Summary and Keywords
Psychodynamic psychotherapies (PDP) is an umbrella term for a variety of therapeutic modalities that have evolved out of the psychoanalytic/psychodynamic tradition, each theorizing a trajectory of human development that includes an etiology of and treatment for psychopathology. PDPs have in common the belief that people have an unconscious mind that influences thoughts and behaviors outside of the individual’s awareness. These processes operate from birth till death and are responsible for adaptive and maladaptive functioning at the level of interpersonal relationships and daily living.
The psychodynamic therapist creates a case formulation for the individual seeking treatment, which incorporates a formal diagnosis with an understanding of the underlying dynamic factors contributing to the individual’s suffering. From this case formulation a treatment plan is created specific to the individual. During treatment, the therapist develops a strong working alliance while utilizing psychodynamic-specific techniques targeted at bringing insight into these unconscious thoughts and behaviors. Greater self-understanding enables greater choice ability and flexibility in functioning.
In contrast to prevalent views, empirical research has found support for the efficacy of PDP in the treatment of mental disorders, including but not limited to: depression, anxiety disorders, somatic disorders, and personality disorders. In general, PDP was found more effective than control conditions and not different from active treatments. PDP effects have been shown to remain stable post treatment.
Psychodynamic psychotherapy (PDP) is an umbrella term for a group of therapeutic modalities that have grown out of the psychoanalytic/psychodynamic tradition. These theories have been derived from various perspectives of human development. The aim is to explain not only normal development of individuals and their personalities, but also how psychopathology develops as maladaptive adaptations during the process of maturation. Inherent in the conceptualization of development trajectories are potential targets for treatment and prevention interventions.
Although the theories of development and the specific targets of treatment may vary across different forms of PDP, they share many foundational commonalities. For example, they share the widespread assumption that the unconscious life of an individual plays an important role in the creation and maintenance of behaviors related to normal personality development or psychopathology. Additionally in common is the idea that biologically rooted drives and impulses and/or their psychological representations create internal conflict within an individual. However, the drives and impulses may be conceptualized as sexual or aggressive in more traditional psychoanalytical theories, but in more modern psychodynamic (PD) theories, as intense desires for affiliation and bonding or mastery and autonomy. Regardless of the type of drive—the interaction between drives or desires and the demands of reality, including morality, create the internal conflict. These internal conflicts are defended against within one’s unconscious through some type of adaptation. Adaptations may be successful and lead to productive behaviors, or the adaptation may be unsuccessful and lead to maladaptive behaviors, which may suit a need in early development but ultimately not serve the individual in the long term. Subsequently, depending on the success of the adaptation or defense, symptoms are created alongside of and as a part of development of an individual’s character. Therefore, symptoms are maladaptive behaviors, thoughts, or feelings that arise from internal conflict and provide both a solution to the problem (compromise formation) and an expression of the problem.
The target of PD treatment is to foster awareness (insight) of the individual’s unconscious conflicts and compromises. Insight in the company of emotional experience, in the context of the therapeutic relationship allows—in some theorists’ view—for a corrective emotional experience, releasing the individual from the need for the maladaptive thoughts, feelings, and behaviors (Sharpless & Barber, 2012). Put simply, self-understanding is likely to increase the choice an individual has over how they behave as well as how they think about their past.
Psychodynamic theory is deeply embedded in many cultures of the 20th and 21st century (e.g., Summers & Barber, 2012) and is the foundation from which many psychotherapies have evolved. Many of the ways people think about their upbringing, their experiences of their mind, their dreams, and everyday experiences have been shaped by psychodynamic theory and thought. It has become widely assumed, for example, that early childhood impacts later life experiences, that it is normal to have internal conflicts, that anxiety is pervasive, that a part of the mind operates outside of one’s awareness, and that mental life is impacted by upbringing and culture. The fathers of the cognitive behavioral traditions of psychotherapy, Albert Ellis and Aaron Beck, had their roots in psychoanalytic training. Psychodynamic theory is the wood from which much of the understanding of the mind and behavior has been carved. Understanding the roots of psychodynamic theory offers anyone a rich and nuanced view of oneself in everyday experiences. However, for the practitioner of any tradition of psychotherapy, psychodynamic theory offers the history and perspective of over a century of thinking, practice, and research, that promise to enrich one’s understanding of patients, theory and technique alike.
Our brief review of the evolution of the vast field of PDP follows its historical development and its attempts to deal with existing controversies about important assumptions of the original theory—for example, the importance of instinct vs. attachment needs. Each developing branch has a unique perspective of what is most important for human development, and its own perspective on psychopathology and treatment interventions. A review the major characteristics of PDP follows in the second section—treatment goals, case formulations, mechanisms of change, and techniques considered common across most PDP. The third section covers research demonstrating the effectiveness of PDP and touches on a few topics of controversy responsible for shaping the future direction of research and theory development. The final section is a glossary of key terms in PDP, a convenient reference for the reader.
A Brief History of the Evolution of PDP
Sigmund Freud’s (1856–1939) invaluable contribution to the field of psychotherapy and psychology as a whole developed over the course of his lifetime. His theories were strongly influenced by his self-analysis, case studies of his patients, the work of contemporary thinkers, and through collaborations and heated debates with fellow psychoanalysts and theorists.
While working with Charcot, Freud was introduced to the plight of the hysterical patient whose symptoms manifested as physical experiences (e.g., paralysis, blindness) with no observable physiological cause. For instance, the hysterical patient who experienced glove anesthesia could not feel or move their hand; however, the nerves connecting the hand to the brain were intact and working. By inducing those patients into hypnosis, Charcot, and subsequently Freud, was able to demonstrate that the symptoms could be relieved. Therefore, neither biology nor conscious awareness could explain the hysterical patient’s symptomatic experience, leading Freud to conclude that it was an idea—not physiology—that was the culprit in the patient’s malady. This inspired Freud to shift from a science of the brain to a science of the mind (Mitchell & Black, 1995). At this point Freud conceptualized a psychic map, as the biological map failed to describe this phenomenon. His work legitimized the disease of the mind these patients suffered from, and the stigmatization of malingering dissipated. Later on, Freud began to emphasize the impact of trauma on the development of the symptoms of hysterics. Freud proposed that due to some type of trauma, feelings that were intolerable were unable to be experienced in the ordinary way and therefore were split from consciousness. He proposed that the treatment needed would provide insight by tracing the patient’s experience of the symptoms to the traumatic event, which caused the split. Through this insight, accompanied by an emotional discharge, called catharsis, the theory predicted that the symptom would be eliminated. In other words, meaning, understanding and emotional experiencing were thought to be the key to the cure.
From 1895 to 1905, Freud developed the topographical model of the mind, which has three components: the unconscious mind—thought to contain unacceptable thoughts and feelings, the preconscious mind—responsible for the preparation and containment of thoughts and feelings capable of becoming conscious and finally, the conscious mind—considered the home of thoughts and feelings in awareness. Of these, Freud posited that the greatest percentage of mental activity resides in the unconscious. In 1923, he reconceptualized the mind according to the structural model. This model contains three levels of the mind. The id is the aspect of the mind that is ruled by unconscious wishes and desires, fueled by biological drives rooted in survival. The id is in direct conflict with unconscious defenses that work to keep unruly drives at bay in the service of reality; this balancing aspect of the mind is called the ego. The ego not only is working to defend against the primitive drives of the id, but also the moralistic perfection demanded by the superego. The superego is a part of the unconscious mind developed through parental influence coupled with societal demands. The conflict of the structural model lies, therefore, not between the consciousness and the unconscious mind, but between desires and defenses within the unconscious mind. The conflict between unconscious motivations and defenses and resultant behaviors became and remain the targets of treatment.
Freud advanced a theory based on psychosexual stages he believed individuals went through during maturation. Psychosexual developmental theory, contains five stages, each focused on a particular erogenous zone: oral, anal, phallic, latent, and genital. In each stage the libido, an instinctual sexual energy, is developed incrementally, passing through the body in a sequential order. In this theory, anxiety is the result of sexual frustration during any of these stages, which transforms, into neurosis.
The Oedipus complex, for classical psychoanalysts—the center of the psychodevelopmental experience, occurs during the phallic stage of development. It is derived from the play, Oedipus Rex, by Sophocles, in which the main character, Oedipus kills his father and marries his mother. The Oedipus conflict therefore describes the desire of the child to have sexual relations with the parent of the opposite sex, and the competition that arises with the parent of the same sex. Through this dilemma, castration anxiety emerges for boys; and for girls, penis envy emerges. If there is not a resolution to this dilemma, in which the child is able to adequately identify with the opposite sex, then neurosis develops. The lack of ambivalence in regards to identification with the ideal of their same sex parent maintains a path for love and success not available to those who become rivalrous to the point of regression. The Oedipal complex has been met by criticisms for not being a universal experience, and further and most vehemently by Karen Horney, for being inherently sexist in conceptualization.
Freud’s work inspired, through admiration, identification, and criticisms, a tremendous outflow of psychoanalytic and psychodynamic thought that maintains a stronghold on continued development of theories of people, their development, their minds, and psychopathology. In North America, three main branches of psychoanalytic theory developed as an outgrowth of Freudian theory: ego psychology, self psychology and object relations theory. In Britain, the three main branches that developed have been contemporary Freudian, independent, and the Kleinian traditions. These traditions are still prevalent, influential, and evolving in the 21st century. Each branch was developed to address a specific controversy within psychoanalysis. Summers and Barber (2012) have suggested that different models are perhaps best used to understand different disorders. Therefore, PD therapists today may consider the presenting problem of the patient and frame the case formulation and treatment plan along whichever branch best aids in the most efficacious treatment for that patient.
Although ego psychology took root in the 1930’s in Vienna, it became firmly established in North America (Mitchell & Black, 1995). Of the three main branches, ego psychology is closest to the original foundation of psychoanalysis. Pathology arises within an individual as a result of unsuccessful compromises attempted by the ego in an effort to balance the instinctual drives of sex and aggression housed in the id, and the demands of the superego striving to live by the moral demands of society. According to ego psychology, there is a shift in focus, from the unconscious desires of the id to the unconscious and defensive function of the ego. More specifically, it is the developmental task of the ego to balance and find compromise between the unconscious demands of the drives (id) and the constraints imposed by the world in which one lives via the superego. The superego, developed from the internalized voice of one’s parents, serves as the arbitrator to what morality and society permit using guilt and shame. The ego defenses are used to resolve the conflict of these warring internal needs. Defenses develop at each developmental stage. In early development, primary defenses are used (e.g., splitting and projection); however, as one ages and matures, more complex defenses emerge (e.g., sublimation and altruism). Mature defenses allow for the expression as well as inhibition of internal conflicts, they contribute to create adaptive compromise formation. If an individual fails to develop more mature defenses as one ages and life becomes more complex or continues to give preference to less mature defenses, pathology ensues.
According to Anna Freud, behaviors are expressions of defenses. She therefore moved the focus of psychoanalysis from tracing symptoms to their origin in repressed contents to understanding how the ego was working to keep unconsciousness conflicts and unwanted thoughts out of awareness. The defensive functioning of the ego is considered part of a person’s character style; therefore, ego psychology expanded analysis from addressing symptoms to addressing change in personality functioning (Freud, 1937).
Ego psychology expanded the psychosexual stages of development to include the entire adult life cycle, which previously concluded at the latency stage. Erik Erickson further elaborated the concept of identity and personal subjectivity, proposing that culture and interpersonal experience helped to shape a person’s development beyond internal instinctual conflict.
In summary, in ego psychology the health of the ego is determined by the quality and type of defenses utilized by the individual to resolve conflict. An ego psychologist would address the symptoms of their patient by first discerning, “what is the conflict and what is the compromise?” When compromises fail at the task of conflict resolution, pathology becomes apparent. It is the task of the therapist to help the patient gain insight into their conflict and compromise, and to reach a better compromise formation. Alfred Lowenstein, Heinz Hartman, Ernst Kris, David Rappaport, and Gertrude and Rubin Blank have been important contributors to the ego psychology viewpoint.
Self psychology explicitly broke away from Freudian drive theory by focusing on “what is the meaning of being human?” For Kohut, man was bedeviled by the individual’s experience of isolation combined with an innate desire to have purpose, rather than by feelings of guilt for having forbidden wishes. The development of the self was not just a series of successfully defended internal conflicts creating one’s character style, rather Kohut proposed that self-esteem developed along its own trajectory. Self-esteem and personal vitality are created through both affiliation (empathy) and conflict (frustration) in interpersonal relationships as well as through cultural influences. Without frustration, the child never struggles and consequently fails to develop confidence in his or her own abilities. Without empathy, the child does not receive the support needed to deal with life’s vicissitudes (Kohut, 1959).
According to Kohut, the goal of analysis is to allow the patient to return to stalled developmental moments and experience having early unsatisfied needs gratified within the therapeutic relationship. This was in contrast to psychoanalysis—in which wishes were not to be gratified. In self-analysis, empathy from the therapist is considered an important intervention.
By providing emphatic immersion for the patient, Kohut became responsible for shifting the patriarchal gender role of the therapist to embody more feminine qualities (Mitchell & Black, 1995). Self psychology analysts attempt to provide optimal amounts of empathy and frustration to allow for repair to self-esteem and to grow the individual’s capacity for closeness with others. Those goals are indicative of mental health.
Important contributors of self psychology are: Howard S. Baker, Margaret N. Baker, Arnold Goldberg, Anna and Paul H. Ornstein, and Ernest S. Wolf.
Directions in Great Britain
During the same time as ego psychology was underway in the United States, disagreements in the British Psycho-Analytic Society (BPAS) were occurring between two prominent child psychologists, Anna Freud, and Viennese psychoanalyst Melanie Klein. These disagreements culminated in the Controversial Discussions, heated scientific meetings held at the BPAS during the Second World War, in which ideas were debated and which led to the emergence of three distinct psychoanalytic groups: the Contemporary Freudians represented by Anna Freud, and later Thomas Freeman, Joseph Sandler, Moses and Egle Laufer; the Kleinians, represented by Melanie Klein, Joan Riviere, Susan Isaacs, Wilfred Bion, and later Hannah Segal, Betty Joseph, and John Steiner; and the Independents or “Middle Group” represented by Ella Freeman Sharpe, James Strachey, Donald Winnicott, Ronald Fairbairn, Michael Guntrip, and Michael Balint. Many British psychoanalysts today continue to identify themselves within one of these three groups, although many have been influenced by the ideas of the other two. The Kleinian school has been particularly influential in countries in South America and, more recently, in Eastern Europe.
The term object in object relations theory refers to a person, specifically the object (person) the individual desires. Freud conceptualized the instinctual drives as aimed at discharging energy—and therefore relationships happened as a result of a person meeting the needs of the discharge. In contrast, for Melanie Klein, innate envy and destructiveness were manifestations of the death instinct and predominated in early life, giving rise to persecutory anxieties of annihilation and primitive defenses, unconscious phantasies and an archaic superego, which characterized the “paranoid schizoid” position (Klein, 1946). At the early stage of development, immature defense mechanisms such as splitting and projection predominate, and a baby is unable to integrate conflicting experiences. If a child is unable to reconcile their good and bad experiences of self or other, splits are created where the self or other is seen as all bad or all good. However, splitting interferes detrimentally with the ability to experience reality as it is. Mental health is considered a developmental achievement of a balanced or integrated view of self and other, where good and bad can exist within the same person. This point of view gradually develops into the more mature “depressive position” with the tolerance of loss and ambivalence (Klein, 1935). Klein emphasized the role of innate drives in the development of the mind, whereas Winnicott emphasized the role of the environment. He posited a central role for the mother in his concepts of the “facilitating maternal environment” and the maternal “holding” functions. The holding function of the analyst and of the analytic situation provides an atmosphere in which the patient can feel safe and contained, even when severe regression has occurred. In contrast to Klein, Winnicott (1971) saw aggression as a creative force necessary for healthy development by enabling individuation and separation. He believed that pathological aggression and antisocial behavior arose as a reaction to early deprivation and trauma (Winnicott, 1956).
Bion’s concept of containment is similar to Winnicott’s (1954) concept of “holding.” Wilfred Bion (1897–1979) posited that infants need their mothers to understand and cope with their early affective experiences, which are “contained” by the mothers and then reflected back to the baby in a “metabolized” form. Mothers attuned to their baby’s feelings and experiences are able to provide successful “containment” for the baby’s experiences. Babies who are able to internalize the mother’s perception of their affective state as well as the mother’s strategy for soothing the infant learn to regulate their emotions. However, if the early caregiver is not attuned to the infant’s affective experience, this mismatch causes the baby to remain frustrated, anxious, angry, and afraid, thereby interfering with healthy development.
A PD oriented therapist conceptualizing a case formulation from an object relations point of view would ask, “What earlier relationship is being replayed in current problematic relationships?” The goal of the treatment would be to have insight into how earlier relationships influence present relationships. The development of a realistic and flexible worldview of self and others in place of rigid and maladaptive representations is considered a successful treatment outcome. In other words, therapists try to help patients to temper extreme views so that they come to appreciate the good and the not so good qualities, which can exist within the same person.
The therapist’s supportive stance is seen as another form of containment, therefore authentic connection with another in a healthy relationship is a therapeutic experience in and of itself. Important contributors to object relations theory are Wilfred Bion, Ronald Fairbairn, Harry Guntrip, Otto Kernberg, Stephen Mitchell, and Donald Winnicott.
Relational Psychoanalysis and Psychotherapies
From object relations theory emerged relational psychotherapies, which further emphasize the interpersonal aspect of individual development. In more traditional object relation theories, innate drives for relationships create fantasies about needs and experiences, which are more important contributors to the development of a person than is their actual experience. In relational psychotherapies, the actual experience between self and others, including the wider cultural influences, are thought to be more responsible for the individual’s experience and development of self than are wishes or fantasies.
Interpersonal theories differ from classic Freudian theory by emphasizing the interpersonal nature of personality development. For Freud, the dynamic elements of the personality were an experience of internal or intrapsychic conflict. Alfred Adler pointed out, however, that individuals were responsive to their interpersonal environment and not only to intrapsychic events. Interpersonal theorists such as Harry Stack Sullivan (1964) saw personality as manifested during interactions with other individuals. He proposed that there is an interpersonal field that exists in the ongoing interaction between people. According to interpersonal theorists, study of this field is more relevant than study of the individual or personality in isolation (Mitchell & Black, 1995). Sullivan broke with traditional psychoanalysis further by changing the perception of the analyst from that of a neutral observer to recognizing the therapist as a participant-observer, in appreciation for how all participants of any interaction shape its dynamics. Besides Sullivan, contributors to interpersonal theory come from diverse areas of psychology and include Ruth Benedict, Erich Fromm, Karen Horney, Fritz Heider, Leonard Horowitz, Timothy Leary, Kurt Lewin, George Herbert Meade, and Irvin Yalom.
John Bowlby was a psychoanalytically trained developmental psychologist who was heavily influenced by ethology and evolutionary concepts in his creation of attachment theory. As a result of accumulating solid empirical results, attachment theory has achieved a reputable standing, not only in psychoanalysis but also in psychology in general (e.g., Fonagy, 2001).
The attachment system is a biologically based system, which engenders the infant with innate strategies for survival by engaging the caregiving system of nearby potential caregivers (Bowlby, 1988). Infants’ adaptation and defenses are aimed at and result from success or failure of engagement with caregivers. It is through the interactions with caregivers that infants develop their attachment pattern. A secure attachment pattern results from successful attempts to get their needs met, which enable the infants to feel safe and encouraged to explore the environment on their own (“felt security”). Building upon earlier object relations theories, affect regulation strategies are developed through the experience of early caregivers attuned to and reflecting to the infants their affective experience resulting in the infants acquiring, through internalization, strategies for tolerating frustration and discomfort. Internalization is a learning process whereby infants create cognitive representations of relationships called internal working models, or schemas. Therefore, cognitive and affective schemas are created as the infant interacts with their early caregivers, and this in turn is thought to shape perceptions and behaviors in relationships for the rest of the individual’s life (Bowlby, 1988).
When a parent is inconsistent or depriving in their response to the child’s needs during development, the child turns to maladaptive self-regulation strategies in the hope to obtain “felt security.” Subsequently, insecure attachment patterns (avoidant and ambivalent) result and with it internal working models of relationships with others that lead to dysfunctional patterns of interpersonal relating throughout the lifespan (e.g., Main, 1995). Both secure and insecure attachment patterns are considered to be organized patterns of attachment. Organized means the child has an organized and predictable set of strategies aimed towards attachment goals. However, there is another pattern of attachment, which is called disorganized and is linked to caregivers who are frightened or frightening. Disorganized attachment is often related to traumatic histories and has been found to predict the development of later psychopathology.
Beatrice BeeBee, Inge Bretherton, Patricia M. Crittenden, Peter Fonagy, Frank Lachmann, Mary Main, and Alan Sroufe have made substantial contributions to the body of attachment theory research, and reading their works is encouraged for a comprehensive overview. Cassidy and Shaver edited an excellent review of attachment research (2008), and Allen offers a compelling integration of attachment theory and clinically relevant findings in relation to trauma (2000).
Commonalities of PDP
Characteristics of PDP
PDP differs from psychoanalysis in several general ways. PDP is a shorter-term treatment and is less intensive, in that it is conducted in weekly, occasionally twice weekly as opposed to four or five sessions a week for psychoanalysis. Additionally, PDP sessions are conducted face to face, whereas in classical psychoanalysis the patient lays on a couch, and the analysts sits behind the patient, allowing for as neutral an observation by the analyst as possible. As aforementioned, a common assumption of PDP’s, and a remnant of psychoanalysis is that people have an unconscious life, including desires, wishes, longings, and conflicts, which may direct behavior outside of the scope of a person’s awareness. Therefore, insight into that unconscious life is the preeminent treatment goal, as this facilitates understanding at an emotional and cognitive level. Understanding one’s contribution to the maintenance of maladaptive patterns and insight into motivations for such behaviors offers people a choice hitherto not available. Hence, the capacity for problem solving is promoted through awareness.
Across PDP modalities, there is an emphasis on the therapeutic relationship as a contributor—or at the least, a precondition—for this change. The therapeutic relationship offers a context for the examination of one’s mental life and therefore offers possibilities to reconstruct the past and present narratives. Most PDP therapists agree that a supportive and accepting therapeutic environment is likely to be required for the delivery of successful interventions.
Transference and counter transference are common considerations in understanding the dynamics between the therapist and patient, and the therapeutic relationship itself is considered a tool for exploration in the service of self-understanding. Transference describes the characteristic interpersonal pattern of relating, which is reflected or rather, brought into existence in the intense relationship between patient and therapist. Malan described two therapeutic triangles, the triangle of conflict, and the triangle of persons. Malan proposed that every interpretation the therapist makes could be understood by these two triangles. In a more traditional model, it is important to focus on “each apex of the triangle” (Malan, 1976, 1979; Menninger, 1958). Events that occur between the therapist and the patients, events occurring in the current life of the patient, and events of the patient’s past must all be addressed and explored (each of them being a corner of the “triangle of person”).
Confrontations aimed to promote awareness are facilitated through the alliance of the patient and the therapist working together. The working alliance between the patient and the therapist allows for interpretations aimed to promote understanding of previously unknown thoughts, ideas, motivations for behavior, and ambiguity towards change in the context of an emotionally charged exchange. These elements are thought to be intrinsic to positive treatment outcome.
Explicit and task oriented homework, which are often central to cognitive and behavioral type of treatments are uncommon in PDP. Nevertheless, there is an implicit assumption that the patients should exercise what they have learned in therapy, and they should attempt to model their therapists by, for example, examining their thoughts and feelings and being curious about their mental states (e.g., Summers & Barber, 2012). PDP uses open-ended questions to help patients develop the capacity for examination of themselves. The use of clarifications and interpretations, whether they be of the interpersonal exchange or of characteristic use of defenses, are common treatment strategies.
Psychodynamic treatment goals are dependent on the particular presentation, needs, and goals of the patient (Summers & Barber, 2012). Patients’ goals often involve the desire to alleviate discomfort related to anxiety, depression, and interpersonal functioning. Furthermore, an individual’s mental health encompasses more than an absence of symptoms but addresses functioning across relationships, access to emotional depth and range, awareness of self, the ability to observe oneself, as well as strategies for affect regulation, combined with one’s ability to integrate those abilities into effective coping strategies. PDP does not deny the existence of biologically based symptoms, however, as a treatment; PDP privileges the treatment of psychologically based symptoms. For many PDPs, regardless of the particular target of intervention (e.g., panic symptoms, sleeplessness, conflict of ego, early relationships), the continued psychosocial development of individuals in adulthood is the ultimate aim of treatment. As people become aware of conflicts and resolve earlier experiences symptoms are expected to ameliorate or be eliminated.
A dynamic case formulation is ideally used in addition to, or in place of, nomological (formal) diagnosis and consists of the understanding of the underlying dynamic factors (conflicts) directing the problematic behavior arising as symptoms in the individual’s experience and behaviors. The case formulation, including some education about the patient’s discrete diagnosis and treatment goals are often discussed during the early phases of treatment. In contrast to more traditional psychoanalysis, goals are set early in PDP. However, as the patient’s understanding changes so can the treatment goals, which necessitate monitoring progress as an important part of treatment. Therefore, maintaining agreement on goals and active progress monitoring are tools used to ensure engagement of patients in their treatment. Interventions are aimed to increase the patient’s insight into their unconscious conflicts or ambivalence, decrease the use of maladaptive defenses, increase the patient’s access to adaptive defensive functioning, increase flexibility within interpersonal functioning and perceptions, and increase the patient’s capacity for mentalization and higher quality mental representations of self and others (Summers & Barber, 2012).
Summers and Barber (2012) provide guidelines and rationale for a comprehensive case formulation based on prior work from (Perry, Cooper, & Michels, 1987). Creating a formal case formulation forces the therapist to think about their patient’s presenting problems and link their history, diagnosis, nondynamic factors, and dynamic factors in a way that makes sense of the case and predicts treatment response. The therapist will have to consider what they do not know, and let seeking to answer those questions help guide the approach to treatment. Summers and Barber further emphasize that the case formulation should not be so rigid as to not take into account the changing patient, but should also have enough structure that the patient feels supported and can trust the therapist has an effective treatment plan in place.
In modern PD theory and practice, there has been an upsurge in treatments designed to target specific disorders, all the while keeping with the PDP tradition of treating the individual as a whole: for example, panic-focused psychodynamic psychotherapy; (Milrod, Busch, Cooper, & Shapiro, 1997), psychodynamic therapy for depression; (Busch, Rudden, & Shapiro, 2016), supportive-expressive therapy for depression (Luborsky, Mark, Hole, Popp, Goldsmith, & Cacciola, 1995), transference-focused psychotherapy (Yeomans, Clarkin, & Kernberg, 2015), and mentalization-based treatment (Bateman & Fonagy, 2016)—both for borderline personality disorders.
Interventions/Techniques of PD
Several concepts and techniques from the early period of Freud’s theory have remained valuable in contemporary PD today. Free association was the main psychoanalytic tool believed to enable access to unconscious thoughts. The patient would report all thoughts as they emerged in the mind, without reservation. The therapist served as a neutral observer allowing for the transference to emerge. From the classical view of transference, wishes, impulses, and fantasies of past relationships were literally “transferred” onto the analyst, due to the lack of interference by the therapist’s neutral stance. In contemporary PD practice, the idea of transference is still relevant, however the concept has broadened. Accurate interpretations of transference are believed to help engender insight in the patient. Self-understanding (insight) is considered the cardinal goal in many PDPs (Messer & McWilliams, 2007).
There are many additional techniques common to various types of PDP. Techniques can be conceptualized on the continuum of supportive to expressive (Luborsky, 1984). Supportive techniques include what is often considered the common factor techniques of psychotherapy, for instance showing acceptance and support towards the patient. Other supportive techniques specific to PDP are ego-strengthening techniques like gratification and boundary setting. Expressive techniques are interventions designed to explore affect and interpersonal themes. Their aims are often to bring to consciousness previously unconscious contents. Examples of expressive techniques include: confrontation, clarification, and interpretation. Because of the active nature of these techniques, they are the focus of research more often than supportive techniques, and findings for expressive techniques have been more substantial than those for supportive techniques (Barber et al., 2013).
Effectiveness of PDP
Empirically Supported Treatments: Advantages and Disadvantages
In North America, the United Kingdom, Australia, New Zealand, and European countries, it is increasingly required that treatments should be supported by a robust evidence base. According to the American Psychologist Association Division 12 Task Force (1995), for a treatment efficacy to be considered well established, the requirement is that at least two well-designed between-group randomized trials either demonstrate superiority to a placebo (pill or psychotherapy) or another treatment, or alternatively, equivalence to an already established treatment (with adequate sample size). The study must include a manualized treatment targeting a well-defined population. Finally, at least two different research teams must demonstrate similar results, providing replication.
The requirement to conduct a randomized control Trial (RCT) for establishment of an “empirically supported treatment” put psychodynamically oriented treatments at a disadvantage. Because of the lack of tradition to conduct RCTs and because, in traditional psychoanalysis, treatments were long lasting and aimed towards complex types of intrapsychic changes that were difficult to quantify, another approach was taken by the APA Division of Psychotherapy (Division 29). Namely, they focused on participant and relationship factors, as they are considered relevant to good outcomes (Norcross, 2011).
As the two task forces were ultimately found to be at odds with one another, the American Psychological Association’s Presidential Task Force on Evidence-Based Practice was formed. Their conclusions emphasized that data from both RCTs and clinical experts were needed to understand what works in psychotherapy (Castonguay & Beutler, 2006). While RCTs provide optimal internal validity (efficacy), and enable us to derive causal relations between treatments and outcome, that methodology does not always account for how efficacious those treatments will be in real world clinical settings (effectiveness). To resolve some of those issues, some investigators have turned to naturalistic studies (Barber, 2009), often investigated via the Practice-Oriented Research networks (POR; Castonguay, Youn, Xiao, Muran, & Barber, 2015). In POR, researchers work hand in hand with clinicians for each step of the process, from developing the research questions, study design, implementation of the protocol, and dissemination of the findings. The data is collected as a part of clinical routine care and allows for capturing symptom presentation and treatment outcome in day-to-day practice. For the most part, the delivery of treatment does not follow a strict protocol and reflects every day practice.
Be it RCTs or naturalistic studies, there is growing body of well-done research that supports the efficacy and effectiveness of PDP in the treatment of a wide range of disorders, both in long and short-term treatments.
Short-Term Psychodynamic Psychotherapy
In contemporary medicine and in mental health, the demand for empirically supported treatments has become the norm. Similarly, there is an ethical requirement for psychologists to provide their patients with the most direct, effective, and non-harmful treatments available.
Short-term dynamic therapy (STDT), developed from the work of Malan, Main, Sifneos, and Davanloo, is a time-limited form of PDP ranging from 8 to 40 sessions. STDT, especially those versions utilized in research, are generally manualized treatments that have been designed to treat specific disorders and that target discrete symptom clusters over structural character changes. The treatment interventions focus on symptoms formulated by a dynamic understanding of the individual’s psychopathological behaviors.
For example, panic-focused psychodynamic psychotherapy (PFPP; Milrod, Busch, Cooper, & Shapiro, 1997) was designed with the understanding that psychological conflicts or un-symbolized affective states are at the root of panic attacks. Interventions are designed to help the individual develop insight into how their panic attacks may be an expression of unconscious conflicts or fears. Insight is posited to give the patient more choices in how to effectively navigate panic symptoms. In a well-designed multi-site RCT, Milrod et al. (2016) and her group compared the treatments of applied relaxation training (ART), cognitive behavioral therapy (CBT), and PFPP for the treatment of 201 patients with a primary DSM-IV diagnosis of panic disorder with or without agoraphobia. They found that all treatments substantially improved patients’ symptoms of panic disorder. Although CBT demonstrated stronger performance at one site, there was no difference between CBT and PFPP in outcome at the other site.
There is a considerable amount of research demonstrating STDT efficacy. Leichsenring et al. (2015) identified 64 RCTs that addressed PDP for specific mental disorders. Only two of the studies included treatment protocols longer than 40 sessions. Leichsenring et al. (2015) concluded that PDP was superior to control conditions for depression and not different from other active form of treatments at end of treatment and at follow up (see also Barber, Muran, McCarthy, & Keefe, 2013). In their meta-analysis of STDT for anxiety disorders, Keefe, McCarthy, Dinger, Zilcha-Mano, and Barber (2014) reported medium to large-effect sizes of PDP compared to controls and no difference with other treatments (see also Leichsenring et al., 2015). Beyond depression and anxiety disorders, PDP has been found to be efficacious in the treatment of somatic disorders, eating disorders, and substance abuse disorders (Leichsenring et al., 2015).
Personality disorders present a more complicated picture, due to the diversity of the personality pathology as well as the diversity of treatment protocols within PDP for personality disorders. That being said, two meta-analyses (Barber et al., 2013; Town, Abbass, & Hardy, 2011) have indicated PDP was more effective than controls in general outcome and no difference between other treatments in both general and secondary outcome. Further, medium-term PDP treatments created specifically to treat borderline personality disorder have been designated by the APA Division 12 (2012) as a well-established treatment (transference focused psychotherapy [TFP]; Clarkin, Levy, Lenzenweger, & Kernberg, 2007) and probably efficacious (mentalization-based treatment [MBT]; Bateman & Fonagy, 2016). Furthermore, Fonagy et al. (2015) showed that adding PDP to treatment as usual for treatment resistant depression resulted in better outcome during follow up but not at treatment termination. Those data are suggestive that long-term PDP could be helpful at improving the long-term outcome of difficult to treat patients. While it is clear that PDP works in treating a multitude of disorders, understanding as to how those treatments work is an ongoing question well worth investigating.
Mechanisms of Change—A Definition
A mechanism of change is one or more active processes that take place within the mind/brain of the patient, accounting for the change in the outcome of a specific treatment. It is important to know if the theoretical assumptions of what changes in people is indeed the actual mechanism at work. In this way, ineffective elements of treatments can be eliminated, and effective elements of treatments can be streamlined and focused towards precise and targeted positive outcomes.
A large body of evidence has established that a variety of types of psychotherapy are effective in the treatment of a range of psychological and psychiatric disorders (e.g., Lambert, 2013). Despite numerous studies, no treatment modality has been consistently shown to be more effective than any other. (For a more thorough discussion of findings see: Barber et al., 2013; Leichsenring et al., 2015). However, even if there was evidence of one treatment working better than another, it would not on its own elucidate “how” the treatment affected change; yet it is the “how” of psychotherapy that is most important for researchers and clinicians to understand (e.g., Kazdin, 2007). Formulating and investigating the mechanisms of change aims to elucidate what is effective in treatments and allows for the refinement of treatment approaches that will better “fit” the distinct needs of individual patients. “Fit” extends beyond matching diagnostic clusters to a particular modality, but considers patient and therapist contributions interactively with symptom presentation to determine moment-to-moment treatment options (e.g., Barber et al., 2013; Norcross, 2011).
Research has begun to investigate these mechanisms of change thought to be specific to the treatment goals and outcomes of PDP, hoping to illuminate if they are indeed the “how” of the treatment success (i.e., symptom reduction; see Barber et al., 2013 for a review). Several mechanisms can be considered as the change mechanisms of treatment, and change in these factors may result in desirable treatment outcome as well.
Investigations of Specific Mechanisms of Change
The concept of the therapeutic alliance has its origins in Freudian thought and emerged implicitly, as Freud considered the patient to be a partner in treatment (Freud, 1912, 1958). For Freud (1958), the transference, and interpretations of the transference, was the main focus of analysis. Ralph Greenson (1965) furthered the concept of alliance by differentiating the transference aspect of the therapeutic alliance, and the real relationship. The “real” relationship gave privilege to what was transpiring between the patient and therapist in earnest, apart from transference. Greenson noted that trust and goodwill were required for the patient to set about the required work of therapy. If the relationship only consisted of transference and projections, this trust could not be established. Greenson (1971) further developed the concept of the alliance as a working or therapeutic alliance, in which the therapist and patient work with one another towards the mutual purpose of moving the treatment forward.
Bordin reconceptualized the alliance by further separating the concept from its exclusive origins of transference, to a broader and trans-theoretical concept. This shift contributed to the ability to measure and study the therapeutic alliance across different treatment modalities and its relation to patient change. The trans-theoretical definition of the alliance comprises three related factors: goals, tasks, and bonds (Bordin, 1979). Goals consist of the overarching aims of the treatment; for a type of PDP, this may be for the patient to gain insight into how conflicts between desires/instincts and defenses manifest in interpersonal difficulties, ultimately, offering the patient more choices in how they attend to their needs and others. For a CBT type of treatment, the goal of treatment may focus on reducing symptoms of depression, to allow the person to gain a deeper fulfillment from their current relationships. Tasks are the immediate interventions used towards achieving said goals. For PDP, this may be offering an interpretation aimed at facilitating insight into transference or for CBT, correction of a distorted cognition, through asking for evidence of a particular thought. The strength of the alliance is dependent on the degree of agreement between therapist and patient on these two aspects of alliance, regardless of the treatment modality. And last, there is the bond, or rather the affective component of the alliance. The bond is both a separate component of the relationship, from which trust for agreements on tasks and goals may evolve, as well as part of an alliance that may develop due to experience of the positive effects of agreement on tasks and goals.
Alliance is a well-validated, small, yet robust predictor of treatment outcome (explaining 8% of the variance; Barber et al., 2013; Horvath, Del Re, Flückiger, & Symonds, 2011; Muran & Barber, 2010). However predicting outcome is not the same as being a mechanism of change. There is strong reason to believe that it is a precondition for change, but there is less research supporting the role of the alliance as a mechanism of change. Nevertheless, there are researchers who believe that the therapeutic relationship itself is an active ingredient of treatment (e.g., Flückiger, Del Re, Wampold, Znoj, Caspar, & Jörg, 2012). Demonstrating temporal precedence, meaning that establishing that the proposed mechanism changes before symptom changes is one requirement for validating an active ingredient in treatments. Zilcha-Mano, Roose, Barber, and Rutherford (2015) were able to establish such a temporal precedence demonstrating change in alliance predicting subsequent symptom reduction in patients suffering from depression. Safran and Muran (2000) contend that attention to ruptures within the alliance, and reparation to those ruptures, is what makes the therapeutic alliance a mechanism of change. Further, researchers are utilizing microanalysis to examine within-session fluctuations of the alliance to gain a more accurate and clinically useful understanding of this proposed mechanism (Falkenstrom and Holmqvist-Larsson, forthcoming). For a more thorough overview of the challenges of examining alliance refer to Muran and Barber (2010).
PD therapists target defenses; therefore, researchers are interested to discern if change in defensive functioning is a mechanism of change in PDP. The patient’s frequency of use and the tendency to implement immature defenses over higher order defenses has been found to correlate with increased levels of psychopathology and symptoms (see Barber et al., 2013 for a review of these findings). A reduction of lower order defenses over treatment and an increase in higher order defenses has been demonstrated. Further, those changes in defensive functioning have been found to relate to positive treatment outcome (e.g., Johansen, Krebs, Svartberg, Stiles, & Holen, 2011). Although defenses are a target of PDP, they have been shown to change positively across different treatment modalities. Perry and Bond (2012) also found evidence that change in defensive functioning during treatment predicted later improvement in symptoms and functioning at follow-up five years later. Defense mechanisms are strongly related to character or personality structure, and change in defense mechanisms may be evidence of deep and long-lasting change. Although promising, further research needs to be done to confirm change in defenses as a mechanism of change.
Insight or self-understanding is thought to be a crucial element in the instigation of change from a PD perspective. The therapist aids in the patient’s acquisition of insight by offering interpretations into different domains (e.g., the patient’s use of defenses, interpersonal patterns of relating). Insight is thought to have an emotional and a cognitive component, and can be experienced in either or both domains. The cognitive experience of insight is a purely intellectual understanding of one’s symptoms, whereas emotional insight is the experience of one’s conflict in a novel way. Both can occur as an epiphany, or one can arrive at insight over time.
There is reasonable support for insight as a mechanism of change for symptom change (For a review, see Gibbons, Crits-Christoph, Barber, & Schamberg, 2007; Barber et al., 2013; Crits-Christoph, Connolly-Gibbons, & Mukherjee, 2013). Early work by Malan (1976) demonstrated a positive correlation between good long-term outcome and genetic transference interpretations (interpretations aimed at insight into history with parents). Later studies similarly demonstrated that insight increases during PDP (e.g., Gibbons et al., 2009), and increases of insight during treatment have been associated with change in symptoms (e.g., Johansen et al., 2011). Among others, Grande and colleagues (2003) were able to establish a temporal relation between increase in self-understanding during treatment and subsequent symptom change during follow-up in patients with various disorders. Studies have demonstrated further evidence of insight as a mechanism of change specific to PDP (Connolly-Gibbons et al., 2009). This work has been extended by two other studies, which linked the use of transference techniques to increase in insight, followed by treatment gains in interpersonal and global functioning (Høglend, 2014). Empirical research demonstrates that moderate use of transference interpretations, when mediated by insight, has specific effects on long-term functioning.
Improving the Quality of Patients’ Mental Representations of Relationships
Quality of Object Relations (QOR; Azim, Piper, Segal, Nixon, & Duncan, 1991), a specific term used for the cognitive and affective representation of an individual’s relationships, is another construct of importance in the PDP change literature. QOR is a construct similar to internal working model or schema in attachment theory. QOR are thought to develop during infancy and early development from the interactions with early caregivers. Events and conflicts alongside affective experience are encoded, which creates enduring expectations of how self and others will behave. Multiple studies have shown that QOR has changed during PDP, and that change in QOR is associated with symptom improvement (e.g., Vermote et al., 2010; see also Barber et al., 2013). Additionally, for individuals with low QOR, transference interpretations led to increased insight and subsequent gains in interpersonal and global functioning (e.g., Høglend, 2014).
Much QOR research has looked at it as a moderator of treatment outcome rather than as a mechanism of change within treatment.
Reflective functioning (RF) has arisen as the newest proposed mechanism of change in PDP (Barber et al., 2013; Fonagy & Bateman, 2006). RF is an individual’s capacity to reflect upon one’s own and others’ motivations for behaviors as well as to comprehend their own and others’ mental states. Inherent to RF is the understanding of the transgenerational transmission of communication and affect regulation strategies, as well as the ultimate opaqueness of other’s thoughts (for a detailed review see Katznelson, 2014). There is evidence that the capacity for mentalization can increase during PDP for patients diagnosed with Borderline Personality Disorder (Levy et al., 2006), but not in other studies for different disorders (e.g., Rudden, Milrod, Target, Ackerman, & Graf, 2006). This discrepancy has led investigators to look into symptom-specific areas of RF. Indeed, panic-specific RF was found to increase during PDT for panic disorder (Rudden, Milrod, Meehan, & Falkenstrom, 2009) and to predict outcome within three treatment conditions; panic specific psychodynamic psychotherapy, cognitive-behavioral therapy, and applied relaxation therapy (Barber et al., 2015). Prevalent in psychodynamic theory is the idea that early caregivers have a great impact on the development of an individual, and psychopathology within that individual. The concept of RF moves this theory forward with a substantial and growing empirical basis. RF has clearly been linked to psychopathology (e.g., Bouchard et al., 2008; Taubner, White, Zimmerman, Fonagy, & Nolte, 2013) and functioning (Levy, Meehan, Reynoso, Lenzenweger, Clarkin, & Kernberg, 2005). However, further research is needed to determine its relation to process and outcome in PDP.
Rigidity in Interpersonal Perceptions and Behaviors
Several psychodynamic theories, attachment and object relations for example, concur that the amount of rigidity with which an individual clings to cognitive and affective schemas can be a determinant of mental health (e.g., Kiesler, 1996). If someone is too rigid in their viewpoint, they are unable to use the environment to modify old schemas or provide new and more adaptive experiences.
For instance, hypervigilance towards the environment may have been adaptive for a child growing up in a domestically abusive household, where knowing how to gauge the mood of the caregiver was important for survival. However, once out of that environment, the previously adaptive hypervigilance can turn into paranoia and inhibit the development of trust that is crucial for relationship intimacy. PDP has been shown to reduce relationship rigidity, however this change has not been related to symptom change (e.g., Gross, Stasch, Schmal, Hillenbrand, & Cierpka, 2007). Investigators have also suggested the existence of a curvilinear relation with symptoms as explanation for this lack of association between symptom levels and change in rigidity (Barber et al., 2013). Nonetheless, developing the ability to view one’s experience from a more varied perspective is a broad treatment goal specific to PDP, which is not necessarily dependent on symptom presentation.
Process and Outcome Research: Techniques and Interventions
The relations between interventions and outcome are complex, as demonstrated by equivocal and contradictory findings. How well an intervention is delivered (therapists’ competence or clinical acumen) must be taken into consideration. For example, although use of interpretation and clarification techniques have repeatedly been found to have a negative relation to treatment outcomes (for a review, see Høglend, 2004), the accuracy of interpretations has been show to relate to treatment outcome (Crits-Christoph et al., 2013). Another important dimension of evaluating intervention includes examining the competent delivery of an intervention. Although earlier reviews had shown a small correlation between competence and outcome, a more recent meta-analysis of this issue, Webb, DeRueis, and Barber (2010), found no relations between competent delivery of an intervention and outcome.
Further, depth of analysis can influence research findings. For example, when expressive techniques have been examined as an aggregate, findings have been equivocal in relation to treatment outcome (Barber et al., 2013). However, investigations of individual interventions (as opposed to expressive techniques as an aggregate) have shown a more consistent relation between process and outcome. For example, in their meta-analysis, Diener, Hilsenroth, and Weinberger (2007) reported a consistent association between exploration of affect and positive therapeutic outcomes. Several studies have demonstrated a link between exploration of interpersonal themes and outcome (see Barber et al., 2013; Crits-Christoph et al., 2013). A comprehensive discussion of process-outcome research is seen in the review of Crits-Christoph et al. (2013), illuminating what happens in a session of psychotherapy that ultimately aids patients in reducing symptoms and gaining the ability to enjoy life more fully.
Psychodynamic therapy has a long and complex history, which is always transforming itself. It will continue to do so. In fact, one could make the point that Beck’s cognitive therapy is a further development of ego psychology. In any case, emerging from psychoanalysis, PDP is widely used in its different forms around the world. Even if current fashion seems to suggest that cognitive behavioral therapy is taking over the field of psychotherapy, we want to make to make the points that (a), knowledge of psychodynamic theory and therapy is likely to lead to a better understanding of clients, and (b), most CBT therapists who go to therapy choose a dynamic therapist. We also want to emphasize that, in contrast to what was known before the 1980’s, in the end of the 20th and beginning of the 21st century, there is clear evidence for the efficacy of PDP and for its mechanism of change.
Glossary of Key Terms
—An early Freudian term, this is the result of the release or purging of repressed affect or experiences, which provides relief of tension created by the burden of repression.
—An intervention to sharpen the patient’s focus on something, often something that is likely to have been previously disconnected or an unorganized experience. It is simply working to bring recognition to a problem so it can then be worked through.
—The outcome of the unconscious conflict between repressed desires and the expression or consequence of fulfillment of those desires. For example, panic attacks can be seen as an attempt to compromise between unconscious desires to be cared for and angry feelings towards loved ones.
—The therapist attempts to bring awareness to an inconsistency presented by the patient. For example, the patient may be displaying a nonverbal cue (smiling) while speaking about a sad event, and the therapist will point out this inconsistency.
Corrective emotional experience
—The reexperiencing of unresolved negative or traumatic emotional experiences of the past in the context of a therapeutic environment, which facilitates a different and more positive experience and perspective of the original event.
—The therapist’s emotional response to the patient, which is formed by a combination of the therapists personal transference process as well as contributions made by the patient’s projections. The therapist’s own transference is expected to arise in the therapeutic relationship, particularly in response to the patient’s presentation and what is taking place in the reality of the interaction of the therapeutic dyad. Countertransference is used by some as an indicator of enactments instigated by the patient and becomes a guide for treatment.
—Defenses are mental processes that help the human mind process internal and external experience. (See Glossary of Defense Mechanisms for a comprehensive list of defense mechanisms.)
—The result of the modification of the id by one’s experience with the external world, the ego is a split off aspect of the id. The ego was developed to modify the impulses of the id into acceptable demands that can be satisfied in compliance with expectations of the external world. The ego is the decision-making aspect of the mind, which negotiates the demands of the id and the superego.
—The process of the therapist and patient participating in a recapitulation of a patient’s early experience. It is brought about by both the patients transference and the therapist countertransference contributions occurring outside of either’s awareness.
—The part of the mind that Freud defined as responding to our instinctual demands and needs. It is the most primitive and impulsive aspect of the mind, demanding immediate gratification of one’s needs.
—The process by which external objects and experiences become intrinsic parts of the makeup of an individual.
Insight or Self-understanding
—Becoming aware of motivations, beliefs, emotions, expectations or behaviors that, until now, have remained under the radar of awareness. Theorists mention two kinds of insight, a cognitive or intellectual understanding of self and an experience of an emotional understanding of self. For lasting change to occur, both types of insight are thought to be necessary.
—An interpretation adds meaning to an experience. A hypothesis the therapist formulates about the “why” of a patient’s experience is presented to the patient. The intent is to help the patient gain understanding of something, often previously held as unconscious motivations, conflicts, or defenses. Interpretations may be made towards transference, defenses, or resistances. For an interpretation to be successful it is important it is well timed (given at a time the patient is likely to be receptive to it), and that it have both cognitive and emotional impact.
—Describes the tendency of the patient to behave in a way that disrupts the treatment process. It may be the patient is ambivalent about changing, or has a fear of annihilation; or it may be a negative response to a troublesome therapeutic intervention. In traditional psychoanalysis, the primary objective was exploration of the resistance.
—In the most general of descriptions, transference is the “transfer” of any feelings, perceptions, and experiences of earlier relationships onto present relationships (broad view of transference) and specifically onto the therapist (the narrow view of transference).
—The revelation by the patient of their factual episodic and affective experiences to the therapist. In modern, and particularly within relational, PDP, therapist self-disclosure is an active part of treatment used in the service of the patient.
—The aspect of the mind that is formed by the values and morals of one’s parents and society. Whereas the id places demands on the ego to gratify instinctual needs, the superego demands the ego strive for moralistic perfection rather than simple realistic goals.
—A traditional psychoanalytic understanding of fantasy is of an unconscious, imaginary scene in which the subject represents the fulfillment of a wish in a way that is distorted by defensive processes to a greater or lesser degree. A modern concept of unconscious fantasy converges with the cognitive therapy concept of schema, and with the attachment theory term of internal working model. Schemas are deep cognitive structures created during early life experiences. Either repetitive patterns of experience, or a singularly traumatic experience create a template, which the individual may use to understand and predict mental states and behavior of others. If the unconscious fantasy develops adaptively, those schemas allow for a worldview closely related to reality. However, maladaptive schemas distort how the present reality is viewed and subsequently, those distortions aid in the maintenance of the schemas.
—The patient has the opportunity in the therapeutic environment to experience maladaptive interpersonal behaviors and habitual responses, while a light is shone on the experience. Within the therapeutic setting, these experiences can be revisited, explored, enacted, interpreted, and re-experienced, until the patient has been able to effectively experience emotionally and understand productively their experience.
Glossary of Defense Mechanisms
—The individual deals with emotional conflicts, or internal or external stressors, by turning to others for help or support. By affiliating with others, the individual can express him or herself, confide problems, and feel less alone or isolated with a conflict or problem. This may also result in receiving advice or concrete help. Confiding leads to an increase in the individual’s coping capacity as the other individual supplies emotional validation and support.
—The individual deals with emotional conflicts, or internal or external stressors, by dedication to fulfilling the needs of others, in part as a way of fulfilling his or her own needs. By using altruism, the individual receives some partial gratification either vicariously or as a response from others. The subject is usually aware to some extent that his or her own needs or feelings underlie altruistic actions. There may also be a direct reward or overt self-interested reason for the subject’s altruistic actions.
Anticipation (Affective rehearsal)
—The individual mitigates emotional conflicts and internal or external stressors not only by considering realistic, alternative solutions and anticipating emotional reactions to future problems, but also by actually experiencing the future distress, by mentally bringing the distressing ideas and affects together. This rehearsal allows the individual to prepare a better adaptive response to the anticipated conflict or stressor.
—The individual deals with emotional conflicts, or internal or external stressors, by excessive daydreaming as a substitute for human relationships, more direct and effective action, or problem solving.
Denial (Neurotic or minor denial)
—The individual deals with emotional conflicts, or internal or external stressors, by refusing to acknowledge some aspect of external reality of his or her experience that would be apparent to others.
—The individual deals with emotional conflicts or internal or external stressors by attributing exaggeratedly negative qualities to oneself or others.
—The individual deals with emotional conflicts, or internal or external stressors, by generalizing or redirecting a feeling about or a response to an object onto another, usually less threatening, object. The person using displacement may or may not be aware that the affect or impulse expressed toward the displaced object was really meant for someone use.
—The individual deals with emotional conflicts, or internal or external stressors, by a temporary alteration in the integrative functions of consciousness or identity. In the defense of dissociation, a particular affect or impulse that the subject is not aware of operates in the subject’s life outside of normal awareness. Both the idea and associated affect or impulse remain out of awareness but are expressed by an alteration in consciousness. While the subject may be dimly aware that something unusual takes place at such times, full acknowledgment is not made that his or her own affect or impulses are being expressed. Dissociation may result in a loss of function or in uncharacteristic behavior.
Help-Rejecting Complaining (Hypochondriasis)
—Help-rejecting complaining (formerly called hypochondriasis, which name we forgo as it can be confused with the symptom disorder) involves the repetitious use of a complaint or series of complaints in which the subject ostensibly asks for help. However, covert feelings of hostility or resentment towards others are expressed simultaneously by the subject’s rejection of the suggestions, advice, or whatever others offer. The complaints may consist of either somatic concerns or life problems. Either type of complaint is followed by a “help-rejecting complainer” response to whatever help is offered.
—The individual deals with emotional conflicts, or internal or external stressors, by emphasizing the amusing or ironic aspects of the conflict or stressor. Humor tends to relieve the tension around conflict in a way that allows everyone to share in it, rather than being at one person’s expense, as in derisive or cutting remarks. An element of self-observation or truth is often involved.
—The individual deals with emotional conflicts, or internal or external stressors, by attributing exaggerated positive qualities to self or others.
—The individual deals with emotional conflicts, or internal or external stressors, by the excessive use of abstract thinking to avoid disturbing feelings.
Isolation of affect
—The individual deals with emotional conflicts, or internal or external stressors, by being unable to experience simultaneously the cognitive and affective components of an experience, because the affect is kept from consciousness. In the defense of isolation, the subject loses touch with the feelings associated with a given idea (e.g., a traumatic event) while remaining aware of the cognitive elements of it (e.g., descriptive details). Only the affect is lost or detached while the idea is conscious. It is the converse of repression, where the affect is retained but the idea is detached and unrecognized.
—Omnipotence is a defense in which the subject responds to emotional conflict or internal and external stressors by acting superior to others, as if one possessed with special powers or abilities.
—The individual deals with emotional conflicts, or internal or external stressors, by indirectly and unassertively expressing aggression toward others. There is a facade of overt compliance masking covert resistance toward others.
—The individual deals with emotional conflicts, or internal or external stressors, by falsely attributing his or her own unacknowledged feelings, impulses, or thoughts to others. The subject disavows his or her own feelings, intentions, or experiences by attributing them to others, usually by whom the subject feels threatened and to whom the subject feels some affinity.
—The subject has an affect or impulse that he finds unacceptable and projects onto someone else, as if it was really that other person who originated the affect or impulse. However, the subject does not disavow what is projected—unlike in simple projection—but remains fully aware of the affects or impulses, and simply misattributes them as justifiable reactions to the other person. Hence, the subject eventually admits his affect or impulse, but believes it to be a reaction to those same feelings and impulses in others. The subject confuses the fact that it was he himself who originated the projected material.
—The individual deals with emotional conflicts, or internal or external stressors, by devising reassuring or self-serving but incorrect explanations for his or her own or others’ behavior.
—The individual deals with emotional conflicts, or internal or external stressors, by substituting behavior, thoughts, or feelings that are diametrically opposed to his or her unacceptable thoughts or feelings.
—The individual deals with emotional conflicts, or internal or external stressors, by being unable to remember or be cognitively aware of disturbing wishes, feelings, thoughts or experiences.
—The individual deals with emotional conflicts, or internal or external stressors, by expressing one's feelings and thoughts directly in order to achieve goals. Self-assertion is not coercive or indirect and manipulative. The goal or purpose of the self-assertive behavior is usually made clear to all parties affected by it.
—The individual deals with emotional conflicts, or internal or external stressors, by reflecting on his or her own thoughts, feelings, motivations, and behavior. The person is able to “see himself as others see him” in interpersonal situations, and as a result is better able to understand other people’s reactions to him or her. The defense is not synonymous with simply making observations or talking about oneself.
—The individual deals with emotional conflicts, or internal or external stressors, by viewing himself or herself or others as all good or all bad, failing to integrate the positive and negative qualities of the self and others into cohesive images; often the same individual will be alternately idealized and devalued.
—The individual deals with emotional conflicts, or internal or external stressors, by channeling rather than inhibiting potentially maladaptive feelings or impulses into socially acceptable behavior. This defense is to be rated present only when a strong functional relationship can be demonstrated between the feelings and response pattern. Classic examples of the use of sublimation are sports and games used to channel angry impulses, or artistic creation that expresses conflicted feelings.
—The individual deals with emotional conflicts, or internal or external stressors, by voluntarily avoiding thinking about disturbing problems, wishes, feelings or experiences temporarily. This may entail putting things out of one’s mind until the right time to deal with them: it is postponing, not procrastinating. Suppression may also entail avoiding thinking about something at the time because it would distract from engaging in another activity that one must do (e.g., not dwelling on tangential problems in order to deal with one pressing problem). The individual can call the suppressed material back to conscious attention readily, since it is not forgotten.
—The individual deals with emotional conflicts, or internal or external stressors, with behavior designed to symbolically make amends for or negate previous thoughts, feelings, or actions.
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