Why Psychodynamic Psychotherapy?

 

I am not averse to top ten lists and came up with 8-points initially but easily found another two.  I have had a few posts over the past year based on my experience in a psychotherapy seminar that I coteach with several experienced instructors.  We meet 2 hours a week – every week over the course of the year.  The first hour is a didactic based on the Cabaniss text Psychodynamic Psychotherapy: A clinical manual. (2).   Over the course of the year, we cover every bullet point and entering into this later than my colleagues – I have been impressed with the level of discussion from both the faculty and residents.  The second hour each week is dedicated to the discussion of specific cases.  Different perspectives are encouraged.  I have made note of when I got an idea for a post here from participation in that seminar.  This teaching format was carefully designed over the course of many years by the instructors who were there long before I joined.  They also describe it as a format where clear improvements can be observed in the residents practicing the techniques.  

Several issues come up when psychotherapy training is discussed for psychiatrists. Over the years it has been a hot political issue.  As previously noted – many people like to characterize the history of psychiatry in an oversimplified manner.  The original asylum psychiatrists had little more than moral treatment of Pinel and Tuke.  That was followed by a period of brain based descriptive asylum psychiatry focused on neuropathology and phenomenology.  That was followed by a period of psychoanalysis and psychodynamic psychiatry.  And finally biological psychiatry starting in about the mid-20^th century with advancements in somatic treatments.

That is the timeline that is typically used to describe American psychiatry – but things are always more complicated.  I trained in the 1980s when departments were often split between the psychotherapy staff and biological psychiatry staff – but the split was really an illusion.  The residents were trained in both. I trained with some of the top biological psychiatrists in the country and they also did psychodynamic formulations and psychotherapy.  During my 3 years of residency, I was supervised for an hour for every hour of psychotherapy I provided every week in addition to the training seminars in psychotherapy.   

At the national level experts in psychotherapy have always worked and published in parallel to the biological psychiatrists and neuroscience-based psychiatrists.  The reality is that you cannot practice psychiatry well without being able to integrate the medical, biological, and the psychotherapy dimensions of the field. 

A general psychotherapeutic approach to the patient is required in psychiatry for several reasons. All medical students learn diagnostic interviewing beginning in the first year of medical school. The basic principles are empathy and open-ended questions.  There is not much content about immediate problems in the interview, how to discuss difficult topics, how (or why) to expand on the phenomenology, and what to do about your personal reactions to the patient.  In a previous post I have discussed this as a reason why supportive psychotherapy is the clinical language of psychiatry.

The evaluation in psychiatry is very often an intervention point. It is not possible to interview the patient in a crisis and have them return at a later date to address the crisis.  Talking and psychotherapeutic interventions are the mainstay of crisis intervention. The psychiatrist needs to assist the patient in resolving the crisis.  These crises can happen at any point in time – even in patients who have been doing well for years.  A psychiatrist always needs to be prepared to do crisis intervention at any point in time and that involves good psychotherapeutic skills. 

Psychotherapy is the treatment of choice for many disorders.  It has been used for decades to treat severe personality disorders and the consensus lately is that it is the preferred treatment over medication in some of those scenarios.  The landscape can be confusing because branded and manualized therapies are often used in clinical trials and even though they can get equivalent results.  It is probably safe to say that psychodynamic psychotherapists used to shifting from supportive to interpretative modes see much of what they do in these psychotherapy manuals and trials.

The therapeutic alliance is most explicit discussed in psychodynamic psychotherapy. It has been written about for decades and is important in all aspects of individualized psychiatric care.  In training it is also discussed as an important anchor point for clarifying the treatment process during periods of conflict or impasse.

Treatment setting is an important aspect of psychiatric care.  In acute care settings, the patient population is selected based on problem severity, lack of response to other therapies, need for additional modalities, and team-based care.  Transference and countertransference is complicated by the fact that it is now occurring at the team and institutional level.  Any psychiatrist working in that setting needs to be able to figure that out and intervene before there are any major problems and assist the team in managing reactions to specific patients and families.

Most of the suggested guidelines for psychotherapy training in residency are competency based rather than based on time.  The reality of training is that there is a shortage of staffing for any centrally recommended training program.  Programs are left to their own devices to provide training in this area. An untapped resource in many areas are retired psychiatrists and therapists who might be willing to volunteer to continue teaching.  That has been my role in this seminar and I find it highly rewarding. 

Training in psychodynamics and all of its theorists also provides and important historical context for the profession.  How were the original concepts modified over the years? Are some of these approaches and concepts (attachment theory, interpersonal psychotherapy, existential psychotherapy, infant psychotherapy, self-psychology, etc) still useful today? 

The most significant aspect of psychodynamic psychotherapy is the unique focus on consciousness. Unless you read about consciousness research explicitly this is the only place where that occurs.  I mentioned last week that when I attended medical school the emphasis was on objectivity and classifying people according to their disease and how well it could be characterized and whether those findings could be replicated. You do not have to be particularly bright to see the shortcoming of this approach.  No two people with asthma, brain tumors, or anemia are alike even after saying they have the same disease.  Their physical state, the way they think about it, their response to treatment, and the way they interact with you as their doctor is unique. In figuring out how to help them with whatever their psychiatric problem is – a diagnosis is only part of the story.  It requires thinking about who they are and why they might be reacting to things the way they do – a formulation.

Finally, and probably most importantly – psychodynamic training prepares the psychiatrist for what is ahead.  The first 5-10 years in practice is a potential minefield.  In today’s practice environment – psychiatrists are often overworked, seeing many people with severe medical and psychiatric problems who also have potentially severe interpersonal problems. Those problems are generally focused on aggression, sexuality, power dynamics like money and autonomy.  There is a general negativity about psychiatry in the press and on social media – largely from people promoting their own interests.  All of that can result in highly stressful situations in practice – especially if there are no colleagues around for consultation.  A psychiatrist can develop anxiety about some of these problems in practice and what can be done about them.  Although the issue has not been studied in the literature – my speculation is that psychiatrists trained in psychodynamics – especially if these topics have been explicitly discussed in training are more prepared to solve them in an effective way than psychiatrists without that exposure.  A typical way this issue is approached is to suggest rules that should not be violated.  Understanding what is happening at an emotional level is probably a better approach.

Reducing the mystery of psychotherapy and having a good idea of how it works is a clear goal. There have been times in my studies where the interventions seemed vague and which interventions were useful was not clear.  I can recall a few highlights over the course of my career that were very enlightening.  The first was a seminar with Otto Kernberg, MD about 30 years ago.  He provided the clearest definitions of the three basic intervention in psychoanalysis and psychodynamics that I have heard.  He described them as, clarification, confrontation and interpretation.  Clarification in this case is communicating the therapists empathic understanding of the patients experiences over time at the conscious and preconscious level.  Confrontation is not the usual adversarial sense, but is used to point out inconsistences or patterns in the patient’s narrative that may have escaped their attention.  In the seminar I attended, Kernberg pointed out that many people may be holding these inconsistencies outside of their awareness and the confrontation serves bring things together in a consistent narrative.  Finally, the interpretation connects patient's conscious experience and unconscious defenses, wishes, or conflicts.  Learning how to do that involves both reading about the theory and basic cases as well as seminar discussions with input from faculty and residents.   

Many consider the interpretation to be the mysterious part of psychodynamics and the secret handshake of this kind of psychotherapy.  It becomes more intuitive with a specific frame for psychodynamic therapy.  The two best examples I can think of are Interpersonal Psychotherapy and the Psychodynamic Life Narrative.  In the first case, Klerman and Weissman used psychodynamic principles to design a manualized therapy for depression.  It was subsequently applied to substance use disorders. Viederman designed the life narrative approach for crisis intervention in college students.  Both therapies are formulation based and designed to be used on a short-term basis.

The flexibility to go from an uncovering or transference based psychodynamic psychotherapy (TFP) to a supportive one is a critical skill.  There are people who will do better with supportive therapy and others who do well with TFP but in a crisis will do better with a supportive approach.  There is a broad range of flexibility in psychodynamic psychotherapy with supportive interventions that are identical to therapies taught separately as cognitive behavioral therapy, and behavioral therapy.  It also provides a framework for existential psychotherapy.     

Mechanisms of change in psychotherapy are written about broadly across therapies and specifically for psychodynamic psychotherapy.  It is safe to say that psychodynamic psychotherapy is more focused on the relationship with the therapist and the central role of emotions and insight. 

That is my brief commentary on the importance of psychodynamics and psychodynamic therapies in psychiatry.  There are many clinical trials for specific conditions that show psychodynamic therapy is effective. Some of those trials are 40 years old at this point.  We have many branded therapies advertised for specific conditions with features that overlap both supportive and psychodynamic psychotherapy adding further support to the claim it is a good approach to teaching psychiatrists.  When I look at the training recommendations for psychiatrists –  if you are running a training program and look at the three choices – psychodynamic psychotherapy should be preferred.  It covers two of the three types of therapy, has a rich history of involvement by psychiatrists at the clinical and theoretical level, and probably provides trainees with a better model for analyzing problems that occur in their future practices.

 

George Dawson, MD, DFAPA  

 

 

References:

 

1:  Kernberg OF.  Severe Personality Disorder: Psychotherapeutic Strategies.  Yale University Press; New Haven; 1984: 381 pp.  

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