Origins of Psychodynamic Psychotherapy
Psychodynamic psychotherapy is the oldest form of psychological therapy used today. Dynamic Psychotherapy, or Psychodynamic therapy, focuses on how influential forces during early development can shape and mold how we think and relate to ourselves and others. Psychodynamic therapy seeks to understand how each patient’s individual life story and subjective experience contribute to emotional suffering.
Sigmund Freud and Psychoanalysis
It is important to note that psychodynamic therapy is based on the work of Viennese Neurologist Sigmund Freud, who developed psychoanalysis. Freud was influenced by many prominent physicians at the time including Viennese physician Josef Breuer, Hippolyte Bernheim (who coined the term Psychotherapy) and Jean Martin-Charcot. Building upon the works of his predecessors and mentors, Sigmund Freud developed a “talking cure” as a cathartic treatment for people with what he termed “psychoneurosis.”
Freud and his followers believed psychopathology could result from the sequestering of unwanted feelings and memories from conscious awareness. He believed the conscious mind used “defense mechanisms” to protect itself from disturbing and distressing feelings and fantasies. In addition, he believed dreams were driven by unconscious processes that could be analyzed and interpreted. The goal of psychoanalysis was to “render the unconscious conscious” or bring the suppressed memories and unconscious feelings, desires, and motives into awareness where they could be integrated with the rest of mental life. To do this, Freud employed a technique termed free association whereby patients would lie on a couch facing away from the psychoanalyst and discuss whatever came to mind. Additionally, unconscious material could be accessed through nonverbal behavior and transference/countertransference patterns as they arise in the relationship between patient and therapist. Over the next century, psychoanalysis underwent many changes in theory and technique which included development of psychodynamic psychotherapy.
Psychodynamic theory views mental life and behavior as the result of compromise between conflicting motives as each of us must make choices in the face of many conflicting wishes, fears, and morals. Psychodynamic theory further postulates that all behavior reflects the mind’s effort to maximize pleasure and satisfaction and minimize anxiety and other distressing feelings. The numerous motivations and conflicts are mostly outside our awareness (unconscious) and so, too, are the defense mechanisms we employ to deal with these conflicts (see defense mechanisms at bottom of page).
The importance of childhood
Psychodynamic theory sees adult psychological life as an extension of the mental life of childhood.
“Childhood wishes and fears along with childhood experiences, both nurturing and traumatic, leave their mark on the developing psyche. These experiences are shaped by the fantasy life of the child which is influenced, in turn, by the cognitive capacities appropriate to the child at any given age. Of special interest to psychodynamic clinicians are enduring experiences of the body and of relationships with others, especially caretakers. Like adults, children experience conflict. Childhood conflicts and the compromises arrived at in the face of conflict endure in the mind of the adult, long after circumstances which produced these conflicts have disappeared. While the psychodynamic concepts of the unconscious, motivation and development were developed through clinical investigation, there is extensive validation for the idea of the unconscious from contemporary cognitive neuroscience and social psychology.” – From Ferrando et al (2008)
Goals of Psychodynamic Psychotherapy
- Resolution of internal conflict
- Improvement in the quality of one’s relationships
- Increased satisfaction with work
- More cohesive sense of self
Typical Structure of Therapy: Patient meets with the therapist 1–2 times/week for 45 minutes sessions.
Free Association: Technique invented by Freud as a replacement for hypnosis as a tool for accessing unconscious material. By noticing apparent gaps in associations, psychoanalysts can pick up resistances and clues to unconscious material.
Resistance: Resistance reflects the patient’s use of defenses in the therapy to avoid unpleasant emotions, but also to resist change. Examples include silences, missed appointments, forgetting, refusing medication and/or dismissing other interventions the therapist makes. Resistance is a window into the patient’s past and internal mind and is explored together in therapy.
Transference: The unconscious mechanism by which patients experience the doctor as a significant figure from the past and thus feelings from the past are reactivated in the here and now with the therapist. Transference occurs in all relationships, but one aspect of dynamic psychotherapy is that the transference is utilized as a tool with which to understand and ultimately modify past patterns of relationships.
Countertransference: The set of feelings evoked in the therapist by the patient. Thought to be a joint creation of feelings induced by the patient via projective identification and unresolved conflicts from the therapist’s past. The therapist must be highly self-aware in order to separate his/her own conflicts from the aspect of countertransference that is useful information about the patient’s internal world.
Therapeutic Alliance: The shared positive feelings between therapist and patient, relatively free of transference distortion, which support their pursuit of the goals of the treatment (see post on Therapeutic Alliance).
Working Through: The repetitive interpretation of transference and resistance until it is integrated by the patient. The therapist points out patterns in the patient’s outside relationships and relates it to patterns in the relationship with the therapist and in early relationships. It is thought that by re-experiencing these patterns in the relationship with the therapist, they are gradually modified and reintegrated.
Termination: Termination is the final phase of the therapy during which the patient reviews the work of the treatment and prepares for the future. The termination phase is likely to reawaken conflicts that have been explored earlier in the treatment, especially conflicts related to separation and autonomy.
Supportive Therapy-Oriented Techniques: Used in most forms of therapy to varying degrees. Examples include
- Encouragement to elaborate: “Tell me more.”
- Empathic validation: “That must have been very stressful”
- Praise: “I am so proud of you for using those coping skills!”
- Affirmation: “I see. Uh huh”
- Clarifications are questions and statements designed to elucidate the patient’s current thoughts, feelings, and/or behavior
- Confrontations gently point out contradictions that might imply unconscious conflict.
- Interpretations are the therapist’s attempt to link the patient’s conscious thoughts, feelings or behavior to unconscious motivations.
Anxiety-Based Defense Mechanisms
Displacement: Transferring emotion onto another person.
EXAMPLE: A parent is angry with a coworker and comes home and starts yelling at his or her kids.
Repression: Bad idea or feeling eliminated from consciousness.
EXAMPLE: Forgetting a traumatic experience.
Isolation of affect: Reality accepted without emotional response.
EXAMPLE: Seeing the dead body of a friend but not showing any emotion.
Intellectualization: Use of intellectual process to avoid affective expression.
EXAMPLE: Explaining the neurobiology of pain when feeling physical or emotional pain.
Acting Out: Emotional outbursts to cover up reality or draw attention to yourself.
EXAMPLE: Temper Tantrums
Rationalization: Making excuses with rational explanations to justify behavior.
EXAMPLE: Telling people you didn’t pass the exam because it was more difficult than previous years.
Reaction Formation: Unacceptable impulse transformed in its opposite.
EXAMPLE: Pyromaniac becomes a firefighter.
Undoing: The action of “reaction formation.” Acting out the reverse of the unaccetable behavior.
EXAMPLE: The pyromaniac puts out a fire.
Passive-Aggressive: Unconscious passive hostility.
EXAMPLE: The irritable clerk at the store telling you she is busy while sitting on her phone looking at Instagram.
Dissociation: Separating from ones experience (i.e., out of body experience).
EXAMPLE: While being physically assaulted, she felt like she was watching it from above.
Mature Defense Mechanisms
Humor: Expression of feelings/thoughts without discomfort.
EXAMPLE: Someone you don’t know starts screaming at you randomly on the street and you laugh it off.
Sublimation: Unacceptable impulse channeled into a more acceptable behavior.
EXAMPLE: The guy who loves to get into fights with other people at bars becomes an MMA fighter to satisfy his desire for fighting.
Suppression: Consciously forgetting (actively trying to forget something despite remembering it).
EXAMPLE: Trying to forget that you’re puppy died.
Narcissistic Defense Mechanisms
Projection: Attributing feelings/thoughts onto someone else.
EXAMPLE: When you don’t really enjoy being around someone and tell people “I know that she doesn’t like me. I just know it. She doesn’t want to hang out with me.”
Denial: Avoiding awareness of a painful reality.
EXAMPLE: Recently losing a loved one and not really believing it to be true.
Splitting: Idealizing and devaluing. Black and white thinking. Either all good or all bad.
EXAMPLE: The nurses at this facility are amazing but the nurses from this other facility are terrible!
Immature Defense Mechanisms
Blocking: Temporarily blanking on the name of someone or forgetting what you were going to say.
EXAMPLE: “I don’t remember her name, but it’s on the tip of my tongue!”
Regression: Return to an earlier stage of development.
EXAMPLE: The 7 year old who starts wetting the bed again after finding out his mom is leaving on a business trip for a month.
Somatization: Psychiatric or emotional discomfort manifesting as physical symptoms.
EXAMPLE: Experiencing a headache during very difficult and anxiety-provoking exam.
Introjection: Unconsciously imitating someone you admire.
EXAMPLE: Dressing like your favorite fashion idol or movie star.
Therapy Flash Cards
- Caligor, E, Kernberg OF, Yoeman,s FE,(2007) Handbook for Dynamic Psychotherapy for Higher Level Personality Pathology, American Psychiatric Press, 2007
- Gabbard, G.O.(2004) Long-term Psychodynamic Psychotherapy: a basic text. Washington, DC, American Psychiatric Publishing, Inc. 2004
- Gabbard, G.O (2005): Psychodynamic Psychiatry in Clinical Practice. 4th Edition. Washington, DC, American Psychiatric Publishing, Inc. 2005.
- Luborsky L, Crits-Cristoph P (1990) UnderstandingTransference: The Core Conflictual Relationship Theme Method. New York: Basic Books.
- Ferrando J., Stephen et al (2008) Psychiatry in Review. 3rd Edition. Educational Testing and Assessment Systems, Inc.
- Vaillant G, Bond M, Vaillant C (1986) An empirically validated hierarchy of defense mechanisms. Archives of General Psychiatry 43: 786–94.
- Bordin E (1976) The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice 16: 252–60.
- Allen J, Fonagy P, Bateman A (2008) Mentalizing in Clinical Practice. Washington, DC: American Psychiatric Association.
- Hinshelwood R, Zarate O (2006) Introducing Melanie Klein. London: Icon Books.
- Stein S (1999) Bion. In S Stein (ed.) Essentials of Psychotherapy. Oxford: Butterworth-Heinemann.
- Phillips A (2007) Winnicott. Harmonsworth: Penguin.
- Bowlby J (2005) A Secure Base: Parent–Child Attachment and Healthy Human Development. Hove: Routledge.
- Mitchell S, Black M (1995) Freud and Beyond: A History of Modern Psychoanalytic Thought. New York: Basic Books.
- Stevens A (2001) Jung: A Very Short Introduction. Oxford: Oxford University Press.