DYNAMIC PSYCHOTHERAPY

BY DR.SRIRAM.R

CHAIRPERSON – DR.RAJ KUMAR

FUNDAMENTAL PRINCIPLE COMMON TO ALL PSYCHOTHERAPIES

How many competent psychologists/psychiatrists does it take to change a person?

ANSWER - Just one, provided the PERSON wants to change

WHAT IS IT? Psychodynamic psychotherapy is a form of 

depth psychology (Tiefenpsychologie – Eugene Bleuler)

Used to reveal the UNCONSCIOUS content of a client's psyche in an effort to alleviate psychic tension.

Form of psychoanalysis, but in addition,

Relies on the interpersonal relationship between client and therapist

HISTORY The principles of psychodynamics were first introduced

in the 1874 publication Lectures on Physiology by German scientist Ernst Wilhelm von Brücke

Brucke suggested all living organisms are energy systems and operate on energy conservation

Freud adopted this concept and applied this dynamic characteristic to the human psyche (Brucke was Freuds supervisor when he was a first year med student)

Later further developed by the likes of Carl Jung, Alfred Adler, Otto Rank and Melanie Klein

DIFFERENCE BETWEEN PSYCHOANALYSIS AND PSYCHODYNAMIC PSYCHOTHERAPY

PSYCHOANALYSIS

Requires daily visits

Analysand lies on a couch with the analyst sitting out of sight and behind

“Free-association” by analysand and a silent analyst. Analyst breaks silence whenever “interpretation” required

Not a very interactive process

“Imposed” on the analysand – payment is required whether they attend the session or not

Takes several years to be effective

DYNAMIC PSYCHOTHERAPY

Once a week (twice/thrice for unstable or highly motivated clients)

Client and therapist sit face to face

The psychotherapist usually talks quite a lot, compared to the “silence” of the psychoanalyst.

Highly interactive process

No binding on the Client, flexible and Client pays therapist on each visit

Treatment generally 1-12/20 sessions (BPP) to more than 50 sessions/several years (LTPP)

WHERE AND WHEN IS IT USED? Psychodynamic psychotherapy, in all its forms, is the

psychotherapy most frequently provided by psychiatrists.

Psychodynamic therapy is useful in long-term, short-term, supportive, crisis intervention, and group/family therapies, with patients of all ages.

Patients hospitalized in psychiatric as well as medical-surgical services can also benefit from a clinician’s psychodynamic orientation.

CENTRAL CONCEPTS People feel and behave as they do for specific reasons.

People are frequently unaware of why they feel or behave in a certain fashion.

Past events and experiences, often outside of awareness, determine how people feel about themselves and their world.

The need to master psychological pain and discomfort is compelling and accounts for why many people behave consistently and predictably in often self-defeating or disappointing ways.

The power of the therapeutic relationship is to provide a safe forum for examining psychological problems, feelings and behaviors by maintaining an open, nonjudgmental, and empathic rapport with the patient.

CENTRAL CONCEPTS The past experiences of both the patient and the therapist have a

role in determining the power of the therapeutic relationship and that life-issues will re-emerge in the therapy (Transference and Counter-transference)

A successful treatment must integrate both cognitive and affective components of the patient’s self-awareness and includes supportive as well as interpretive interventions.

Use of free association as a major method for exploration of internal conflicts and problems.

Focusing on interpretations of transference, defense mechanisms, and current symptoms and the ”working through” of these present problems.

Trust in insight as critically important for success in therapy.

UNDERSTANDABLE REASONS UNDERLIE FEELINGS,WISHES, AND BEHAVIOR

Patient’s current behavior due to his past experiences

Therapist should always have the question “Why now?”

Therapist should listen to the client in a distinct manner and watch out for indirect clues

Material, for example, may be expressed through jokes, shifts in topic, revelations at the very end of a session, metaphors, and symbols

Watch out for resistance and ambivalence

UNDERSTANDABLE REASONS UNDERLIE FEELINGS,WISHES, AND BEHAVIOR

Ambivalence may be subtle or overt. It may take the form of missed appointments or an unwillingness to explore specific areas of the patient’s life

Resistance is a common example of ambivalence and the patient jumps from a more upsetting to a less upsetting topic

Serves as a protective function against threatening feelings and fantasies

Greater understanding of resistance is essential for understanding the client

FEELINGS AND BEHAVIOR ARE OFTEN A MYSTERYTO THE PATIENT

The notion that people experience and act on unknown wishes and fears is an enlightening concept for many patients

Long term memory is important here. It is divided into implicit and explicit memory as we know.

Implicit memory is procedural, begins to form after birth, does not require conscious attention or intact hippocampal function

Implicit memory is what is important in psychoanalysis

FEELINGS AND BEHAVIOR ARE OFTEN A MYSTERYTO THE PATIENT

Much of mental life is outside of awareness

Experience of self and other is decided by “affective neural templates” which in turn depends on reciprocal interaction between mother and infant

These affective templates help in organising neural structure

Implicit memory plays a role in psychological trauma – that is why patients cannot recall fully the experiences of severe abuse and neglect

THE PAST LIVES IN THE PRESENT

Implicit memory + need to ward off/contain trauma or emotional disruption = inaccessible experiences

Early experiences shape personality and IP experiences eg. A child who loses a parent and is forced to live with an alcoholic/abusive/depressed parent

These children grow up with anxiety and fear of abandonement of IP relationships

“Disorganised attachment” - abused and neglected infants and toddlers are unable to develop a cohesive sense of self and trust of others because they experienced their mothers as “frightened” (unable to care) and “frightening” (unable to empathise)

PERCEPTUAL DISTORTIONS ARE UBIQUITOUS

An individual’s responding to someone in the present (therapist) as if that person were an important figure from the past is known as “transference”

Neurobiologically, it changes the neural circuitry

Clinicians, too, have feelings about and responses to patients that may be confusing at times

Although once considered unhelpful, these responses—referred to as “countertransference”,actually facilitate treatment enormously

Countertransference -> “Why a feeling arises?” ->A view of the patient’s psychic process and also in assessing “engagement” of the therapist

PERCEPTUAL DISTORTIONS ARE UBIQUITOUS

Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms such as rage, hatred, mistrust, parentification, extreme dependence, or even placing the therapist in a god-like or guru status

To quote Freud, "the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment (Resistance), becomes its best tool“

A therapist who is sexually attracted to a patient must understand the countertransference aspect (if any) of the attraction, and look at how the patient might be eliciting this attraction

Once any countertransference aspect has been identified, the therapist can ask the patient what his or her feelings are toward the therapist, and can explore how those feelings relate to unconscious motivations, desires, or fears.

SELF-DEFEATING BEHAVIOR

How is it that some people never learn from their mistakes?

For example, why has a man married three women in succession, each one alcoholic and abusive? Or why might a victim of childhood sexual abuse place herself in dangerous situations that facilitate further trauma?

People repeat unhelpful behavior in an attempt to master enduring conflict or trauma, ever hopeful that they can repair or resolve painful experiences by placing themselves once again in a precarious situation to “make it turn out differently”

SELF-DEFEATING BEHAVIOR

Perhaps one of Freud’s more helpful clinical insights was the recognition that behaviors are repeated unless one becomes aware of patterns and reasons for the predictability of the behavior

To paraphrase Freud, those who cannot remember certain affect-laden experiences are doomed to repeat them

One aspect of dynamic psychotherapy is to help the patient appreciate the compelling repetition of unhelpful situations or behaviors in which remembering can then replace repeating or reliving

THE EMOTIONAL AND THE INTELLECTUAL ASPECTSIN THERAPY

Cognitive and affective components of negative experiences to be examined

Cathartic experiences alone are unlikely to provide relief or promote behavioral change, and therapists should not offer to explain the “dynamics” of clients psychopathology

Early attachment relationships are encoded as affect-laden implicit memory

The therapist should help the patient examine predictable feelings and distortions within the safe therapeutic relationship

THE EMOTIONAL AND THE INTELLECTUAL ASPECTSIN THERAPY – How does PP help?

It promotes changes in neural structure that afford the patient an additional resource for feeling and behaving differently

Restructures intense implicit memories within the context of a therapeutic relationship

Many mistakenly consider only interpretive, clarifying, or confronting interventions as being “psychodynamic”

Additional “Supportive” interventions are suggestion, reassurance, advice giving, praise, and environmental manipulation

Substantial gains can be made in supportive therapy with patients who are experiencing significant psychiatric illness

A psychodynamically informed approach is also exceptionally helpful in appreciating the meaningfulness of medication to the patient

Thus plays a vital role in medication compliance

TASKS OF THE PSYCHODYNAMIC PSYCHOTHERAPIST?

BOUNDARIES

Ethically, the clinician should never takes advantage of the patient to meet his or her own financial, sexual, or other personal needs

A clinician should not confide his or her problems and needs, transforming the therapy into an unhelpful experience for the patient

Clinician should explain to the patient the time, place and fee for therapy and should never be late for the appointment

EFFECTIVE INTERPRETATION

Empathize

Identify a patient’s behavior and emotional patterns, especially transferences, through understanding often subtle or initially confusing communication

Recognize the meaning of one’s own fantasies and responses to the patient (countertransference)

Maintain a verbal flow that deepens the treatment

Appreciate the timing and dosage of interpretations

Be patient

EFFICACY AND USES

Many psychiatrists are unaware of the substantial research supporting the helpfulness of psychodynamic psychotherapy

The psychodynamic treatment approach is not limited to long-term psychotherapy alone

Has broad applicability across the life span in crisis and supportive interventions, combined treatment, brief dynamic psychotherapy, group/family treatment, inpatient psychiatry, and consultation-liaison psychiatry

Treatment effect size is robust in some anxiety, personality (especially Cluster C), mood, and substance abuse disorders

EFFICACY AND USES

Patients are much better off immediately after treatment, and follow-up assessments show that they maintain their gains

Studies of combined treatment using psychotherapy and pharmacotherapy also support the benefits of treatment (Kay J : Psychotherapy and Medication, Oxford Textbook of Psychotherapy)

Several RCT and meta-analysis have supported the use of psychodynamic therapy for personality disorders, major depression, anxiety disorders, and some eating disorders, as well as posttraumatic stress disorder, panic disorder, somatoform disorders, and substance use disorders (Gabbard)

SHEDLER’S REVIEW

In 2010, American Psychologist, the journal of the American Psychological Association, published a review article by Jonathan Shedler, PhD, associate professor of psychiatry at the University of Colorado Denver, School of Medicine, which explored the efficacy of psychodynamic psychotherapy

Shedler reviewed 8 meta-analyses (comprising 160 studies) of psychodynamic therapy, plus 10 meta-analyses of other psychological treatments and antidepressant medications

He focused on effect size: 0.8 is considered a large effect; 0.5, a moderate effect; and 0.2, a small effect. The overall mean effect size for antidepressant medications approved by the FDA between 1987 and 2004 was 0.31. The effect sizes for psychodynamic therapy and other psychotherapies were much higher.

COCHRANE LIBRARY

One methodologically rigorous meta-analysis of psychodynamic therapy, published by the Cochrane Library, included 23 randomized controlled trials of 1431 patients with a range of common mental disorders

The studies compared patients who received short-term (less than 40 hours) psychodynamic therapy with controls (wait list, minimal treatment, or treatment as usual)

The overall effect size was 0.97 for general symptom improvement

The effect size increased by 50%, to 1.51, when patients were reevaluated 9 or more months after therapy ended

COMBINATION THERAPY – MEDS + PP

Glen O.Gabbard, Textbook of Psychotherapeutic Treatments, Pg-138, 2009, First edition

THANK YOU