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Psychodynamic Psychotherapy
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Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. It evolved from and largely replaced psychoanalysis in the mid-20th century. Psychodynamic psychotherapy relies on the interpersonal relationship between client and therapist more than other forms of depth psychology. In terms of approach, this form of therapy uses psychoanalysis adapted to a less intensive style of working, usually at a frequency of once or twice per week. Principal theorists drawn upon are Freud, Klein, and theorists of the object relations movement, e.g., Winnicott, Guntrip, and Bion. Some psychodynamic therapists also draw on Jung or Lacan or Langs. It is a focus that has been used in individual psychotherapy, group psychotherapy, family therapy, and to understand and work with institutional and organizational contexts. In psychiatry, it is has been used for adjustment disorders, as well as posttraumatic stress disorder (PTSD) but more often for personality-related disorders.

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    1. History

    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.[1]

    2. Approaches

    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.[2][3] The presumed maladaption develops early in life and eventually causes difficulties in day-to-day life.[4]

    Psychodynamic therapies focus on revealing and resolving these unconscious conflicts that are driving their symptoms.[5] 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.[6] 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.[6]

    3. Core Principles and Characteristics

    Although psychodynamic psychotherapy can take many forms, commonalities include:[6][7]

    • 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.

    4. Efficacy

    Psychodynamic psychotherapy, both short-term and long-term, is an effective psychotherapy. Psychodynamic psychotherapy is an evidence-based therapy (Shedler 2010) and its more intensive form, psychoanalysis has also been proven to be evidence-based. Later meta-analyses showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs,[8][9][10] but these arguments have also been subjected to various criticisms.[11][12][13][14] 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.[15][16]

    A systematic review of Long Term Psychodynamic Psychotherapy (LTPP) in 2009 found an overall effect size of .33.[17] Others have found effect sizes of .44–.68.[10]

    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.[18] Other reviews have found an effect size of .78–.91 for somatic disorders compared to no treatment[19] and .69 for treating depression.[20] 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.[21]

    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."[22] In 2017, a meta-analysis of randomized controlled trials found psychodynamic therapy to be as efficacious as other therapies, including cognitive behavioral therapy.[23]

    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.

    5. Client-therapist Relationship

    Because of the subjectivity of each patient's potential psychological ailments, there is rarely a clear-cut treatment approach.[6] Most often, therapists vary general approaches in order to best fit a patient's specific needs.[6] 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.[6] Therefore, the patient-therapist relationship must be extremely strong.[6]

    Therapists encourage their patients to be as open and honest as possible.[6] Patients must trust their therapist if this is to happen.[6] 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.[24]

    References

    1. Horacio Etchegoyen: The Fundamentals of Psychoanalytic Technique, Karnac Books ed., New Ed, 2005, ISBN:1-85575-455-X
    2. Horowitz, Mardi J. (1988). Introduction to psychodynamics: A new synthesis. Basic Books. 
    3. 3.0.co;2-3. PMID 10877462.  https://dx.doi.org/10.1002%2F%28sici%291097-4679%28200006%2956%3A6%3C723%3A%3Aaid-jclp3%3E3.0.co%3B2-3" id="ref_3">Kwon, Paul; Lemon, Katherine E. (2000). "Attributional style and defense mechanisms: A synthesis of cognitive and psychodynamic factors in depression". Journal of Clinical Psychology 56 (6): 723–735. doi:10.1002/(sici)1097-4679(200006)56:6<723::aid-jclp3>3.0.co;2-3. PMID 10877462.  https://dx.doi.org/10.1002%2F%28sici%291097-4679%28200006%2956%3A6%3C723%3A%3Aaid-jclp3%3E3.0.co%3B2-3
    4. Lerner, H. "Psychodynamic perspectives." The Handbook of Clinical Psychology 1 (2008): 127-160.
    5. Silverman, Lloyd H. (1985). "Research on psychoanalytic psychodynamic propositions". Clinical Psychology Review 5 (3): 247–257. doi:10.1016/0272-7358(85)90047-9.  https://dx.doi.org/10.1016%2F0272-7358%2885%2990047-9
    6. Schlesinger, H.J. (2014). "Some Principles Of Generic Psychodynamic Psychotherapy: A Primer For New Psychotherapists". https://mindsplain.com/wp-content/uploads/2020/08/some-priniciples-of-generic-psychodynamic-psychotherapy.pdf. 
    7. Sundberg, Norman (2001). Clinical Psychology: Evolving Theory, Practice, and Research. Englewood Cliffs: Prentice Hall. ISBN 978-0-13-087119-0. 
    8. Shedler J (2010). "The efficacy of psychodynamic psychotherapy". The American Psychologist 65 (2): 98–109. doi:10.1037/a0018378. PMID 20141265.  https://dx.doi.org/10.1037%2Fa0018378
    9. Leichsenring F (June 2005). "Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data". The International Journal of Psycho-Analysis 86 (Pt 3): 841–68. doi:10.1516/rfee-lkpn-b7tf-kpdu. PMID 16096078.  https://dx.doi.org/10.1516%2Frfee-lkpn-b7tf-kpdu
    10. "Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis". The British Journal of Psychiatry 199 (1): 15–22. July 2011. doi:10.1192/bjp.bp.110.082776. PMID 21719877.  https://dx.doi.org/10.1192%2Fbjp.bp.110.082776
    11. McKay D (2011). "Methods and mechanisms in the efficacy of psychodynamic psychotherapy". The American Psychologist 66 (2): 147–8; discussion 152–4. doi:10.1037/a0021195. PMID 21299262. https://fordham.bepress.com/psych_facultypubs/318. 
    12. "Is there room for criticism of studies of psychodynamic psychotherapy?". The American Psychologist 66 (2): 148–9; discussion 152–4. 2011. doi:10.1037/a0021248. PMID 21299263.  https://dx.doi.org/10.1037%2Fa0021248
    13. "When it comes to evaluating psychodynamic therapy, the devil is in the details". The American Psychologist 66 (2): 149–51; discussion 152–4. 2011. doi:10.1037/a0021190. PMID 21299264.  https://dx.doi.org/10.1037%2Fa0021190
    14. "No ownership of common factors". The American Psychologist 66 (2): 151–2; discussion 152–4. 2011. doi:10.1037/a0021056. PMID 21299265.  https://dx.doi.org/10.1037%2Fa0021056
    15. "The emerging evidence for long-term psychodynamic therapy". Psychodynamic Psychiatry 41 (3): 361–84. 2013. doi:10.1521/pdps.2013.41.3.361. PMID 24001160.  https://dx.doi.org/10.1521%2Fpdps.2013.41.3.361
    16. "The current state of the empirical evidence for psychoanalysis: a meta-analytic approach". Harvard Review of Psychiatry 21 (3): 107–37. 2013. doi:10.1097/HRP.0b013e318294f5fd. PMID 23660968.  https://dx.doi.org/10.1097%2FHRP.0b013e318294f5fd
    17. "The effectiveness of long-term psychoanalytic psychotherapy--a meta-analysis of randomized controlled trials". Clinical Psychology Review 32 (2): 81–92. March 2012. doi:10.1016/j.cpr.2011.11.003. PMID 22227111.  https://dx.doi.org/10.1016%2Fj.cpr.2011.11.003
    18. Anderson, Edward M.; Lambert, Michael J. (1995). "Short-term dynamically oriented psychotherapy: A review and meta-analysis". Clinical Psychology Review 15 (6): 503–14. doi:10.1016/0272-7358(95)00027-M.  https://dx.doi.org/10.1016%2F0272-7358%2895%2900027-M
    19. "Short-term psychodynamic psychotherapy for somatic disorders. Systematic review and meta-analysis of clinical trials". Psychotherapy and Psychosomatics 78 (5): 265–74. 2009. doi:10.1159/000228247. PMID 19602915.  https://dx.doi.org/10.1159%2F000228247
    20. "The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis". Clinical Psychology Review 30 (1): 25–36. February 2010. doi:10.1016/j.cpr.2009.08.010. PMID 19766369.  https://dx.doi.org/10.1016%2Fj.cpr.2009.08.010
    21. "Intensive short-term dynamic psychotherapy: a systematic review and meta-analysis of outcome research". Harvard Review of Psychiatry 20 (2): 97–108. 2012. doi:10.3109/10673229.2012.677347. PMID 22512743.  https://dx.doi.org/10.3109%2F10673229.2012.677347
    22. "A quality-based review of randomized controlled trials of psychodynamic psychotherapy". The American Journal of Psychiatry 168 (1): 19–28. January 2011. doi:10.1176/appi.ajp.2010.08060843. PMID 20843868.  https://dx.doi.org/10.1176%2Fappi.ajp.2010.08060843
    23. Steinert, Christiane; Munder, Thomas; Rabung, Sven; Hoyer, Jürgen; Leichsenring, Falk (2017). "Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes". The American Journal of Psychiatry 174 (10): 943–953. doi:10.1176/appi.ajp.2017.17010057. PMID 28541091.  https://dx.doi.org/10.1176%2Fappi.ajp.2017.17010057
    24. Leichsenring, Falk; Leibing, Eric (2003). "The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis". American Journal of Psychiatry 160 (7): 1223–1232. doi:10.1176/appi.ajp.160.7.1223. PMID 12832233.  https://dx.doi.org/10.1176%2Fappi.ajp.160.7.1223
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