20 Minutes

By THE BALANCE
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Psychodynamic psychotherapy, like psychoanalytic therapy, is an extensive kind of talk therapy centered on psychoanalytic concepts. However, psychodynamic treatment places a greater emphasis on the patient-therapist interaction than on the patient’s connection with his or her outer environment. Psychodynamic treatment is often shorter than psychoanalytic therapy in terms of session duration and frequency, however that may not always be the norm.

The psychodynamic approach differs from other forms of treatment in that it focuses on identifying, recognizing, comprehending, communicating, and conquering negative and conflicting sentiments and buried emotions in hopes of improving the patient’s social experiences and interactions. This includes facilitating the patient in comprehending how previously suppressed emotions influence present decision-making, behavior, and relations. Additionally, psychodynamic therapy seeks to assist persons who are capable of understanding the underlying causes of their social troubles but are unable to resolve them on their own. Through this in-depth extraction and analysis of prior feelings and experiences, patients learn to assess and address present challenges and modify their conduct in the present relationship.

While psychodynamic therapy is frequently used to relieve symptoms of depression, it can also be utilized to manage a variety of many other psychological and mental health disorders:

  • Major Depressive Disorder (MDD)
  • Stress and anxiety disorders (including social anxiety)
  • Disorders of posttraumatic stress (PTSD)
  • Excessive Worry
  • Phobia disorders
  • Sexual challenges
  • Obsessive-compulsive disorder (OCD)
  • Disabilities of temperament and personality
  • Schizophrenia
  • Loneliness and Isolation (including social dissociation and detachment)
  • Diseases that do not appear to have a physical origin
  • Other mood disorders

Obsessive-compulsive disorder (OCD) is a severely debilitating illness marked by recurring obsession and uncontrollable compulsive behaviors. According to new studies, OCD is much more prevalent than previously thought. In OCD, both selective serotonin reuptake medications and CBT have been demonstrated to be similarly effective, with response rates ranging from 55% to 65% and relapse rates of 20-25% or less. As a result, there is a need for more research into effective treatments.

With a longstanding therapeutic history of explaining and managing OCD from a psychodynamic approach, there is currently no scientific evidence for psychodynamic therapy. Latest anxiety studies, on the other hand, indicate that manual guided short-term psychodynamic therapy (STPP) could be a viable therapeutic option. Depending on Luborsky’s supporting expressive therapy, a framework of STPP for OCD was established. The program consists of 12 modules that incorporate both supporting expressive therapy features (such as an emphasis on the core conflictual relationship theme, CCRT, and the helpful alliance) as well as disease-specific aspects of therapy. The treatment is discussed briefly in the following paragraphs.

The CCRT related to OCD symptoms is measured at the outset of therapy. A CCRT has three parts: a wish (W, for example, hostile or erotic urges), an external reaction to others (RO, for example, being criticized), and an internal response to self (RS, for example, obsessive and/or compulsive tendencies). With the use of CCRT, the counselor relates the person’s OCD symptoms (RS) to his or her wishes (or instincts and impacts, W) as well as others’ (anticipated) reactions (RO). The CCRT is referred to as the “OCD protocol” by the patient. Patients can use this method to figure out their stress and OCD reactivity patterns. It converts the symptoms of the patient into interpersonal interactions (both internal and external).

The emotive (interpretive) portion of SE therapy helps improve the patient’s emotional and cognitive awareness of his or her problems as well as the underlining CCRT. An expressive approach to resolving the CCRT for Lady Macbeth’s excessive rinsing in Shakespeare’s Lady Macbeth could be; as we’ve seen, your compulsive cleaning (RS) is linked to your rage, Duncan’s killing (W), and shame (internalized RO). You’re attempting to undo your deed and alleviate your feelings of shame through your excessive cleaning procedures.  You are substituting moral rectitude with physical hygiene and cleanliness by washing your hands over and over.

The CCRT and its elements are explored in existing and historical relationships, including the “now and here” interaction with the psychotherapist, during treatment. Working with the CCRT is likely to increase patients’ comprehension of their problems, lessen OCD symptoms, and assist them in establishing more appropriate behaviors (RS), according to existing evidence. Patients are instructed to focus on their OCD scheme both during and between sessions, which entails monitoring their feelings, including physiological aspects, and identifying the CCRT elements that cause stress and Obsessions. Patients may get greater awareness and understanding of their OCD symptoms as well as a degree of stability (i.e., not feeling powerless in the face of OCD) as a result of this.

The supporting portion of the treatment considers creating a solid therapeutic bond to be the most important component. Luborsky has created numerous concepts for forming a solid alliance, including communicating a sense of acceptance and understanding, as well as recognizing the person’s increasing capacity to operate on his or her difficulties in just the same way that the clinician does.

We included disease-specific therapy features that were clinically effective in OCD into the manual-guided paradigm of STPP in an attempt to tailor the treatment, especially to OCD. For instance, they may include:

Identifying the difference between thought and action (e.g., Identifying the difference between thought and action (e.g., If you have carnal fantasies for these young females, this will not imply that you have agreed to have sex).

Helping reduce the inflexible and strict superego (consciousness) that is common in patients of OCD (e.g., by not criticizing the person for aggressive and sexual urges; by allowing patients to oppose the superego’s demands that are stringent and irrational). The RO portion of the CCRT can be considered to include the superego.

Sigmund Freud’s initial suggestion to OCD patients was to force them to confront their fears and then utilize the arousing sensations to focus on the fundamental conflict dispute or the CCRT. You feel terrified that something awful may occur to your spouse when you have these erotic (hostile, etc.) thoughts about young women, the therapist could ask. You’re attempting to stop this by following your routine practices. We’ll focus on your anticipation, which means not doing your rituals and enduring the anxiety, and then see what happens.

Educating the person about the disorder and therapy, resolving uncertainty and establishing therapeutic goals, creating a supportive internal dialogue, resolving (possible) non-response and opposition, and concentrating on relapse prevention and termination are among the other modules of CCRT.

In psychodynamic concepts, using anxiety to avoid thinking about other distressing situations is referred to be a defense mechanism. This idea can be traced back to Sigmund Freud’s signal theory of anxiety, which argued that defenses are created to keep us from focusing on more difficult, contested, or stressful events or feelings. According to this signal theory, a small quantity of anxiety induced by a prospective hazard “signals” the ego to be aware of the risk. To keep the threat from getting too dangerous, defense systems are activated. The focus of the treatment was on acquiring insight into the potential harm so that the patient might see that it was not as bad as he or she imagined. There’s a remarkable parallel here with acceptance-based treatment: removing the techniques for suppressing emotions leads to a reduction in anxiety.

However, in addition to avoidance, psychodynamic perspectives on stress and anxiety have focused on additional determinants of elevated anxiety levels (protection). While developing theories of anxiety, many psychodynamic theorists focused on the importance of human interpersonal relationships on psychological development.

Horney (1950) proposed that interactions that harm children’s psychological development (e.g., caregivers who are controlling, overly protective, overly punitive, or insensitive) lead to a lack of trust in oneself and others, a sense of loneliness and hopelessness, and “basic anxiety” in the children. Another interpersonal-psychodynamic hypothesis of anxiety proposed by Sullivan (1953) is that anticipating rejection from the primary caregiver at a young age is a factor. Fairbairn (1952) stressed the anxiety-producing conflict between the child’s sense of dependency on the caretaker and a fear of being smothered and losing identity, while Klein (1975) linked anxiety to the child’s worry of being unable to evoke the caretaker when needed. All of these models have instilled self-and other perceptions that are aroused later in life, influencing ongoing interpersonal connections and causing anxiety. It’s uncertain whether this generalized anxiety correlates to the current DSM-IV GAD diagnosis.

Despite this, our early perspectives informed the development of a brief, focal psychodynamic-interpersonal therapy for generalized anxiety disorder. According to Roemer and Orsillo, Borkovec (1999) has recently added strategies for changing interpersonal issues into CBT for GAD (current issue).

Anxiety can be treated with supportive-expressive psychodynamic therapy. The case for establishing a relations-oriented psychodynamic treatment for Generalized Anxiety Disorder (GAD) arises not only from the historical significance of psychodynamic groups in anxiety but also from fresh empirical findings tying interpersonal components to GAD. For example, Borkovec, Robinson, Pruzinsky, and De Pree (1983) discovered that anxiety was linked to increased interpersonal difficulties. Using retrospective recall techniques, Lichtenstein and Cassidy (1991) discovered that GAD participants reported significantly more attachment troubles with primary caregivers than non-GAD respondents. GAD patients reported higher levels of entanglement and role reversal (i.e., the child taking on parental responsibilities), as well as more preoccupying anger and shifting feelings toward the caregiver. Furthermore, GAD patients experienced more rejection as children than non-GAD patients.

We hypothesize that a set of dangerous or distressing interpersonal experiences results in a set of fundamental wishes/desires, anticipations, belief systems, and thoughts about oneself and other people, based on historical psychodynamic literary works on defenses and early developmental factors in anxiety, as well as recent research on worry as avoidance and interpersonal factors in GAD. These wishes/desires are usually driven by fears of desertion, violence, disappointment, or criticism from others and include getting affection, consistency, or care from others. The anxiety connected with these interpersonal goals and beliefs is so strong that the person with GAD avoids thinking about the wishes, memories, and feelings that led to the worries. To prevent these cravings, sensations, and recollections, one method is to become overly cognitively engaged (worried) with current events. The SE model, in contrast to traditional psychoanalysis, does not limit GAD formation to early childhood events. Interpersonal catastrophes and pressures can strike at any age, but a long period of insecure attachment throughout childhood is more likely to result in unrealistic expectations of others that last far into adulthood.

The set of interpersonal wants, desires, belief systems, and emotions becomes a component of cyclical feedback systems after it has been created, repeating the imagined situations that initially triggered anxiety. The SE model formalizes the core conflictual relationship theme’s (CCRT) cyclical, recurrent relationship patterns, which are made up of three elements: the wish or desire, the apparent or anticipated reaction from the other person, and the self-response. The counselor’s major expressive (exploratory) role in SE treatment is to create a CCRT for each patient and use it to guide therapies. The therapist’s primary support role in SE treatment is to establish and maintain a good therapeutic alliance.

GAD anxiety, according to this theory, can be caused by a variety of factors. The most basic is a persistent fear of not achieving what one desires in relationships. The concern component of anxiety is regarded to be a defensive response, as previously noted. Other anxiety symptoms, such as physical symptoms, can also be a defense mechanism (i.e., focus on bodily symptoms as a way of avoiding emotions). Personal circumstances might sometimes add “realistic” fear to the mix of worries and defenses carried over from past relationships.

To summarize, today’s prevalent SE model resembles Roemer and Orsillo’s comprehensive acceptance-based approach in certain ways. Among these is the concept of worry as a type of avoidance (defense). As previously stated, CBT has a strong emphasis on interpersonal patterns, which is an important part of SE treatment (Borkovec, 1999). Such interpersonal patterns are not included in the therapeutic focus of the Roemer and Orsillo models, indicating a significant departure from the models.

What are the treatment differences between an integrated CBT package that focuses on both cognitive avoidance and interpersonal problems and the brief, focal SE psychodynamic treatment? Assuming that an interpersonal component is included in the Roemer and Orsillo (this issue) model, or that it could easily be added using Borkovec’s alteration of CBT for GAD, what are the treatment differences between an integrated CBT package that focuses on both cognitive avoidance and interpersonal problems and the brief, focal SE psychodynamic treatment? The distinctions boil down to a question of attention for the most part.

Only a small amount of time can be devoted to interpersonal issues within the confines of a brief (e.g., twelve to twenty session) CBT treatment, which may also include setting a session agenda, teaching relaxation skills, monitoring automatic thoughts, examining evidence for the patient’s beliefs, generating various interpretations, and other CBT and acceptance-oriented methods. The idea in traditional psychodynamic therapy, and particularly this specific type of SE therapy, is that patients will need a lot of therapy session time to recollect their interpersonal encounters in-depth memories, feelings, and thoughts of what happened. The therapist remains relatively engaged within a brief treatment paradigm and supports the elicitation of specific narratives surrounding interpersonal encounters, but the unfolding of this information is regarded to be most beneficial when done at the patient’s pace. SE therapy, on the other hand, is less structured than CBT.

SE therapists, on the other hand, are less directive than CBT therapists. Traditional psychoanalysis would almost entirely eschew directive tactics for fear of complicating the therapeutic connection and making it more difficult to distinguish between patient transference reactions to the therapist and an established authority figure position. SE treatment is more open to incorporating directed methods and avoids the “blank screen” stereotype associated with psychoanalysis. However, some patients may not see therapy as a place to discuss their recurring interpersonal challenges that are causing distress after being trained in several different skills (e.g., relaxation treatment, monitoring techniques, meditation exercises, and problem-solving strategies) and a substantial amount of psycho-educational material over time. This concern can be mitigated by achieving a balance between didactic and skill-building components, as well as interpersonal content expression and conversation.

Psychodynamic psychotherapy is one of the many types of psychotherapy used to treat depression. Psychodynamic psychotherapy assumes that childhood events, unresolved problems, and previous relationships have a substantial impact on one’s current circumstances. Adult relationships are thus understood to be the result of childhood unconscious patterns. It reveals the unconscious patterns of interpersonal interactions, conflicts, and wants that produce sadness.

The type of psychodynamic psychotherapy used depends on the patient’s depression and personality. Psychodynamic treatment alone can treat mild to moderate depression. The majority of studies evaluating psychodynamic psychotherapy for depression have been done on mild to moderately depressed patients.

Psychodynamic therapy and pharmacotherapy are required for patients with moderate to severe depression, especially suicidal ideation or neurovegetative symptoms (loss of sleep, appetite, and energy). Candidacy for psychodynamic psychotherapy depends on the patient’s personality, motivation, and social and occupational functioning.

Treatment guidelines — It is based on the following tenets:

  • During the history-taking, clinicians should elicit a patient’s life narrative and listen to how the patient expresses depression. The clinician should also inquire about past and present stressors, as well as their underlying meaning to the patient.
  • The clinician and patient must agree on therapy goals. Depressive syndrome resolution is an explicit goal, but so is altering personality traits that make the patient prone to depression; awakening unconscious sensations, thoughts, and habits that create sadness and relationship issues.
  • This includes stresses (e.g., relationship breakdown) and individual personality inclinations (e.g., perfectionistic demands for oneself) that can lead to sadness.
  • With the help of analyzing and describing repeating patterns and unconscious conflicts that occur in relationships outside of therapy and in relationships with the physician, the clinician helps the patient comprehend the origins of depression. The physician also discusses the patient’s defense mechanisms, both useful (e.g., preventing overwhelming anxiety) and harmful (e.g. (e.g., preventing self-examination on the part of the patient). It has been shown that gaining knowledge of these patterns, conflicts, and defenses leads to the betterment of mental health.
  • Clinical observation of patient-clinician interaction, For example, a patient may inquire about the clinician in order to foster a social relationship beyond the professional one.
  • Clinicians should avoid providing personal information to keep the treatment focused on the patient. Also, less physical knowledge about the doctor increases the risk of unconscious transference. So rather than directly answering a patient’s questions, uncover their underlying significance. However, expressing a present emotion or sharing a common interest with the patient might strengthen the therapeutic bond.
  • The clinician assesses the patient’s unconscious resistance to help. The physician also examines countertransference in reaction to the patient’s resistance and other behaviors.

Individual, face-to-face treatment is the norm. However, psychodynamic therapy has been modified for use in groups and online. There are two types of psychodynamic treatment. Time-limited therapy typically includes 12–24 weekly sessions over three-six months. One or two sessions per week of open-ended long-term therapy. Short-term therapy is ineffective when long-standing personality features hamper recovery from the depressive condition. Each session lasts about 50 minutes.

If one physician provides psychodynamic psychotherapy and another prescribes antidepressants, they must be part of the same treatment team. The clinicians must agree that there are no secrets between them and that they will regularly speak about any issues they may have. Those new to psychodynamic psychotherapy should be supervised by a seasoned professional. However, the two treatments differ in some aspects. Unlike in psychoanalysis, when patients recline on a couch, in psychodynamic therapy they sit and face the therapist. Also, unlike psychoanalysis, psychodynamic therapy does not use dreams to investigate the patient’s unconscious processes.

Psychodynamic approaches to trauma and post-traumatic stress disorder (PTSD) put an emphasis on a variety of distinct factors that may impact or contribute to the development of PTSD symptoms, including the following:

  • Childhood tragedies (specifically related to the extent of attachment with caretakers or parents)
  • Existing domestic relationships
  • Unconscious protective techniques that individuals adopt to defend themselves from distressing feelings and thoughts that arise as a consequence of a traumatic experience

Unlike cognitive behavioral therapy, psychodynamic therapy puts a focus on the unconscious mind, which incorporates negative symptoms, desires, and emotions that are too difficult to address explicitly. Even while these unpleasant emotions, impulses, and beliefs are not conscious, they still affect our actions. For instance, unconscious feelings may induce you to resist initiating a new relationship with someone due to the possibility of resurfacing those painful feelings. This is an illustration of how ideas and feelings influence actions. Psychodynamic therapy, like cognitive behavioral therapy, seeks to alter behavior. It is simply that the route is different.

To achieve change in symptoms or behavior, one must first connect with and “process through” one’s unpleasant unconscious feelings. To accomplish this, the psychodynamic therapist will help patients in recognizing the defense mechanisms that are used currently, understanding why they are being used (to avoid uncomfortable unconscious feelings associated with a traumatic event), and linking with and accurately releasing previously ignored thoughts and feelings.

For instance, a psychodynamic therapist may see one of the following defense strategies over the course of numerous sessions:

  • Disavowal. When a patient denies the magnitude of the influence of a traumatic event on their life. This is a frequent defense strategy used by people to protect themselves from something they are incapable of coping with.
  • Displacement. It occurs when a patient expresses anger and places blame on family members despite the fact that they have done nothing to earn it. In this situation, the therapist may read this conduct as an indication that the patient is genuinely upset with and criticizing themselves for the traumatic experience, but because this rage and remorse are too painful to bear, they are directed toward others.

In both of these instances, the therapist would interpret the patient’s conduct and inform the patient of his or her assessment.

What are the Benefits of Psychodynamic Therapy?

Russell B. Carr, MD, a military psychiatrist, has spent the last six years dealing with troops who have failed to respond to cognitive-behavioral therapy. He has devised a novel treatment based on interpretive systems theory. This current interpretation of psychoanalysis, pioneered by Robert Stolorow, Ph.D., asserts that guilt and seclusion are at the core of trauma.

Carr’s therapy, as defined in the October 2011 issue of Psychoanalytic Psychology, has demonstrated potential in assisting troops who have not reacted to CBT by treating the existential angst evoked by trauma and the sense that their all-inclusive universe has lost significance. Carr’s objectives are lofty, but his intervention is brief—requiring twice-weekly meetings for up to three months. As a result, Carr discovered, the therapist must explicitly set goals, maintain the flow of dialogues, and immediately create rapport with clients. Short-term therapy — which is characteristic of CBT but less prevalent in psychoanalytic techniques — is frequently the only choice available in military situations, he notes.

“In the military, there is frequently the situation where a patient or therapist is leaving soon,” says Carr. “It’s a transient population, and it limits the length of time we have to work together.”

A critical component of intersubjective therapy is assisting clients in verbalizing their sentiments about traumatic situations. These are not always bad emotions. According to the article, one patient discovered he relished the scent of burning human flesh, but was afterward shocked and embarrassed by his first reaction. Carr assisted the soldier in processing the event and reconnection with the civilian world by demonstrating empathy and not abandoning him.

Carr discovered that convincing troops that a therapist — as well as family and friends — can comprehend a portion of what they are living through alleviates their PTSD symptoms. In certain instances, he argues, troops even benefit from the experience.  By acknowledging the frailty of life, you may refocus on what matters and avoid wasting time on things that don’t.

Support for psychodynamic therapy for the management of schizophrenia, psychotic disorders, and other forms of psychosis has declined in recent years. This is not wholly due to a loss of reliability or effectiveness, but rather to a change in research from established therapeutic procedures to more novel alternatives. Nevertheless, a recent study done by Bent Rosenbaum of the University of Copenhagen’s Department of Psychology found that psychodynamic therapy remains one of the most successful kinds of treatment.

Rosenbaum contrasted treatment as usual (TaU) to TaU combined with supportive psychodynamic psychotherapy (SPP) in a group of 269 persons hospitalized for psychosis. Overall functioning and symptom severity were assessed prior, during, and after the 2-year therapy session. Rosenbaum discovered that the SPP leads to positive results far more than the TaU group on all measures of functioning and psychotic symptoms. Over the past two years of treatment, individuals in the SPP group experienced significant improvements in social functioning and substantial reductions in regressive symptoms.

These findings suggest that psychodynamic therapy and the main components of that method can still meet the needs of a large number of persons suffering from schizophrenia and other psychotic disorders. Rosenbaum argues that doctors should focus on the fundamentals of psychodynamic therapy while working with psychotic clients. This includes overcoming impediments to emotion regulation, psychological wellbeing associated with a sense of self, and the formation and maintenance of relationships. Cognitive development and attention to the present moment should also be addressed to guarantee that individuals who suffer from these challenges receive the most benefit.

Rosenbaum expects that this research will reintroduce therapists to SPP and similar approaches. When utilized in conjunction with medical and social treatment techniques, it aids in rehabilitation.  SPP should thus be considered as a strategy in future studies and treatment. This will offer therapy options for people with varying degrees of mental illness.

With the development of cognitive-behavioral therapy (CBT) in the treatment of psychosis, psychodynamic therapy faced criticism for both its effects and procedures. NICE guidelines urge that CBT be administered to patients suffering from psychosis, defining it as:

A brief psychotherapeutic interaction in which service users:

  • Make connections between their beliefs, emotions, and behaviors and their present or previous symptoms and/or performance, and
  • Reconsider their views, attitudes, and beliefs in light of the objective symptoms.
  • Additionally, a component of the intervention should include the following:
  • Service users who are vigilant about their own beliefs, emotional state, and actions in relation to a symptom or recurrence of symptoms, and/or
  • Promotion of alternate coping mechanisms for the target symptom, and/or 
  • Promotion of alternate coping mechanisms for the target symptom, and/or 
  • Enhancement of functionality’

While some CBT procedures are incompatible with a psychodynamic approach, it is obvious that CBT and psychodynamic therapy share a great deal of ground. Certain CBT procedures are not only congruent with psychodynamic approaches but are necessary components of them. Consider the investigation of voices, in which psychodynamic therapists, like CBT therapists, will want to learn about the content of the voices’ statements, as well as their essence, properties, developmental history, and instigating factors, as well as their possible connections to other events and experiences.

In the midst of this uncertainty, NICE in 2009 recommended that psychodynamic treatment for individuals with schizophrenia should not be given. This argument relies only on the results of RCTs. Surprisingly, the NICE guidelines also suggest that psychodynamic concepts be applied to understand better the perspective and interactions of those with psychosis — which, obviously, includes relations with therapists. A supportive therapy like SPP, in which the therapist uses psychodynamic precepts to comprehend the clinician-patient relationship connection, could perhaps fit in nicely into NICE’s supportive treatment and counseling categorization than their psychodynamic therapy classification, which describes an antiquated strategy in which the therapist waits for content to spring up from the patient without provoking or leading them to a conclusion and maintains an extent of opacity to assist in the design of a transference relationship. Supportive treatments should not be regularly provided as policy interventions, according to NICE, but patient wishes should be considered, particularly if other more effective psychological treatments are not accessible locally.

There is also an issue with taking the statement that psychoanalytic therapies should not be administered to patients who are psychotic at surface level. This means that psychodynamic therapy could be an effective, RCT-backed solution for a condition the patient is dealing with in conjunction with their psychosis or when they are not suffering any psychotic symptoms at the time of commencing the psychodynamic therapy.