Which of the following therapies is more concerned with removing specific troubling symptoms then with facilitating new ways of thinking?

5.10.1.1 Definition of Psychodynamic Therapy

The term psychodynamic therapy covers psychotherapeutic approaches which share the assumption that psychological disorders are rooted in conflicting motivational states, often unconscious, which the individual responds to with a variety of habitual strategies (psychiatric symptoms). Most psychodynamic formulations specify that such conflict is “intrapsychic” (e.g., Brenner, 1982); others include interpersonal conflict, but even there the implication remains that conflict occurs between an internal state and the internal meaning of an external situation (Sullivan, 1953). Psychological intervention is conceived of as assisting individuals to use and develop their inherent capacities for understanding, learning, and emotional responsiveness, in response to the therapeutic relationship and especially the therapist's interpretations of the patient's motivations and strategies, to arrive at more adaptive resolutions. There is no fixed set of techniques to be used in this task, and different therapeutic orientations emphasize different, although substantively overlapping, procedures. Distinctions between types of psychodynamic therapy can be made along several lines; for example, we distinguish psychodynamic individual therapy from group therapy (Rose, 1972) or family approaches (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1978), expressive from supportive techniques (Luborsky, 1984), Freudian from Kleinian psychoanalytic orientation (King & Steiner, 1991), and therapies may be distinguished according to the relative emphasis of adjuncts such as play (Schaefer & Cangelosi, 1993), art (Simon, 1992), or drama (Johnson, 1982).

This chapter will principally concern itself with individual psychodynamic psychotherapy, using the verbal or play technique.

Discussion

Psychodynamic therapy is frequently used in clinical practice (Norcross & Rogan, 2013). Efficacy research, however, has been neglected in psychodynamic therapy for a long time. There remain concerns among some psychodynamic therapists and researchers about applying the methodology of RCTs to psychodynamic therapy (Westen, Novotny, & Thompson-Brenner, 2004). While it is true, for example, that studying unconscious conflicts or processes poses a unique challenge to research on psychodynamic therapy, the outcome of psychodynamic therapy in the form of observable manifestations of improvement may be studied. With regard to the problem of treatment manualization, the available RCTs using treatment manuals show that the complex interpersonal process of psychodynamic therapy can be manualized (Table 4.1), but treatment manuals should not be mistaken as cookbooks. Current manuals allow for a wide range of flexibility in therapist behavior (Leichsenring & Salzer, 2014; Leichsenring & Schauenburg, 2014; Leichsenring & Steinert, 2017b). Even LTPP may be manual-guided, as shown by the RCTs by Bateman and Fonagy (2009), Clarkin et al. (2007), and Vinnars et al. (2005) Furthermore, the methodological quality of studies of psychodynamic therapy was shown to be comparable to those of CBT (Gerber et al., 2011; Thoma et al., 2012), demonstrating that the methodology of RCTs may be as adequately applied to psychodynamic therapy as to CBT.

In recent years, efficacy research on psychodynamic therapy has caught up, and evidence is beginning to accumulate (Abbass et al., 2014; Barber et al., 2013; Steinert, Munder, et al., 2017). According to the results presented in this review, there is substantial evidence for the efficacy of psychodynamic therapy in depressive, anxiety, somatoform, eating, substance-related, and personality disorders. This is consistent with a recent Cochrane Report that found psychodynamic therapy to be efficacious in common mental disorders (Abbass et al., 2014). Effects of psychodynamic therapy were found to be stable or even increased in follow-up assessments (Abbass et al., 2009, 2014; Leichsenring & Rabung, 2008).

Although there is a growing body of evidence for the efficacy of psychodynamic therapy, there are also some limitations. Only a few studies exist that are sufficiently powered to show equivalence to an alternative treatment (Leichsenring, Luyten, et al., 2015). However, this is true for CBT as well (Cuijpers, 2016). With regard to the comparison of psychodynamic therapy and CBT, no substantial differences in efficacy were found in the studies that were sufficiently powered for testing equivalence (Crits-Christoph et al., 1999; Driessen et al., 2013; Leichsenring, Luyten, et al., 2015; Leichsenring et al., 2014; Zipfel et al., 2013). Equivalence of psychodynamic therapy to treatments established in efficacy was recently explicitly tested and demonstrated (Steinert, Munder, et al., 2017). If future research confirms that there are no substantial differences in outcome between the different forms of bona fide psychotherapy in common mental disorders, the next question becomes which patients benefit more from which kind of therapy, such as is addressed by Piper et al. (2001).

In the RCTs included here, various methods of psychodynamic therapy were used (Table 4.1). However, from an empirical perspective, it is not clear how “different” the various approaches really are. For the treatment of anxiety disorders and depressive disorders, the various approaches were shown to be consistent with each other and to overlap to a high degree (Leichsenring & Salzer, 2014; Leichsenring & Schauenburg, 2014; Leichsenring, & Steinert, 2018). Thus developing unified or transdiagnostic protocols for the psychodynamic treatment of major mental disorders is possible and may be an important target for future research and practice.

Nevertheless, open questions remain requiring further research on psychodynamic therapy. For specific mental disorders, further RCTs are required. This applies, for instance, to obsessive-compulsive disorder and PTSD. For PTSD, only two RCTs exist (Brom et al., 1989; Steinert, Bumke, et al., 2017). Further, more adequately powered equivalence trials are needed. In future studies of psychodynamic therapy, not only measures of symptoms or DSM criteria should be applied, but also measures more specific to psychodynamic therapy. Future studies should also examine whether there are specific gains achieved only by psychodynamic therapy; this is known as the question of “added value.” Such an added value was demonstrated, for example, by Levy et al. (2006) comparing psychodynamic therapy to DBT with regard to improvements in reflective functioning and attachment. Research should address the mechanisms of change not only of psychodynamic therapy, but also of other bona fide treatments beyond brand names of treatment. This is important to further improve the treatments. Last but not least, more attention needs to be devoted to the question of what works for whom with regard to patient characteristics beyond the diagnosis.

At present, no method of psychotherapy may claim to be the gold standard (Leichsenring & Steinert, 2017a). Monocultures have rarely proved to be successful. A plurality of (evidence-based) therapies is to be welcomed, both in treatment and research. Only plurality allows for bridging the gaps between the different approaches and for learning from each other to further improve the treatment of patients with mental disorders (Roy-Byrne, 2017).

6.19.7.2.3 Psychodynamic Therapy

Psychodynamic therapy involves identifying interpersonal patterns in one's current and past relationships, helping a client to recognize these patterns, and then gradually working with the client to provide corrective emotional experiences and modify interpersonal patterns through the use of the therapeutic relationship as a curative agent. Few psychodynamic therapies have been examined in treatment of anxiety disorders, including GAD. Crits-Christoph et al. (2005) examined the efficacy of 16-weekly sessions (plus 3 monthly booster sessions) of psychodynamic treatment for GAD. Therapy focused on understanding clients' anxiety symptoms as they related to interpersonal conflicts and working through the interpersonal conflicts and problematic interpersonal patterns. Crits-Christoph et al. (2005) conducted an open trial of 46 adults with GAD, and an RCT of the brief psychodynamic therapy in comparison to supportive, nondirective therapy in 38 adults with GAD. Results indicated that the brief psychodynamic therapy led to changes in nonassertive, exploitable, and intrusive interpersonal problems from pre-therapy to post-therapy. These changes were associated with improvement in GAD symptoms and worry. There were no differences between the two treatments on symptom severity scores; however, there were a number of participants who achieved symptom remission (Hamilton Anxiety Score of less than 7), with 46% of those in the psychodynamic group and 12.5% of those in the supportive listening group achieving remission. These results suggest that psychodynamic therapy could be an efficacious intervention for GAD; however, further studies are necessary to examine whether a longer intervention would be more efficacious.

6.1.1 Psychodynamic Therapies

Psychodynamic therapies focus on intrapsychic conflicts that may be affecting the individual’s coping and adjustment. Emotional insight, gained through the therapeutic process, is the goal of treatment for resolution of these conflicts and establishment of more effective coping styles. In addition, this form of therapy focuses on resolution and acceptance of social and physical losses that are characteristic of old age and addresses unresolved issues from various stages of development that may be contributing to the person’s distress. Psychodynamic therapies also frequently incorporate a focus on the “self” and maintaining self-esteem through the trials and tribulations of the aging process.

Psychodynamic Therapy

Psychodynamic therapy has a long history in the treatment of EDs, particularly AN. Psychodynamic models vary considerably; however, the goals of most are to assist individuals to develop modes of feeling and expressing power and dependency; to attenuate the severe superego along with primitive guilt; to develop more adaptive strategies for coping than the current eating behaviors; and to return the individual back to a healthy nutritional, physical, emotional and cognitive state (Herzog, 1995). There have been very few empirical studies examining the efficacy of psychodynamic treatments. In studies that have examined time-limited psychodynamic therapy for EDs, the results have been disappointing (Dare et al., 2001).

Publisher Summary

Psychodynamic therapy is effective in a number of controlled studies of eating disorder patients, with short-term outcomes equivalent to cognitive-behavioral therapy in studies where the comparison was made. Thus, a long clinical tradition combines with more recent outcomes literature to provide a solid evidence base for using a psychodynamic approach to the treatment of eating disorders. However, there are some difficulties inherent in using an approach that focuses primarily on relationship, exploration, and interpretation when treating patients with eating disorders. Though it is true that short-term, behaviorally oriented treatments often result in limited improvement and symptom-substitution, it is equally true that long-term psychodynamic therapies can flounder due to intractable symptoms. Symptoms can become health- or even life-threatening, creating a sense of urgency (and sometimes, actual emergency) rarely experienced with other disorders. Frightened family members and managed care pressures add to this recipe for therapist angst, making it extremely difficult for clinicians to retain a reflective stance and maintain a treatment frame that facilitates psychodynamic work.

Conclusion

Psychodynamic therapy in the form of guided self-help via the internet is a modern implementation of psychodynamic principles. This mode of delivery holds promise for the potential to reach individuals who may not otherwise have access to sophisticated psychological intervention. For others, internet delivery may be ideally suited to their preferences and life demands. The results from four RCTs provide encouraging evidence of the powerful effects in the treatment of depression and anxiety disorders both in the short term and in the long term.

By way of concluding this chapter, the words of Alexander and French (1946) are timeless and appropriate to consider: “We believe and hope that our book is only a beginning, that it will encourage a free, experimental spirit which will make use of all that detailed knowledge which has been accumulated in the last fifty years in this vital branch of science, the study of the human personality, to develop modes of psychotherapy ever more saving of time and effort and ever more closely adapted to the great variety of human needs” (p. 341).

The recent developments in internet-based psychodynamic therapy could be a way to continue this work, with the same experimental spirit, in a way that will benefit suffering individuals throughout the world.

PSYCHODYNAMIC THERAPY

According to psychodynamic philosophy, posttraumatic symptoms are an attempt to manage the traumatic stress. Consequently, it is viewed not as a defective but rather an adaptive response. For example, when the survivor of a traumatic event experiences intrusive and avoidant symptoms (core symptoms of PTSD) it is viewed as a biphasic attempt to cope with the trauma (Van der Hart et al., 1989; Foa et al., 2009). A fundamental point of distinction between psychodynamic therapy and other forms of therapy is the concept of symptoms as compromises whose meanings must be understood and resolved. In addition, the concept of transference, unique to this philosophy, plays a significant role in reflecting a realistic appraisal of the therapist’s character and the ensuing therapeutic alliance. The psychodynamic therapist elicits meanings in order to make unconscious meaning and symbolism conscious. As the patient develops increased understanding of their experience, response, and underlying belief system which guides or reinforces how they operate it presents an opportunity for improved coping. Due to the focus of psychodynamic psychotherapy being on basic problems in interpersonal relationships it may be useful in working with patients diagnosed with complex PTSD. Psychodynamic therapy is a sophisticated, highly focused psychotherapeutic approach, beneficial when the patient and therapist have a strong therapeutic alliance (indicative of intelligence, ability to verbalize, high-level thinking process, trust, ability to tolerate negative feelings, etc.) and are in agreement regarding the identified clinical issues and the treatment plan. Brief psychodynamic therapy can be beneficial when there are identified distinct points of focus in therapy versus common general points of distress often presented by patients with PTSD who also demonstrate instability which would be contraindicative of this method of intervention (Foa et al., 2009).

Psychodynamic therapy benefits the patient by facilitating the recovery of a sense of self and helping the patient to learn new coping strategies to deal with intense emotions. It typically consists of three phases:

Establish a sense of safety

Explore the trauma experience in depth

Help the patient re-establish connections with family, friends, societal interactions, and other sources of meaning.

While the general focus of psychodynamic therapy is on Sigmund Freud’s theoretical point of view there are numerous theories which deviate from Freud in some beliefs or are additive to the understanding of fundamental beliefs. Combining beliefs and interventions in this theoretical orientation can be useful. Psychoanalytic techniques stem from the central concepts of conscious and unconscious levels of mental activity, defenses, conflicts, symptoms as meaningful representations, transference, and the therapeutic relationship. The analyst’s (a neutral responder) single investment is in the patient’s progress toward autonomy and health. This is primarily an expressive therapy that seeks to enhance and broaden a patient’s understanding of unconscious issues within the safety of the therapeutic relationship. It is sometimes difficult to separate the boundaries between psychodynamic and cognitive behavioral therapies; both recognize the specific needs of the individual (Brierre and Scott, 2006).

The techniques used in psychodynamic therapy include the following:

The therapist is a facilitator of the therapeutic process (ultimately, the patient analyzes themselves)

The analyst must be trusted and considerate with a shared commitment to honesty and candor. The therapist employs observation, confrontations, and interpretations to test hypotheses with the patient

Free association is the fundamental aspect of the patient saying whatever is on his or her mind

Analysis follows associations, explore dreams, symptomatic acts, transference, and counter-transference (which allows for the understanding of the complex network of ideas, memories, wishes, fears, and fundamental individuality

The use of observations, appropriate confrontations, and interpretations to test hypotheses with the patient

Hypnotic and other abreaction techniques (to uncover repressed material)

Methods to facilitate the re-establishment of a sense of coherence and meaning

Processing and diminishing irrational guilt

Finding meaning.

The use of “brief psychodynamic therapy” (Mann, 1973; Foa et al., 2009) emphasizes the factor of separation by keeping the number of sessions (12) at the forefront of their work, with the belief that impending closure results in a final burst of progress. This form of therapy works best when treatment focuses on a single theme such as a conflictual relationship.

The Veterans Health Administration, Department of Veterans Affairs (2007) states that brief psychodynamic psychotherapy helps survivors of trauma to learn new ways of dealing with emotional conflicts caused by traumatic experience. Psychodynamic psychotherapy helps patients to understand how their past affects how they feel now specifically by:

Identifying cues/triggers of stressful memories and other symptoms

Finding ways to cope with intense feelings about the past

Becoming more aware of their thoughts and feelings, so that they can change their reactions to them

Raising their self-esteem.

Treatment of Specific Phobias

Cognitive – Behavioral Therapy

Specific phobias are among the most treatable of psychiatric disorders, and cognitive – behavioral therapy (CBT) is considered the most effective treatment. A recent meta-analysis reported that the average participant receiving cognitive and behavioral interventions showed more improvement than 85% of nontreated individuals. Although behavioral and cognitive interventions arose from distinct theoretical traditions, the interventions are typically combined in practice. A fundamental component of CBT is repeated and systematic exposure to feared stimuli. An exposure hierarchy is created consisting of feared situations that are ranked from least distressing to most distressing (see Table 1). The individual begins by confronting an object or situation ranked low on the exposure hierarchy in a gradual and predictable manner that maximizes the patient's perception of control. The individual is encouraged to remain in the situation until anxiety reduces by at least 50% rather than escaping from the situation when anxiety becomes too intense.

Table 1. Sample hierarchy of feared situations for spider phobia

Feared situation	Distress (0–100)
Most distressing: allow large spider to crawl on arm	100
2nd most distressing: touch large spider with finger	90
3rd most distressing: allow small spider to crawl on arm	80
4th most distressing: touch small spider with finger	70
5th most distressing: walk within 1 ft of large spider	60
6th most distressing: stand in room with large spider, walk within 5 ft of spider	50
7th most distressing: walk within 1 ft of small spider	40
8th most distressing: stand in room with small spider, walk within 5 ft of spider	30
9th most distressing: view photo of real spider, then touch it	20
10th most distressing: view cartoon photo of spider, then touch it	10

Exposure therapy can be conducted in a number of ways. In vivo exposure involves coming into direct contact with the feared stimulus. An individual with a spider phobia might begin exposure therapy by observing photos of a spider and then move through the exposure hierarchy by touching photos of a spider, being in the same room as a spider, moving progressively closer to a spider, touching a small spider, and then eventually touching a large spider. In vivo exposure has demonstrated robust effect sizes across a variety of types of specific phobias and is considered the most effective form of exposure therapy. In vivo exposure is often conducted in conjunction with participant modeling, a technique grounded in social learning theory in which the patient observes the therapist confronting the feared stimulus effectively before attempting the exposure on his or her own. In some cases, imaginal or virtual reality exposure might be used if it is not practical to perform in vivo exposure (e.g., fear of hurricanes) or if the phobia is sufficiently severe such that in vivo exposure would be too distressing in the early stages of treatment. For example, an individual with a spider phobia might imagine a spider in graphic detail and later imagine touching the spider and allowing it to crawl up his or her arm. Systematic desensitization is an approach that combines imaginal exposure with relaxation training. The rationale behind this treatment is that repeated exposure to feared stimuli in conjunction with the use of an anxiety-incompatible response (i.e., relaxation) should eliminate the conditioned fear response. Although it has been found to be an effective treatment for specific phobias, the addition of relaxation training does not appear to improve outcome beyond the effect of exposure therapy alone. Regardless of the exposure method used in therapy, homework between sessions, consisting of exposure exercises conducted either alone or with a helper, is considered a core component of CBT.

Due to the physiologically different processes operating in blood-injection-injury phobias, traditional in vivo exposure therapy requires modification to reduce the vasovagal response and potential for fainting. Patients are first taught to recognize early signs of drop in blood pressure and then practice tensing and then releasing the tension in the body. Muscle tension is then used in combination with in vivo exposure exercises. This applied muscle tension technique has been found to be an effective treatment for blood-injection-injury phobias.

Individuals taking part in imaginal or in vivo exposure therapy typically move up the exposure hierarchy at a gradual pace over a number of treatment sessions. However, research has demonstrated that a massed approach to treatment with prolonged exposure within one session can also be effective. In one session treatment (OST), patients are exposed to their entire hierarchy, starting with the least distressing situation and moving up to the most distressing situation, within a single 3 h session. In flooding therapy, patients immediately confront a feared situation ranked at the top of the exposure hierarchy. Both of these treatment approaches are quite cost and time effective; however, flooding therapy requires a very motivated patient who is willing to remain in a situation that provokes intense anxiety.

Habituation is one potential mechanism by which exposure therapy reduces conditioned fear responses. Habituation refers to a decrement in response (e.g., psychophysiological response or subjective fear) as a result of repeated exposure to the feared stimuli (see Figure 1). Habituation theory assumes that prolonged exposure will result in fear reduction; however, habitation has been questioned as a mechanism of change in exposure therapy because some patients do not experience fear reduction with prolonged exposure. Further, some patients experience reductions in physiological responding during exposure without a corresponding reduction in subjective fear, a finding that cannot be reconciled with habituation theory. The mechanism currently thought to best account for fear reduction is extinction learning. Patients learn not only to unlearn a previously learned association (e.g., spiders are dangerous) during exposure therapy, but more importantly, they learn to attribute novel significance to the conditioned stimulus (e.g., spiders are relatively safe). During this process, separate mental representations (e.g., spiders are dangerous and spiders are safe) exist simultaneously and compete with one another. Which representation is selected depends on the match or mismatch between the context in which extinction learning occurred and the context in which the fear cue is subsequently encountered. One implication of extinction learning is that the extinction of learned fear during exposure therapy does not easily generalize to new situations unless the new situation contains salient stimuli that were present during extinction learning trials, thus, many exposure exercises should be conducted across a variety of contexts. The extinction learning theory is also compatible with the emotional processing theory, which proposes that fear reduction during exposure therapy requires the learning and integration of new information that is incompatible with the existing representations of threat that are coded in memory.

Figure 1. Habituation/extinction learning curve.

The cognitive component of CBT aims to elicit and challenge negative automatic thoughts regarding the perception of threat and the inability to cope effectively with threat and to replace these automatic thoughts with more realistic and adaptive thoughts (see Table 2). Exposure exercises are also viewed as an important component of cognitive therapy; however, the rationale for exposure differs in cognitive therapy. Rather than habituating to the feared stimuli or extinguishing learned fear, exposure exercises are framed as behavioral experiments or hypothesis testing. Individuals with specific phobias learn that their feared consequences do not occur and their anxiety does not persist at catastrophic levels. The mechanism thought to account for fear reduction in cognitive therapy is expectancy violation. During behavioral experiments, erroneous beliefs regarding the probability and severity of feared consequences are disconfirmed and corrective information regarding the threat is incorporated.

Table 2. Sample thought record for dog phobia

Situation	Emotion	Automatic thoughts	Evidence	Countering statement
Encounter a dog on the street.	Fear (90%)	The dog will bite me and I will get rabies.	For: Some dogs bite., Some dogs have rabies., Against: It is rare to get bitten by a dog., I am not provoking the dog., The dog is on a leash., Most domestic dogs get rabies shots.	Although it is not impossible to get rabies from a dog bite, it is extremely unlikely especially if it is a domestic dog and I am not provoking it., There are effective treatments to prevent rabies if a dog bites me.

Abstract

The phrase “psychodynamic therapy” refers to the family of treatment approaches based on the early work of Sigmund Freud. It is one of the major forms of contemporary psychotherapy practice and has undergone a great deal of theoretical and technical modification over the past 120 years. Its main techniques have been cataloged and many forms of psychodynamic therapy have been manualized. There is mounting evidence not only in favor of its efficacy, but also in terms of theory-based mechanisms of change and the research generativity of its concepts (e.g., attachment theory).