40. Psychoanalytically Oriented Psychotherapies

8/12/2019 40. Psychoanalytically Oriented Psychotherapies

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VI Therapeutic Approaches in Psychiatry

40. PSYCHOANALYTICALLY ORIENTEDPSYCHOTHERAPIES

James L jaco6son, M.D. , and Alan M aco6son, M. D

1. Describe psychoanalytically oriented psychotherapy.

Psycho analytically oriented psychotherapy som etimes called psycho dynam ic psychotherapy)encom passes a group of psychotherapeutic approaches found ed on the discoveries of Sigmund F reudand later refined and expanded by a number of other researchers, clinicians, and theoreticians. Thisgroup of approach es is based on the belief that current behavior, emotion s, capacities for function-ing, and patterns of relationship are deeply influenced by ones experiences early in life.

2. How might early life experiences affect the present?Psychoanalytically oriented therapists believe that early developm ental experiences influence later

behavior and that such influences often are outside of norm al awareness. The early experiences are re-tained in the unconscious mind as expectations about relationships,beliefs about ourselves and the world

around us, and mechanisms to control uncomfortable feelings and thoughts and prevent them fromcoming into the conscious mind. These unconscious processes determine present feelings and actions.Thus, the past shapes the present through forces that are sometimes known and som etimes unknow n.

For example, a person m ay m aintain a haughty, aloof attitude toward others that results ina painfullack of em otional closeness. In the course of therapy, it is discovered that this way of relating was de-veloped to protect the person earlier in life against a hostile relationship with a demeaning caregiver.Hence, the person developed false superiority to protect from internal feelings of inadequacy, andaloofness to main tain distance from relationships that may be perceived as threateningto self-esteem.

3. How is psychoanalytic therapy conducted?Psychoanalytic therapy comprises verbal interaction between patient and therapist in an effort to

elucidate unconscious past forces that affect current emotions and actions. Intensive therapy often ispaced at 1-2 sessions per week over several weeks to years. Inpsychoanalysis he most involvingapproach based on psychodynam ic principles, the course of treatment often is longer, with more fre-quent meetings up to4-5 times per w eek). This process allows the patient to reexperience with theanalyst, in a deeply felt way, earlier emo tional involvements. The bringing forward of past experi-ences and reexperiencing them in the present is calledtransference. Most peo ple are unaware oftransference, although it frequently shapes the way in which they relate to other people.

Such unawareness is maintained by u nconscious mental processes known asdefense mecha-nisms. Althoug h defense mechan isms vary widely e.g., repression of mem ory, denial, disconnec tionof emotion from event [isolation], externalization of blame, internalization, sublimation), theircommon p urpose is to keep potentially anxiety-provoking events and feelings out of aw areness. In p sy-choanalysis and in some forms of psychodynam ic therapy, the therapist or analyst interprets i.e., com-ments on) defensive maneuvers to gradually uncover their origins by expanding the patients awarenessof current events defensive maneuvers) and historical events origins). This process stirs uncom fort-able feelings and seemingly unacceptable thoughts, and defense mechanisms may be activated in the

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relationship with the therapist. They may present as apparent resistances, such as reactions to thetherapist that lead to breaks in the free flow of discu ssion. In such cases, the therapist offers furthercomm entary on the nature of the resistance, which may lead to further understanding of the difficul-ties i n the interpersonal relationship.

4. What are the benefits to the patient?Through repeated, successive interpretation and intense experience of the connection between

current personal involvement with both the therapist and other people) and past events, the patientlearns about the forces directing his o r her own behavior.As unconscious sources of difficulty grad-ually emerge in the therapeutic relationship, the therapist or analyst explains them to the patient overand over again in an effort to expand understanding.

Unconscious forces are dem onstrated in daily life, in work, in dreams, and in every human en-deavor. The patient, in an intimate, evolvin g relationship w ith the therapist or analyst, experiencesincreasingly deep em otional and intellectual understanding of these forces and how they shape atti-tudes and relationships. Moreover, heor she can com pare previously unconscious perceptionstocurrent experiences w ith the therapist. This comparison provides an opportunity to gain control overthe previously unknown impulses and defensive reactions, leading to changed feelings about selfand improved relationships with others. The result is greater freedom to make choices in work and inestablishing loving relationships. Often, new developm ental processesor the reestablishment ofnormal development ensues.

5. Define transference and countertransference.In its broadest form ,transjerence is bringing intoa current life experience, su ch as a relation-

ship, the beliefs, expectations, and perceptions from previou s relationships. In analytic therapy trans-ference often refers to relationships from particular stages of development. For example, a patientmay ex perience his wife in the sam e way that he experienced on e of his parents in childhood.Although there may be some similarityto the way his w ife behaves, the total perception is coloredby the early experience; hence, this is a transference relationship.

Countertransference is a specific reaction of the therapist to the patients transference.Examples include feelings, thoughts, and attitudes that are reactions to specific events in therapy.The therapist may exp erience such a reaction o r feeling as being unlike him- or herself; this is oftena hint to the presence of a countertransference reaction. For exa mple, the therapist may be unusuallysilent, angry, or affectionate.

Both transference and countertransference can be elucidated to increase understanding of be-havior and to assist in the progressof therapy. If not addressed and discussed, such reactions maystall the therapeutic endeavor or lead to negative reactions and cessation of treatment.

6. How are dreams used in psychodynamic psychotherapy and analysis?Dreams were initially seen by Freud as the royal road to the unconscious. They were thought

to contain a direct view into the uncon scious life of the individual. Thus, dream interpretation w asonce considered the central method for understanding unconscious phenom ena.

Dream elemen ts aresymbolic representations of current life events as wellas earlier life expe-riences and conflicts. Although dream s still play an imp ortant role in psychodynamic psychotherapy,they now are seenas on e of many sources of information about hidden w ishes and fears that are rel-evant to both current and past functioning. The therapist or analyst may focus on current concerns

manifested by the content of the dreamor on representations of the past. He o r she may aska patientto associate i.e., let the mind wander and freely react to different though ts and feelings) to the dreamas a whole or the different elements o f the dream to unm ask and elabo rate what the sym bols in thedream represent. Such associations are termed thelatent content.

Curren t analytic thought places equal or perhaps more) emphasis on transference as the royalroad to the unconscious. Other phenomena that help to elucidate unconscious processes include slipsof the tongue knownas parapraxis), fantasies, daydreams, resistance, and virtually any recurrentway of relating in life.


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7. What are defense mechanisms?Defense m echanisms are the metho ds by which ind ividuals seek to regulate basic instincts.

Instincts m ay be thought of primarily as aggressive and sexual. Defense m echanisms are conceptual-ized as part of a process called the ego or theI. Freuds initial theory of personality highlighted a

conflict between the desire for gratification of basic instincts and the need to control unw anted ordangerous pressure for gratification. He conceptualized repressionas the egos central mechanism ofdefense, but various defense mechanisms are now recognized.

Repression refers to the mechanism by which internal urges, thoughts, and feelings andmem ory of events are forgotten. They are contained in unconscious or repressed) mem ory. Th erepressed is not recognized, but the effects of wh at has been repressed tend to remain. F or example,a person may forget or repress a traumatic event, yet retain an emotion that he o r she cannot con -nect to a particular situation. Inexplicable sadness unattached to a mem ory, but present in responseto certain interpersonal cues, likely results from repression.

Other mechanisms of d efense includedenial altruism intellectualization projection inter-nalization and sublimation. Each mechanism representsa somewhat different method of dealingwith unacceptable thou ghts, feelings, wishes, or events. Although such defensive operations occu rlargely outside the individuals awareness, they become manifest as types of behavior in all relation-ships, including the therapeutic relationship. The therapist helps the patient to understand defensivemaneuvers and become more aware of their influence on everyday functioning. With the therapistshelp, the patient can change behavioral patterns.

8. Who is treatable with psychoanalysis or psychoanalytic psychotherapy?Th e clinician m ust assess the patients relative s trength s and cap abilities as well as relative

weaknesses and difficulties. Psychoanalysis and psychoanalytic psychotherapy are not specificallyindicated or contraindicated by particular disorders. The individual who is likely to benefit from psy-choanalytic psychotherapy suffers long-standing symptoms suchas depressed mood, anxiety, andrepetitive patterns of behavior that result ina sense of limited choices and enjoyment. The personscapacities m ay be thwarted by his or her ow n actions; there may bea sense of falling sh ort or disap-pointment with the outcome of behavior and ways of relating. The person may have difficulty beingspontaneous or feeling close to others. Therealso may be a sense of inordinate suffering.

Concurrently, there must be adequate psychological and emotional strength to endure the explo-rations of psychoanalytically oriented therapy. For exam ple, the person must have dem onstratedsome capacity to achieve, such as a history of satisfaction in relationships with friends or work. Thecapacities to form relationships, self-observe, and contain strong feelings adequately also arestrengths that may aid in the psychotherapeutic process.

The psychoanalyst or therapist assesses specific patterns of defensive functioning and the natureof relationships to evaluate to the required sturdiness and m otivation. Exploratory and exposing ap-proaches dem and considerable patient resilience-as well as support from the clinician.

9. Are risks associated with exploratory psychoanalytic psychotherapy or analysis?Yes. As with any treatment, risks are involved. Dynam ic analytic therapy often is anxiety-pro-

voking because of its attempt to pierce the comforting defensive operations used by the patient tocop e with unwanted feelings. Ideally, these unwanted feelings gradually emerge into awareness.The therapist must first determine whether the patient is prone to impulsive actions, which m ay bedangerou s if anxiety-prov oking feelings and instincts becom e mo re accessible som etimes called

acting out). The therapist m ust assist in managing the expression of such impu lses. Th e goal is abalance between un covering unconscious elements and maintaining current em otional stability.

Psychoanalytically oriented psychotherapy is designed to promotea transitory regression inwhich the patient experienc es earlier ways of relating to people. Regression by definition means re-turning to a form er state. Earlier states of development can be painful to exp erience and lead to be-havior that is no longer appropriate. The result may be transient functioning that is less adaptive. Forexample, a patient may reexperience the full force ofa humiliating experience with his or her fatherand hence be left more vulnerable.A criticism from a supervisor at work may feel humiliating, and an


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over-reaction can lead to an angry response or even quitting the job. Furthermore, such regressionmay persist and lead to chron ic over-dependence on the therapist.

10. Differentiate exploratory and ego-supportive approaches.The psychodynam ic framework includes exploratory therapies thatuncover unconscious motives

and experiences, thereby w eakening defenses. The u se of psychoanalytic understandingto strengthenrather than diminish defenses is called ego-supportive psychotherapy. Some of the techniques of sup-portive psycho therapy are similar to those used in cognitive and behavioral therapies see chapters 41and 42). On e particularly well-defined m ethod, based in p art on psychodynamic principles and devel-oped by Klerman and W eissman, has been termed interpersonal psychotherapy. It is a comm only usedshort-term, dynamic psychotherapy that contains supportive therapy principles.

11. Describe interpersonal psychotherapy.Interpersonal psychotherapy was designedas a short-term treatment modelfor patients with de-

pression. It has been empirically evaluated in a series of studies. A manual describes the methods

and techniques for therapeutic intervention in a consistent, reproducible fashion. Interpersonal ther-apy focuses primarily on thesocial roles and interpersonal interactions in the patients past andcurrent life experiences. Although the entire life-span is covered, the interpersonal therapist places aclew emp hasis on current factors, especiallya patients disappointment in person al role expectationsas well as disputes and problems in relationships. The interpersonal therapist directs the patient toone or two problem areas in current functioning, which then become the primary focus of the ther-apy. Examples include grief overa loss; disputes in m am ag e, family, and work; role transitions suchas retirement o r jo b demotion; andloss through divorce.

Although the interpersonal therapist recognizes the importance of defense mechanisms, he orshe does not attempt to address internal conflict asa source of curren t problems. Instead, behaviors

and emotions are examinedas they relate to current interpersonal problems.

12. Differentiate interpersonal psychotherapy and uncovering approaches.Interpersonal therapy, as a supportive approach, helps tobuild on current capacities to function

rather than uncover inn er conflict. The primary focus is not endu ring personality and character prob-lems or earlier life experiences, although they may play a role in depression. T he twin goals are:1 )relieve symptoms through reduction of grief, and2) help the patient develop better strategies fordealing with current problems associated with the onset of depressive symptoms.

Interpersonal Psychotherapy Uncovering nalytic Psychotherapies

What has contributed to the patients current

What are the current stresses?Who are the key persons involvedin the cur-

rent stress?What are the current disputesand disappointments?

Is the patient learning how to cope with theproblem?

What are the patients assets?How can 1 help the patient to ventilate painful

Why did the patient become what heor she isand/or where is the patient going ?

What was the patients childhood like?What is the patients character?

depression?

Is the patient cured?

What are the patients defenses?How can I find out why this patient feels guilty,

emotions and talk about situations that

evoke guilt, sham e, resentment?How can I help the patient clarify his or herwishes and have more satisfying relation-ships with others?

How can I correct misinformation and suggestalterna tives? rect ideas?

Adapted from KlermanG, Weissman M, Rovsanville B, Cherron E: InterpersonalPsychotherapyof Depression.New York Basic Books, 1984.

asham ed, or resentful?

How can I understand the patients fantasy life andhelp him or herto gain insight into the originsof present behavior?

How can I help the patient discover false or incor-


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PsychoanalyticallyOriented Psychotherap ies 209

13. How long do psychoanalytically oriented therapies take?Therapeu tic approaches range f rom short-term, well-defined therapies with specific focus,

which m ay require only2-8 sessions, to psychoanalysis, which may require4 or 5 sessions per weekfor many years. Brief forms of treatment focus on specific current problems that result in an out-

break of particular sym ptom s, such as anxiety or depressed mood. The long-termfoims address thesource of cu rrent difficulty, but also attempt to u nderstand an d change basic, long-held patterns ofrelating to others as wellas feelings about self that have developed overa lifetime. Hence, the goalso each particular form o therapy are direc tly related to the length o treatment

The long er forms of treatment involve the development of anintense interpersonal relation-ship the elucidation of of multiple aspects of that relationship, and the development of the personalstrength and ability to move beyond it. This relationship may be viewed similarly to other importantinterpersonal relationships that enhance development, su chas with a parent, sibling, friend, grand-parent, or mentor. The length of treatmentis influenced, therefore, by the goals of therapy and thedegree to which the primary focu s is on the relationship between patient and therapist.

Supportive psycho therapies also vary greatly in duration. Sup por t can last througha specific lifeevent job change, divorce, grief over the deathof a parent), or it may bea long-standing therapeuticrelationship that helpsfragile patients sufficiently to allow them to functionat work and avoid sui-cid e attempts and costly hospitalizations.

14. Differentiate dynamic analytic and behavior therapies.In simp le terms, behavior therapies attempt to m odify observable behavior through variousre-

inforcement strategies. For exam ple, if an individual is afraid of snakes, behavioral therapy m aydesensitize the patient to this fear by having him or her learna specific method of attaininga relaxedstate, and then, during relaxation, introducing the idea of a comm on earthworm. Subsequently, a pic-ture of an earthworm is introduced, followed by the idea of a com mon, nonthreatening snake. Afterapicture of a snake, gradual steps may leadto viewing a snake in a contained environment suchas azoo. There is no focus on the origin or symbolic representation of the fear.

In psychodynamic psychotherapy, the therapist focuses on both the origin and the object of thefear. Behavior therapy offersa strategy of managing a sym ptom without the necessity of understand-ing its meaning or origin. In psychodynamic psychotherapy, management strategies are developedsecondarily.

15. Are there uses of psychoanalytic principles other than for psychotherapy?The psychoanalytic m ethod in which the patient says everything that com es to mind in the con-

text of an interpersonal relationship is botha method of psychotherapy anda tool for learning abouthuman mental functioning . Based on such information, various theories of human m ental function-ing and n ormal development from infancy to old age have evolved. Hence, these principles also pro-vide a tool for investigating inner life,a theoretical framework for hum an dev elopmen t, and amechanism of viewing the functioningof the human mind.

From a more practical viewpoint, psychoanalytic principles can be used to understand patientsreactions to medical illness, compliance and adherence problems in outpatient m edical and psychi-atric practice, and the complexities of hum an behavior as manifest in any form of clinical practice. Itmay well be that the psychodynamic perspective has its broadest application in understandingdoctor-patient interchange rather thanas a specific methodfor therapy. Indeed, clinicians using psy-chopharmacologic, behavioral, and other techniques can use this approach to enrich their under-

standing of the patient.

BIBLIOGRAPHY

1 B a h t M, B a h t E: Psychotherapeutic Techniquesin Medicine. Lo ndon,J.B. Lippincott, 1961.2. Binder JL: Research findings on short-term psychodynamic therapy techniques. In The Hatherleigh Guides

3. Greenson RR: The Technique and Practiceof Psychoana lysis, vol.1 New York, International UniversitySeries. NewYork, Hatherleigh Press, 1996, pp 79-97,

Press. 1967.


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4. Jacobson AM , ParmeleeDX: Psychoanalysis: Critical Explorations in Contem porary Theory and Practice.

5 Klerman G, Weissman M Rovsanville B, ChevronE: Interpersonal Psychotherapyof Depression. New York,

6. Luborsky L: Theories of cure in psychoanalytic psychotherapies and the evide nce for them. Psychoanalytic

7. Mann J: Time-Limited Psychotherapy. Cambridge,MA Harvard University Press,1973.8. Sloane RB, Staples FR, Cristol AH, etal: Psychotherapy Versus Behavior Therapy. Cambridge,M A

9. Wachtel PL: Psychoanalysis and Behavior Therapy. New York, Basic B ooks, 1977.10. Stem DN: T he Interpersonal Worldof the Infant. New York, BasicBooks, 1985.I I RothsteinA : Models of the Mind. New York, International Universities Press, 1985.12. Vaillant G E ed): Ego Mechanisms of Defense: Guide for Clinicians and Researchers. Washington, DC,

New York, Brunn erM azel,1982.

Basic Books, 1984.

Inquiry 16 2):257-264, 1996.

Harvard University Press, 1975.

American P sychiatric P ress,1992.

4 1. COGNITIVE-BEHAVIORAL THERAPYJ acq u eh eA Samson, Ph.D

1. What is cognitive behavioral therapy?Cognitive-behavioral therapy (CBT) combines treatment approaches of both cognitive and be-

havioral therapy. The principles were first outlined in a treatment manual specifically targeted to de-pression by Beck et aL3

The basis of cognitive therapy is the observation that negative feelings result from faulty cog-nitive processing. Incoming information is selectively filtered so that perceptions are distortedtoward negative conclusions. Faulty processing is identified by examining a patients spontaneousthoughts occurring throughout the day or after specific events. These automatic thoughts are keyto understanding a patients core system of assumptions and beliefs about the self and the world.CBT treatments first help a patient become aware of automatic thoughts and underlying assumptionsand beliefs. The patient is then encouraged to seek evidence by which to support or refute the as-sumptions, and to modify beliefs based on a more balanced view of all available information.

Behavioral techniques are integrated throughout CBT treatment to facilitate change. Specificexercises for thought stopping, relaxation, and impulse control may be combined with monitoring

and adjusting daily activities to increase mastery and pleasure experiences. Graded task assignmentsand systematic graded exposures also may be used.

2. Give an example of cognitive distortion.A depressed patient reported to her cognitive therapist that she felt sad over the weekend. In re-

constructing the events of the weekend, she noted that the sadness began during a telephone call onSaturday morning from an old friend. The therapist then encouraged her to remember the conversa-tion and the point at which she first felt sadness. She remembered that her friend Sarah was dis-cussing her plans to take a vacation but did not invite the patient to come along. Her first automaticthought was: Sarah doesnt want me along because Im no fun. Her next thought was, Nobody

wants to be with me. I have no friends. She then thought, 1 will be alone for the rest of my life.Gloomy thoughts indeedThe patients faulty processing began with her first reaction to the news of Sarahs vacation.

When the therapist asked the patient to examine the evidence for her assumption that Sarah did notwant to be in her company, she had to say that there was no evidence; the fact that Sarah called indi-cated that Sarah enjoyed her company. Once the distortion i n the automatic thought was workedthrough, the patient felt more hopeful about the future and was able to say that she might ask Sarahif they could plan to do something together soon .

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40. Psychoanalytically Oriented Psychotherapies