Depression is a common and serious disorder that has negative effects on the way a person thinks and functions. The purpose of the present study was to evaluate the effectiveness of integrative therapy (short-term psychodynamic and cognitive behavioral therapy) in increasing ego strength and treating depression in a case of major depressive disorder. In this study, a single-subject research design (A-B-A-B design) was used and the client was evaluated during the four stages of beginning, middle, and end of treatment and six months of follow-up by the Beck Depression Inventory and Inventory of Ego Strengths. The results showed the effectiveness of integrative therapy in increasing ego strength, reducing depression, and improving the quality of life of the client.

Integrative Therapy, Short-Term Psychodynamic, Cognitive Behavioral Therapy, Ego Strength, Depression

Aziz MO (2023) The Effectiveness of Integrative Therapy (Short-Term Psychodynamic and Cognitive-Behavioral Therapy) in Enhancing the Ego Strength and Treating Depression (Case Study), with Follow-Up. JSM Anxiety Depress 4(1): 1026.

According to Wellman’s Encyclopedia of Behavioral Sciences, depression is associated with a feeling of helplessness and blaming oneself for such a feeling. The World Health Organization(WHO) predicted that depression would rank second in the global burden of disease and would be one of the priority conditions covered by the WHO’s mental health Gap Action Program [1]. Bromet et al., studied 18 countries and concluded that the average lifetime and 12-month prevalence of major depression were 14.6% and 5.5% in high-income countries and 11.1% and 5.9% in low to middleincome countries, respectively.

Depression is characterized by a constant depressed mood that is associated with loss of interest or pleasure, decreased energy that lasts at least two weeks, decreased self-confidence, self-blame, decreased ability to concentrate, changes in motorsensory activities, and sleep and appetite disorders. In its most severe form, depression can lead to suicide and increase the risk of mortality [2,3].

Data on the prevalence of depression indicate gender differences, showing that it occurs in about 1 to 25 percent of women and its prevalence is about 5 to 15 percent in men. There are also differences between the two genders in coping with depression. Women are more likely to ruminate on their conditions and blame themselves for being depressed, but men are more inclined to ignore their feelings and keep their minds off by engaging in various activities (2,4). The ego is one of the important factors that play an important role in the psychological functioning of the mind and mental health. Health and illness are a function of the ego’s ability to manage properly the pressure of desires influenced by instincts so that they don’t contradict the limitations of the real world and the superego. This ego’s ability to manage conflicting demands of id, superego, and the requirements of external reality is referred to as ego strength [5]. The ego strength is theoretically related to the level of personality organization and helps people to achieve emotional stability and better cope with internal and external stress [6,7].

As the ego is in charge of managing the mental system, psychological problems appear when the ego is unable to perform its duties and create functional stability. Ego strength indicates the individual’s capacity to tolerate stress [8]. In this regard, the results of the study by Petrovi? et al. [9], showed that aggressive alcoholics had weaker ego-strength than nonaggressive alcoholics and experienced more depressive reactions and suicide attempts. The results obtained from the study by Einy et al. [8], indicated that the degree of psychological disturbances and ego strength was different in people who suffered from emotional traumas such as anxiety disorders than the normal people. Soba?ski et al. [10], and Chhansiya and Jogsan [11], argued that people who enjoyed good ego strength could have better psychological and social functioning and suffered from less anxiety and vice versa.

Different approaches have been used to study and treat depression, including cognitive-behavioral therapy and psychodynamic psychotherapy. Cognitive-behavioral therapy is one of the most effective interventions for the treatment of psychiatric diseases such as depression, anxiety, dependence, and substance abuse. Studies show the effectiveness of cognitivebehavioral therapy in the treatment of moderate to severe [12,13]. Cognitive-behavioral therapy is mainly based on selfhelp and the therapist aims to help the client to develop the skills needed to solve not only current problems but also similar future problems. Accordingly, cognitive behavioral therapy has a relative advantage over other psychological interventions [14].

Cognitive-behavioral therapists help the patients to find a cognitive approach to their problems by focusing on thought patterns instead of emotions. At the same time, cognitive therapists also note that emotions often contain valuable information. Greenberg and Jeremy have shown how expressing emotions and therapeutic alliance can help patients to use their emotions as a source of information about their unsatisfied needs [15,16]. Another well-known and important technique used for psychodynamic treatments is short-term psychodynamic psychotherapy. It is integrated, short-term, and intensive in nature and many studies have confirmed its effectiveness. Psychodynamic psychotherapy is based on self awareness and uses such techniques as clarification; defense analysis, confrontation, and interpretation to help patients get rid of symptoms or disorders. In some cases, it is effective in changing the personality [17]. Evidence shows that the benefits of psychodynamic psychotherapy are lasting and stable and extend clearly beyond the signs of recovery. Psychodynamic psychotherapy seeks to discover aspects of the self that have remained unknown. It can be applied in a long-term and short term [18,19].

Landen argued that there are only two main approaches, action-oriented and insight-oriented approaches, the combination of which is desirable. Most of the treatments that refer to the action-oriented approach, such as behavioral therapy, encourage action to change behavior, while treatment with the insight-oriented approach, such as psychodynamic therapy, seeks to discuss issues of concern to enhance understanding. Clearly, the most effective and lasting therapeutic change require an increase in understanding and a behavioral change. According to Frank, all approaches to psychotherapy operate on the same principles, and the second approach can be considered as a series of attempts to translate one therapeutic language, usually psychoanalysis, into another one that is usually learning theory. This issue culminated in the work of Doller and Miller who argued that the major differences between approaches could be more linguistic than intrinsic [20].

During the reviews, no research was found that was directly related to the subject of the present research. However, there have been some studies that are indirectly related to the subject of this research and the variables considered in it:

-  The research by Driessen et al. [21], showed that adding short-term psychodynamic psychotherapy to antidepressants was effective in treating depression.

- The results of the study by Ólason et al. [22], demonstrated that cognitive-behavioral therapy for depression and anxiety as part of a rehabilitation program for chronic pain could increase the long-term benefits of treatment.

- The results obtained from the research by Soares et al. [23], indicated that cognitive-behavioral therapy was more effective than psychodynamic therapy in the treatment of the major depressive disorder.

- Driessen et al. [24], argued that short-term psychodynamic psychotherapy as an experimental treatment had been used many times in the treatment of depression, but it was not clear whether all subgroups of depressed patients could benefit from this treatment.

- Goodyer et al. [25], concluded in their research that the cognitive behavioral therapy, short-term psychodynamic psychotherapy, and brief psychological intervention for the treatment of depression were significantly different in terms of theoretical and clinical approach and were associated with a similar degree of clinical improvement, cost-effectiveness, and subsequent maintenance of lowered depressive symptoms.

- In a study on cognitive-behavioral versus psychodynamic therapy for major depression, Driessen et al. [26], concluded that psychodynamic therapy could be as effective as cognitive behavioral therapy in important aspects of patient functioning other than reducing depressive symptoms.

- Goldstone et al. [27], demonstrated in their research that both psychodynamic psychotherapy and cognitive behavior therapy were effective in treating depression and neither was superior to the other.

- Besharat et al. [4], showed that ego strength can play a mediating role in the relationship between dimensions of perfectionism and depressive symptoms.

In the end, the purpose of the present article evaluate the effectiveness of integrative therapy (short-term psychodynamic and cognitive behavioral therapy) in increasing ego strength and treating depression in a case of major depressive disorder.

In the present study, a single-subject research design (A-B-A-B design) was used. Sampling was conducted by purposive and convenience sampling methods. The studied sample was one of the clients referring to a counseling center in Hamadan, who was selected using the clinical interview and Beck Depression Inventory. In the research, the beginning, middle, end of treatment and six months of follow-up by ego strength was evaluated by Beck Depression Inventory. The following formula was used to calculate the percentage of the client’s recovery.

% A0-A1/A0=A?

Where A0 indicates the score of the client in the baseline, A1 indicates the score of the client in the termination Session, and A? represents the degree of the client’s recovery [28].

Research Instruments

- Beck Depression Inventory: this inventory consists of 21 self-report items and each item contains 4 phrases and each phrase is given a score from 0 to 3, and the client must choose one of the phrases. This inventory enjoys high validity and reliability according to the studies conducted in Iran. In the research by Ghasemzadeh, the reliability coefficient of the total inventory was obtained to be 0.87 and its test-retest coefficient was obtained to be 0.74 [29].

- Psychological Inventory of Ego Strengths (PIES): This inventory was developed by Markstrom et al. It measures ego strengths including hope, will, purpose, competence, fidelity, love, care, and wisdom, and consists of 64 items. The items are scored by a 5-point Likert scale ranging from 1 (does not describe me well) to 5 (describes me very well). The highest score that a person can get is 320 and the lowest score is 60 [8]. Calculating Cronbach’s alpha, Strom et al. reported the reliability of this inventory to be 0.68. Altafi also reported Cronbach’s alpha for the Iranian samples to be 0.91 and the split-half reliability was obtained to be 0.77.

The treatment sessions consisted of thirteen 90-minute sessions that were held once a week. At first, the treatment process was described to the client and her informed consent was obtained. The client was a 30-year-old female graduate student who suffered from depressive symptoms for one year due to not being admitted to her desired field of study, her brother’s accident, and constant comparisons with her friends. She had such clinical symptoms as feelings of sadness and guilt, shedding tears, boredom, loss of appetite and weight, sleep disorders, headaches, difficulty in concentration, self-criticism, self-blame, perfectionism, and feelings of anxiety when speaking in public and expressing desires. After the clinical interview and psychiatrist diagnosis, the major depressive disorder was diagnosed. The client had no history of any pharmaceutical or psychological intervention during the past year and had insight into her problem. She underwent an integration of psychodynamic psychotherapy and cognitive behavioral therapy during 13 sessions of 1.5 hours per week. The integrative therapy included short-term psychoanalysis, cognitive behavioral therapy, and exercise. All treatment sessions involved the same structure so that at the beginning of each session, a 5-10 minute follow-up of the conditions of the client and the homework was done. In the initial sessions, short-term psychoanalysis was used to identify developmental stages, psychological needs, defense mechanisms, anxious thoughts, neuroticism style, identifications, and the problem history. The subject of the sessions was extracted from the given homework or was based on what had been preoccupied the client and she wanted to talk about them. At the end of each session, other homework was offered if necessary. The purpose of this homework was to teach the skills to the client that seemed she had not learned. The lack of some skills was recognized by unlocking the unconscious and obtaining insight into the problem. In this way, self-efficacy and self-confidence were strengthened.

Session 1: This session was spent on psychological education and familiarizing the client with depressive disorder, treatment method, how to do homework, and the need to do them and attend the treatment sessions. Performing aerobic exercises was also one of the elements that every session was emphasized and supervised to be done certainly. The purpose of this session was to gain general acquaintance with the client, make the client familiar with the treatment method and the problem she had, and create and measure the degree of the therapeutic alliance with the client.

Session 2: At the beginning of this session, the situation of the client during the last week and how the client spent the last week were evaluated. It was difficult for the client to write down her thoughts and do exercise. She stated that “it was difficult for her to do exercise”. However, she had done it more or less. According to the materials that the client had recorded during the last week and the issues that preoccupied mostly the client, the psychodynamic approach was used. The client’s biggest problem was studying the courses and the increased probability of being under academic prohibition. These issues caused a lot of anxiety in her and were addressed using psychodynamic techniques. By addressing the anxiety, it became clear that one of the reasons for the client’s depression was her lack of interest in the field of study and the university to which she had been admitted. This problem also existed in the previous years when she was accepted to the University for a bachelor’s degree. It had created a sense of humiliation and anger towards her, and following this feeling, the client had crawled into her shell and deprived herself of everything. She did not consider herself a good and worthy child for her family. The session lasted an hour and a half. At the end of the session, it was emphasized to record thoughts and do exercise as the homework of the next week.

Session 3: Evaluating and reviewing the previous session and homework and talking about homework written according to the wishes of the client. During this session, the client’s relationship with her parents was discussed. In the process of psychodynamic analysis of the relationship with parents, their excessive emphasis on the education and her excellence and ignoring her when she did something wrong or she was not successful in school were recognized. The client gained the insight that she also ignored herself and her needs when faced with a problem. Here, the anger towards the parents, especially the mother, was recognized. The client faced it with difficulty and a lot of anger. In this regard, one of the things that the client said about her parents was that “they constantly encouraged me or forced me to do things that I could not do, and when I could not do something right; they did not talk to me for a few days or treated me very coldly”. At the end of the process of unlocking emotions and expressing them, the client felt relieved and relaxed. The session lasted about an hour and a half, and at the end of the session, the homework of the previous session was repeated.

Session 4: Evaluating and reviewing the previous session and the situation of the client. The client reported a better feeling in this session. She said that she had been able to study more time than in the past. During this session, a topic that was the importance of others’ view of the client was selected according to her wishes and the recorded thoughts. It was addressed by psychodynamic techniques. For example, the client stated she was sensitive to the view of others in a group, and this caused her to worry. It recognized that in the past, her mother constantly reminded her of the right way to behave in front of others, and now she behaves the same way. Regarding this issue, a process similar to the process of the previous session was repeated. At the end of this session, doing homework, recording thoughts, and doing exercise were also repeated.

Session 5: Evaluating and reviewing the previous session and the situation of the clients. During this session, the client reported that she concluded during the last week that the importance of other people’s views, as discussed in the previous session, was due to the type of parents’ relationship with her and the internalization of it over the years. It was up to the client to decide whether she wanted to continue this condition or not. It should be noted that the client reported a better state of mind, and this was visible in her face and words. During this session, a topic was also selected according to recorded thoughts and the priority of the client and was addressed by the psychodynamic techniques. In this session, the failure to being admitted to the desired university was considered. She recalled her experience with one of the professors in an earlier semester and her anger towards him. In this regard, she said: “he questioned my research in front of all my classmates and considered it worthless and useless. He humiliated me, and every time I wanted to see him, I became anxious and embarrassed.” This experience of angry towards the professor caused the client to remember again her relationship with her parents, and the corrective experience occurred. At the end of the session, the homework of the previous session was repeated and the client was asked to perform some behaviors that she did not do before due to fear of others’ reactions and write the feedback of others. In addition to the issues mentioned in the first session, the purpose of this session was to conduct a behavioral test, create doubts about the cognitive structure of the client, and help to consolidate her insight into her problem.

Session 6: Evaluating and reviewing the previous session. At the beginning of this session, the client reported that her relationship with her parents had improved and she could share some of her concerns with them and did not face a bad reaction. In her relationship with some of her friends, she had done things that she supposed to be important to them. However, their reactions were no what she thought, and discussion was made in this regard. Then, the feelings of the client towards the daughter of one of their relatives who had constantly been compared to her in the past were considered. During the session, the feelings of hatred and anger towards the mentioned girl and then her parents recognized and the client realized that sometimes she had been jealous too, and it was interesting to her. Finally, the homework of the previous session was repeated, and the client was asked to write down situations where she did not dare to express herself.

Session 7: Evaluating and reviewing the previous session and the conditions of the client. In this session, the client reported a significant improvement so that her study hours were increased considerably. During this session, the recorded thoughts were addressed. It was interesting that the negative thoughts were greatly reduced. Unlike the normal cognitive behavioral therapy sessions, those thoughts were then reviewed and analyzed, and this caused more insight to be gained and some negative thoughts were resolved without the usual process of analysis. The client stated: “I have recently found out that I have more contact with my parents and I spend more time with them.” During the session, the skill of assertiveness was considered according to the writings of the client, and she was asked to apply this skill in her real life. The homework of the previous sessions was repeated, and practicing the skill of assertiveness and responding to thoughts were also added. The purpose of this session was to increase the level of self-confidence of the client and train the skills which were assumed that she had not learned in her development process and the need to train them had been recognized during the treatment sessions.

Session 8: Evaluating and reviewing the previous session and the skill of assertiveness. The client reported good experiences and it was decided to repeat the same process during the next sessions and report the result. The thoughts and given answers were considered during the session and the skill of assertiveness was repeated. Additionally, the extreme perfectionism of the client and its consequences were discussed, and the technique of mental imagery was used in this regard, and the client was asked to not perform completely some actions during the next week and write the result for the next session and bring it along with the recorded thoughts.

Session 9: Evaluating and reviewing the previous session and the feedback provided by the client. The client stated that although she had recognized the consequences of extreme perfectionism, it had been very difficult for her not to do her works properly. To solve this problem, the psychodynamic techniques were used to analyze the reasons for perfectionism, and at the end of the session, the gain and loss technique was used to further examine perfectionism and its effects on the client’s life as the homework of the next session.

Session 10: Evaluating and reviewing the previous session and the feedback provided by the client and working on the homework of the previous session. This session was still spent on perfectionism and its effects on the life and mood of the client. Additionally, the skill of problem-solving was taught and the end of the session was similar to that of the previous session.

Session 11: Evaluating and reviewing the previous session and the feedback provided by the client, working on the homework of the previous session and the skills of assertiveness and problem solving, applying the homework, substituting the available belief with a new belief, and training and practicing the skill of problem-solving. Finally, the feedback was provided by the client at the end of the session and the homework of the previous sessions and the skill of problem-solving were repeated.

Session 12: Evaluating and reviewing the previous session and the feedback provided by the client, applying the homework of the previous session. The client reported a significant improvement in her educational condition, her sleep and appetite problems had been eliminated, weight gain had occurred, and her satisfaction and life expectancy had increased. Thus, the next session was scheduled for two weeks later. It should be noted that the negative thoughts had decreased to one case during the week that did not preoccupy the client much. However, it was addressed and the client was asked to continue to do all that she had learned during the following weeks.

Session 13: Evaluating and reviewing the previous session and the feedback provided by the client. The improvement process had been maintained and there was no problem. Therefore, the treatment was terminated. In the end, the client was tested again and the results confirmed the client’s improvement. The followup of the client’s conditions six months after the treatment showed the stability of her conditions and the maintenance of the treatment results.

Table 1 shows

Table 1: The scores of the client in the Beck Depression Inventory and the Psychosocial Inventory of Ego Strengths.

the client scores in the Beck Depression Inventory and the Psychosocial Inventory of Ego Strengths. Obtaining a score of 25 in the Depression Inventory, the subject suffered symptoms of depression in the first session. This score decreased to 15 in the sixth session and 9 in the twelfth session. In the Psychosocial Inventory of Ego Strengths, the score of the subject was 213 at the baseline. However, it reached 220 in the middle of the treatment sessions and 258 in the final session, after six months of follow-up, the treatment results continued. (Table 1) (Figure 1 and 2).

Figure 1: The severity of depressive symptoms based on the Beck Depression Inventory.

Figure 2: The level of ego strength based on the Psychosocial Inventory of Ego Strengths.

Figures 1 and 2 shows the trend of changes in the level of depression and ego strength in the client.

The present study investigated the effectiveness of the integration of cognitive-behavioral therapy and short-term psychotherapy in increasing ego strength and treating major depression during 13 sessions. The subject was tested in three stages: beginning, middle, and end of treatment by the Beck Depression Inventory and the Psychosocial Inventory of Ego Strengths.

The results showed that the given methods were effective in increasing ego strength, reducing depressive symptoms, and improving the mental health of the client. The results were both statistically and clinically significant. The client’s self-reports in each session and at the end of the sessions also indicated that the treatment process was useful for her. Additionally, the results obtained from the evaluations by the clinical psychologist, behavioral measurements, the measurement of symptoms and social and academic function using the interviews and observations indicate the reduction of symptoms, the treatment of depression, and improvement of the client’s performance.

The increase in ego strength and the gradual decrease in the subject’s score in the Beck Depression Inventory during 13 treatment sessions so that it reached from 25 to 9 indicated a higher than average effectiveness of the mentioned methods in treating the client’s depression. There has been no research on the integration of the two methods of treatment. However, the results obtained have been consistent with the results of studies that have investigated separately the effect of each of these methods on the treatment of depression, including Driessen et al. [21-26], Goldstone [27], Goodyer et al. [25], Khalatbari and Aghajani [30], Barzegar Damadi et al. [31], and Khaledian et al. [32].

In this study, the main hypothesis was that both psychodynamic psychotherapy and cognitive behavioral therapy are effective and well-known therapies, although there is much debate about their effectiveness and stability. The results of some studies have cast doubt on the efficacy of these two methods of treatment [33-35,18] and have brought about the reversibility or the lack of cost-effectiveness regarding them. The integrative use of the active and exploratory psychodynamic and cognitivebehavioral techniques in the treatment sessions causes them to complement each other, provides insights and deep experiences, and enhances personal development. According to Gold and Striker, homogeneous and active use of cognitive-behavioral therapy within the framework of psychodynamic psychotherapy often leads to the development and strengthening of a positive therapeutic alliance. Their study showed mainly that the integration of cognitive-behavioral therapy in the short-term psychodynamic psychotherapy was significantly associated with positive treatment consequences in some functions. By increasing the use of cognitive-behavioral techniques along with psychodynamic psychotherapy, the therapists can be more confident in emphasizing the therapeutic alliance when providing explanations for their approach [36].

As mentioned above, the level of ego strength is related to the level of personality organization and helps people to achieve emotional stability and better cope with internal and external stress. However, the low level of ego strength causes psychological problems such as depression. For example, Higgins argued that low ego strength was associated with depressive symptoms such as guilt and lack of influence on surroundings, or Davis et al., showed that the low ego strength led to low selfesteem [37]. Thus, as ego strength increases, the depressive symptoms such as guilt and low self-esteem decrease and the ego can manage more effectively the personality, leading in turn to the development of personality, creating a new perspective as a result of the correction of defense mechanisms and cognitive errors, and causing to gain insight and awareness of the emotions and the conflicts in the unconscious. Integrating such elements as creating a new self-perception, behavioral changes, correcting defense mechanisms and cognitive errors, and paving the way for learning new skills causes the increased therapeutic alliance that enhances the effectiveness of the integrative approach in increasing ego strength and reducing the depressive symptoms. However, this issue needs further research.

In this study, it was tried to use unique features, differences, and similarities of each of the techniques to achieve a treatment method that had considerable effects, was cost-effective, created insight in the client, helped to identify and eliminate defense mechanisms and cognitive errors according to the problem of the client, and contributed to creating some skills in the client. People may lack some skills considering their problem, neuroticism style, and defensive mechanisms. This integrative method of treatment makes it possible for them to experience new situations, provide insights into past problems, helps to unlock the unconscious and provides the grounds for the emotional experience and the behavioral tests so that the client can see the inefficiency of his/her behavioral style and opinions and can learn new skills and enhance his/her self-efficacy and self-confidence.

One of the limitations of this research was that it used a single sample. It is suggested that future research investigate the effects of this method on other disorders individually and in groups in the form of various treatment groups.

Statement of human rights

Informed consent: In accordance with the terms and conditions of Iran informed consent was obtained from all individual participants included in the study. For person in the integrative therapy process of treatment, the number of sessions, and so on were explained and she informed consent was obtained.

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