Psychodynamic psychotherapy

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Psychodynamic psychotherapy
MeSH D064889

Psychodynamic psychotherapy (or psychodynamic therapy) and psychoanalytic psychotherapy (or psychoanalytic therapy) are two categories of psychological therapies. [1] [2] [3] [4] Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. [5] The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. [6] Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

Contents

Psychodynamic psychotherapy relies on the interpersonal relationship between client and therapist more than other forms of depth psychology. They must have a strong relationship built heavily on trust. In terms of approach, this form of therapy uses psychoanalysis adapted to a less intensive style of working, usually at a frequency of once or twice per week, often the same frequency as many other therapies. The techniques draw on the theories of Freud, Klein, and the object relations movement, e.g., Winnicott, Guntrip, and Bion. Some psychodynamic therapists also draw on Jung, Lacan, or Langs. It is a focus that has been used in individual psychotherapy, group psychotherapy, family therapy, and to understand and work with institutional and organizational contexts. [7] In psychiatry, it has been used for adjustment disorders as well as post-traumatic stress disorder (PTSD), but more often for personality-related disorders. [8] [9]

History

The principles of psychodynamics were introduced in the 1874 publication Lectures on Physiology by German physician and physiologist Ernst Wilhelm von Brücke. Von Brücke, taking a cue from thermodynamics, suggested all living organisms are energy systems, governed by the principle of energy conservation. During the same year, von Brücke was supervisor to first-year medical student Sigmund Freud at the University of Vienna. Freud later adopted this new construct of "dynamic" physiology to aid in his own conceptualization of the human psyche. Later, both the concept and application of psychodynamics were further developed by the likes of Carl Jung, Alfred Adler, Otto Rank, and Melanie Klein. [10] Psychodynamic therapy has evolved from psychoanalytic theory, with some later modifications in the therapeutic practice experienced since the mid-20th century. [11]

Approaches

Most psychodynamic approaches are centered on the concept that some maladaptive functioning is in play, and that this maladaption is, at least in part, unconscious. [12] [13] The presumed maladaption develops early in life and eventually causes difficulties in day-to-day life. [14] Psychodynamic therapies focus on revealing and resolving these unconscious conflicts that are driving their symptoms. [15]

Major techniques used by psychodynamic therapists include:

The first type of resistance is conscious resistance, where the client is deliberate about not communicating the information needed because of distrust in the system, therapist, shame or rejection of the interpreter. [19]

The second, repression resistance, also referred to as ego resistance, is used by the client to keep unacceptable thoughts, feelings, actions, and/ or impulses in the unconscious. This could be done by the patient blocking thoughts and communications during free associations, not remembering events. [20]

The third, id resistance, is unlike the other two because it arises from the unconscious and is driven by id impulse. It resists change or treatment to further repeat the trauma in different situations, known as repetition compulsion. [21] Additionally, there may be transference of views, feelings, and/or wishes of the patient onto the analyst, often the therapist, that were initially directed towards other impactful individuals in the patient's life. This is often people in early childhood such as parents, siblings, or other important people. By addressing these projected views it is hoped to help the patient reexperience, address, and analyze the effects; and to resolve current distress it could be causing. [22] [23] As in some psychoanalytic approaches, the therapeutic relationship is seen as a key means to understanding and working through the relational difficulties which the client has suffered in life. [23]

Core principles and characteristics

Although psychodynamic psychotherapy can take many forms, commonalities include: [23] [24]

Efficacy

Psychodynamic psychotherapy is an evidence-based therapy. [25] Later meta-analyses showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs, [25] [26] [27] but these arguments have also been subjected to various criticisms. [28] [29] [30] [31] For example, meta-analyses in 2012 and 2013 came to the conclusion that there is little support or evidence for the efficacy of psychoanalytic therapy, thus further research is needed. [32] [33]

A systematic review of Long Term Psychodynamic Psychotherapy (LTPP) in 2009 found an overall effect size of 0.33. [34] Others have found effect sizes of 0.44–0.68. [27]

Meta-analyses of Short Term Psychodynamic Psychotherapy (STPP) have found effect sizes ranging from 0.34 to 0.71 compared to no treatment and was found to be slightly better than other therapies in follow up. [35] Other reviews have found an effect size of 0.78–0.91 for somatic disorders compared to no treatment [36] and 0.69 for treating depression. [37] A 2012 meta-analysis by the Harvard Review of Psychiatry of Intensive Short-Term Dynamic Psychotherapy (ISTDP) found effect sizes ranging from 0.84 for interpersonal problems to 1.51 for depression. Overall ISTDP had an effect size of 1.18 compared to no treatment. [38]

In 2011, a study published in the American Journal of Psychiatry made 103 comparisons between psychodynamic treatment and a non-dynamic competitor and found that 6 were superior, 5 were inferior, 28 had no difference and 63 were adequate. The study found that this could be used as a basis "to make psychodynamic psychotherapy an "empirically validated" treatment." [39] In 2017, a meta-analysis of randomized controlled trials found psychodynamic therapy to be as efficacious as other therapies, including cognitive behavioral therapy. [40]

Client-therapist relationship

Because of the subjectivity of each patient's potential psychological ailments, there is rarely a clear-cut treatment approach. [23] Most often, therapists vary general approaches in order to best fit a patient's specific needs. [23] If a therapist does not understand the psychological ailments of their patient extremely well, then it is unlikely that they are able to decide upon a treatment structure that will help the patient. [23] Therefore, the patient-therapist relationship must be extremely strong. [23]

Therapists encourage their patients to be as open and honest as possible. [23] Patients must trust their therapist if this is to happen. [23] Because the effectiveness of treatment relies so heavily on the patient giving information to their therapist, the patient-therapist relationship is more vital to psychodynamic therapy than almost every other type of medical practice. [41]

See also

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Psychoanalysis is a set of theories and therapeutic techniques that deal in part with the unconscious mind, and which together form a method of treatment for mental disorders. The discipline was established in the early 1890s by Sigmund Freud, whose work stemmed partly from the clinical work of Josef Breuer and others. Freud developed and refined the theory and practice of psychoanalysis until his death in 1939. In an encyclopedia article, he identified the cornerstones of psychoanalysis as "the assumption that there are unconscious mental processes, the recognition of the theory of repression and resistance, the appreciation of the importance of sexuality and of the Oedipus complex." Freud's colleagues Alfred Adler and Carl Gustav Jung developed offshoots of psychoanalysis which they called individual psychology (Adler) and analytical psychology (Jung), although Freud himself wrote a number of criticisms of them and emphatically denied that they were forms of psychoanalysis. Psychoanalysis was later developed in different directions by neo-Freudian thinkers, such as Erich Fromm, Karen Horney, and Harry Stack Sullivan.

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.

Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

Clinical psychology is an integration of human science, behavioral science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.

Transference is a phenomenon within psychotherapy in which repetitions of old feelings, attitudes, desires, or fantasies that someone displaces are subconsciously projected onto a here-and-now person. Traditionally, it had solely concerned feelings from a primary relationship during childhood.

The Dodo bird verdict is a controversial topic in psychotherapy, referring to the claim that all empirically validated psychotherapies, regardless of their specific components, produce equivalent outcomes. It is named after the Dodo character in Alice in Wonderland. The conjecture was introduced by Saul Rosenzweig in 1936, drawing on imagery from Lewis Carroll's novel Alice's Adventures in Wonderland, but only came into prominence with the emergence of new research evidence in the 1970s.

<span class="mw-page-title-main">Play therapy</span> Childrens mental health therapy method

Play therapy refers to a range of methods of capitalising on children's natural urge to explore and harnessing it to meet and respond to the developmental and later also their mental health needs. It is also used for forensic or psychological assessment purposes where the individual is too young or too traumatised to give a verbal account of adverse, abusive or potentially criminal circumstances in their life.

Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo.

A therapeutic alliance, or working alliance, is a partnership between a patient and their therapist that allows them to achieve goals through agreed-upon tasks.

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<span class="mw-page-title-main">Forensic psychotherapy</span> Psychological treatment of violent offenders

Forensic psychotherapy is the application of psychological knowledge to the treatment of offender-patients who commit violent acts against themselves or others. This form of treatment allows for a therapist to potentially understand the offender and their mental state. It gives the individual providing treatment the opportunity to examine further whether the offender’s criminal behavior was a conscious act or not, what exactly their association with violent behavior is, and what possible motives could have driven them. The discipline of forensic psychotherapy is one that requires the involvement of individuals other than simply the therapist and patient. A therapist may collaborate with other professionals, such as physicians, social workers, and other psychologists in order to best serve the offenders’ needs. Whether the treatment is successful or not relies on a multitude of things, but typically ensuring that a systemic approach is taken and that all involved in the treatment process are well informed and supportive has proven to be the most effective. In addition to group work, forensic psychotherapy may also involve therapeutic communities, individual interaction with victims as well as offenders, and family work. In order for this specialized therapy to be as effective as possible, it demands the compliance of not only the patient and therapist, but of the rest of society as well. The main focus of forensic psychotherapy is to obtain a psychodynamic understanding of the offender in order to attempt to provide them with an effective form of treatment. Guidelines have been set to ensure proficiency in the field of Forensic Psychology.

Psychoanalytic dream interpretation is a subdivision of dream interpretation as well as a subdivision of psychoanalysis pioneered by Sigmund Freud in the early 20th century. Psychoanalytic dream interpretation is the process of explaining the meaning of the way the unconscious thoughts and emotions are processed in the mind during sleep.

<span class="mw-page-title-main">History of psychotherapy</span>

Although modern, scientific psychology is often dated from the 1879 opening of the first psychological clinic by Wilhelm Wundt, attempts to create methods for assessing and treating mental distress existed long before. The earliest recorded approaches were a combination of religious, magical and/or medical perspectives. Early examples of such psychological thinkers included Patañjali, Padmasambhava, Rhazes, Avicenna and Rumi.

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

Supportive psychotherapy is a psychotherapeutic approach that integrates various therapeutic schools such as psychodynamic and cognitive-behavioral, as well as interpersonal conceptual models and techniques.

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.

Dr. Allan Abbass is professor, psychiatrist, and founding Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Nova Scotia, Canada.

Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.

References

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  3. ↑ Psychoanalytic Council. (2022)
  4. ↑ American Psychoanalytical Association (2022). Psychoanalytic Psychotherapy
  5. ↑ Psychodynamic psychotherapy - guidetopsychology.com
  6. ↑ American Psychoanalytical Association (2022).vs. psychodynamic therapy
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  35. ↑ Anderson, Edward M.; Lambert, Michael J. (1995). "Short-term dynamically oriented psychotherapy: A review and meta-analysis". Clinical Psychology Review. 15 (6): 503–14. doi:10.1016/0272-7358(95)00027-M.
  36. ↑ Abbass A, Kisely S, Kroenke K (2009). "Short-term psychodynamic psychotherapy for somatic disorders. Systematic review and meta-analysis of clinical trials". Psychotherapy and Psychosomatics. 78 (5): 265–74. doi:10.1159/000228247. hdl: 10072/30557 . PMID   19602915. S2CID   16419162.
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  40. ↑ Steinert, Christiane; Munder, Thomas; Rabung, Sven; Hoyer, Jürgen; Leichsenring, Falk (2017). "Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes". The American Journal of Psychiatry. 174 (10): 943–953. doi: 10.1176/appi.ajp.2017.17010057 . PMID   28541091.
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