Psychodynamic Psychotherapy

Psychodynamic Psychotherapy

Psychodynamic Psychotherapy DK Freedheim, Case Western Reserve University, Cleveland, OH, USA JM DiFilippo, Independent Clinical Practice, Strongsvill...

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Psychodynamic Psychotherapy DK Freedheim, Case Western Reserve University, Cleveland, OH, USA JM DiFilippo, Independent Clinical Practice, Strongsville, OH, USA S Klostermann, Case Western Reserve University, Cleveland, OH, USA r 2016 Elsevier Inc. All rights reserved.

Glossary Countertransference Reactions of the therapist that are displacements of unconscious thoughts, feelings, and wishes onto the client. Defense mechanisms Automatic mental strategies utilized to avoid direct knowledge of unwanted unconscious thoughts and feelings. Ego psychology The movement that focuses on the role of the environment and defense mechanisms, as opposed to early childhood traumas and instinctual drives. Interpretation Revealing to a patient unconscious determinants of behavior, unlikely to become manifest without the therapist's aid. Libido The life force or energy that strives for expressions of pleasure, love, and self-preservation.

Object relations The movement that attributes psychopathology to inadequate early environments rather than to internal drives or conflicts. Resistance Expression of the client's ambivalence to participate fully in treatment due to fears and uncertainty related to doing something new and unfamiliar. Self psychology The movement that views the development of a cohesive and positive sense of self as the primary goal of therapy. Transference The displacement of feelings, thoughts, or impulses toward individuals in a person's past onto individuals in the present. Unconscious Thoughts, feelings, and memories that are forced outside of awareness because they constitute a threat to the individual and would elicit anxiety or unacceptable feelings.


The Beginnings

The term psychodynamic psychotherapy includes a wide range of therapeutic techniques and theoretical perspectives stemming from the early work of Sigmund Freud (1856–1939) and his colleagues. For more than a century, their psychoanalytic principles have been a major influence in the treatment of mental and behavioral problems. When Freud introduced his theories in the late nineteenth century, the medical community was shocked by many of the concepts, primarily the role of infant sexuality in human development. Yet, by the early twentieth century, his writings had impacted not only the medical field but also much of Western culture, especially in the arts, drama, and literature. Several early concepts even became incorporated into one's everyday language (e.g., ‘Freudian slip’). The two world wars contributed to the rapid expansion of the fields of both psychiatry and psychology, bringing new insights, theories, and approaches. As a result, the early models of mental disorders and treatment techniques changed dramatically. Despite all the modifications in the field, many of those early concepts continue to have an important role in understanding psychological development and emotional disorders. In this article of the Encyclopedia, the basic psychoanalytic theories are reviewed, their evolution over the years is examined, and their influence on the methods of psychotherapy, as well as the influence of changing life styles on the practice of psychotherapy, is considered. The research thus far that has endeavored to measure the results of psychodynamic psychotherapies, and the educational requirements for professionals entering the field, is also explored. Below, the terms ‘patient’ and ‘client’ are used interchangeably.

At the end of the nineteenth century, medical scientists, such as Mesmer, Charcot, Breuer, and Freud, were searching for ways to understand the human mind and relieve the mental anguish of patients seeking treatment. After experimenting with drugs, hypnosis, and even ‘laying hands’ on the heads of patients, Freud simply encouraged his patients to speak freely and honestly about whatever was on their minds. He termed the method free association; one of his patients called it ‘talking therapy,’ which became a key technique for psychoanalysis. The early treatment formed the ‘traditional’ method of psychoanalysis – 50-min appointments, at least 5 days a week, for up to 4 or 5 years, if necessary. The patient lies on a couch and talks freely; the therapist sits behind, unresponsive and neutral, but infrequently may ‘interpret’ a thought or dream. The purpose was to discover emotional conflicts that needed to be understood. The process encouraged transference, the patient's applying similar feelings to the therapist that had been felt toward family members and repressed before coming out during the free association. Transference became a core element of the analysis and led to the patient's gaining insight into the formerly repressed conflicts. As forgotten memories came to the surface, Freud conceptualized three contents of the human mind – the conscious, preconscious (easily recallable memories), and unconscious (forgotten and repressed memories). The latter contained forbidden feelings or thoughts that required energy to suppress. Freud and colleagues, particularly his daughter, Anna, defined a number of defense mechanisms or ways patients avoided direct knowledge of unwanted thoughts and feelings – denial,


Encyclopedia of Mental Health, Volume 3


Psychodynamic Psychotherapy

projection, regression, and others that are discussed later in the article. The analytic process released the energy repressing the memories and interpretation fostered insight into the sources of conflict, resulting in the alleviation of symptoms that plagued his patients. Soon other theoretical concepts emerged, such as the meaning of dreams (i.e., repressed wishes and fears); the driving impulse seeking pleasure, the libido, and its representation (Id); the opposite moral prohibition on these impulses (Superego); and the executive function mediating between the two (Ego). A central role in determining one's personality was the resolution of the Oedipal conflict, the ‘universal’ attraction of a child to the opposite-sexed parent, jealousy of the spouse of that parent, and the forbidden wishes of the child related to that conflict. Freud also devised a developmental model of personality in which the child progressed through dynamic phases focusing on oral (pleasure of and regulation of sucking and food intake), anal (regulation of bowels), phallic (awareness of genital sensations), latency (a calming period before adolescence), genital (maturity of sexual expression) toward adulthood (realization of the rewards of love and work). Disruptions or traumas during the developmental phases could contribute to psychological disorders by being repressed or subject to other defensive mechanisms. As analysts turned to the treatment of children, new techniques (such as play therapy) reinforced many of Freud's concepts of child development. (For a more in-depth understanding of psychoanalysis, see the article on Psychoanalysis.)

From Psychoanalysis to Psychotherapy Freud's early emphasis was on uncovering repressed emotional traumas, often stemming from the Oedipal conflict. The first serious breaks from this model of the traditional analysis appeared with the writings of Rank, Ferenczi, and Anna Freud. They turned the focus of the therapeutic process from only uncovering unconscious memories, wishes, and fears toward the goal of strengthening the adaptive defenses of the patient to better cope with problems in current interpersonal relationships (cf., Eagle and Wolitzky, 1992). The writings of Hartmann (on ego psychology), Kernberg (on object relations), Kohut (on self psychology), and others further deviated from Freud's original theories and methodology. The understanding of the developing personality shifted from the focus on resolving Oedipal-related issues to the evolving perceptions of the self and important objects (i.e., others) that were crucial in the life of the individual (Horowitz, 1998). From the mid-twentieth century, psychodynamic therapy began to emphasize a more direct, interactive, and supportive role for the therapist in guiding the patient toward a better understanding of the source of psychological problems. The standard 4–5 sessions was modified to as few as 1 appointment per week. The couch was replaced with face-to-face sessions. Psychotherapists moved from their mainly distant stance in therapy to enhancing the relationship between the client and therapist. The attention of the therapist shifted from only listening to the patient to include the therapist–patient


interaction. Interpretation was timed to enhance the understanding of feelings and problems presented by the patient (Summers and Barber, 2010). When the question of the distinction between psychoanalysis and psychodynamic psychotherapy was hotly argued, Alexander (1954) proposed that the difference lay not in the length of the sessions but in the supportive versus uncovering methods of the therapy. By the late twentieth century, most psychotherapy shifted from previous goals of understanding the unconscious to at least three basic types: exploratory, dealing with present issues and setting priorities; focused, confronting defenses directly to overcome current conflicts; and supportive, reinforcing strengths and appropriate choices of the patients. Briefer therapies required a ‘working alliance,’ in which trust in the therapist was crucial for fostering openness on the part of the client (Wolitzky, 2011). Some flexibility on the role of the therapist's self-disclosure replaced the earlier imperative of maintaining neutrality and abstinence. Once forbidden, selfdisclosure became permitted and even valued to enhance freer expression by clients (Wachtel, 2008; see article on SelfDisclosure). Over the last several decades, many of the techniques of psychodynamic psychotherapy have proven applicable to group therapy (Rutan et al., 2007). Also, short-term psychodynamic therapy has developed into a field of its own, with specific methods and treatment goals (Rawson, 2002; Ursano et al., 2004). The total number of sessions may range from fewer than 5–20 or more. Techniques differ widely, but have several common features. For example, it is important to establish an early trusting relationship with the client. The presenting problems are delineated and treatment goals are mutually established. Further, the therapist explores, confronts, and even challenges the client's defenses, depending on the comfort and style of the therapist (Davanloo, 2005). The therapist also reinforces adaptive defenses and coping mechanisms and may give homework assignments. The therapist must be sensitive as to what intrapsychic and interpersonal conflicts to explore and what to ignore, as the aim of the work is to help the patient through specific problem areas and not prolong the treatment (cf., Crits-Christoph and Barber, 1991). (Further discussions on therapy can be found in articles on Psychotherapy, Integrative Psychotherapy, and Child Psychotherapy.)

Present Realities As the twentieth century came to a close, psychotherapy was subject to the same benefits and constraints as medical treatments. Third-party payers became available and both private insurance carriers and government payment programs demanded empirically proven treatments at the lowest possible costs. The era of intensive, long-term therapy with the aim to understand and alter the basic character of the patient began to decline. As differentiated from the traditional model, where all conflicts and relationships needed to be ‘analyzed,’ most contemporary psychotherapy has evolved into a much more focused treatment of symptoms, conflict resolution, and helping clients to recognize when to seek further counseling.


Psychodynamic Psychotherapy

But even with much modification of the techniques in therapy, an understanding of psychoanalytic concepts can serve as a guide to the patient's struggles.

neuropsychologists argue that most information processing takes place outside of awareness in a more efficient and automatic manner relative to conscious thinking. The concept of the unconscious most likely will continue to undergo considerable revision through future theory and research.

Evolution of Principles of Psychoanalytic Theory Freud himself repeatedly revised his conceptualization of many of the early psychoanalytic principles during the course of his lifetime. Subsequent psychodynamic theorists have rediscovered, revised, and expanded on his original writings. The theoretical concepts of the unconscious, defenses, transference, countertransference, resistance, interpretation, insight, and working through are examined below, with particular emphasis on the ways in which they have changed from the time of Freud to the modern day.

The Unconscious The unconscious contains thoughts, feelings, and memories that are beyond one's awareness. Although Freud was not the first person to describe the unconscious, he played a key role in understanding how it relates to psychopathology and psychotherapy (Luborsky et al., 2011). Through his work on the interpretation of dreams, Freud developed a topographical model of the mind consisting of three parts: the conscious, the unconscious, and the preconscious. Freud postulated that one's conscious thoughts and feelings were only a very small fraction of all mental activity and that the unconscious exerted far more power, relative to the conscious mind. According to Freud, the unconscious is comprised of instinctual drives and wishes (e.g., aggressive, antisocial, and sexual) that are forced outside of awareness because they would otherwise constitute a threat to the individual and elicit anxiety or unacceptable feelings. Freud noted that the unconscious drives and wishes constantly strive to be discharged and brought to conscious awareness but are blocked by defenses and/or allowed expression only in a distorted form (Sandler et al., 1992; Uleman, 2005). Freud asserted that an understanding of the unconscious had applications for dream interpretation and for diagnosing psychopathology. He also argued that the way to improve a person's mental health was through the psychoanalytic process of carefully bringing material from unconsciousness to consciousness (Epstein, 1994). However, there has been considerable debate about the presence and role of the unconscious over the past century. Currently, the emphasis on the relevance of the unconscious differentiates psychodynamic psychotherapy from many other forms of psychotherapy, such as cognitive behavioral treatment. At the same time, Freud's conceptualization of the unconscious has had a strong influence on the present-day Gestalt therapy and on some schools of family therapy (Luborsky et al., 2011). Scientists outside of the realm of psychotherapy have also studied the concept of the unconscious (Greenwald, 1992; Kihlstrom et al., 1992; Roffman and Gerber, 2009). Within the last two decades, cognitive neuropsychologists have used laboratory research to investigate a significantly different view of the unconscious, or what they term ‘subliminal perception’ or ‘the cognitive unconscious.’ Contemporary cognitive

Defenses Defenses are automatic mental strategies utilized in the face of unconscious fears and conflicts as well as external threats and stressors. In Freud's early work with free association, he noticed that patients would often censor or distort their thoughts and feelings in response to ‘signal anxiety,’ a conflict between their unconscious wishes or drives and their moral prohibitions or external restrictions (Perry et al., 2009). Freud viewed defenses as a primary form of resistance in psychoanalysis (Ursano et al., 2004). Defenses generally serve a protective function to the individual to avoid painful or upsetting emotional material from the unconscious. Although people often employ defenses outside of awareness, some individuals may have partial awareness of their use (Perry et al., 2009). Adaptive defenses promote mental health by allowing a person to live without becoming overwhelmed and by allowing flexibility in decision making. However, less mature defenses may distort reality to the point that they create problems in relationships and functioning (Luborsky et al., 2011; Ursano et al., 2004). Thus, maladaptive defenses come with the cost of constricting awareness and limiting the freedom to choose and control various ways of responding to stress (Perry et al., 2009). A few of the many common defense mechanisms include repression, regression, denial, reaction formation, displacement, and intellectualization. Freud described repression as the blocking out of conscious awareness of intolerable feelings, drives, and recollections. Regression is a retreat into an earlier phase of development, often as a reaction to trauma. Denial is the process by which the psychological pain is ignored but is still somewhat available to consciousness. Reaction formation is the magnification of one emotion in order to repress the opposite, intolerable emotion. Displacement is the transfer of emotions, thoughts, or wishes from the original source to a safer, less threatening one. Intellectualization is the excessive use of cognitive thinking without the accompanying affective experience. Although the specific strategy for each defense mechanism differs, all defenses operate by helping the person avoid pain or conflict. Two of the more primitive defenses include splitting and projective identification. Splitting is the separation of positive and negative aspects of the self and others, such that there is instability in self-image and vacillation between idealization and devaluation of others. Projective identification involves ascribing one's own unacceptable feelings or impulses to another person in an attempt to control that person. In the course of contemporary psychodynamic psychotherapy, the therapist helps the client to identify and understand unhealthy defenses, carefully tolerate the previously threatening material that activated the defense, work through resistance to change, and engage in more adaptive coping strategies. New measures of defensiveness are being developed and utilized for clinical and research purposes. For example,

Psychodynamic Psychotherapy

the Defense Mechanism Rating Scale is a therapist report, a quantitative rating scale that identifies 30 defenses as they occur in session (Perry et al., 2009). The scale shows promise for treatment as an immediate evaluation of a client's response to a therapist's specific intervention in session as well as a longterm assessment of changes in symptoms and personality organization. (For a fuller explanation of defenses, see the article on Defense Mechanisms.)

Transference Broadly speaking, transference is the displacement of feelings, thoughts, or impulses toward individuals in a person's past onto individuals in the present. Using the metaphor of a printing method during his time, Freud proposed that transference is a stereotype plate whereby prototypes of earlier relationships can be brought forth into the future (Levy and Scala, 2012). Although transference occurs in everyday human relationships, it is often magnified in the client's relationship with the therapist in psychodynamic psychotherapy (Michels, 1985; Weiner and Bornstein, 2009). Indeed, the concept of transference is an important factor in treatment and is one of the ways in which psychodynamic psychotherapy can be distinguished from other approaches. Subsequent psychodynamic theorists have made modifications to Freud's concept of transference. Melanie Klein (1882–1960) emphasized the ways in which a client can elicit therapist's feelings and behaviors such that the therapist actually behaves in a manner consistent with the client's earlier object of the transference (Levy and Scala, 2012). In this way, Klein explained that transference can be reality based and not necessarily a distortion by the client. Theorists continue to debate the extent to which transference represents reality versus distortion (Gelso and Bhatia, 2012; Gill, 1982; Weiner and Bornstein, 2009). Some theorists consider transference to be coconstructed by the client and therapist and to present a new opportunity to understand ways in which the client's past influences current realities, rather than considering it to be simply a reenactment of an earlier relationship (Eagle and Wolitzky, 1992). There have been ongoing controversies regarding the benefits of analyzing the transference in psychodynamic therapy. In his later writings, Freud considered transference interpretations to have a curative effect. However, subsequent theorists began to deemphasize transference interpretation in favor of the ‘corrective emotional experience’ derived from the therapeutic relationship. Furthermore, some research found that transference interpretations were associated with negative treatment outcome for clients with personality disorders. Nevertheless, most contemporary psychodynamic therapists continue to pay attention to, monitor, and work with transference even if they never discuss it in the course of treatment (Levy and Scala, 2012). Recent randomized control trials have demonstrated that low to moderate frequency of transference interpretations are beneficial both in the short and long terms, even among clients with borderline personality disorder, who have a weak therapeutic alliance (Clarkin et al., 2007; Høglend et al., 2006, 2008). As a result, there has been a resurgence of interest in transference interpretation and


the development of treatment protocols focusing on the transference aspect of the psychodynamic work. Those with other theoretical orientations, including cognitive behavioral scientists, have adopted transference as a subject of their own empirical investigation. Through experimental manipulation, researchers have examined the phenomenon of ‘behavioral confirmation’ in transference and have provided support for the notion that there is repetition of behaviors and feelings onto a target person whose characteristics resemble the subject's past significant others (Berk and Andersen, 2000). Thus, the concept of transference has had influence beyond psychodynamic psychotherapy and has become revised and adopted within other theoretical movements.

Countertransference Countertransference refers to reactions of the therapist that are displacements of unconscious thoughts, feelings, and wishes onto the client. As early as 1910, Freud noted that the therapist's countertransference reactions should be avoided because the distortion creates a significant obstruction to psychoanalysis (Betan and Westen, 2009; Wolitzky, 2011). Psychoanalysts have refined their understanding of countertransference over the past century. They have debated the breadth of its definition, at times expanding its meaning to encompass all of the therapist's conscious and unconscious reactions to the patient and at other times reverting to Freud's narrower conceptualization (Sandler et al., 1992; Weiner and Bornstein, 2009). Many psychotherapists appreciate that not all of their reactions to the patient constitute a distortion and that the client plays an important role in eliciting responses in others. Most contemporary psychoanalysts view countertransference as a fundamental, beneficial aspect of treatment. For example, countertransference can serve as a useful barometer of the therapeutic alliance and can provide an example of the types of thoughts and feelings that the client elicits from others (Hamilton, 1988). Through attention to and management of countertransference, a therapist can correct errors in professional judgment, such as being indulgent, seductive, controlling, or patronizing. Furthermore, as therapists recognize their own unconscious responses to the client, hidden meanings in the patient's material may become apparent, which benefit the psychoanalytic work (Sandler et al., 1992). Recently, even cognitive therapists have discovered the importance of recognizing countertransference in the context of cognitive therapy. For cognitive therapists, countertransference does not involve an unconscious process and differs significantly from its traditional conceptualization. Nevertheless, the principle of countertransference has been influential and currently is being revised and adapted to other forms of psychotherapy (Ivey, 2013).

Resistance Resistance in psychotherapy is an expression of the client's ambivalence to participate fully in the treatment process due to an internal struggle between a desire for change and fears of addressing the past. For example, the client may talk excessively about trivial matters; avoid particular content or its


Psychodynamic Psychotherapy

associated feelings; feel guilty about feeling better; cancel appointments; or make excuses to arrive late, leave early, or terminate treatment. Within the context of free association, Freud initially considered resistance to be the result of the client's conscious expression of negativity toward treatment, and he advocated for its elimination. However, as his own thinking evolved, he came to appreciate that resistance is an unconscious process that requires understanding and respect for the defensive purpose it serves the client (Stark, 1994). Furthermore, he noted that resistance is an ever-present phenomenon in treatment as the patient defends against unconscious, threatening material. In the century since Freud, psychoanalysts have remained true to Freud's revised conceptualization of resistance and have regarded observation and interpretation of the subtle manifestations of resistance to be a critical part of a psychoanalyst's skill set (Sandler et al., 1992). Contemporary psychodynamic psychotherapists recognize that resistance must be identified and examined before it can be eliminated. Therapists assist clients in exploring material that has been pushed away from awareness so that it can be integrated and worked through (McWilliams, 2004). The therapist generally allows resistance to build to the point that the client can identify and explore it through the therapist's gradual series of clarifications and confrontations. However, on rare occasions when deemed appropriate, the therapist may choose to abruptly break through resistance with a single, direct statement that is expected to be received positively (Weiner and Bornstein, 2009). Both the interpretation and working through of resistance are essential components of the psychotherapeutic process. Within the past decade, there has been increased attention to the role of resistance within other theoretical orientations, including cognitive therapy. Cognitive theorists address resistance (as manifested by noncompliance, self-handicapping behavior, and a patient's desire for abrupt termination) via specific interventions, assessments, and educational diagrams (Leahy, 2001). In addition, motivational interviewing, which includes addressing resistance to change as its primary goal, has gained popularity among therapists. It has become a useful approach to the early stages of therapy or, alternatively, it can be used as an intervention in and of itself. Thus, although the understanding of and approach to resistance differs from its origins, there is a noteworthy influence of psychodynamic principles on other theoretical orientations.

think, feel, and behave in a more self-determined, satisfying manner. Interpretation challenges clients in two main ways. First, interpretation requires them to consider something new and to give up former habits of thinking about themselves and others. A sense of loss is inherent in the process of interpretation, even if what is relinquished has been dysfunctional. Second, interpretation poses a threat to clients' judgment in that it conveys that there has been something erroneous in their previous way of life. Not surprisingly then, interpretation is often met with uneasiness and must be approached prudently (Weiner and Bornstein, 2009). Contemporary psychotherapists carefully consider what to interpret and when this should occur. In general, interpretations should pertain to the areas of the client's life that are causing distress, including sources of anxiety, ineffective coping strategies, and distorted perceptions of themselves and others. In short-term psychodynamic therapy, interpretations involve the client's use of defenses in session, especially because they are powerful here-and-now examples of observable behavior rather than mere recollections of the past (Eagle and Wolitzky, 1992).

Insight and Working Through Insight and working through refer to the client's understanding of previously unconscious material, not just on a cognitive or intellectual level but on a deeper emotional realm that produces fundamental changes in feelings, thoughts, and behavior. In his earliest writings, Freud demonstrated an appreciation for the limitations of insight alone to produce meaningful results and asserted that it is necessary for patients to engage in the laborious task of repeatedly applying the newly acquired information to various aspects of their lives. Some contemporary psychoanalysts have reconceptualized working through as a process by which the client resumes healthy development (Sandler et al., 1992). Others have deemphasized the role of insight in treatment in favor of attending to the corrective emotional experience of the therapeutic relationship. However, insight and working through remain critical avenues for promoting long-standing positive change in the client and are key principles that distinguish psychodynamic psychotherapy from other approaches.

Theoretical Derivations from Freud Ego Psychology

Interpretation Interpretation refers to a therapist's intervention that seeks to generate long-term changes in the client's self-awareness through identification of unconscious determinants of behavior. Interpretations differ from other interventions (e.g., questioning, clarifications, exclamations, and confrontations) in that they address content that is beyond the patient's awareness and unlikely to become manifest without the therapist's aid. Interpretations are best presented as hypotheses to be explored and as catalysts for further self-exploration. The goal of interpretation is to allow clients to integrate previously unconscious material into consciousness, thus freeing them to

Gradually, early followers of Freud began to adapt his ideas to address a wider range of human experience. Although these therapists largely adhered to Freud's basic principles, their new theories moved away from or completely abandoned Freud's instinctual drive theory. The earliest of the departures was ego psychology. The ego psychology movement stemmed from a growing recognition that analytic theory failed to explain all aspects of the human experience and the evolution of the person as it occurs in typical development. Thus, the interest solely on significant early childhood traumas and instinctual drives gave way to the role of the environment and a focus on defenses.

Psychodynamic Psychotherapy

Heinz Hartmann (1894–1970) is commonly recognized as the father of ego psychology. Hartmann was one of the first theorists to move away from the idea of conflict and to recognize the existence of inborn, conflict-free ego functions, such as language and thinking, which would emerge independently from Freud's instinctual drives, given a suitable environment (Eagle and Wolitzky, 1992). Hartmann was also the first theorist to relate the idea of adaptation to human psychology, acknowledging the reciprocal relationship between an organism and its environment (Blanck and Blanck, 1974; Mitchell and Black, 1995). Hartmann coined the term and concept of the ‘average expectable environment,’ which is important in the development of later object relations theories. With this term came recognition that an organism has the ‘capacity to act on itself’ (Blanck and Blanck, 1974). Hartmann's ideas challenged a fundamental assumption of psychoanalytic thought. His theory suggested that the ego does not develop out of the id, but rather that these structures initially exist together in an undifferentiated matrix, that ego apparatuses are inborn, and eventually the ego and id differentiate (Blanck and Blanck, 1974). Theorists like Anna Freud (1895–1982) also began to suggest that bringing unconscious impulses into consciousness was not sufficient and that in order to make real change the therapist had to address the patient's defenses (Mitchell and Black, 1995). So, along with ego psychology came a shift in how analysis worked. The focus was less on the id and more on the ego, and therapists recognized the limitations of free association as the only vehicle to change. In addition, the analyst had a more active role to play in identifying and interpreting the patient's defenses. The ego itself had become a topic worthy of analysis, and the goal was less about uncovering impulses and more about improving defenses.

From Ego Psychology to Object Relations Ego psychology's interest in the evolution of typical functioning lent itself to the founding of what some have termed ‘developmental ego psychology’ (Mitchell and Black, 1995). Margaret Mahler (1897–1985) recognized the importance of early relationships. She took the idea of an average expectable environment and proceeded to describe the normal developmental stages an infant goes through in such an environment. These stages include the autistic, symbiotic, and separation–individuation phases, the last referring to the child's understanding of him- or herself as a separate, autonomous human being. If a child is ‘stuck’ in the earlier phases, serious disturbances of the personality can develop (Hamilton, 1988). Because of her interest in both the ego and the emergence of severe disturbances in childhood, Mahler serves as a bridge connecting ego psychology and object relations theory. Object relations theories recognize the centrality of the early mother–infant relationship for several arenas: personality development, development of internal representation of self and others, and the child's early understanding of and expectations for interpersonal relationships. Further, object relations theories attribute psychopathology to inadequate early environments rather than to internal drives or conflicts.


Influential early object relations theorists include Melanie Klein and D.W. Winnicott (1896–1971). Klein was one of the earliest analysts to work with children and to use and interpret symbolic play as a way to access children's inner world. Thus, she helped to set the stage for the use of what is today referred to as play therapy. Winnicott saw the self as having competing desires for individuation and intimacy. He developed the idea of transitional objects, such as a blanket, that help children transition from their early symbiotic relationship with their mother to genuine object relations, providing them some protection against separation anxiety (Winnicott, 1953). Otto Kernberg (b. 1928) utilized object relations theory in developing an understanding and treating the complex nature of borderline personality disorders (Kernberg et al., 1989). In his conceptualization, the primitive defenses of splitting and projective introjections fail to mature, leading to intolerable close relationships in adulthood. A recent summary of his theories (Kernberg, 2012) describes his approaches to therapy with patients with severe pathology. In terms of its implications for treatment, object relations theory leads the therapist to place less emphasis on the goals of traditional psychoanalysis, such as bringing the unconscious into consciousness. Instead, the focus is more on the patient–therapist relationship, which is used as an agent of change by correcting a patient's experience with prior bad relationships (objects). The goal of therapy is, at least in part, for the patient to choose more appropriate people with whom to form relationships (i.e., to select more appropriate objects) and to alter maladaptive interpersonal patterns (Eagle and Wolitzky, 1992; see the article on Object Relations Therapy).

Self Psychology The theorist most identified with the self psychology movement is Heinz Kohut (1913–81), who viewed the development of a cohesive and positive sense of self as the motivation of all patients (Wolitzky, 2011). Unlike traditional Freudian theory, which considers narcissism as pathological and as something individuals typically move away from in the interest of pursuing love of others, Kohut saw narcissism as developing in either a healthy or unhealthy way. He viewed the development of love of self as being separate from love one develops for other objects and suggested that a love of others is not necessary to lead a fulfilling life (Eagle and Wolitzky, 1992). By making this claim, Kohut brought into question Freud's stance that individuals are driven by instinctual (or sexual) gratification (Kohut and Wolf, 1978). According to Kohut, healthy development is dependent on the ability of a child's parents to provide what Wolitzky (2011) terms ‘adequate empathic attunement’ (p. 90). Failure of parents to provide appropriate empathy is seen as the source of most psychopathology. However, intensive therapy can reproduce the essential elements of the patient's early environment in order to make up the inadequate environment. The goal of therapy is not to interpret unconscious conflict but to help the patient to develop or strengthen one's sense of self. The experience of being fully understood by


Psychodynamic Psychotherapy

another person is seen as curative, in that it allows the patient to resume healthy growth.

Evidence-Based Research Historically, there has been little emphasis on evidencebased outcome studies for psychodynamic psychotherapy as compared with the numerous randomized controlled trials conducted for cognitive behavioral and pharmacological interventions. Psychodynamic clinicians have been skeptical that measures of symptom reduction alone could adequately assess the complexities of the psychodynamic approach and reflect the structural changes that take place within clients during the course of treatment. Thus, although many cognitive behavioral therapies have been established as empirically supported treatments for a number of disorders, the limited body of research to support psychodynamic approaches has resulted in their being perceived as inferior or ineffective. However, within the past decade, there has been mounting evidence from both randomized controlled trials and naturalistic studies to affirm the effectiveness of psychodynamic psychotherapy for a wide range of psychological problems. Psychodynamic treatment manuals and audio/video recordings have gained increased acceptance by researchers and clinicians seeking to improve therapy outcome and adherence (Town et al., 2012). According to Leichsenring's (2009) review of many metaanalyses, short-term psychodynamic psychotherapy appears to be as effective as cognitive behavioral approaches to depression, anxiety, substance problems, somatoform disorders, eating disorders, and various personality disorders and more effective than placebo therapy. One recent meta-analysis of treatment outcomes found significantly greater improvement in depressed patients receiving intensive short-term dynamic psychotherapy, as compared with wait-list control or other treatments (Abbass et al., 2012). Notably, positive gains from psychodynamic treatment tend to increase over time, suggesting that this approach brings about fundamental structural changes in the client (Shedler, 2010). There is a shift in current empirical inquiry toward understanding the processes in psychodynamic psychotherapy as they relate to client outcome, both over the course of a single therapy session and in the long term. For example, small qualitative studies are beginning to investigate the resolution of ruptures in the therapist–client relationship within a session and how the therapeutic alliance facilitates positive treatment outcome (Safran et al., 2009). Similarly, research on transference-focused psychodynamic therapy is beginning to examine the specific underlying mechanisms of change now that its effectiveness for borderline personality disorder has been established (Levy et al., 2009). Recent methodological advances have enhanced research of psychodynamic treatments. Psychometrically sound measures of countertransference have the potential to aid in the understanding of how the therapist's reactions to the client affect the course of treatment (Betan and Westen, 2009). In addition, quantitative observer ratings of defense mechanisms offer new ways of identifying a client's use of defenses in response to a specific therapist intervention in session and

throughout treatment (Perry et al., 2009). An appreciation for how specific psychodynamic principles serve as key elements for change will complement the findings from traditional treatment outcome studies. The Shedler–Westen Assessment Procedure (SWAP) is a promising new instrument that goes beyond specific symptom report and assesses many internal changes that can occur within a client during the course of treatment (Shedler, 2010). The clinician-rated SWAP provides an opportunity to compare the effects of treatment guided by different theoretical orientations on a more meaningful range of client experiences than on symptoms alone. Psychotherapy process research reveals that many therapists who self-report allegiance to theoretical orientations other than a psychodynamic approach actually use principles specific to psychodynamic theory (Shedler, 2010). Further, the use of psychodynamic psychotherapy techniques has been associated with positive outcome, regardless of therapists' self-reported therapeutic orientation (Albon and Jones, 1998). Therefore, it is imperative that future process research studies check adherence to theoretical orientation and examine the ways in which psychodynamic principles have influenced the practice of other approaches in promoting long-term benefits to clients. (For a fuller discussion on outcome, see the article on Psychotherapy Effectiveness.)

Educational Requirements Freud wrote that medical training need not be a requirement for analysts and might even be a detriment to the process (Freud, 1926). In fact, one of the tenets of psychoanalysis is that the therapist is prohibited from touching the patient, precluding any physical examination. Nevertheless, since Freud and his intimate circle of colleagues were physicians, his followers required that the practice of psychoanalysis be reserved for psychiatrists. It is of interest that Anna Freud and many of the pioneers in the field did not have such training. Notably, these analysts worked primarily with children. In any event, for many years into the twentieth century, only MDs were permitted training in the International and United States Psychoanalytic Society's training institutes – with the exception of child therapists (NB, the first author was admitted to such a program in 1960). Eventually, the tide began to turn, expanding psychoanalytic training to other mental health professions. In 1985, four clinical psychologists initiated a lawsuit against the American Psychoanalytic Association for its restrictive training and membership policies, a suit based on Sherman Antitrust grounds. They had the backing of Division 39, the psychoanalytic division of the American Psychological Association. With several branches of the Psychoanalytic Association on the verge of changing their long-standing policy, the International and US Institutes agreed to a settlement of the lawsuit in 1988. As a result, qualified students from other mental health fields were permitted access to psychoanalytic training programs. Over the last several decades, with most psychiatrists focusing on prescribing psychotropic medications, the number of those engaged in psychodynamic therapy has diminished greatly. In fact, only a small number of psychiatrists (estimated at 10%) primarily practice psychotherapy (Moran, 2009).

Psychodynamic Psychotherapy

Graduate training in psychotherapy is part of the curriculum for clinical and counseling psychologists and clinical social workers. Formal training in psychodynamic therapy includes the origins of psychoanalytic concepts as well as later developments in theory, such as object relations and self psychology. In addition, there is explicit instruction in therapeutic techniques (often with the aid of video teaching tapes) and experience with several training cases, under supervision. Personal analysis continues to be a requirement of formal psychoanalytic training institutes and personal therapy is encouraged by most university graduate programs. The benefits of trainee psychotherapy are to enhance self-understanding, to experience therapy from the client's view, and to learn from a qualified therapist. Recently, however, the focus of graduate clinical education has shifted to cognitive behavioral therapies, and there are now fewer programs that offer training in psychodynamic therapy. A recent survey found that although a number of psychology doctoral and master's degree programs claim to be open to psychoanalytic thought and to incorporate psychoanalytic theory into coursework, few programs have analytically trained faculty who offer clinical training in psychoanalytic approaches to therapy (Downing et al., 2012). Further, in a survey of psychology predoctoral internship sites conducted in 2006, just 13% of sites were ‘high’ in their selfreported psychoanalytic orientation, 29% were rated as ‘medium,’ and 58% were rated as ‘low’ (Downing et al., 2006). These findings are compared with rates of 35%, 29%, and 37%, respectively, found in a survey conducted approximately ten years before (Ainslie et al., 1997), which indicate a decrease in the extent to which predoctoral internships offer opportunities for psychoanalytically oriented training.

The Future The theoretical formulations and evolving practice of psychodynamic psychotherapy have made a remarkable impact on the field of mental health. In addition to expanding the science of human emotions, many patients have benefitted from the treatment techniques. Whether the phenomena of psychoanalysis, which arose like Haley's Comet, will disappear – only to reappear again – is a matter of speculation. Regardless, the impact of Freud and his many followers, as well as his detractors, not only has shaped the way one approaches psychotherapy but also has shaped one's understanding of the human mind.

See also: Cognitive-Behavioral Psychotherapy. Defense Mechanisms. Psychoanalysis. Psychotherapy. Psychotherapy Effectiveness. Transference and Countertransference

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