Psychodynamic psychotherapy

The principles of psychodynamics were introduced in the 1874 publication Lectures on Physiology by German physician and physiologist Ernst Wilhelm von Brücke. Von Brücke, taking a cue from thermodynamics, suggested all living organisms are energy systems, governed by the principle of energy conservation. During the same year, von Brücke was supervisor to first-year medical student Sigmund Freud at the University of Vienna. Freud later adopted this new construct of “dynamic” physiology to aid in his own conceptualization of the human psyche. Later, both the concept and application of psychodynamics were further developed by the likes of Carl Jung, Alfred Adler, Otto Rank, and Melanie Klein.[7]

Most psychodynamic approaches are centered on the concept that some maladaptive functioning is in play, and that this maladaption is, at least in part, unconscious.[8][9] The presumed maladaption develops early in life and eventually causes difficulties in day-to-day life.[10]

Psychodynamic therapies focus on revealing and resolving these unconscious conflicts that are driving their symptoms.[11] Major techniques used by psychodynamic therapists include free association, dream interpretation, recognizing resistance, transference, working through painful memories and difficult issues, and building a strong therapeutic alliance.[12][13] As in some psychoanalytic approaches, the therapeutic relationship is seen as a key means to understanding and working through the relational difficulties which the client has suffered in life.[12][13]

Although psychodynamic psychotherapy can take many forms, commonalities include:[12][13][14]

• An emphasis on the centrality of intrapsychic and unconscious conflicts, and their relation to development;
• Identifying defenses as developing in internal psychic structures in order to avoid unpleasant consequences of conflict;
• A belief that psychopathology develops especially from early childhood experiences;
• A view that internal representations of experiences are organized around interpersonal relations;
• A conviction that life issues and dynamics will re-emerge in the context of the client-therapist relationship as transference and counter-transference;
• Use of free association as a major method for exploration of internal conflicts and problems;
• Focusing on interpretations of transference, defense mechanisms, and current symptoms and the working through of these present problems;
• Trust in insight as critically important for success in therapy.

Psychodynamic psychotherapy, both short-term and long-term, is an effective psychotherapy. Psychodynamic psychotherapy is an evidence-based therapy (Schedler 2010) and its more intensive form, psychoanalysis has been proven to be evidence-based, also. Later meta-analyses showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs,[15][16][17] but these arguments have also been subjected to various criticisms.[18][19][20][21] For example, Meta-analyses in 2012 and 2013 came to the conclusion that there is little support or evidence for the efficacy of psychoanalytic therapy, thus further research is needed.[22][23]

A systematic review of Long Term Psychodynamic Psychotherapy (LTPP) in 2009 found an overall effect size of .33.[24] Others have found effect sizes of .44–.68.[17]

Meta-analyses of Short Term Psychodynamic Psychotherapy (STPP) have found effect sizes ranging from .34–.71 compared to no treatment and was found to be slightly better than other therapies in follow up.[25] Other reviews have found an effect size of .78–.91 for somatic disorders compared to no treatment[26] and .69 for treating depression.[27] A 2012 meta-analysis by the Harvard Review of Psychiatry of Intensive Short-Term Dynamic Psychotherapy (ISTDP) found effect sizes ranging from .84 for interpersonal problems to 1.51 for depression. Overall ISTDP had an effect size of 1.18 compared to no treatment.[28]

In 2011, a study published in the American Journal of Psychiatry made 103 comparisons between psychodynamic treatment and a non-dynamic competitor and found that 6 were superior, 5 were inferior, 28 had no difference and 63 were adequate. The study found that this could be used as a basis "to make psychodynamic psychotherapy an "empirically validated" treatment."[29] In 2017, a meta-analysis of randomized controlled trials found psychodynamic therapy to be as efficacious as other therapies, including cognitive behavioral therapy.[30]

A 2011 meta study showed that long-term psychodynamic psychotherapy was superior to less intensive forms of psychotherapy in complex mental disorder. Depending upon severity of the underlying pathology, longer-term psychotherapy is required. For example, individuals functioning at Level 1 of the DSM Personality Functioning Scale would require less treatment than one functioning at Level 2 or above. Studies have also demonstrated that those who received psychodynamic psychotherapy continued to grow post-therapy whereas those who received cognitive Behavior therapy did not.

Because of the subjectivity of each patient's potential psychological ailments, there is rarely a clear-cut treatment approach.[12][13] Most often, therapists vary general approaches in order to best fit a patient's specific needs.[12][13] If a therapist does not understand the psychological ailments of their patient extremely well, then it is unlikely that they are able to decide upon a treatment structure that will help the patient.[12][13] Therefore, the patient-therapist relationship must be extremely strong.[12][13]

Therapists encourage their patients to be as open and honest as possible.[12][13] Patients must trust their therapist if this is to happen.[12][13] Because the effectiveness of treatment relies so heavily on the patient giving information to their therapist, the patient-therapist relationship is more vital to psychodynamic therapy than almost every other type of medical practice.[31]

• Anna Freud
• Robert Langs
• Malan triangles
• Models of abnormality
• Psychodynamic Diagnostic Manual