2. FUNDAMENTAL PRINCIPLE COMMON TO
ALL PSYCHOTHERAPIES
How many competent psychologists/psychiatrists does it
take to change a person?
ANSWER - Just one, provided the PERSON wants to change
3. WHAT IS IT?
Psychodynamic psychotherapy is a form of depth
psychology (Tiefenpsychologie – Eugene Bleuler)
Used to reveal the UNCONSCIOUS content of a client's
psyche in an effort to alleviate psychic tension.
Form of psychoanalysis, but in addition,
Relies on the interpersonal relationship between client
and therapist
4. HISTORY
The principles of psychodynamics were first introduced in
the 1874 publication Lectures on Physiology by German
scientist Ernst Wilhelm von Brücke
Brucke suggested all living organisms are energy systems
and operate on energy conservation
Freud adopted this concept and applied this dynamic
characteristic to the human psyche (Brucke was Freuds
supervisor when he was a first year med student)
Later further developed by the likes of Carl Jung, Alfred
Adler, Otto Rank and Melanie Klein
5.
6. DIFFERENCE BETWEEN PSYCHOANALYSIS AND
PSYCHODYNAMIC PSYCHOTHERAPY
PSYCHOANALYSIS
Requires daily visits
Analysand lies on a couch with the analyst
sitting out of sight and behind
“Free-association” by analysand and a
silent analyst. Analyst breaks silence
whenever “interpretation” required
Not a very interactive process
“Imposed” on the analysand – payment is
required whether they attend the session
or not
Takes several years to be effective
DYNAMIC PSYCHOTHERAPY
Once a week (twice/thrice for unstable or
highly motivated clients)
Client and therapist sit face to face
The psychotherapist usually talks quite a lot,
compared to the “silence” of the
psychoanalyst.
Highly interactive process
No binding on the Client, flexible and Client
pays therapist on each visit
Treatment generally 1-12/20 sessions (BPP) to
more than 50 sessions/several years (LTPP)
7. WHERE AND WHEN IS IT USED?
Psychodynamic psychotherapy, in all its forms, is the
psychotherapy most frequently provided by
psychiatrists.
Psychodynamic therapy is useful in long-term, short-
term, supportive, crisis intervention, and group/family
therapies, with patients of all ages.
Patients hospitalized in psychiatric as well as medical-
surgical services can also benefit from a clinician’s
psychodynamic orientation.
8. CENTRAL CONCEPTS
People feel and behave as they do for specific reasons.
People are frequently unaware of why they feel or behave in
a certain fashion.
Past events and experiences, often outside of awareness,
determine how people feel about themselves and their world.
The need to master psychological pain and discomfort is
compelling and accounts for why many people behave
consistently and predictably in often self-defeating or
disappointing ways.
The power of the therapeutic relationship is to provide a safe
forum for examining psychological problems, feelings and
behaviors by maintaining an open, nonjudgmental, and
empathic rapport with the patient.
9. CENTRAL CONCEPTS
The past experiences of both the patient and the therapist have
a role in determining the power of the therapeutic relationship
and that life-issues will re-emerge in the therapy (Transference
and Counter-transference)
A successful treatment must integrate both cognitive and
affective components of the patient’s self-awareness and
includes supportive as well as interpretive interventions.
Use of free association as a major method for exploration of
internal conflicts and problems.
Focusing on interpretations of transference, defense mechanisms,
and current symptoms and the ”working through” of these
present problems.
Trust in insight as critically important for success in therapy.
10. UNDERSTANDABLE REASONS UNDERLIE FEELINGS,
WISHES, AND BEHAVIOR
Patient’s current behavior due to his past experiences
Therapist should always have the question “Why now?”
Therapist should listen to the client in a distinct manner and
watch out for indirect clues
Material, for example, may be expressed through jokes,
shifts in topic, revelations at the very end of a session,
metaphors, and symbols
Watch out for resistance and ambivalence
11. UNDERSTANDABLE REASONS UNDERLIE FEELINGS,
WISHES, AND BEHAVIOR
Ambivalence may be subtle or overt. It may take the form
of missed appointments or an unwillingness to explore
specific areas of the patient’s life
Resistance is a common example of ambivalence and the
patient jumps from a more upsetting to a less upsetting
topic
Serves as a protective function against threatening feelings
and fantasies
Greater understanding of resistance is essential for
understanding the client
12.
13. FEELINGS AND BEHAVIOR ARE OFTEN A MYSTERY
TO THE PATIENT
The notion that people experience and act on
unknown wishes and fears is an enlightening concept for
many patients
Long term memory is important here. It is divided into
implicit and explicit memory as we know.
Implicit memory is procedural, begins to form after birth,
does not require conscious attention or intact hippocampal
function
Implicit memory is what is important in psychoanalysis
14. FEELINGS AND BEHAVIOR ARE OFTEN A MYSTERY
TO THE PATIENT
Much of mental life is outside of awareness
Experience of self and other is decided by “affective neural
templates” which in turn depends on reciprocal interaction
between mother and infant
These affective templates help in organising neural
structure
Implicit memory plays a role in psychological trauma – that
is why patients cannot recall fully the experiences of severe
abuse and neglect
15. THE PAST LIVES IN THE PRESENT
Implicit memory + need to ward off/contain trauma or
emotional disruption = inaccessible experiences
Early experiences shape personality and IP experiences eg. A
child who loses a parent and is forced to live with an
alcoholic/abusive/depressed parent
These children grow up with anxiety and fear of
abandonement of IP relationships
“Disorganised attachment” - abused and neglected infants
and toddlers are unable to develop a cohesive sense of self
and trust of others because they experienced their mothers
as “frightened” (unable to care) and “frightening” (unable to
empathise)
16. PERCEPTUAL DISTORTIONS ARE UBIQUITOUS
An individual’s responding to someone in the present
(therapist) as if that person were an important figure from the
past is known as “transference”
Neurobiologically, it changes the neural circuitry
Clinicians, too, have feelings about and responses to patients
that may be confusing at times
Although once considered unhelpful, these responses—
referred to as “countertransference”,actually facilitate
treatment enormously
Countertransference -> “Why a feeling arises?” ->A view of the
patient’s psychic process and also in assessing “engagement”
of the therapist
17. PERCEPTUAL DISTORTIONS ARE UBIQUITOUS
Transference is often manifested as an erotic attraction towards a
therapist, but can be seen in many other forms such as rage, hatred,
mistrust, parentification, extreme dependence, or even placing the
therapist in a god-like or guru status
To quote Freud, "the transference, which, whether affectionate or
hostile, seemed in every case to constitute the greatest threat to the
treatment (Resistance), becomes its best tool“
A therapist who is sexually attracted to a patient must understand the
countertransference aspect (if any) of the attraction, and look at how
the patient might be eliciting this attraction
Once any countertransference aspect has been identified, the
therapist can ask the patient what his or her feelings are toward the
therapist, and can explore how those feelings relate to unconscious
motivations, desires, or fears.
18. SELF-DEFEATING BEHAVIOR
How is it that some people never learn from their mistakes?
For example, why has a man married three women in
succession, each one alcoholic and abusive? Or why
might a victim of childhood sexual abuse place herself in
dangerous situations that facilitate further trauma?
People repeat unhelpful behavior in an attempt to master
enduring conflict or trauma, ever hopeful that they can
repair or resolve painful experiences by placing
themselves once again in a precarious situation to
“make it turn out differently”
19. SELF-DEFEATING BEHAVIOR
Perhaps one of Freud’s more helpful clinical insights
was the recognition that behaviors are repeated
unless one becomes aware of patterns and reasons for
the predictability of the behavior
To paraphrase Freud, those who cannot remember
certain affect-laden experiences are doomed to repeat
them
One aspect of dynamic psychotherapy is to help the
patient appreciate the compelling repetition of unhelpful
situations or behaviors in which remembering can then
replace repeating or reliving
20. THE EMOTIONAL AND THE INTELLECTUAL ASPECTS
IN THERAPY
Cognitive and affective components of negative
experiences to be examined
Cathartic experiences alone are unlikely to provide
relief or promote behavioral change, and therapists should
not offer to explain the “dynamics” of clients
psychopathology
Early attachment relationships are encoded as affect-
laden implicit memory
The therapist should help the patient examine predictable
feelings and distortions within the safe therapeutic
relationship
21. THE EMOTIONAL AND THE INTELLECTUAL ASPECTS
IN THERAPY – How does PP help?
It promotes changes in neural structure that afford the
patient an additional resource for feeling and
behaving differently
Restructures intense implicit memories within the context
of a therapeutic relationship
Many mistakenly consider only interpretive, clarifying,
or confronting interventions as being “psychodynamic”
Additional “Supportive” interventions are suggestion,
reassurance, advice giving, praise, and environmental
manipulation
22. Substantial gains can be made in supportive
therapy with patients who are experiencing
significant psychiatric illness
A psychodynamically informed approach is also
exceptionally helpful in appreciating the
meaningfulness of medication to the patient
Thus plays a vital role in medication compliance
24. BOUNDARIES
Ethically, the clinician should never takes advantage of
the patient to meet his or her own financial, sexual, or
other personal needs
A clinician should not confide his or her problems and
needs, transforming the therapy into an unhelpful
experience for the patient
Clinician should explain to the patient the time, place and
fee for therapy and should never be late for the
appointment
25. EFFECTIVE INTERPRETATION
Empathize
Identify a patient’s behavior and emotional patterns,
especially transferences, through understanding often
subtle or initially confusing communication
Recognize the meaning of one’s own fantasies and
responses to the patient (countertransference)
Maintain a verbal flow that deepens the treatment
Appreciate the timing and dosage of interpretations
Be patient
26. EFFICACY AND USES
Many psychiatrists are unaware of the substantial research
supporting the helpfulness of psychodynamic
psychotherapy
The psychodynamic treatment approach is not limited to
long-term psychotherapy alone
Has broad applicability across the life span in crisis and
supportive interventions, combined treatment, brief
dynamic psychotherapy, group/family treatment,
inpatient psychiatry, and consultation-liaison psychiatry
Treatment effect size is robust in some anxiety, personality
(especially Cluster C), mood, and substance abuse
disorders
27. EFFICACY AND USES
Patients are much better off immediately after treatment,
and follow-up assessments show that they maintain their gains
Studies of combined treatment using psychotherapy and
pharmacotherapy also support the benefits of treatment (Kay
J : Psychotherapy and Medication, Oxford Textbook of
Psychotherapy)
Several RCT and meta-analysis have supported the use of
psychodynamic therapy for personality disorders, major
depression, anxiety disorders, and some eating disorders, as
well as posttraumatic stress disorder, panic disorder,
somatoform disorders, and substance use disorders
(Gabbard)
28. SHEDLER’S REVIEW
In 2010, American Psychologist, the journal of the American
Psychological Association, published a review article by
Jonathan Shedler, PhD, associate professor of psychiatry at
the University of Colorado Denver, School of Medicine, which
explored the efficacy of psychodynamic psychotherapy
Shedler reviewed 8 meta-analyses (comprising 160 studies) of
psychodynamic therapy, plus 10 meta-analyses of other
psychological treatments and antidepressant medications
He focused on effect size: 0.8 is considered a large effect; 0.5,
a moderate effect; and 0.2, a small effect. The overall mean
effect size for antidepressant medications approved by the
FDA between 1987 and 2004 was 0.31. The effect sizes for
psychodynamic therapy and other psychotherapies were
much higher.
29. COCHRANE LIBRARY
One methodologically rigorous meta-analysis of
psychodynamic therapy, published by the Cochrane
Library, included 23 randomized controlled trials of 1431
patients with a range of common mental disorders
The studies compared patients who received short-term
(less than 40 hours) psychodynamic therapy with controls
(wait list, minimal treatment, or treatment as usual)
The overall effect size was 0.97 for general symptom
improvement
The effect size increased by 50%, to 1.51, when patients
were reevaluated 9 or more months after therapy ended
30. COMBINATION THERAPY – MEDS + PP
Glen O.Gabbard, Textbook of Psychotherapeutic Treatments, Pg-138, 2009, First edition
