Effectiveness of Psychodynamic and Psychoanalytic Psychotherapy Approaches

Many modern practitioners claim that psychoanalytic or psychodynamic approaches in the treatment of depression have little research to support their use at this time. It is widely acknowledged that while most therapists may make use of psychodynamic theoretical constructs to help conceptualize an individual’s personality or specific case, it is likely that applied approaches in these areas are ineffective and should be avoided.

However, multiple recent researches provide a serious supportive data that the long-term psychoanalytic or psychodynamic approaches may offer deeper treatment for the “underground” depression causes, than more accepted short-term therapeutic approaches as CBT and IPT, described earlier.




Depression Explanations under Psychodynamic Theories


There are multiple explanations that fall under the psychodynamic "umbrella" that explain why a person develops depressive symptoms. Psychoanalysts historically believed that depression was caused by anger converted into self-hatred ("anger turned inward"). A typical scenario regarding how this transformation was thought to play out may be helpful is further explaining this theory. Neurotic parents who are inconsistent (both overindulgent and demanding), lacking in warmth, inconsiderate, angry, or driven by their own selfish needs create a unpredictable, hostile world for a child. As a result, the child feels alone, confused, helpless and ultimately, angry. However, the child also knows that the powerful parents are his or her only means of survival. So, out of fear, love, and guilt, the child represses anger toward the parents and turns it inwards so that it becomes an anger directed towards him or herself. A "despised" self-concept starts to form, and the child finds it comfortable to think thoughts along the lines of "I am an unlovable and bad person." At the same time, the child also strives to present a perfect, idealized (and therefore acceptable) facade to the parents as a means of compensating for perceived weaknesses that make him or her "unacceptable". Caught between the belief that he or she is unacceptable, and the imperative to act perfectly to obtain parental love, the child becomes "neurotic" or prone to experiencing exaggerated anxiety and/or depression feelings. The child also feels a perpetual sense that he or she is not good enough, no matter how hard he or she tries.

This neurotic need to please (and perpetual failure to do so) can easily spread beyond the situation in which it first appears, such that the child might start to feel a neurotic need to be loved by everyone, including all peers, all family members, co-workers, etc. The goal of a traditional psychodynamic psychotherapy might be to help the child (now an adult in therapy) to gain insight into the mistaken foundations of his or her belief in his or her badness and inadequacy so that the need to punish himself/herself and to be perfect decreases.

Psychodynamic Theory Assumptions

  • Psychoanalytic psychologists see psychological problems as rooted in the unconscious mind.
  • Manifest symptoms are caused by latent (hidden) disturbances.
  • Typical causes include unresolved issues during development or repressed trauma.
  • Treatment focuses on bringing the repressed conflict to consciousness, where the client can deal with it.
Psychodynamic Theory Overview

Psychodynamic Theory is one of the oldest theories in psychology in which patients are treated are viewed within a model of illness that attempts to identify something that may be lacking. Each individual is perceived to be made up from a dynamic that begins in early childhood and continually progresses throughout life. This way of thinking, however, is generally considered a watered-down version of the more conservative and rigid psychoanalytic school of thought. Psychoanalysis in itself emphasizes the belief that all adult problems are directly related to events in one’s childhood. Very few therapists today can afford to practice strict psychoanalysis anymore, and as a result, it is typically practiced only by psychiatrists who have spent many personal hours being analyzed themselves as well as attending psychoanalytic institute. This is more than likely the kind of therapy people imagine when they think of therapy in terms of a “shrink.”

Therapists who practice this theory have a tendency to look at individuals as the composite of their parental upbringing. Their focus is on the means for settling conflicts between themselves and their parents as well as within themselves. Psychodynamic therapists tend to believe in the theoretical constructs of the ego (which acts as a force similar to a referee) and the superego (known as the conscience) as well as an id that exists inside all of us that tends to act as a devil’s advocate working against the thought process of the conscience. All of these constructs work together to make up the personality and the role of the unconscious is emphasized meaning that contrary to what else you may think, what you don’t know can indeed hurt you and more often than not, it does just that.

The development of an adult’s personality is viewed in terms of whether he or she was able to successfully maneuver through the psychosexual stage of childhood development. Because of this belief, adults are unlikely to know how they are screwed up and as a result may not even recognize the signs of mental distress or mental disorder. Most psychotherapists tend to view adults with varying degrees of “bad.”

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Psychodynamic therapy vs. Psychoanalysis

Psychoanalytic therapy is based upon psychoanalysis but is less intensive, with clients attending between three to seven sessions a week. Psychoanalytic therapy is often beneficial for individuals who want to understand more about themselves. It is particularly helpful for those who feel their difficulties have affected them for a long period of time and need relieving of mental and emotional distress.
Together, the therapist and the client try to understand the inner life of the client through deep exploration. Uncovering an individual's unconscious needs and thoughts may help them to understand how past experiences have affected them, and how they can work through these to live a more fulfilling life.

Psychodynamic counseling or psychotherapy evolved from psychoanalytic theory, however it tends to focus on more immediate problems, be more practically based and shorter term than psychoanalytic therapy. Carl Jung, Alfred Adler, Otto Rank and Melanie Klein are all widely recognized for further developing the concept and application of psychodynamics.

Psychodynamic therapy focuses on unconscious thought processes which manifest themselves in a client's behavior. The approach seeks to increase a client's self-awareness and understanding of how the past has influenced present thoughts and behaviors, by exploring their unconscious patterns.

Clients are encouraged to explore unresolved issues and conflicts, and to talk about important people and relationships in their life. Transference (when clients transfer feelings they have toward important people in their life onto the therapist) is encouraged during sessions.

Compared to psychoanalytic therapy, psychodynamic therapy seeks to provide a quicker solution for more immediate problems.

While there are many similarities between psychoanalysis and Psychodynamic therapy still there are some differences, here are some of similarities and differences among them:
  • Both methods depend on understanding the relationship between the conscious and the unconscious mind.
  • Psychoanalysis requires daily visits to the psychoanalyst, while Psychodynamic sessions are usually just once a week.
  • While during psychoanalytical treatment patient lies on a couch with the analyst sitting out of sight behind him/her, during the psychodynamic session the client and the psychotherapist sit face-to-face.
  • In Psychodynamic therapy the therapist usually talks less and stays silent for longer periods.
  • Treatment length can range from 1 to 12 sessions, to about 20 sessions, and to several years, while psychoanalytical brief therapy is not common.
  • Both methods involve more understanding for the thoughts and emotions more than cognitive behavior therapy where deep understanding may not be that necessary.
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Common Elements to Psychoanalysis and Psychodynamic Psychotherapy

Therapeutic Neutrality

The psychotherapist’s job is not to be a nanny or a friend; rather, the psychotherapist must help clients understand their unconscious motivation. Hence the psychotherapist must act with a certain therapeutic distance, or therapeutic neutrality, never acting from personal desire, and always keeping every word and action of the therapeutic relationship (also called the therapeutic alliance) deliberately focused on the clinical process of healing. 

Transference

It is common, and even expected, for the client to experience feelings for the psychotherapist that are called a transference reaction; these feelingsare really no different than common “love” or hate. The psychoanalyst Jacques taught that this common “love” is a belief in another; that is, it is a belief that the other person has some knowledge you lack. (Hate, being the reciprocal of love, means that your belief in the other person has, for some reason, dissolved.) And in this transference the client’s intense belief in the psychotherapist can cause some difficult problems that must be resolved within the psychotherapeutic work.

For example, your feelings can resemble the mixed feelings (i.e., love and hate) you had in childhood for your parents, and you can begin to treat your psychotherapist according to these feelings, all out of proportion to what is actually happening in the psychotherapy. In such a case, you need to realize that the psychotherapist is only doing his or her job of bringing these feelings to light; it’s your feelings, not the person of the psychotherapist, that are important.

Also, you can come to believe that your psychotherapist has the personal ability to redeem your sense of inner worthlessness, and so you can start to feel special and become very fond of, or even sexually attracted to, him or her. The therapeutic cure, however, must come from facing—not seducing—your inner emptiness.

So if transference isn’t handled carefully it will lead to disaster. For example, many clients have had their lives ruined by sexual affairs with their psychotherapists, all because the psychotherapist took the client’s erotic feelings personally and failed to help the client understand their clinical meaning.


Transference can also frighten you into terminating psychotherapy prematurely, rather than working through the feelings—especially the angry feelings—within the treatment. For example, during the therapeutic process you will experience many emotions that are similar to the intense and confusing emotions you felt as a child. Disappointment. Anger. Confusion. Feeling misunderstood. Feeling devalued. Feeling abandoned. Many different events—some of them just chance occurrences during psychotherapy and some of them deliberate therapeutic interventions by the psychotherapist—will trigger these emotions. (Experiencing these negative reactions to the psychotherapy process itself is called a negative transference.) Just remember that when you feel an emotion in psychotherapy, the therapeutic task will be to name it as an emotion and understand it as an emotion—not get caught in it as if it were your helpless destiny. For if you get caught in it, you will feel victimized and will blame the psychotherapist for your pain, and the entire therapeutic process will feel like judgment and criticism. And then, in deep bitterness, you will want to “get away” from the psychotherapy just as you wanted to get away from the original emotions as a child.

Counter-transference

Counter-transference can be considered the reverse of transference; that is, the term describes the psychotherapist’s unconsciously activated reactions to the client. If these feelings are taken personally, the psychotherapist could become angry, abusive, spiteful, indifferent, or even seductive. If the counter-transference gets too intense the psychotherapist might have to end the treatment and refer the client to someone else, for the client’s own protection.

Counter-transference, however, should be distinguished from the psychotherapist’s in-the-moment feelings about the psychotherapeutic situation, because these feelings can be used clinically. For example, if your psychotherapist begins to feel bored, it could be an indication that you are unconsciously avoiding an important issue.

Therefore, the psychotherapist’s emotional reactions to the treatment are neither “right” nor “wrong.” The real issue is whether these feelings are used clinically, for therapeutic benefit.                                     

Free Association

In the technical language of psychoanalysis, free association is a mental process by which one word or image spontaneously brings to mind other words or images. In both psychoanalysis and psychodynamic psychotherapy it can be very important for you to just say what comes to your mind, without censoring yourself, because this process allows your psychotherapist to make interpretations about your psychological defenses. For example, as you identify a thought or mental image that occurs along with a feeling, you can focus your attention on that thought or image and ask yourself what other thoughts or images come to mind. Following the “tracks” of a string of associations can lead you to the original experience that engendered the feeling in the first place.
           
The greatest hindrance to free association—and to the progress of psychotherapy itself—is the childhood experience of having to guard the things you say and do so as to avoid getting criticized by a demanding parent. When this defense continues into adulthood, it not only obstructs your capacity for honest and intimate interpersonal communication, but it also causes you to feel afraid of saying anything spontaneously in psychotherapy. Not knowing what is hidden in your unconscious, you will feel terrified that anything you say might be more revealing of the truth than you would like.

The simple, but hard, solution to this dilemma is to commit yourself to getting to the truth of your life, no matter how painful it may be. In all reality, the truth won’t kill you; on the contrary, the truth will set you free from your slavery to unconscious fear.                                                                                                    

Resistance

One final therapeutic concept to consider is resistance. Freud defined resistance as “whatever interrupts the progress of analytic work,” such as being late, missing a session, “holding back” your thoughts in the moment (i.e., refusing to speak about them) or avoiding a particular issue. In its most simple and practical sense, resistance results from fear, often the fear of having to face and relinquish one’s victim anger. In other words, the task of treatment is the complex and frightening task of being able to recognize and overcome the tendency to lie to yourself.

Nevertheless, Lacan warned us not to confuse resistance with defense and formulated the famous statement that “there is no other resistance to analysis than that of the analyst himself.” In other words, if the psychotherapist makes interpretations or interventions that are clinically inaccurate, the client will get defensive, and that will interrupt the therapeutic work. In plain English, this means that a client will only explore therapeutic material so far as is comfortable in the moment; the psychotherapist, therefore, must always be aware of just how far the client is willing to go and not “push” the client beyond these temporary limits. Imprudent attempts to push a client can end up pushing the client right out of psychotherapy.


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