Don Nathanson interesting comments about my emphasis on parental failures in the cause of depression call for some elaboration on my part. Nathanson calls attention to the undisputed facts that many depressed patients respond well to pharmacological treatments with relief of the major symptoms. He did not say but it is probably also true that some of these patients did not respond nearly as well to psychotherapy.
He suggests that the affect disorder is "often (not always, of course) secondary not to affect management scripts forged within inadequate parenting situations, but to a biological disorder of shame affect that leaves the individual mired in the experience of shame and therefore unable to risk any expansion of self-concept." In other words - if I understand correctly - the depressive symptomatology is due primarily to biological factors and that the psychological experiences are not etiological but secondary to the biology.
I would propose instead that in the depressive disorders, probably like most psychopatholgy, one can almost always assume at least three kinds of etiological factors: 1)inherent biological predisposition, 2)traumatic conditions emanating from the environment during early development (what I would call faulty selfobject experiences during development), and 3)environmental insults as precipitating events in the here-and-now ( what I would call precipitating malattuned selfobject experiences in the here-and-now). Quantitatively it is usually almost impossible to tell precisely how much of each of these three kinds of developmental and precipitating experiences are the decisively pivotal ones in a particular case. It is not an either/or question but a how much of this vs how much of that question.
Some patients respond well to only biological intervention, others to only psychological intervention and some need both while a few others do not respond at all to any approach that has been tried. It is up to the patient jointly and in consultation with his or her therapist to decide which approach is to be tried first.
Furthermore, it is important to keep in mind that a desirable favorable response to treatment does not solve the question of the cause. Many patients respond very well to all kinds of different types of psychotherapy without regard to the therapistís theoretical orientation. This is still a puzzling phenomenon and suggests that perhaps the therapists concern or empathy or some other non-specific factor may be the decisive one. I personally believe that the therapistís concern and empathy provide for the patient needed selfobject experiences that are strengthening to the patientís self and thus enable the patient to deal with the symptoms. But I am quite aware that one can easily construct other theories that would similarly explain the observations.
Similar considerations should be kept in mind about pharmacological treatment. In the absence of a clear understanding of the etiology and dynamics of a syndrome or symptoms it is wise to be cautious in linking relief of symptoms by medication with assumptions about the etiology of these symptoms. Sometimes I have seen patients who have suffered head trauma and subsequently suffered from headaches. Other patients suffer headaches secondarily to some psychological insult, especially if the experience had evoked strong affects such as shame or anger. Both of these different types of headaches can be ameliorated with a variety of medications - aspirin, ibuprofen, acetaminophen, stronger narcotics, etc. - without clarifying the etiology of these headaches. In my view, psychotherapists should use symptom relieving medication to make their patients more comfortable while at the same time pursuing the psychological treatment to investigate the cause, to provide the needed selfobject experiences to the patient and to gradually provide insights that will eventually allow the patient to go on in life without the therapist. A tall order that unfortunately is not always achieved.