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Basic Psychology: Psychodynamic psychotherapy

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 Contents

  1. Introduction
  2. History
  3. Approaches
  4. Core principles and characteristics
  5. Efficacy
  6. Client-therapist relationship 

Introduction

Psychodynamic psychotherapy, also known as psychoanalytic psychotherapy, is a type of psychoanalysis and/or depth psychology in which the primary goal is to reveal the unconscious content of a client's psyche in order to relieve psychic tension, which is inner conflict within the mind caused by extreme stress or emotional hardship, often in the state of distress. In the mid-twentieth century, it evolved from and largely replaced psychoanalysis.

Psychodynamic psychotherapy, more than other types of depth psychology, is based on the interpersonal relationship between client and therapist. They must have a solid relationship based on trust. In terms of approach, this type of therapy employs psychoanalysis modified for a less intensive style of working, usually once or twice per week, which is often the same frequency as many other therapies. The primary theorists consulted are Freud, Klein, and object relations theorists such as Winnicott, Guntrip, and Bion. Some psychodynamic therapists use Jung, Lacan, or Langs as well. It has been used in individual psychotherapy, group psychotherapy, family therapy, and to understand and work with institutional and organisational contexts. It has been used in psychiatry for adjustment disorders, as well as post-traumatic stress disorder (PTSD), but it is most commonly used for personality-related disorders.

History

Ernst Wilhelm von Brücke, a German physician and physiologist, introduced the principles of psychodynamics in his 1874 book Lectures on Physiology. Taking a cue from thermodynamics, Von Brücke proposed that all living organisms are energy systems governed by the principle of energy conservation. Sigmund Freud, a first-year medical student at the University of Vienna, was von Brücke's supervisor that year. This new concept of "dynamic" physiology was later adopted by Freud to aid in his own conceptualization of the human psyche. Carl Jung, Alfred Adler, Otto Rank, and Melanie Klein later expanded on both the concept and application of psychodynamics.

Approaches

The majority of psychodynamic approaches are based on the idea that some maladaptive functioning is at work, and that this maladaption is, at least in part, unconscious. The presumed maladaption appears early in life and eventually causes problems in daily life. Psychodynamic therapies are concerned with uncovering and resolving the unconscious conflicts that are causing their symptoms.

Psychodynamic therapists commonly employ the following techniques:
  • Free association:: The client is encouraged to communicate with the therapist their true feelings and thoughts. This is done with the client aware that it is a safe space, and it is done without judgement or consequence. These thoughts and/or responses may be irrelevant, illogical, and humiliating to the patient. This is to aid in the access of unconscious information, memories, or impulses that the patient might not have been able to bring to the surface otherwise. They can be interpreted once they have been brought to the conscious mind. 
  • Dream interpretation:(also known as dream analysis) The client keeps a record of their dreams and communicates or relays them to the therapist, sometimes with the help of free association, and the content is then analysed or interpreted for hidden meanings, underlying motivations, and other portrayals.
  • Recognizing resistance: This could take many different forms, with minor variations depending on the type of resistance. Clients withholding or withholding information for better assistance and interpretation. This is frequently used as a defence by the client. This could be divided into three types of resistance
The first type of resistance is conscious resistance, in which the client deliberately fails to communicate the necessary information due to distrust in the system, therapist, shame, or rejection of the interpreter.

The client uses repression resistance, also known as ego resistance, to keep unacceptable thoughts, feelings, actions, and/or impulses in the unconscious. This could be accomplished by the patient blocking thoughts and communications during free associations and failing to recall events.

The third type, id resistance, differs from the other two in that it arises from the unconscious and is motivated by id impulse. It resists change or treatment in order to repeat the trauma in different situations, which is referred to as repetition compulsion. Furthermore, there may be a transference of the patient's views, feelings, and/or wishes onto the analyst, often the therapist, that were previously directed towards other influential individuals in the patient's life. This is frequently people in early childhood, such as parents, siblings, or other significant figures. It is hoped that by addressing these projected views, the patient will be able to reexperience, address, and analyse the effects, as well as resolve any current distress. The therapeutic relationship, as in some psychoanalytic approaches, is viewed as a critical means of understanding and working through the client's relational difficulties in life.

Core principles and characteristics

Although psychodynamic psychotherapy can take many forms, the following are commonalities:
  • An emphasis on the importance of intrapsychic and unconscious conflicts in development;
  • recognising defences as developing in internal psychic structures in order to avoid unfavourable outcomes of conflict;
  • A belief that psychopathology develops primarily as a result of early childhood experiences;
  • A belief that internal representations of experiences are structured around interpersonal relationships.
  • A belief that life issues and dynamics will resurface as transference and counter-transference in the context of the client-therapist relationship;
  • Use of free association as a primary method of resolving internal conflicts and problems;
  • concentrating on interpretations of transference, defence mechanisms, and current symptoms, as well as the resolution of these current issues;
  • Trust in insight is critical for success in therapy.

Efficacy

Psychodynamic psychotherapy is an evidence-based therapy (Shedler 2010), and psychoanalysis, its more intensive form, has also been proven to be evidence-based. Later meta-analyses demonstrated that psychoanalysis and psychodynamic therapy were effective, with outcomes comparable to or greater than other types of psychotherapy or antidepressant drugs, but these arguments have also been challenged. For example, meta-analyses conducted in 2012 and 2013 concluded that there is little support or evidence for the efficacy of psychoanalytic therapy, implying that more research is required.

In 2009, a systematic review of Long Term Psychodynamic Psychotherapy (LTPP) found that the overall effect size was 0.33. Others have discovered effect sizes ranging from 0.44 to 0.68.

Short Term Psychodynamic Psychotherapy (STPP) was found to be slightly better than other therapies in follow-up meta-analyses, with effect sizes ranging from 0.34–0.71 compared to no treatment. Other studies have found an effect size of 0.78–0.91 for somatic disorders versus no treatment and 0.69 for depression treatment. A meta-analysis of Intensive Short-Term Dynamic Psychotherapy (ISTDP) published in the Harvard Review of Psychiatry in 2012 found effect sizes ranging from 0.84 for interpersonal problems to 1.51 for depression. In comparison to no treatment, ISTDP had an effect size of 1.18.

A study published in the American Journal of Psychiatry in 2011 compared psychodynamic treatment to a non-dynamic competitor and discovered that 6 were superior, 5 were inferior, 28 had no difference, and 63 were adequate. According to the study, this could be used as a foundation "to make psychodynamic psychotherapy a "empirically validated" treatment. A meta-analysis of randomised controlled trials published in 2017 found psychodynamic therapy to be just as effective as other therapies, including cognitive behavioural therapy.

A meta-analysis published in 2011 found that long-term psychodynamic psychotherapy outperformed less intensive forms of psychotherapy in the treatment of complex mental disorders. Longer-term psychotherapy may be required depending on the severity of the underlying pathology. Individuals functioning at Level 1 of the DSM Personality Functioning Scale, for example, would require less treatment than those functioning at Level 2 or higher. According to studies, those who received psychodynamic psychotherapy grew after therapy, whereas those who received cognitive behavioural therapy did not.

Client-therapist relationship

Because of the subjectivity of each patient's potential psychological ailments, there is rarely a clear-cut treatment approach. Generally, therapists will vary general approaches in order to best fit a patient's specific needs. If a therapist does not thoroughly understand their patient's psychological problems, it is unlikely that they will be able to devise a treatment plan that will benefit the patient. As a result, the patient-therapist relationship must be extremely strong.

Therapists encourage their patients to be as candid and open as possible. If this is to occur, patients must have faith in their therapist. Because the effectiveness of treatment is so heavily dependent on the patient providing information to their therapist, the patient-therapist relationship is more important in psychodynamic therapy than in almost any other type of medical practise.

References

  • British Psychoanalytic Council. (2018). What is psychoanalytic psychotherapy? (https://ww w.bpc.org.uk/about-psychotherapy/what-psychotherapy) 
  • American Psychoanalytical Association (2018). Psychoanalytic Psychotherapy (http://www.a psa.org/content/psychoanalytic-psychotherapy) 
  • Psychodynamic psychotherapy (http://www.guidetopsychology.com/txtypes.htm#Psychodyn amic) - guidetopsychology.com
  • Freedheim, D.K.; DiFilippo, J.M; Klostermann, S. (2015). Encyclopedia of Mental Health (2nd ed.). New York: Elsevier. pp. 348–356. ISBN 978-0-12-397753-3. 
  • Granström, Kjell (2006). Dynamik i arbetsgrupper (2 ed.). Lund: Studentlitteratur. p. 197. ISBN 9789144008523. 
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