of clinical psychology, 1-6.

Freud, S. (1917). Mourning and melancholia. The standard edition of the complete psychological works of Sigmund Freud, 14(1914-1916), 237-58.

Gabbard, G. O. (2014). Psychodynamic psychiatry in clinical practice (5th ed.). American Psychiatric Publishing, Inc.

Ghapanchi, A., Masjedi-Arani, A., Fathali Lavasani, F., & Atef Vahid, M. K. (2022). Object Relations and Core Conflictual Relationship Theme in Patients with Major Depression and Normal Individuals. Journal of Practice in Clinical Psychology, 10(2), 165-176. https://doi.org/10.32598/jpcp.10.2.812.3

Habiba, M. (2022). The effectiveness of short-term intensive dynamic psychotherapy in changes in defensive styles and cognitive-emotional coherence in patients with depression. Sistan and Baluchestan University. [Persian]

Hadinezhad, H., Tabatabaeian, M., & Dehghani, M. (2014). A Preliminary Study for Validity and Reliability of Bell Object Relations and Reality Testing Inventory. Iranian Journal of Psychiatry and Clinical Psychology (IJPCP), 20(2), 162-169. [Persian]

Herbert, G. L., McCormack, V., & Callahan, J. L. (2010). An investigation of the object relations theory of depression. Psychoanalytic Psychology, 27(2), 219. https://doi.org/10.1037/a0019423

Heshmati, R., Javadpour, S., HajiSaghati, R., & Haollahzadeh, S. (2021). The effect of intensive short-term dynamic psychotherapy (ISTDP) an emotional suppression and negative affect in patients with treatment-resistant depression: a single-subject study. Journal of Research in Psychopathology, 2(6), 31-39. https://doi.org/10.22098/JRP.2022.10218.1057

Høglend, P., Hersoug, A. G., Bøgwald, K. P., Amlo, S., Marble, A., Sørbye, Ø., & Crits-Christoph, P. (2011). Effects of transference work in the context of therapeutic alliance and quality of object relations. Journal of Consulting and Clinical Psychology, 79(5), 697. https://doi.org/10.1037/a0024863

Lievaart, M., Franken, I. H., & Hovens, J. E. (2016). Anger assessment in clinical and nonclinical populations: Further validation of the State–Trait Anger Expression Inventory‐2. Journal of Clinical Psychology, 72(3), 263-278. https://doi.org/10.1002/jclp.22253

Kernberg, O. F. (2006). Psychoanalytic controversies: The pressing need to increase research in and on psychoanalysis. The International Journal of Psychoanalysis, 87(4), 919-936. https://doi.org/10.1516/46N7-ULAM-DQKR-VGRT

Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. The International Journal of Psycho-Analysis, 16, 145.

Kugler, K., & Jones, W. H. (1992). On conceptualizing and assessing guilt. Journal of personality and Social Psychology, 62(2), 318. https://doi.org/10.1037/0022-3514.62.2.318

Mahdiyanfar, E., Mahdiyan, H., & Jahangiri, A. (2024). Compare the effectiveness of mindfulness and schema therapy on anger management, marital conflict and quality of life. Psychological Achievements, 31(1), 341–372. https://doi.org/10.22055/psy.2023.42636.2945 [Persian]

Naziri, Gh. (2003). The role of guilt in the information processing process of obsessive-compulsive patients and its roots in parenting. IUMS. [Persian]

Rahimi, C. (2014). Application of the Beck Depression Inventory-II in Iranian University Students. Clinical Psychology and Personality, 12(1), 173-188. [Persian]

Rezaei, S., Mojtabaei, M., & Shomali Oskoei, A. (2022). Comparison of the Effectiveness of Intensive Short-Term Dynamic Psychotherapy and Schema Therapy on Depression, Anxiety in Mothers with Autistic Children. Journal of Applied Psychology, 66(2). https://doi.org/10.48308/APSY.2022.226991.1312 [Persian]

Robinaugh, DJ., & McNally, RJ., (2010). Autobiographical memory for shame or guilt provoking events: Association with psychological symptoms. Behaviour Research and Therapy. 1; 48(7), 646-52. https://doi.org/10.1016/j.brat.2010.03.017

Ściegienny-Lemler, A., Mielimąka, M., Jęda, P., Klasa, K., Skrobol, K., Dudek, D., & Sobański, J. A. (2026). Prognostic Factors for Guilt Reparation in Psychodynamic Group Psychotherapy. Journal of Contemporary Psychotherapy, 1-8. https://doi.org/10.1007/s10879-026-09715-y

Shabani, A., Masoumian, S., Zamirinejad, S., Hejri, M., Pirmorad, T., & Yaghmaeezadeh, H. (2021). Psychometric properties of Structured Clinical Interview for DSM-5 Disorders-Clinician Version (SCID-5-CV). Brain and Behavior, 11(5), e01894. https://doi.org/10.1002/brb3.1894

Sharifi, V., Asadi, S M., Mohammadi, M R., Amini, H., Kaviani, H., Semnani, Y., et al. (2004). Reliability and Feasibility of The Persian Version of The Structured Diagnostic Interview for DSM-IV (SCID). Advances in Cognitive Sciences; 6 (1 and 2), 10-22. [Persian]

Sharifi, V., Shadloo, B., & Shahrivar, Z. (2017). Structured clinical interview for DSM-5 disorders: SCID-5-CV clinician version. Tehran: EbneSina.

Spielberger, C. D. (1999). State-Trait Anger Expression Inventory-2. Lutz, Florida: Psychological Assessment Resources.

Town, J. M., Abbass, A., Stride, C., Nunes, A., Bernier, D., & Berrigan, P. (2020). Efficacy and cost-effectiveness of intensive short-term dynamic psychotherapy for treatment resistant depression: 18-Month follow-up of the Halifax depression trial. Journal of Affective Disorders, 273, 194-202. https://doi.org/10.1016/j.jad.2020.04.035

Town, J. M., Falkenström, F., Abbass, A., & Stride, C. (2022). The anger-depression mechanism in dynamic therapy: Experiencing previously avoided anger positively predicts reduction in depression via working alliance and insight. Journal of Counseling Psychology, 69(3), 326. https://doi.org/10.1037/cou0000581

Wei, M., Qin, Y., Niu, X., Niu, S., Mu, F., Yang, L., ... & Liu, Y. (2025). Marriage and postpartum major depressive disorder: A systematic review and meta-analysis of cohort studies. Journal of Psychiatric Research, 182, 83-91. https://doi.org/10.1016/j.jpsychires.2025.01.004