Psychodynamic Therapy

Psychodynamic Therapy

Background

Theoretically underpinned by the work of Freud, the “father of modern psychotherapy” (Moore et al, 2010:2), psychodynamic therapy is focused on the impact of past experiences that have a deep influence on current behaviours and shape interactions and perceptions in interactions with others (Ursano et al, 2008). Identification of these implicit, or unknown past trauma influences through therapeutic support will assist the client to gain increased control over behaviours and interactions with others (Kay, 2006; Ursano et al, 2008 ).

Psychodynamic therapy has been exposed to influence and adjustment over the past 50 years to incorporate brief approaches better suited to the time framed input of health organizations (Moore et al, 2010; Abbass et al, 2006; Churchill et al, 2010). The practice of short – term psychodynamic therapy (STPP) has strong international support (Churchill et al, 2010). A systemic review of psychodynamic psychotherapy in Australia by Gaskin (2012), cited a survey of all 41 – member organizations of Psychotherapy and Counselling Federation of Australia, and found that “30/% of respondents regarded psychodynamic approaches as being their primary theoretical orientation.” (pp. 2).

Treatment

The literature identifies quite a shift in treatment from a traditional psychoanalytic perspective where “an exhaustive exploration of the past” (Ursano et al, 2008:2) may require weekly contacts over many years, to the brief focused work of current times where the therapist takes “an active role in the helping process, fostering and sustaining a treatment focus and initiating interventions within this focus to challenge maladaptive defensive patterns and provide new, corrective relationship experiences.” (Ursano et al, 2008:2).

The focus of intervention is to “make contact with and comprehend … the patients inner world in order to engage in an interpretive examination of it.” (Kay, 2006:170).

A three-stage process

Accepting –         Affirming the patients past and present subjective experience.

Understanding – Appreciating the conscious and the unconscious contributions

to the patient’s emotional problems.

Explaining   –     The therapist expresses through interpretations, his/her

understanding to the patient.           (Kay, 2006:171).

Freud’s concept of transference “as a reconstruction of patients’ repressed past ”transferred” onto the relationship with the therapist” (Hogland et al, 2006:1739) is fundamental. The emergence of subconscious memories and past developmental experiences that are repeated in the patterns of the clients interpersonal relationships, are ‘transferred’ into the counseling experience. “Exploring the transference … is all part of the attempt to understand the inner world of the patient – the world of how the patient sees and experiences people and events, the world of psychic reality.” (Ursano et al, 2008:5). The therapists capacity to interpret, reframe and explain current behaviours and responses supports the client in understanding their ‘self’, therefore gaining increased ability to more positively manage their interactions with others, and life events. “The therapists capacity to be at ease with emotional intensity is a critical skill” (Kay, 2006:171).

Therapeutic relationship

The therapeutic relationship is “considered the central vehicle for change” (Moore et al, 2010), and is well supported as fundamental to successful intervention (Gaskin, 2012; Ursano et al, 2008; Moore et al, 2010; Kay, 2006). It is within the confidence and safety of a sound therapeutic alliance, that the client is enabled to build trust in the process of treatment (Ursano et al, 2008); the client must be able to rely on the structure of the emotional and physical boundaries provided by the clinician to successfully engage in the therapeutic process (Kay, 2006:171).

Efficacy

Ursano et al (2008), cite evidence of effective treatment of symptoms of poor self-esteem, depression, and a growing evidence for efficacy in Borderline Personality Disorder (BPD). A Cochrane review of efficacy for schizophrenia identified a poor evaluation process reporting limited data and poor efficacy. Abbass et al (2006), conducting a systemic review of STPP, found modest but sustained improvement in common mental disorders including anxiety, depression, and certain behavioural disorders and personality problems. The Gaskin (2012) review of Australian literature over the previous 10 years, identified effective treatment of depression, generalized anxiety disorder (GAD), somatic symptoms, and borderline, compulsive, avoidant and dependant personality disorders. Similarities in support are identified by Leichsenring et al (2009) who compared STPP and CBT in treating GAD, and whilst concluding STPP to be effective, found CBT to be superior. A favourable editorial comment by Milrod (2009) to this research, queried the potential efficacy of manualised expressive psychotherapy (a STPP) in treating some aspects of BPD, which present with some similarity in symptoms to GAD (pp. 842-843).

 

A two-year study set in Stockholm, Sweden, compared manualised expressive psychotherapy, with a non – manualised STPP in treating two comparative sample groups (N=76, and N=80), diagnosed with BPD Vinnars et al (2005). Efficacy for both groups was clearly established, however it must be noted that treatment for the manualised groups was made up of 40 weekly contacts with clients, and 40 weekly supervision sessions for clinicians; the non manualised, ‘treatment as usual’ group received an average of 21 sessions. It is useful to note that this research identifies that ‘treatment as usual’ for psychodynamic therapy in North America community mental health settings, averaged 8 sessions (Vinnars et al 2005:1934).

 

Finally, Shedler (2010) has provided an extensive and respected meta – analyses of treatment outcome studies, of both long and brief forms of psychodynamic psychotherapy, and notes support for various diagnostic groups – depression, BPD and interpersonal relationship concerns. Furthermore, Shedler recognizes the impact on “other therapies (that) include techniques and processes that have long been core, centrally defining features of psychodynamic treatment .” (pp. 107). This research notes session numbers ranging from 21 – 40 for STPP (pp. 101); one may well wonder how a public funded community mental health service might realistically embrace such a therapy model, regardless of efficacy.

 

Reference list

Abbass, A.A., Hancock, J.T., Henderson, J. & Kisely, S.R. (2006). Short -term psychodynamic psychotherapies for common mental disorders (Review). In, The Cochrane Library, 2006, Issues 4. pp 1-54.

 

Churchill, R., Davies, P., Caldell, D., Moore, T.H.M., Jones, H., Leis, G. & Hunot, V. (2010). Psychodynamic therapies versus other psychological therapies for depression (Protocol). In, The Cochrane Library, 2010. Issue 9. pp. 1-18

 

Gaskin, C. J. (2012) , The Effectiveness of psychodynamic psychotherapy: A systemic review of recent international and Australian research. Melbourne: PACFA. pp. 1- 33.

 

Hogland, P., Amlo, S., Marble, A., Bogwald, K-P., Sorbye, O., Cosgrove – Sjaastad, M. & Heyerdahl, O. (2006). Analysis of the Patient – Therapist Relationship in Dynamic Psychotherapy: An Experimental Study of Transference Interpretations, In, American Journal of Psychiatry, 163:10, October 2006. pp 1739 – 1746.

 

Kay, J. (2006). The Essentials of Psychodynamic Psychotherapy. In, FOCUS Spring 2006, Vol. IV, No. 2. pp 167-172.

 

Leichsenring, F., Salzar, S., Jaeger, U., Kachele, H., Kreische, R., Leweke, F., Ruger, U., Winkelbach, C. & Leibig, E. (2009). Short – Term Psychodynamic Psychotherapy and Cognitive – Behavioral Therapy in Generalised Anxiety Disorder: A Randomised, Controlled Trial. In, American Journal of Psychiatry, 166:8, August 2009. pp. 875 – 881.

 

Malmsberg, L., Fenton, M. & Rathbone, J. (2001). Individual psychodynamic psychotherapy and psychoanalysis for schizophrenia and severe mental illness (Review). In, The Cochrane Library, 2001, Issues 3. pp 1-54.

Milrod, B., (2009). Psychodynamic Psychotherapy Outcome for Generalized Anxiety Disorder. In, American Journal of Psychiatry, 166:8, August 2009. pp. 841-844

 

Moore, T.H.M., Hunot, V., Davies, P., Caldwell, DF., Jones, H., Lewis, G., & Churchill, R. (2010). Psychodynamic therapies versus treatment as usual for depression(Review). In, The Cochrane Library, 2010, Issue 9. pp 1-15.

 

Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. In, American Psychological Association, Vol.65, No. 2, pp. 98-109. DOI: 10/1037/a0018378.

 

Ursano, R.J., Sonnenberg, S.M., & Lazar, S.G. (2008). In, Psychodynamic Psychotherapy, In, R. Hales, et al (Eds.), The American Psychiatric Publishing Textbook of Psychiatry (5th ed. pp.). American Psychiatric Publishing, Arlinington,

 

Vinnars, B., Barber, J.P., Noren, K., Gallop, & Weinryb, R.M. (2005). Manualized Supported-Expressive Psychotherapy Versus Nonmanualized Community – Delivered Psychodynamic Therapy for Patients With Personality Disorders: Bridging Efficacy and Effectiveness. In, American