May is Mental Health Month! Have I said that already? Anyway, this is yet another one of my Dirty Dozen lectures. It’s on Psychodynamic Psychotherapy.
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Dirty Dozen on Psychodynamic Psychotherapy by Jim Amos, MD
Psychodynamic Therapy Core Beliefs
-We feel and behave as we do for specific reasons.
-We’re often unaware of why we feel and behave in certain ways.
-Past experiences, often outside our awareness, determine how we feel about ourselves and our world.
-The need to master psychological pain is compelling and accounts for why many of us behave consistently and predictably in often self-defeating ways.
Psychodynamic Therapy Core Beliefs, cont.
-The power of the therapeutic relationship is built on the physician’s ability to provide a safe environment for examining emotions and psychological problems in a nonjudgmental, empathic way, i.e., rapport.
-The past experiences of both patient and therapist play a role in determining the power and valence (positive or negative) of the therapeutic relationship.
-Successful treatment must integrate both affective and cognitive components of patient’s self-awareness and includes supportive as well as interpretive interventions.
Essential Assumptions
-Maladaptive relationship patterns are learned in the past.
-Such maladaptive patterns are maintained in the present.
-Dysfunctional relationship patterns are reenacted in vivo in the therapy.
-The therapeutic relationship has dyadic quality.
-The therapeutic focus is on the chief problematic relationship pattern.
Behavior Is Not Haphazard
-Therapists ask “Why is the patient expressing this topic now?”
-Process communication (complementary to content)
-Listen for understanding
-Patients communicate on multiple levels and often indirectly
-Jokes, revelations at end of session, metaphors, sudden shifts in topic
Behavior Is Not Haphazard, cont.
-Resistance: Paradoxical phenomenon of ambivalence that all pts have about treatment
-Tends to provoke subtle, covert, and sometimes overt oppositional behavior that prevents deeper understanding of problems
-Protects pt against threatening feelings and fantasies
-A form of defense mechanism-a way of relating to internal and external worlds in an attempt to avoid unpleasant and strong feelings. There are both adaptive and maladaptive defense mechanisms
Defense Mechanisms
-Defenses (or resistance, which amounts to the same thing) are one of the three different means by which people cope with threats, the other two being social supports and cognitive coping strategies.
-Defenses are coping processes. They are unconscious distortions of inner and outer reality for protecting the ego from disorganizing anxiety and depression. They may seem odd. They may also mature over time.
-Confronting people with their defenses can be unwise. Recognizing them in order to make sense of otherwise inexplicable behavior and to make rough predictions about response to therapy is helpful.
Defense Mechanism Examples
-Denial: refusal to appreciate information about oneself or others
-Projection: attribution of conflicted thoughts or feelings to another or to a group of people
-Identification: patterning of oneself after another
The Past is Present
-Implicit memory and the need to avoid unpleasant, disruptive feelings
-May explain why some traumatic experiences are not accessible
-Transference & countertransference: responding to someone in the present as if that person were an important figure from the past.
-Used for corrective experiences and encouraging more adaptive behavior as pt becomes of aware of this phenomenon
Self-Defeating Behavior
-Making the same mistake repeatedly, e.g., marrying abusive, alcoholic partners
-Might understand this as attempts to master enduring conflict or trauma in order to finally resolve the painful experience
-Remembering can replace reliving-challenge of psychodynamic therapists is to foster this
Essential Operations of Psychodynamic Psychotherapy
-Accepting: Therapist affirms the pt’s past and present subjective experience.
-Understanding: Therapist appreciates both the conscious and unconscious contributions to the pt’s emotional problems.
-Explaining: Therapist expresses, through interpretations, his or her understanding to the pt.
References
-Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004
-Focus: The Journal of Lifelong Learning in Psychiatry. Psychotherapy. Ed. Jerald Kay, MD. Spring 2006. Vol. IV, No.2.
Author: James Amos
I'm a retired consult-liaison psychiatrist. I navigated the path in a phased retirement program through the hospital where I was employed. I was fully retired as of June 30, 2020. This blog chronicles my journey. View all posts by James Amos
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