Future of Psychodynamics

[Messerschmitts]

I just started my adolescent psych rotation today and so far it's been really cool. However, it appears my attending is an analyst, and a self-proclaimed fan of Freud. He gave a chalk talk about defence mechanisms today and went into the psychodynamic theory of how splitting develops in Borderlines due to failure to integrate "good" and "bad" parts of caregivers during early childhood.

Perhaps it's how modern medical students are being educated, but it all sounds like hocus pocus to me. I think the theories are interesting, but they are not falsifiable (to my knowledge), and therefore unscientific. Give me my neurotransmitters anyday. But perhaps I am being too harsh. There are certainly many things in psychiatry that cannot be easily explained by serotonin imbalances. But then again, maybe we just don't know enough about serotoin yet. Don't get me wrong, I am all about psychotherapy, and there are obviously plenty of scenarios in which SSRIs will not solve your patient's problem. However I feel everything we do should, as much as is practical, be based on empirical evidence and falsifiable, reproducible research.

What is the current view on the role of psychodynamics/analysis will serve in modern psychiatry?

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[whopper]

There is data showing that DBT works on Borderline PD people--& that data has been replicated. DBT does work on the theory as your attending suggests.

Children have several biological drives pushing their behavior, and data from the environment often times goes counter to that biological drive. These are not specific to Borderline but take these for example..

The desire to have sex--imaging having that in a society that looks down upon sex. That is a more understandable comparison since most of us I'm have been told in 1 form or another not to have sex. This in the worst extremes has caused or at least contributed to some pretty strange deviant sexual behavior.

In Borderlines--take for example a girl under age 10 who has been raped multiple times by her uncle. Borderlines often times are females who have been abandoned or sexually traumatized. Children under age 10 have several drives pushing them to trust their adult relatives, after all they are dependent on adults for survival. That trust was broken in one of the worst ways & extremes possible--> leading to mixed messages of the ultimate extremes in Borderlines--leading to dysregulated emotions.

You can question that theory, and questioning is a good thing, however studies do show that DBT works, and DBT's main theories are based on the splitting you mentioned.

"Falsifiable" doesn't work here in our society. Unless you want to engage in an experiment where you rape 100 seven year old girls, and don't rape another 100 seven year old girls to show that Borderline may or may not exist, and its correlation with sexual abuse, you're not going to have much "falsifiable" data that I think you're talking about with Borderlines.

Several aspects of medicine are not falsifiable because to make them so, we'd have to experiment on humans as if they were lab animal test subjects. We do the best we can given the experimental methods we can ethically perform.

 

[Messerschmitts]

Several aspects of medicine are not falsifiable because to make them so, we'd have to experiment on humans as if they were lab animal test subjects. We do the best we can given the experimental methods we can ethically perform.

That is a good point.

 

[erg923]

Hi everybody!...........

I dont care much for Freud, but I cant deny that deep down I belive he discovered (or at least was the first to fully articulate) some important universal truths about the human condition and nature of the human psyche. I tend to side with Paul Meehl's view on this one. That is- When science catches up, I think we will find that Freud's ideas were the ones closest to "the truth."

I agree with Whooper also. Med school (and grad school in clinical psych especially) teach you about "science" and that all good science should be falsifiable. And indeed it should. However, whether or not a theory is falsifiable is a great academic question, but loses some (not all) of its relevevance when you get out into practice. The truth is, you use what ya got and you use what works. If sometimes that requires a long couch and emploring "the fundamental rule", I say, so be it.

 

[cleareyedguy]

Hi everybody!...........

I dont care much for Freud, but I cant deny that deep down I belive he discovered (or at least was the first to fully articulate) some important universal truths about the human condition and nature of the human psyche

You have mighty high standards

 

[erg923]

I dont care for Freud as a scientist is what I meant. Hans Eysenck and Robin Dawes, among others, have some good writings and critiques of Freuds sometimes not so accidental data falsifications and biases.

 

[dl2dp2]

There is data showing that DBT works on Borderline PD people--& that data has been replicated. DBT does work on the theory as your attending suggests.

Children have several biological drives pushing their behavior, and data from the environment often times goes counter to that biological drive. These are not specific to Borderline but take these for example..

The desire to have sex--imaging having that in a society that looks down upon sex. That is a more understandable comparison since most of us I'm have been told in 1 form or another not to have sex. This in the worst extremes has caused or at least contributed to some pretty strange deviant sexual behavior.

In Borderlines--take for example a girl under age 10 who has been raped multiple times by her uncle. Borderlines often times are females who have been abandoned or sexually traumatized. Children under age 10 have several drives pushing them to trust their adult relatives, after all they are dependent on adults for survival. That trust was broken in one of the worst ways & extremes possible--> leading to mixed messages of the ultimate extremes in Borderlines--leading to dysregulated emotions.

You can question that theory, and questioning is a good thing, however studies do show that DBT works, and DBT's main theories are based on the splitting you mentioned.

"Falsifiable" doesn't work here in our society. Unless you want to engage in an experiment where you rape 100 seven year old girls, and don't rape another 100 seven year old girls to show that Borderline may or may not exist, and its correlation with sexual abuse, you're not going to have much "falsifiable" data that I think you're talking about with Borderlines.

Several aspects of medicine are not falsifiable because to make them so, we'd have to experiment on humans as if they were lab animal test subjects. We do the best we can given the experimental methods we can ethically perform.

This is a specious argument for psychoanalysis. There are many diseases caused by ethically questionable causes, but just because you can't do double blinded trials on their etiology doesn't mean that you can formulate a genuinely scientific theory on their causality. In fact, many scientific disciplines (i.e. astronomy, ecology, geophysical sciences etc.) are observation based. If you do science correctly and carefully, you can reach many useful scientific insights through observation.

However, psychodynamics isn't science, and it shouldn't be labeled as such. Psychodyanmic theories are not falsifiable IN PRINCIPLE. However, this doesn't mean that this schematic per se isn't useful. It's like violin isn't science, but it doesn't mean that it doesn't have a place in society. And as far as the question of childhood trauma and personality disorders, scientific theories are hard because not every who was abused develop psychiatric problems...most victims recover markably well. Most psychiatric disorders, especially personality disorders, are probably caused by a multitude of genetic and environmental factors. Modern statistical methods, imaging methods, genetic methods and techniques from social sciences and artificial intelligence are BEGINNING to make sense of these interactions. One day we may even be reasonably accurately predict these syndromes, possibly with complex mathematical models, just like how environmental scientists can reasonably predict that the earth is getting warmer.

However, before these new techniques can clarify everything, you do whatever works. And that whatever works right now is psychodynamics. Psychodyanmics is a very very crude approximation that is close to the miasma theory of physical illness. It works on some people and fails on others. We have no clue as to the underlying mechanisms either in its efficacy or in its failure. Nevertheless, physicians in Europe used that theory to treat people for centuries before anything superior was able to replace it.

 

[worriedwell]

I think if people can get past what the downside has been from psychoanalysis on the progress of psychiatry for many years, they can't deny that psychodynamics are real as a concept. It ain't easy work and it is so labor intensive that the model that most doctors are trained in doesn't jive well with it, but as an explanatory model. I think it has value and a good bit of it has empirical evidence in some form as far as I know.

The more psychiatry I do, the more I just can't help but be a huge fan of being open to learning psychodynamic theory as a psychiatrist and allowing it to improve my toolbelt for helping my patients. I have found that it actually is not mutually exclusive with any treatment, including other psychotherapies. In fact, more and more it serves as the underlay for all the work I do and I've trained intensively in other types of psychotherapy.

The more you work with people and the more you stay open to dynamic issues, the more undeniable a role it has it certain parts of psychiatry therapeutics. I'm not saying the actual implementation of treatment is that good, I'm just saying that understanding the concepts are really helpful to me as a psychiatrist and especially troubleshooting "standard of care treatments" like CBT and psychopharm, I find it helpful overcoming obstacles and being patient and empathic to those patients where I have an impasse or am exceedingly frustrated.

But thats just me. My advice is to stay open minded and don't be overly dogmatic with any treatment you learn, including biological psychiatry. Quite frankly, you have to be humble on the massive forces that pharmaceutical industries are on our collective paradigm for mental disorders, and realize that "serotonin deficiencies" are huge oversimplications that help us peddle our SSRI's to everybody and medicalize sadness in sometimes countertherapeutic ways.

 

[sunlioness]

I am so not a fan of Freud. Here's a guy who turned likely true stories of incest into "fantasy wish fulfillment" and the Oedipus Complex. Those women hadn't really been having sex with their fathers as children, they just wished they had.

I am a fan of Colin Ross. Dr. Ross says rightly that psychotherapy should be able to be studied to determine its efficacy as well as anything else and he designs his interventions to be testable in that fashion.

 

[Doc Samson]

I am so not a fan of Freud. Here's a guy who turned likely true stories of incest into "fantasy wish fulfillment" and the Oedipus Complex. Those women hadn't really been having sex with their fathers as children, they just wished they had.

I am a fan of Colin Ross. Dr. Ross says rightly that psychotherapy should be able to be studied to determine its efficacy as well as anything else and he designs his interventions to be testable in that fashion.

Psychotherapy is VERY difficult to study because you cannot standardize the self. Even the most basic manualizable psychotherapeutic interventions are likely to have very different results if they're delivered by Darth Vader vs. Mr. Rogers. You cannot have the therapy and sham therapy delivered by the same person, because then it's not a blinded study. This is the major limitation in getting the "evidence base" that some folks seem so desperate for in psychodynamic psychotherapy.

As far as not being a fan of Freud for his (not insignificant) flaws - well you might as well write off Hippocrates for not doing double-blinded studies, or every surgeon prior to Lister for not using sterile technique. Freud was a genius who basically invented the practice of psychiatry - you might not like him, but you have to respect him.

 

[surftheiop]

Psychotherapy is VERY difficult to study because you cannot standardize the self. Even the most basic manualizable psychotherapeutic interventions are likely to have very different results if they're delivered by Darth Vader vs. Mr. Rogers. You cannot have the therapy and sham therapy delivered by the same person, because then it's not a blinded study. This is the major limitation in getting the "evidence base" that some folks seem so desperate for in psychodynamic psychotherapy.

As far as not being a fan of Freud for his (not insignificant) flaws - well you might as well write off Hippocrates for not doing double-blinded studies, or every surgeon prior to Lister for not using sterile technique. Freud was a genius who basically invented the practice of psychiatry - you might not like him, but you have to respect him.

You always seem to be a big proponent of psychotherapy, as a C/L do you get to do much (any) psychotherapy?

 

[strangeglove]

You always seem to be a big proponent of psychotherapy, as a C/L do you get to do much (any) psychotherapy?

Psychotherapy, defined by active listening with a neutral, empathetic stance with the goal of relieving suffering, should occur in every patient interaction.

 

[surftheiop]

Psychotherapy, defined by active listening with a neutral, empathetic stance with the goal of relieving suffering, should occur in every patient interaction.

Sorry I wasnt more specific
I meant when you have a patient interaction where your billing for psychotherapy.

 

[Doc Samson]

Sorry I wasnt more specific
I meant when you have a patient interaction where your billing for psychotherapy.

I use psychotherapeutic principles almost daily in my CL work. I see a lot of somatization and conversion where psychodynamics are invaluable. Obviously the delirium/dementia portion of my job has rare use for psychodynamic interpretation, but I like have a complete toolkit that I can apply to my work.

In terms of billing - no I don't separately bill for psychotherapy since I have to bill using consultation codes. Spending time doing therapy in the course of the consultation can result in a higher level of billing however, since consultation coding is based on documentation, case complexity, and/or time spent in counseling or coordination of care. So - a relatively straightforward case with scant documentation could still be billed as a level 4 consult so long as you note "80 minutes in care of patient, with >50% in counseling."

 

[sunlioness]

As far as not being a fan of Freud for his (not insignificant) flaws - well you might as well write off Hippocrates for not doing double-blinded studies, or every surgeon prior to Lister for not using sterile technique. Freud was a genius who basically invented the practice of psychiatry - you might not like him, but you have to respect him.

I'm not "writing off" Freud for his lack of double blinded studies or other such things that were not practiced during his day. I may have a thing or two to say about modern practitioners who dismiss the value of science and cite Freud as the reason why it is not necessary (just as I would have problems with a modern surgeon who decries sterile technique because it wasn't used before Lister), but I'll let Freud slide on that one.

The reason I dislike and don't respect Freud personally is because he's a guy who initially got things right and then sold out the truth when he found it wasn't politically tenable, thereby creating a legacy that continues to sell people out to this very day. Freud was a guy who got it right . . . initially. His "seduction theory" was pretty much on the money. Freud initially thought that the incest histories his patients were reporting to him were true and the cause of their psychopathology. He reported this in various papers and conferences. He got no press. People just did not want to hear that little girls were having sex with their dads. So he gave up. Within a few years, he abandoned this philosophy and decided that these stories were fantasies of what his patients wished had happened to them. And now people listened to him and thought that Freud was the greatest thing since sliced bread. Still today, we learn in all seriousness about repressed fantasy and the Oedipal complex and all about how little girls really want to get it on with dad. Freud sold out his own patients back then and his legacy continues to sell people out today. No, I don't have any respect for that.

Freud did come up with some good stuff though that I do have a lot of respect for. For instance, the concept of ego defenses is very useful. I respect Freud's place in history. He made some useful contributions. But overall I think he more deserves respect for being one of the earliest psychiatrists and having some interesting ideas about things SOME of which turned out to be valid and useful, but NOT as this God-like figure who got it all right and whom we continue to follow exactly today (not that anyone here is advocating doing so). Just as I don't blame any surgeon before Lister who operated without sterile technique, but definitely WOULD blame a surgeon who took that as an example and a reason to operate without sterile technique today.

Psychotherapy, defined by active listening with a neutral, empathetic stance with the goal of relieving suffering, should occur in every patient interaction.

Then I guess you would say that all physicians are in fact psychotherapists. This description isn't anything that psychiatrists have cornered the market on. Or even physicians. Nurses can do this too. Under this definition, my internist is a top notch psychotherapist. Makes me wonder what psychologists go to school all those years for and why I needed all those lectures and supervision during residency.

 

[strangeglove]

Then I guess you would say that all physicians are in fact psychotherapists. This description isn't anything that psychiatrists have cornered the market on. Or even physicians. Nurses can do this too. Under this definition, my internist is a top notch psychotherapist. Makes me wonder what psychologists go to school all those years for and why I needed all those lectures and supervision during residency.

You got it. It's just that psychiatrists should be better at this than other doctors. Sadly, not all psychiatrists can say that they are better psychotherapists than your typical internist. This is a problem caused by a decline in psychotherapy training in psychiatry residencies.

 

[Doc Samson]

I'm not "writing off" Freud for his lack of double blinded studies or other such things that were not practiced during his day. I may have a thing or two to say about modern practitioners who dismiss the value of science and cite Freud as the reason why it is not necessary (just as I would have problems with a modern surgeon who decries sterile technique because it wasn't used before Lister), but I'll let Freud slide on that one.

The reason I dislike and don't respect Freud personally is because he's a guy who initially got things right and then sold out the truth when he found it wasn't politically tenable, thereby creating a legacy that continues to sell people out to this very day. Freud was a guy who got it right . . . initially. His "seduction theory" was pretty much on the money. Freud initially thought that the incest histories his patients were reporting to him were true and the cause of their psychopathology. He reported this in various papers and conferences. He got no press. People just did not want to hear that little girls were having sex with their dads. So he gave up. Within a few years, he abandoned this philosophy and decided that these stories were fantasies of what his patients wished had happened to them. And now people listened to him and thought that Freud was the greatest thing since sliced bread. Still today, we learn in all seriousness about repressed fantasy and the Oedipal complex and all about how little girls really want to get it on with dad. Freud sold out his own patients back then and his legacy continues to sell people out today. No, I don't have any respect for that.

Freud did come up with some good stuff though that I do have a lot of respect for. For instance, the concept of ego defenses is very useful. I respect Freud's place in history. He made some useful contributions. But overall I think he more deserves respect for being one of the earliest psychiatrists and having some interesting ideas about things SOME of which turned out to be valid and useful, but NOT as this God-like figure who got it all right and whom we continue to follow exactly today (not that anyone here is advocating doing so). Just as I don't blame any surgeon before Lister who operated without sterile technique, but definitely WOULD blame a surgeon who took that as an example and a reason to operate without sterile technique today.



Then I guess you would say that all physicians are in fact psychotherapists. This description isn't anything that psychiatrists have cornered the market on. Or even physicians. Nurses can do this too. Under this definition, my internist is a top notch psychotherapist. Makes me wonder what psychologists go to school all those years for and why I needed all those lectures and supervision during residency.

Whether all or some of Freud's patients were actually victims of incest is neither here nor there. The histories he took resulted in the Oedpial theory which is a useful psychodynamic construct. It provides the basis for much of attachment theory. If you don't think that little boys have a primary attachment to their mothers that results in fantasy/play of getting rid of their father, then I have a 2 year old son (who likes to kick Daddy out of bed on weekend mornings and play "duck Daddy" in the pool) that I think you could learn something from.

 

[hkusp]

It helps to differentiate between psychoanalytic (Freudian) and psychodynamic (neo-Freudian). Most the the ideas started by Freud were pretty original, but it seems as those defense mechanisms are the only thing that came out of Freud that made it.

Neo-Freudian psychodynamic theory was taken by Karen Horney, Winnicott, Adler, Klein, and those folks to a different system. The most popular subsets of psychodynamic are self psych, ego psych, and object relations. In these subsets, behavior is all about past experiences, object permanance, internalized objects, and motivations.

In my own therapy I often conceptualize problems from an object relations perspective (to address covert motivations for behavior) but use it in an evidence based way to address to the Patient.

The psychiatry residents that went through with us were only taught Freudian psychology and did not get exposed to any of the good neo-Freudian ideas. So, don't count it out until you read about object relations and ego psychology. That is good nerd fun right there!!

 

[BabyPsychDoc]

It helps to differentiate between psychoanalytic (Freudian) and psychodynamic (neo-Freudian). Most the the ideas started by Freud were pretty original, but it seems as those defense mechanisms are the only thing that came out of Freud that made it.

Neo-Freudian psychodynamic theory was taken by Karen Horney, Winnicott, Adler, Klein, and those folks to a different system. The most popular subsets of psychodynamic are self psych, ego psych, and object relations. In these subsets, behavior is all about past experiences, object permanance, internalized objects, and motivations.

In my own therapy I often conceptualize problems from an object relations perspective (to address covert motivations for behavior) but use it in an evidence based way to address to the Patient.

The psychiatry residents that went through with us were only taught Freudian psychology and did not get exposed to any of the good neo-Freudian ideas. So, don't count it out until you read about object relations and ego psychology. That is good nerd fun right there!!

I would just add Bowlby with his attachment theory as one of the key contributors to the neo-Freudian psychodynamic psychiatry.

 

[erg923]

I think its so funny that we describe/refer to humans and human relationships as "objects" in dynamic theory (ie., Object Relations theory). For a profession with a rep for being so coddly and warm....that pretty cold stuff.....

 

[TX515]

Then I guess you would say that all physicians are in fact psychotherapists.

I wouldn't. I see a lot of "see how much money I can make without being sued" practiced.

 

[Doc Samson]

It helps to differentiate between psychoanalytic (Freudian) and psychodynamic (neo-Freudian). Most the the ideas started by Freud were pretty original, but it seems as those defense mechanisms are the only thing that came out of Freud that made it.

Neo-Freudian psychodynamic theory was taken by Karen Horney, Winnicott, Adler, Klein, and those folks to a different system. The most popular subsets of psychodynamic are self psych, ego psych, and object relations. In these subsets, behavior is all about past experiences, object permanance, internalized objects, and motivations.

In my own therapy I often conceptualize problems from an object relations perspective (to address covert motivations for behavior) but use it in an evidence based way to address to the Patient.

The psychiatry residents that went through with us were only taught Freudian psychology and did not get exposed to any of the good neo-Freudian ideas. So, don't count it out until you read about object relations and ego psychology. That is good nerd fun right there!!

I'd agree that a Freudian-only education is a limiting as a medication-only one. I'd recommend the book below (which was our core psychotherapy text in residency) for a nice review of all the various psychodynamic theories from Freud through Kernberg.

http://www.amazon.com/Freud-Beyond-...sr_1_1?ie=UTF8&s=books&qid=1251478694&sr=8-1#

 

[cleareyedguy]

The reason I dislike and don't respect Freud personally is because he's a guy who initially got things right and then sold out the truth when he found it wasn't politically tenable, thereby creating a legacy that continues to sell people out to this very day. Freud was a guy who got it right . . . initially. His "seduction theory" was pretty much on the money. Freud initially thought that the incest histories his patients were reporting to him were true and the cause of their psychopathology. He reported this in various papers and conferences. He got no press. People just did not want to hear that little girls were having sex with their dads. So he gave up. Within a few years, he abandoned this philosophy and decided that these stories were fantasies of what his patients wished had happened to them. And now people listened to him and thought that Freud was the greatest thing since sliced bread. Still today, we learn in all seriousness about repressed fantasy and the Oedipal complex and all about how little girls really want to get it on with dad.

wow--I'm surprised and a little sad to read that you seriously believe that this is true.

As said by someone else, if you don't think childhood fantasy is an important element in personal development, I don't know what to say. And if you think that Freud's theories were significantly influenced by what would be popular, you're just wrong (though, if he were, he wouldn't try to get popular by asserting that little boys fantasize about getting intimate with mom).

 

[billypilgrim37]

It is a perfectly valid complaint to note that psychodynamics has terrible misogynistic, homophobic, and racist roots which we should acknowledge and condemn. There are plenty of reasons to be triggered by the personal failings of Freud, Jung, Reich, etc. Much of these failings were well within cultural context, but that doesn't mean we should ignore them or entirely forgive their proponents.

It would not be valid to fail to note how much of these terrible roots have been addressed and ameliorated by progressives within the field more recently.

It would also not be terribly ungood to fail to avoid not using double negatives. Maybe.

To be serious, the wikipedia article on penis envy actually has this really nice 2-3 paragraphs that addresses some of the feminist criticism of psychoanalysis and some of the very good work that has at least partially addressed some of the problems that arise.

 

[strangeglove]

And if you think that Freud's theories were significantly influenced by what would be popular, you're just wrong (though, if he were, he wouldn't try to get popular by asserting that little boys fantasize about getting intimate with mom).

I think what SL is trying to say is that Freud's episteme was influenced by the prevailing society of his time, just as our notion of how receptors work is shaped by things like pharmaceutical companies. For example, the notion of the id and ego is intimately bound up with Victorian sexuality and colonialist notions of the primitive. This, of course, doesn't invalidate Freud. It just means that you have to think a little bit more if you are using his theories to understand things other than neuroses in straight European people.