Psychodynamic Psychotherapy
By
Dr. Muhammad Najib Mohamad Alwi
MD DIC MSc MRCPsych
Lecturer and Psychiatrist
Department of Psychiatry
School of Medical Sciences
Universiti Sains Malaysia
Contents:
1. Introduction to Psychodynamic Psychotherapy
2. Mode of action of Dynamic Psychotherapy
3. Types of Psychodynamic Psychotherapy:
a) Freudian Psychoanalysis
b) Brief Dynamic Psychotherapies
4. References
Introduction
It is difficult to clearly define and
differentiate between Psychoanalysis and its “children” – the psychoanalytical
psychotherapies.
For Freud, psychoanalysis is a form of treatment
in which transference and resistance play a central role. But other forms of
Psychoanalytical Psychotherapies also put much importance in these areas with
some modification in approach or conceptualization.
In the end, a pragmatic view about the difference
between psychoanalysis and psychoanalytical psychotherapy boils down to the
frequency, intensity and duration of therapy i.e. more than three times a week
is psychoanalysis – anything less than that is everything else. Thus, when
relating to “psychodynamic” psychotherapy we refer to the “psychoanalytical
approach” of treatment described below.
Psychoanalytical approach to psychotherapy
involves a theory of personal meaning
and a theory of development. It seeks
a personal meaning of a situation or an illness for the patients in terms of
individual biography and assumes a level of unconscious
meaning which influences the behaviour of both patients and therapists.
From the psychoanalytical point of view, a
patient’s behaviour and how he reacts to a particular situation may be
influenced by his past experiences which could include unconscious feelings or
processes. These unconscious feelings may have been transferred into his
current relationships although they might have originated from his earlier
relationships. The understanding of these processes is hoped to enhance
personal growth (development).
Mode of action of Psychodynamic Psychotherapy
Grunbaum (1984) and others suggest that it is the
‘non-specific factors’ that explain good outcomes in analysis. Steiner (1989)
described three positions of psychoanalytical movements on the mode of action
of psychoanalysis:
a)
Classical/conflict
model:
·
The ego repressed ‘problematic experience’
(Stiles et al. 1995) to maintain
coherence
·
Satisfaction is
sacrificed for the sake of security (maladaptive solution)
·
This will be
reproduced in transference: anger or
amorous feelings towards the therapist
·
Treatment helps
patients to gain insight into these processes and use this ‘awareness’ to
respond more fully to his experience
b)
Kleinian-object
relation/conflict model:
·
There is conflict
between love and hate : the need for dependency and the fear of loss
·
The self is
depleted through projective
identification leading to misperception
and therefore distortion of reality
·
Transference
is characterised by these processes (projective identification and
misperception)
·
The task of the
therapist is to contain these projections and return them to the patient when
he is able to accept them (Bion 1962)
·
Resistance: difficulty
acknowledging dependency on the therapist who will then be an object of envy
and loss
·
Analysis moves the
patient from the splitting of the paranoid-schizoid
position to the wholeness of the depressive
position.
c) Interpersonal-object relations/deficit model:
·
Focuses on present
transference: the living unconscious between analyst and patient
·
Resistance is a
manifestation of deficit (not conflict): patient is unable “developmentally” to
react differently and thus clings to old maladaptive patterns (the only way he
knows) (Fairbairn 1958)
·
Treatment produces
change by offering a new experience of empathy and attention, from which the
patient can build a secure sense of self in relation to another
Thus, in general, psychodynamic psychotherapy
“cures” by producing insight, containment and new experience.
Types of Psychodynamic Psychotherapy
Psychoanalysis
comprises of three interrelated strands: a set of specific psychotherapeutic
techniques (e.g. free association and interpretations), a model of psychological
development and a metapsychology (speculative hypotheses about the nature and
structure of the mind).
A. FREUDIAN PSYCHOANALYSIS
In the evolution of Freudian Psychoanalysis, he had adopted,
revised and discarded different theoretical models:
·
Catharsis: neurosis resulted from
the ‘damming up’ of painful affect and if mental distress could be
released via its verbal expression (abreaction) under hypnosis, relief would
follow.
·
Free association: neurosis is a result of unconscious conflict. At the core of
this conflict were instinct-driven phantasies
(unconscious wishes) concerning sexuality (Three Essays on Sexuality 1905).
Transference phantasies were an in-vivo re-enactment of the patient’s core
difficulties.
·
Repetition compulsion: Freud viewed that adults often repeat (mostly in disguised
form) their infantile attachments and conflicts, and that such tendency to
repeat patterns from the past was often at the root of the difficulties of his
patients. It has remained a central feature of psychoanalytic thinking that
much of the psychopathology presented by patients and much of their disturbed
relationship with reality is due to the constant repetition throughout life of
unresolved, disturbed early relationships which have their main origin during
childhood (“repetition compulsion”).
·
Clinical regression: refers to a particular aspect of the analytic relationship
whereby modes of functioning from the patient’s past are re-experienced or
re-enacted with the analyst by the patient. (Such regression can take place in
normal life, particularly when the individual is going through critical times).
When this occurs, adult ways of dealing with reality are put to one side and
primitive ways of functioning are re-activated and predominate.
·
Important Concepts: Primary Process Thinking, Secondary Process Thinking, Transference,
Counter-Transference, Resistance, Working Through, Topographical and Structural
Models of the Mind, Defence Mechanisms etc. (PLEASE READ).
·
Ultimately, the classical psychoanalysis is where
patients is seen in the traditional setting with the patient lying on a couch
and the analyst sitting behind for four or five sessions per week. It remains
invaluable for patients who wish to understand themselves better as a means of
dealing with difficulties in their lives.
B. BRIEF DYNAMIC PSYCHOTHERAPIES
Although brief dynamic psychotherapies are often
seen as the poor cousins of long-term therapy (psychoanalysis), much of Freud’s
original work was brief, and longer term work developed later. In fact, most of
the psychotherapy carried out in the public sector worldwide is brief, lasting
one to several sessions or up to 6 months.
Selection
of patients (Malan,
Tavistock Clinic)
Patients do better with brief therapy when:
1. The problem is neurotic i.e. the patient has a
relatively intact personality with a discreet neurotic difficulty.
2. There is a degree of psychological
sophistication.
3. The patient is motivated to change.
4. The patient has a capacity to respond to
interpretations.
5. The patient is flexible and has problem solving
ability.
6. There is a history of good childhood
interpersonal relationships.
7. The patient is looking for understanding of his
or her problems rather than symptomatic relief.
NB: The above list may give the impression that
only rather ‘healthy’ people would benefit from brief therapies! Interestingly,
some brief therapies e.g. Cognitive Analytic Therapy (CAT) were claimed to work
best with patients who have fragmented and disturbed personalities!
Technical
Features of Brief Dynamic Psychotherapy: (Stifneos)
1. Working alliance is needed but some flexibility
may be possible in longer term therapies.
2. Time-limited. Some approaches are absolutely
rigid about the number of sessions prescribed; others more flexible. However
there is always a clear and explicit limitation.
3. Therapy focuses on a problem. This may be a
concrete life event, a therapy focus, or a focus in the transference. Balint
described “selective attention” and “selective neglect” on issues tangential to
the focus.
4. Therapist is more active than in longer term
therapy. It is recognised that behavioural and didactic cognitive elements play
an important, although not explicit part in the treatment, such as modeling.
5. Therapist provokes anxiety in the patient with
active clarification and confrontation of conflicts.
6. Early utilisation of the transference. This is an
element of the confrontation.
7. Links are made between past and present. Malan
described these links as the two triangles of conflict and of person. The
triangle of conflict is challenged and worked through, and then links can be
made within the triangle of person.
Defence Therapist
Impulse Anxiety Others Past relationship
TRIANGLE OF CONFLICT
TRIANGLE OF PERSON
8. Problem solving takes place with therapist and
patient in alliance to achieve this.
9. There is avoidance of pre-genital anxieties and
regressions by the patient. This is required with more character disordered
patients.
10. Early termination and there is a focus on this throughout
the therapy.
Different Approaches in Brief Dynamic Psychotherapy:
1.
Brief Focal
Psychotherapy (Malan and the Tavistock Group)
·
An application of
psychoanalysis but time limited and constrains itself to a focus.
·
Therapist is more
active than in analysis.
·
Confrontation is
used but not excessive.
·
Length is between 14 and 26 sessions.
·
A good therapeutic
outcome is achieved where the patient could work with termination issues and
the selection criteria (see above) is satisfied.
2.
Time Limited
Therapy (Mann)
·
Similar to Malan’s
but Mann focuses on a factor he calls the “present and chronically endured
pain”. This is explored for twelve hours
variously distributed.
·
Confrontation is
not excessive.
·
Ending issues are focused
on.
3.
Anxiety Provoking
Therapy (Stifneos)
·
Relies on early
confrontation and challenging to establish the patient’s difficulties in the
room where they can be explored.
·
Woks best for
unresolved oedipal conflicts over between 8
and 20 sessions.
4.
Short Term Dynamic
Psychotherapy (Davanloo)
·
Early and heavy
confrontation is used, such that the patient appears to be hectored.
·
Once some of the
issues and conflicts have emerged, they can be worked through.
·
Over 40 sessions, long standing problems
e.g. obsessionality and phobias will be tackled.
5.
Cognitive Analytic
Therapy (CAT) (Ryle)
·
Borrows techniques
like homework and diary from cognitive therapy.
·
Uses these and
sophisticated understanding of transference and counter-transference phenomena
to try to “map” out for the patients the “states” that they get into.
e.g.
borderline patients can see how the
seemingly unrelated parts of their personality and experience link up and this
is often drawn up diagrammatically for them.
·
Writing of a
formulation and focus for the patient early on.
·
A discharge summary
of the therapy given to the patient and discussed in the last few sessions.
REFERENCES
1. Grunbaum, A. (1984) The Foundations of
Psychoanalysis, Berkeley: University of California Press.
2. Steiner, J. (1989) ‘The Aim of Psychoanalysis’,
Psychoanalytic Psychotherapy 4: 109-120.
3. Stiles, W. et al. (1995) ‘Therapist contributions
to psychotherapeutic assimilation: an alternative to the drug metaphor’ British
Journal of Medical Psychology, 68: 1-13.
4. Bateman, A., Holmes, J (1995). Introduction to
Psychoanalysis: Contemporary Theory and Practice. Routledge. London and New
York.
5. Stifneos, P. (1989) Brief Psychodynamic and
Crisis Therapy (In Comprehensive Textbook of Psychiatry – Kaplan and Sadok).
6. Mann (1973) Time Limited Psychotherapy. Harvard
University Press.
7. Ryle, A. (1990) Cognitive Analytic Therapy: Active participation in change. Wiley Publications.
8. Lecture notes by my respectable Consultants…. Dr P Foster, Dr L Grespi… to name a few.
Comments
and views are very much welcomed 
Dr M Najib M Alwi