Psychodynamic Therapy

Psychodynamic therapy (psychoanalysis) is a psychological treatment based on Freudian and neo-Freudian personality theories in which the therapist helps the patient explore the unconscious dynamics of personality. The analyst engages with the patient, usually in one-on-one sessions, often with the patient lying on a couch and facing away. The goal of the psychotherapy is for the patient to talk about his or her personal concerns and anxieties, allowing the therapist to try to understand the underlying unconscious problems that are causing the symptoms (the process of interpretation). The analyst may try out some interpretations on the patient and observe how he or she responds to them.

The patient may be asked to verbalize his or her thoughts through free association, in which the therapist listens while the client talks about whatever comes to mind, without any censorship or filtering. The client may also be asked to report on his or her dreams, and the therapist will use dream analysis to analyze the symbolism of the dreams in an effort to probe the unconscious thoughts of the client and interpret their significance. On the basis of the thoughts expressed by the patient, the analyst discovers the unconscious conflicts causing the patient’s symptoms and interprets them for the patient.

The goal of psychotherapy is to help the patient develop insight—that is, an understanding of the unconscious causes of the disorder (Epstein, Stern, & Silbersweig, 2001; Lubarsky & Barrett, 2006), but the patient often shows resistance to these new understandings, using defense mechanisms to avoid the painful feelings in his or her unconscious. The patient might forget or miss appointments, or act out with hostile feelings toward the therapist. The therapist attempts to help the patient develop insight into the causes of the resistance. The sessions may also lead to transference, in which the patient unconsciously redirects feelings experienced in an important personal relationship toward the therapist. For instance, the patient may transfer feelings of guilt that come from the father or mother to the therapist. Some therapists believe that transference should be encouraged, as it allows the client to resolve hidden conflicts and work through feelings that are present in the relationships.

One problem with traditional psychoanalysis is that the sessions may take place several times a week, go on for many years, and cost thousands of dollars. To help more people benefit, modern psychodynamic approaches frequently use shorter-term, focused, and goal-oriented approaches. In these “brief psychodynamic therapies,” the therapist helps the client determine the important issues to be discussed at the beginning of treatment and usually takes a more active role than in classic psychoanalysis (Levenson, 2010).

Humanistic Therapies

Just as psychoanalysis is based on the personality theories of Freud and the neo-Freudians, humanistic therapy is a psychological treatment based on the personality theories of Carl Rogers and other humanistic psychologists. Humanistic therapy is based on the idea that people develop psychological problems when they are burdened by limits and expectations placed on them by themselves and others, and the treatment emphasizes the person’s capacity for self-realization and fulfillment. Humanistic therapies attempt to promote growth and responsibility by helping clients consider their own situations and the world around them and how they can work to achieve their life goals.

Carl Rogers developed person-centered therapy (or client-centered therapy), an approach to treatment in which the client is helped to grow and develop as the therapist provides a comfortable, nonjudgmental environment. In his book, A Way of Being (1980), Rogers argued that therapy was most productive when the therapist created a positive relationship with the client—a therapeutic alliance. The therapeutic alliance is a relationship between the client and the therapist that is facilitated when the therapist is genuine (i.e., he or she creates no barriers to free-flowing thoughts and feelings), when the therapist treats the client with unconditional positive regard (i.e., values the client without any qualifications, displaying an accepting attitude toward whatever the client is feeling at the moment), and when the therapist develops empathy with the client (i.e., that he or she actively listens to and accurately perceives the personal feelings that the client experiences).

 

The development of a positive therapeutic alliance has been found to be exceedingly important to successful therapy. The ideas of genuineness, empathy, and unconditional positive regard in a nurturing relationship in which the therapist actively listens to and reflects the feelings of the client is probably the most fundamental part of contemporary psychotherapy (Prochaska & Norcross, 2007).

Psychodynamic and humanistic therapies are recommended primarily for people suffering from generalized anxiety or mood disorders, and who desire to feel better about themselves overall. But the goals of people with other psychological disorders, such as phobias, sexual problems, and obsessive-compulsive disorder (OCD), are more specific. A person with a social phobia may want to be able to leave his or her house, a person with a sexual dysfunction may want to improve his or her sex life, and a person with OCD may want to learn to stop letting his obsessions or compulsions interfere with everyday activities. In these cases it is not necessary to revisit childhood experiences or consider our capacities for self-realization—we simply want to deal with what is happening in the present.

Cognitive-behavior therapy (CBT) is a structured approach to treatment that attempts to reduce psychological disorders through systematic procedures based on cognitive and behavioral principles. As you can see in the figure “Cognitive-Behavior Therapy”, CBT is based on the idea that there is a recursive link among our thoughts, our feelings, and our behavior. For instance, if we are feeling depressed, our negative thoughts (“I am doing poorly in my chemistry class”) lead to negative feelings (“I feel hopeless and sad”), which then contribute to negative behaviors (lethargy, disinterest, lack of studying). When we or other people look at the negative behavior, the negative thoughts are reinforced and the cycle repeats itself (Beck, 1976). Similarly, in panic disorder a patient may misinterpret his or her feelings of anxiety as a sign of an impending physical or mental catastrophe (such as a heart attack), leading to avoidance of a particular place or social situation. The fact that the patient is avoiding the situation reinforces the negative thoughts. Again, the thoughts, feelings, and behavior amplify and distort each other.

Cognitive-Behavior Therapy

CBT is a very broad approach that is used for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, attention-deficit, and psychotic disorders. CBT treats the symptoms of the disorder (the behaviors or the cognitions) and does not attempt to address the underlying issues that cause the problem. The goal is simply to stop the negative cycle by intervening to change cognition or behavior. The client and the therapist work together to develop the goals of the therapy, the particular ways that the goals will be reached, and the timeline for reaching them. The procedures are problem-solving and action-oriented, and the client is forced to take responsibility for his or her own treatment. The client is assigned tasks to complete that will help improve the disorder and takes an active part in the therapy. The treatment usually lasts between 10 and 20 sessions.

Depending on the particular disorder, some CBT treatments may be primarily behavioral in orientation, focusing on the principles of classical, operant, and observational learning, whereas other treatments are more cognitive, focused on changing negative thoughts related to the disorder. But almost all CBT treatments use a combination of behavioral and cognitive approaches.

Combination (Eclectic) Approaches to Therapy

To this point we have considered the different approaches to psychotherapy under the assumption that a therapist will use only one approach with a given patient. But this is not the case; as you saw in the figure “The Many Types of Therapy Practiced in the United States”, the most commonly practiced approach to therapy is an eclectic therapy, an approach to treatment in which the therapist uses whichever techniques seem most useful and relevant for a given patient. For bipolar disorder, for instance, the therapist may use both psychological skills training to help the patient cope with the severe highs and lows, but may also suggest that the patient consider biomedical drug therapies (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2002). Treatment for major depressive disorder usually involves antidepressant drugs as well as CBT to help the patient deal with particular problems (McBride, Farvolden, & Swallow, 2007).

One of the most commonly diagnosed disorders is borderline personality disorder (BPD). Consider this description, typical of the type of borderline patient who arrives at a therapist’s office:

Even as an infant, it seemed that there was something different about Bethany. She was an intense baby, easily upset and difficult to comfort. She had very severe separation anxiety—if her mother left the room, Bethany would scream until she returned. In her early teens, Bethany became increasingly sullen and angry. She started acting out more and more—yelling at her parents and teachers and engaging in impulsive behavior such as promiscuity and running away from home. At times Bethany would have a close friend at school, but some conflict always developed and the friendship would end.
By the time Bethany turned 17, her mood changes were totally unpredictable. She was fighting with her parents almost daily, and the fights often included violent behavior on Bethany’s part. At times she seemed terrified to be without her mother, but at other times she would leave the house in a fit of rage and not return for a few days. One day, Bethany’s mother noticed scars on Bethany’s arms. When confronted about them, Bethany said that one night she just got more and more lonely and nervous about a recent breakup until she finally stuck a lit cigarette into her arm. She said “I didn’t really care for him that much, but I had to do something dramatic.” When she was 18 Bethany rented a motel room where she took an overdose of sleeping pills. Her suicide attempt was not successful, but the authorities required that she seek psychological help.

Most therapists will deal with a case such as Bethany’s using an eclectic approach. First, because her negative mood states are so severe, they will likely recommend that she start taking antidepressant medications. These drugs are likely to help her feel better and will reduce the possibility of another suicide attempt, but they will not change the underlying psychological problems. Therefore, the therapist will also provide psychotherapy.

The first sessions of the therapy will likely be based primarily on creating trust. Person-centered approaches will be used in which the therapist attempts to create a therapeutic alliance conducive to a frank and open exchange of information.

If the therapist is trained in a psychodynamic approach, he or she will probably begin intensive face-to-face psychotherapy sessions at least three times a week. The therapist may focus on childhood experiences related to Bethany’s attachment difficulties but will also focus in large part on the causes of the present behavior. The therapist will understand that because Bethany does not have good relationships with other people, she will likely seek a close bond with the therapist, but the therapist will probably not allow the transference relationship to develop fully. The therapist will also realize that Bethany will probably try to resist the work of the therapist.

Most likely the therapist will also use principles of CBT. For one, cognitive therapy will likely be used in an attempt to change Bethany’s distortions of reality. She feels that people are rejecting her, but she is probably bringing these rejections on herself. If she can learn to better understand the meaning of other people’s actions, she may feel better. And the therapist will likely begin using some techniques of behavior therapy, for instance, by rewarding Bethany for successful social interactions and progress toward meeting her important goals.

The eclectic therapist will continue to monitor Bethany’s behavior as the therapy continues, bringing into play whatever therapeutic tools seem most beneficial. Hopefully, Bethany will stay in treatment long enough to make some real progress in repairing her broken life.

One example of an eclectic treatment approach that has been shown to be successful in treating BPD is dialectical behavioral therapy (DBT; Linehan & Dimeff, 2001). DBT is essentially a cognitive therapy, but it includes a particular emphasis on attempting to enlist the help of the patient in his or her own treatment. A dialectical behavioral therapist begins by attempting to develop a positive therapeutic alliance with the client, and then tries to encourage the patient to become part of the treatment process. In DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviors are maladaptive, and showing the client better alternatives. The therapist will use both individual and group therapy, helping the patient work toward improving interpersonal effectiveness, emotion regulation, and distress tolerance skills.

Summary