More from Nancy McWilliams:
Two men may be clinically depressed, with virtually identical vegetative signs (sleep problems, appetite disturbance, tearfulness, psychomotor retardation, etc.), yet have radically disparate subjective experiences. One feels bad, in the sense of morally deficient or evil. He is contemplating suicide because he believes that his existence only aggravates the problems of the world and that he would be doing the planet a favor by removing his corrupting influence from it. The other feels not morally bad but internally empty, defective, ugly. He also is considering suicide, not to improve the world, but because he sees no point in living. The former feels a piercing guilt, the latter a diffuse shame. In object relations terms, the first man is too full of internalized others telling him he is bad; the second is too empty of internalizations that could give him any direction. Diagnostic discrimination between the first kind of depression (“ melancholia” in the early psychoanalytic literature and “introjective depression” more recently [Blatt, 2008]) and the second, a more narcissistically depleted state of mind (Blatt’s “anaclitic” depression), is a critical one for very practical reasons. The man with the first kind of depressive experience will not respond well to an overtly sympathetic, supportive tone in the interviewer; he will feel misunderstood as a person more deserving than he knows he really is, and he will get more depressed. The man with the second kind of subjective experience will be relieved by the therapist’s direct expression of concern and support; his emptiness will be temporarily filled, and the agony of his shame will be mitigated.
McWilliams does a good job of tracing the major lines of psychoanalytic thought that have emerged from accumulating clinical experience. Her understanding of the first man draws upon Freud's structural theory of the mind. Within this framework, unacceptable guilt-ridden anger is redirected toward the self. An emphasis in this case becomes the patient's defensive patterns of dealing with unacceptable thoughts, wishes and feelings.
In the second case, a self-psychological understanding is useful. Rather than depression driven by unacceptable anger turned inward, the depression reflects an inner life that is barren. As McWilliams argues, there may be important implications for how a patient will react to therapeutic interventions and how treatment would proceed depending upon our understanding of the depression in each case.
And though it wasn't McWilliams's point in the passage above, I think these examples also show why a broad-umbrella, disease-model of depression is viewed by many of us as inadequate.