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.  

2:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression.  Basic Books, Inc; New York; 1984: 255 pp.

3: Viederman M. The Psychodynamic Life Narrative. Psychiatry. 1983 Aug;46(3):236-246. PubMed PMID: 27719516.

4:  Holly A Swartz.  Interpersonal Psychotherapy (IPT) for depressed adults: Indications, theoretical foundation, general concepts, and efficacy. In: UpToDate, Roy-Byrne P (Ed), UpToDate, Waltham, MA, 2018.  Accessed February 17, 2018.

5:  Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct;14(3):270-7. doi: 10.1002/wps.20238. PMID: 26407772; PMCID: PMC4592639.

6:  Høglend P, Hagtvet K. Change mechanisms in psychotherapy: Both improved insight and improved affective awareness are necessary. J Consult Clin Psychol. 2019 Apr;87(4):332-344. doi: 10.1037/ccp0000381. Epub 2019 Jan 10. PMID: 30628797.

7:  Churchill R, Moore THM, Davies P, Caldwell D, Jones H, Lewis G, Hunot V. Psychodynamic therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD008706. DOI: 10.1002/14651858.CD008706. Accessed 12 May 2026.

8:  Høglend P. Exploration of the patient-therapist relationship in psychotherapy. Am J Psychiatry. 2014 Oct;171(10):1056-66. doi: 10.1176/appi.ajp.2014.14010121. PMID: 25017093.

9:  Nakamura K, Iwakabe S, Heim N. Connecting in-session corrective emotional experiences with postsession therapeutic changes: A systematic case study. Psychotherapy (Chic). 2022 Mar;59(1):63-73. doi: 10.1037/pst0000369. Epub 2021 Jul 22. PMID: 34291996.

10:  Abbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovska S, Crowe E. Short‐term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD004687. DOI: 10.1002/14651858.CD004687.pub4. Accessed 12 May 2026.

11:  Perry JC, Bond M. Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. Am J Psychiatry. 2012 Sep;169(9):916-25. doi: 10.1176/appi.ajp.2012.11091403. PMID: 22885667.

12: Babl A, Grosse Holtforth M, Perry JC, Schneider N, Dommann E, Heer S, Stähli A, Aeschbacher N, Eggel M, Eggenberg J, Sonntag M, Berger T, Caspar F. Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial. J Affect Disord. 2019 Jun 1;252:212-220. doi: 10.1016/j.jad.2019.04.021. Epub 2019 Apr 8. PMID: 30986736.

13:   Yakeley J. Psychoanalysis in modern mental health practice. Lancet Psychiatry. 2018 May;5(5):443-450. doi: 10.1016/S2215-0366(18)30052-X. Epub 2018 Mar 21. PMID: 29574047.

14:  Blatt SJ, Behrends RS. Internalization, separation-individuation, and the nature of therapeutic action. Int J Psychoanal. 1987;68 ( Pt 2):279-97. PMID: 3583573.

Less Time To Do More…. Psychotherapy On Acute Care Units

 

Less Time To Do More….

As part of my brief series on the role of psychotherapy in psychiatry I thought I would pull this book off my bookshelves and discuss it.  It was published in 1993 and that was about the time I bought it.  At that time, I had just finished working as the Medical Director of a CMHC and consulting at a local hospital and was about 4 years into my role as an acute care psychiatrist on an inpatient unit.  I was trained in psychotherapy in residency and provided it across all of these settings as well as individual and group supervision to masters level psychotherapists.  That supervision included accepting cases referred from them for psychotherapy if they felt uncomfortable treating that person.

Managed care hit hard from my first day on the acute care unit.  Companies decided that they could easily deny care to psychiatric inpatients by using what was eventually became their dangerousness standard.  In other words, if a reviewer made an arbitrary decision that the patient was no longer dangerous, they would stop payment and the patient would be discharged.  As someone who did this work for 22 years that is a bizarre standard designed primarily save the insurance company money and they were very good at that. They were also successful in setting up a sham appeal process that could not be challenged.  The result is suboptimal care and inpatient units that are essentially revolving doors that discharge patients before they are stable.

If you think of a competency-based standard for psychotherapy – that is the ability to manage your own life and medical care, make decisions in your best interest, and problem solve and make good decisions in novel situations that was all a second priority to symptom stabilization.  If a patient was admitted because of mania and grandiose delusions – those symptoms were targeted with pharmacotherapy and once they were mostly gone – the patient needed to be discharged.  At some point in the late 1990s – public payors like Medicaid and Medicare stopped using contractors to do these utilization reviews and the process was internalized by health care organizations.  Instead of being harassed by an outside reviewer – the harassment became internal for patients covered by public insurance.

The additional context at the time was a rift in psychiatry between psychiatrists who identified as either biologically based, therapy based or eclectic meaning a combination of both (2).  This paper was written at the time I trained but even that description was an oversimplification. There were medical psychiatrists, consultation-liaison psychiatrists, neuropsychiatrists, and community psychiatrists.  They all had their models of care and their own ideas about how psychotherapy should or should not be integrated into that care.  I was fortunate to have access to a wide variety of psychotherapists and very active didactics.  But nobody really talked much about how psychotherapy fits into typical psychiatric practices. In a previous post, I listed supportive psychotherapy resources and that was an obvious skill needed across all settings.  It was occasionally demonstrated by attending physicians but most of what they seemed to do were diagnostic interviews. 

Less Time to Do More seemed to take on that problem specifically in the inpatient setting. The introductory chapter on therapeutic communities discussed a common model used to run inpatient units.  The regulatory function of the community was discussed to help patients with severe mental illnesses reintegrate following an episode of decompensation. Kohut’s self-psychology was presented as a possible model of the self-object matrix critical for early childhood development with groups and group processes taking on that role.  Groups leaders need to monitor the level of cohesion in both patient and staff groups to main their roles in assisting in self-regulation and reinforcing adaptive behavior.

Chapter 2 (3) starts to get to the heart of the matter. It discusses relevant psychodynamics at the individual patient and staff level. Inpatient treatment is ideally multidisciplinary. The team I worked with consisted of nurses, nursing assistants, social workers, and occupational therapists. Each team member plays an invaluable role in how the inpatient environment works and how it is therapeutic for patients. The psychodynamic model is the best way to make sense of it. Even then it is not an easy job. Most hospitals use siloed management with every discipline under different administrators. There is no assurance that any of the administrators know as much about how to care for patients as the inpatient staff does. There is internal politics as well as the question about what happens when there is an inevitable staff-wide crisis. Examples of those crises include threats or violence against staff members, serious allegations against staff by patients or their families, and incidents resulting in patient injury. Many of these complications can be prevented by staff awareness of the involved psychodynamics that includes transference and countertransference reactions and defenses that are typically used by people with severe psychiatric disorders and their families.

I have seen psychiatrists operate at two extremes in the acute care inpatient environment.  At one end I would call it the old hospital visit model.  The assumption is that inpatient care is basically a side hustle and most of the serious work occurs in this physician’s outpatient practice or clinic.  They appear briefly early in the morning on the inpatient unit, talk to the patients under their care briefly, do not participate in any team meetings, and may or may not talk with nursing staff.  They may depend on nurses to call them at points during the day with progress reports and decide whether to make medication changes or discharge the patient.  Before a hospitalist model in medicine – this is how many primary care physicians worked as attendings at hospitals.  

At the other end is the full time attending.  The inpatient unit is his or her primary job.  They have daily team meeting with all team members in attendance and discuss progress as well as problems. Those problems can be at the level of the individual patient, their family, the staff, the administration, the probate court, outside consultants, law enforcement, and the physical environment. Team meetings are necessarily complex and in a less time environment rapid decision making is the rule rather than the exception. The schedule of when patients are seen depends on what happens in that team meeting.  Any acute medical or psychiatric problems take priority, followed by systems problems like conflicts between staff and administrators, followed by discharges.  That all happens before noon and individual patients are seen (along with new admissions) over the rest of the day. That is the most straightforward description of this model where most days are far from routine.

A psychiatrist operating in that second environment needs certain technical skills. Above all else – they need to be aware of their personal reactions to what is going on in the inpatient environment.  How much of that reaction is reality based and how much is based in countertransference?  I heard a quote recently from Kernberg where he said the most significant work of a therapist is to contain their countertransference aggression and there is no better place to practice that than an inpatient unit. The psychiatrist operating in that environment is often a flash point for scapegoating when anything goes wrong or even not as well as expected. During my tenure it was common to see psychiatrists blamed for being assaulted by patients, for not discharging patients fast enough, for ignoring nursing staff requests, and for being too authoritarian.  In todays overmanaged health care environment any one of those complaints can trigger a major investigation by hospital committees and result in reports credentialling agencies or medical boards whether they are factual or not. Controlling countertransference aggression in such an environment can be an impossible task.

Ideally the psychiatrist is in a role with reasonable team members and can interact with them in such a way they recognize their value.  That occurs by genuine active dialogue with them discussing patient care and any problems that the staff member might be having. This may seem obvious but it was not until my first few years as an inpatient psychiatrist that I realized the only reason my patients were in the hospital was that they needed nursing care.  I could do my 30–60-minute visits anywhere. The nursing staff was with them 24/7 and for clear reasons.  Other disciplines also need support form psychiatry.   Inpatient social work is a clear example.  The social workers I had the privilege of working with were all excellent and found themselves doing the impossible job of discharge planning.  They were calling 20-30 places a day for a single patients trying to get them out of the hospital (we rarely discharged anyone to the street).  That is a high stress situation especially when you have a supervisor asking you why you have not seen enough of the other patients.

All of these scenarios require a psychiatrist who can intervene supportively (education, encouragement, problem solving) and existentially (empathic listening and reflection) with fellow staff members.  That does not mean they are doing supportive psychotherapy with their colleagues.  It does mean that the genuine and human interactions they have with their valued coworkers may translate well into the therapy they are able to do to assist patients.  It may also lead to valuable insights like the one I had about the nursing staff. 

Additional chapters in this book provide good information on interacting with outpatient therapists and the importance of recognizing potentially disruptive defense mechanisms like projection, projective identification and splitting and how they can be contained on inpatient units. Containing countertransference aggression was emphasized especially because it can be magnified more in an inpatient setting where there are more possible recipients.     

The authors were generally confident about providing inpatient psychotherapy to a patients with a diverse number of conditions.  Some of the time frames discussed approximated 2 weeks and these days that is about a week longer than many these days. Some variables affecting length of stay (LOS) were not discussed.  The most important one of these is involvement in civil commitment and how that is handled. I looked at the issue on my unit and it added another 21 days and even longer after the State of Minnesota passed a law allowing county sheriffs to send mentally ill inmates directly to state hospitals on a priority basis. Like all inpatient factors it was a mixed blessing – more time for all therapies and recovery but the wrath of administrators blaming staff for not using enough medication fast enough, doing too many civil commitments, or not discharging unstable patients.

My approach in the inpatient setting was to have daily team meetings, engage my team in productive patient focused discussions, and see all my patients for at least 30 minutes a day.  I would also see family members at their request when they came in to visit or scheduled family meetings with or without my social work staff and at times nursing staff of they had available time.  I was very focused on the phenomenological-empathic approach to interviewing people with severe problems. I generally felt that patients realized that I was very interested in talking to them about more than symptoms.  Just that aspect had significant effects on people who were angry, non-disclosing, paranoid and accusatory, and used projection and splitting defenses. I was able to establish long term relationships with many people who were considered refractory to treatment and they were able to make progress.

Part of those discussions involved a detailed discussion of delusional thought content and how it was affecting their life. I commonly asked for their initial experience and the very first time they had those thoughts.  We would reconstruct that incident and discuss what happened as a place to begin.  From there we would discuss how these thoughts affected their relationships and ability to manage their lives.  I found that asking them about their theory of what happened or was happening to them was a useful question. Once their theory was discussed we could discuss whether they were aware of other possible theories to explain what happened.  This is a much better approach than getting into an argument of who believes what.  “Well, I understand you believe that!” is a judgmental rather than an empathic statement that simply states that you are not interested in what the patient has to say. 

Inpatient psychotherapy is also a place where competency can not only be emphasized but it may be critical for survival.  Exploring why a patient believes that they do not have diabetes or a fatal illness and trying to help them with a working solution is one example.  Working with them on how to avoid confrontations with the police is another. I have worked with many manic patients who found themselves in life threatening situations when they overestimated their physical abilities due to mania. And there are the more frequent discussions of how to avoid hospitalizations, how to manage severe psychiatric illnesses including suicidal thoughts and inability to function at times.

The thousands of discussions I have had with these folks over the years led me to the conclusion that supportive psychotherapy is the language of psychiatry.  On the inpatient unit it operates at multiple levels in a very high stress environment.  In the next few posts, I will look at more specific interventions.

The main theme I am hoping to stress in these posts is that no matter what you are going as a psychiatrist – a psychotherapeutic intervention should be part of it. It reminds me of a thought experiment one of my brightest teachers presented to ma as we were talking after clinic one day:

“OK George - suppose you are out there as a psychiatrist for a few years and you are at a party.  A woman comes over to you at that party that you don’t know and starts to make small talk. Are you thinking like a psychiatrist or not?”

The tenor of these posts should suggest the answer…..

 

George Dawson, MD, DFAPA

 

 

References:

1:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. 1993.

This is a 1993 publication so I am not recommending it at this point. It is a good outline of necessary psychotherapeutic concepts but is not long on specifics apart from some vignettes.

2:  McHugh PR. William Osler and the new psychiatry. Ann Intern Med. 1987 Dec;107(6):914-8. doi: 10.7326/0003-4819-107-6-914. PMID: 3318611.

3:  Silver PA, Goldberg RL.  Integrating Somatic and Psychological Treatment in Inpatient Settigs. in:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. pp: 23-38.