Psychoanalytic Therapy

Psychoanalytic or psychodynamic psychotherapy is an umbrella term that describes the psychotherapeutic clinical application of a larger group of theories and principles stemming from psychoanalysis. Psychoanalysis began as the work of Sigmund Freud and quickly expanded through the work of his contemporaries, including Sandor Ferenczi, Carl Jung, Otto Rank, and Alfred Adler. The term "psychoanalytic psychotherapy" is often used interchangeably with "psychodynamic psychotherapy," but these terms are distinguished from psychoanalysis.  Psychoanalysis and psychodynamic psychotherapy use similar techniques, theories, and approaches to listening and understanding. Notable differences are intensity, frequency, and length of the treatment, whereas psychoanalysis is more intensive and of longer duration. In addition, the term "evidence-based psychotherapy" (EBP) is defined as psychotherapy that utilizes published findings to inform clinical decision-making.  Cognitive behavioral therapy (CBT) is frequently considered the prime exemplar of EBP, and psychodynamic psychotherapy has been historically excluded from this list of EBPs. Recent literature, however, has suggested that this distinction may be outdated and inaccurate, as emerging research on psychodynamic psychotherapies has demonstrated efficacy and effectiveness for various conditions. Several forms of psychodynamic psychotherapies derive from their associated theories. Theorists include: Freud. Ferenczi. Adler. Jung. Stack Sullivan. Kohut. Kernberg. Balint. Erikson. Klein. Sharpe. Bowlby. Winnicott. Ainsworth. McWilliams. Associated theories include drive theory, ego psychology, object relations theory, interpersonal psychoanalysis, self-psychology, and others. During the initial development period of psychoanalysis, Sigmund Freud was the primary contributor and leader of the movement, and many of the significant initial discoveries and methods developed are attributed to Freud. In his position as the leader and progenitor, Freud attempted to curate and develop psychoanalysis carefully, often requiring other theorists to follow his primary tenets or be expelled from the movement.  After Freud's passing, the field grew in a varied manner, with theorists and followers developing unique theories, lexicons, schools, and organizations. The following table provides a non-exhaustive list of theorists and their associated contributions, which often overlap with one another, given the collaboration—for example, multiple personality theories developed as a result of each theorist's formulation. Modern psychodynamic psychotherapy may utilize one or several of these theories to develop case formulations. Of note, the foundations of various other forms of psychotherapy, including humanistic, existential, and cognitive-behavioral, can be traced to the psychoanalytic movement. Historically, each psychoanalytic theory and its associated school developed and operated independently, and as such, a unified definition of psychodynamic psychotherapy is difficult to identify. This is further clouded by the development of various other psychotherapies, which resulted in reciprocal influence. To remedy this, recent definitions have been proposed in the primary literature, where the principles of psychodynamic psychotherapy may number between four and seven features. By one definition, as introduced by Otto Kernberg, the psychoanalytic technique consists of interpretation, analysis of transference and countertransference, and technical neutrality. 1. Transference is considered the "unconscious repetition in the here and now of pathogenic conflicts from the past" for the patient within the session. Analyzing the transference is considered in this definition as the primary source of change. 2. Countertransference is considered "the analyst's total, moment-to-moment emotional reaction to the patient and to the particular material that the patient presents." Tolerance of countertransference is considered necessary for high-fidelity treatment. Understanding the countertransference can provide important information for the treatment. 3. Technical neutrality refers to the therapist abstaining from personal gratification obtained through the therapeutic relationship, along with a natural and sincere approach to the treatment. This is as opposed to the concept of anonymity, where the analyst is considered a "blank slate" on which the patient places all their emotions and thoughts. 4. Interpretation is a blanket term for the specific verbal communication from the analyst to the patient. Interpretation within this definition is classified as "clarification," "confrontation," and "interpretation proper." Clarification seeks to elucidate the patient's conscious thoughts; confrontation seeks to tactfully bring unconscious thoughts, emotions, or behaviors into the patient's awareness; and interpretation attempts to provide a hypothesis to bring together all aspects of the patient's communication. Paulina Kernberg published an article outlining empirically supported postulates of psychodynamic psychotherapy with children, which can be extrapolated for adults: 1. Complex, unconscious processes lead to conscious thought and behavior deterministically. 2. Internal representations of one's experience with important people and the external world shape the person's foundational assumptions and expectations. 3. Observable thoughts and behaviors arise from more than a single unconscious origin. An individual's spoken language can have multiple meanings. 4. Conflict within the psyche is often present and a part of normal development. Conflicts are either external or internal. External conflicts happen between the needs of the person and the needs of the environment. Internal conflicts happen within the mind, such as between the person's impulses or desires and internalized societal prohibitions. 5. Defenses are mental processes that alleviate anxiety and maintain the individual's homeostasis. Defenses change throughout development from initial immature to mature defenses. Rigid defenses can prevent further development. 6. Resistance to change maintains stability but can slow the therapeutic process. 7. Transference provides an opportunity to understand and change internalized relational patterns. 8. Therapist neutrality establishes a safe setting for the therapeutic relationship by aiming to allow free expression by the patient. The therapist seeks to follow the individual's lead. In this case, neutrality is defined as "the [therapist's] cultivation of a non-judgmental, respectful, empathic, supportive attitude toward the patient.". 9. The therapist must recognize and understand their countertransference, which may provide insight into the patient's internal conflicts. Awareness of countertransference is also key to maintaining the therapist's neutrality which should not be affected. Another third definition introduced by Jonathan Shedler discusses seven features that distinguish psychodynamic psychotherapy from other psychotherapy modalities. These are the following: 1. Emphasis on emotion and its expression. 2. Exploration of avoidance attempts from thoughts and feelings. 3. Identifying recurrent patterns or themes. 4. Discussing past experiences. 5. Emphasis on interpersonal relations. 6. Emphasis on the therapy relationship. 7. Exploring fantasy life. Transference and countertransference similarly have varying definitions. Sigmund Freud's original definition of transference and countertransference was that both occur within the bounds of the therapeutic relationship. The patient experienced transference, and the therapist experienced countertransference. Both were considered impediments to treatment that required "working through." Their respective definitions have since expanded to encompass the patient's and provider's emotions, behaviors, thoughts, biases, and all other individual contributions to the therapeutic relationship. Transference and countertransference reactions are no longer considered pathological unless they negatively impact relationships or the fulfillment of needs.  Additionally, transference and countertransference are now considered integral parts of all relationships and are particularly important to attend to within the therapeutic relationship. Transference phenomena have also been discussed in the context of medical practice. Some practitioners of CBT consider forms of countertransference and transference as key concepts to be explored within the treatment and in therapy supervision. Practitioners of CBT formulate transference and countertransference differently from practitioners of psychodynamic psychotherapy. Most notably, practitioners of CBT use CBT-related terms, such as automatic thoughts and cognitive distortions, to define the concepts. Aaron Beck described transference in publications from the 1970s and following as a "schematic response." Discussions within CBT have also noted the importance of analyzing the therapeutic relationship in individuals with personality disorders.