Psychodynamics question

[AdamB1818]

New resident here with sincere question about psychodynamics. What is done when the psychiatrist and the patient come to an understanding of the patient's unconscious. For example, if it is discovered that the patient is avoiding close relationships due to subconscious conflicts with their parents, how is this used to help the patient? Psychodynamics seems like a great modality to point out the root of the problem, but how can we use it to work toward a solution?

---

Members don't see this ad.

 

[splik]

most psychodynamic work is not focused on making interpretations, and most interpretations will likely go over the patient's head. We call those interpretations that lead to meaningful change "mutative interpretations" and most such interpretations occur in the transference affect. The transference affect is the more readily accessible feelings that the patient has about the therapist. Most psychodynamic work focuses on the relationship between the therapist and the patient, and the patient may discover (or the psychiatrist may reflect) that their response to the therapist is an enactment of behavior in other important relationships. In your example of someone who avoids close relationships (unlikely to be due to conflicts with their parents per se), this will almost certainly come out in their relationship with the psychiatrist. They may desperately wish to be cared for and understood, but rebel against the unfamiliarity of it and fear dependence on the psychiatrist who they fear will abandon them or reject them as a parental figure did. It is not some intellectual realization that will lead to change (and in fact there is the danger that the patient or therapist, especially if obsessional, will use intellectualization and interpretations as a way to hide from powerful feelings or resist change), but the affect generated. When the patient experiences the warmth and holding environment of the therapist - someone who genuinely cares, who won't abandon them, reject them, scorn them, invalidate them - and can tolerate and help them to experience and manage powerful feelings, they may begin to feel safe with letting others get close to them.

 

[watto]

Well stated by Splik. I would add that there is some utility in helping the patient turn against the defense, to see it as self-defeating ultimately, and to experience emotion relating to this. To see the cruelty of treating oneself in such a manner and turn against it, just as one would defend a child being abused by an adult.

 

[deleted736562]

most psychodynamic work is not focused on making interpretations, and most interpretations will likely go over the patient's head. We call those interpretations that lead to meaningful change "mutative interpretations" and most such interpretations occur in the transference affect. The transference affect is the more readily accessible feelings that the patient has about the therapist. Most psychodynamic work focuses on the relationship between the therapist and the patient, and the patient may discover (or the psychiatrist may reflect) that their response to the therapist is an enactment of behavior in other important relationships. In your example of someone who avoids close relationships (unlikely to be due to conflicts with their parents per se), this will almost certainly come out in their relationship with the psychiatrist. They may desperately wish to be cared for and understood, but rebel against the unfamiliarity of it and fear dependence on the psychiatrist who they fear will abandon them or reject them as a parental figure did. It is not some intellectual realization that will lead to change (and in fact there is the danger that the patient or therapist, especially if obsessional, will use intellectualization and interpretations as a way to hide from powerful feelings or resist change), but the affect generated. When the patient experiences the warmth and holding environment of the therapist - someone who genuinely cares, who won't abandon them, reject them, scorn them, invalidate them - and can tolerate and help them to experience and manage powerful feelings, they may begin to feel safe with letting others get close to them.

To add, the above is the relational/interpersonal perspective which I like. A more classical approach though would fit more with what the OP described. The focus is less on the therapist/pt relationship and the therapist supposedly takes a more distant and "objective" stance to uncover the unconscious drives and the defenses.

 

[dl2dp2]

New resident here with sincere question about psychodynamics. What is done when the psychiatrist and the patient come to an understanding of the patient's unconscious. For example, if it is discovered that the patient is avoiding close relationships due to subconscious conflicts with their parents, how is this used to help the patient? Psychodynamics seems like a great modality to point out the root of the problem, but how can we use it to work toward a solution?

LOL the real answer is most of time nothing is done. Most of the time nothing happens with the supposed “insight”. This is why if you want to effect changed quickly you need behaviorally oriented treatment. Or at least have a different frame (ie Brief Dynamic). The fact that something is “subconsciously” causal is not falsifiable and has no immediate therapeutic implication.

The entire premise of psychodynamic treatment is fundamentally in conflict with empiricism and evidence based medicine. However, for a variety of reasons it’s 1) very useful 2) fun. For the right fit it’s the only way to answer certain questions that has a flavor of “what should I do with my life” which trigger psychiatric symptoms. The treatment is useful in particular for the relief of symptoms — just having the insight sometimes transforms persistent subject distress into something more ordinary and circumscribed, like grief. It is also debatable whether psychodynamic treatment per de is “deeper” and whether the revealed insight is more fundamental. In my clinical experience, very often what is actually deeper and more fundamental has to do with alteration in behavior. Tolstoy talks about this in Anna Karenina as “treatment” of “work”. Psychodynamic insight is often used as smoke and mirror by everyone involved to AVOID deeper issues.

Hope this is useful 😉 you have to change your mindset a bit for psychodynamics. It’s very zen/Eastern/right brain. Good thing to know/think about even if you don’t practice it.

 

[EarlyCareerAcademicPsych]

New resident here with sincere question about psychodynamics. What is done when the psychiatrist and the patient come to an understanding of the patient's unconscious. For example, if it is discovered that the patient is avoiding close relationships due to subconscious conflicts with their parents, how is this used to help the patient? Psychodynamics seems like a great modality to point out the root of the problem, but how can we use it to work toward a solution?

This is a great question! I appreciate the responses offered so far. I'd highly recommend that you try to find out whether the people answering your questions are actual practitioners of that kind of psychotherapy. You'll tend to get a certain kind of answer from psychiatrists who got some training in psychotherapy during residency, who now do other kind of work, and who have an initial impression formed as a novice.

I'll out myself as a psychotherapist-psychiatrist. About half of my clinical work is doing individual and group psychotherapy. However, because I work in the VA system, I mostly work in the "Evidence-Based Psychotherapy" frame which - for VA - means Prolonged Exposure & Cognitive Processing Therapy for patients with PTSD and DBT for patients who need more than that. I also co-lead a psychodynamic psychotherapy group for 8 years and my own personal therapy has been in the psychodynamic relational frame. Soooo ... that that into consideration with the comments that I lay down next.

Insight - or awareness in the language of mindfulness - is not a trivial achievement. It is very difficult to work on a problem if you are not aware of it. In my view, this is great strength of psychodynamic work. And it may take months/years to bring something into awareness. Once you know the problem, then you can apply all kinds of solutions to it.

I disagree with the claim that psychodynamic work cannot be studied in a scientific way. It is true that the temporary hypotheses formed (called interpretations) are shifting and difficult to pin down. But the clinical work itself can be studied in RCTs and this has been done. Do patients get better in psychodynamic psychotherapy? The short answer is "yes, some do". This is not controversial for anyone who has looked into decades of psychotherapy research. Now, how they get better, what kinds of methods help the most, what kinds of therapies help the most -- this is a much more difficult area to study. IMO, the point that sluox made above is most relevant to process research and not to outcomes research.

 

[dl2dp2]

I disagree with the claim that psychodynamic work cannot be studied in a scientific way. It is true that the temporary hypotheses formed (called interpretations) are shifting and difficult to pin down. But the clinical work itself can be studied in RCTs and this has been done. Do patients get better in psychodynamic psychotherapy? The short answer is "yes, some do". This is not controversial for anyone who has looked into decades of psychotherapy research. Now, how they get better, what kinds of methods help the most, what kinds of therapies help the most -- this is a much more difficult area to study. IMO, the point that sluox made above is most relevant to process research and not to outcomes research.

Outcomes can be studied scientifically. Still, the process is not scientific. I can randomized people to a fortuneteller vs. CBT therapist. And they may have similar outcomes (esp. if you adjust for certain populations). Doesn't mean that fortunetelling is scientific. One key criteria for what is and isn't science is mechanism. Psychodynamic mechanisms are not scientific by being unfalsifiable. This doesn't necessarily hamper their practical utility.

I also find the idea that everything that's worthwhile needs to be scientific illogical. Psychodynamic treatment often engages with things that are value-laden. Other things in our society that are value-laden are typically not driven by science. For example, nobody cares if the practice of law is scientific, or lobbying, or investment banking, etc. Scientific validity is not a good criterion in the validity of psychodynamic treatment. However, it MAY be a good criterion in making judgements about whether a third party payer ought to pay for things purely on efficacy. It seems legit to me that insurance could deny reimbursing fortunetelling even if it's proven to be equally effective in symptomatic relief. This point triggers people to no end, even though everyone knows that asymptotically in a converging system where a minimum amount of money would drive the max amount of efficacy, psychodynamic psychiatry would probably fall by the way side--and it has. Indeed, in such a system you'd just give everyone [in a below average severity outpatient context, i.e. people who are eligible for psychodynamic treatment] a pill and rely on placebo effect, which is essentially what we have in most of the OECD countries.

 

[downwithDTB]

Please explain how you prove that CBT's proposed mechanism of effecting change IS in fact it's actual mechanism of change?

You can come up with a bunch of proxies but there is no way that you can prove that CBT ACTUALLY works through the mechanism that it is proposed to work through (no more than you can prove that dynamic therapy doesn't actually work through a cognitive behavioral mechanism).

You may wish read up on the debates about the role of habituation in exposure therapies.

If you propose the definitive experiment below, I will laud you to no end as one of the most brilliant scientists of our generation. There is lots of evidence that psychotherapies efficacy is moderated by more than what's in a manual, including therapist experience and quality.

 

[WisNeuro]

You guys should really break this out into a separate thread, as it could get very interesting. As a partial answer to the above, dismantling methodologies help us support mechanisms of change in treatments. We could easily slide down the slop of solipsism, but there are definitely ways to examine mechanisms of change, from a variety of levels (translational, receptor level, behavioral, etc).

 

[dl2dp2]

Please explain how you prove that CBT's proposed mechanism of effecting change IS in fact it's actual mechanism of change?

You can come up with a bunch of proxies but there is no way that you can prove that CBT ACTUALLY works through the mechanism that it is proposed to work through (no more than you can prove that dynamic therapy doesn't actually work through a cognitive behavioral mechanism).

You may wish read up on the debates about the role of habituation in exposure therapies.

If you propose the definitive experiment below, I will laud you to no end as one of the most brilliant scientists of our generation. There is lots of evidence that psychotherapies efficacy is moderated by more than what's in a manual, including therapist experience and quality.

You can at least come up with a reasonable hypothesis of how this might work. Other kinds of psychotherapies (i.e. prolonged exposure, motivational enhancement, mindfulness based etc) have better (more plausible) brain based mechanistic hypotheses. At least you can write them down and possibly test them if the right methods exist. The assumptions are scientific.

Psychodynamic psychotherapy fundamentally is antithetical to this kind of empirical verification. There is some attempt in the field to move away from the fundamentally subjective nature of this ("neuropsychoanalysis") but it's pretty clear that there's no organized psychoanalyst who's interested in "walk the walk" and apply for grants to examine these issues. Which, as I said, is perfectly fine with me--and I do psychodynamics in my practice on a daily basis. I think the value of psychoanalysis is has very little to do with whether its assumptions are scientific or not. It seems a pointless exercise to examine whether two interpretation of the Moonlight Sonata is better through a randomized trial, or whether I would organize my donor advised fund around one cause vs. another. Lots of things in life are worthwhile BECAUSE they are subjective and individualized. Lots of things in life are worthwhile because they were created through a history and a set of institutional rituals to resolve value-related questions that are unrelated to empiricism.

 

[deleted736562]

Psychodynamic psychotherapy fundamentally is antithetical to this kind of empirical verification. There is some attempt in the field to move away from the fundamentally subjective nature of this ("neuropsychoanalysis") but it's pretty clear that there's no organized psychoanalyst who's interested in "walk the walk" and apply for grants to examine these issues. Which, as I said, is perfectly fine with me--and I do psychodynamics in my practice on a daily basis. I think the value of psychoanalysis is has very little to do with whether its assumptions are scientific or not. It seems a pointless exercise to examine whether two interpretation of the Moonlight Sonata is better through a randomized trial, or whether I would organize my donor advised fund around one cause vs. another. Lots of things in life are worthwhile BECAUSE they are subjective and individualized.

I disagree with this. A lot of the relational stuff is based on attachment theory, which is empirically testable. The idea of following the affect and the holding environment are backed up by scientific evidence and are testable - and in fact there are scientists working precisely on those questions with connection to dynamic theory.

I'd also argue that what people noticed to work in therapy, forming the basis of theoretical foundations, IS empiricism. Perhaps not as rigorous as a clinical trial or something, but it starts from empirical observation. At the end of the day therapy is more of an art than a science but the underlying core themes can and are scientifically put to the test.

 

[clausewitz2]

I disagree with this. A lot of the relational stuff is based on attachment theory, which is empirically testable. The idea of following the affect and the holding environment are backed up by scientific evidence and are testable - and in fact there are scientists working precisely on those questions with connection to dynamic theory.

I'd also argue that what people noticed to work in therapy, forming the basis of theoretical foundations, IS empiricism. Perhaps not as rigorous as a clinical trial or something, but it starts from empirical observation. At the end of the day therapy is more of an art than a science but the underlying core themes can and are scientifically put to the test.

Empiricism and the hypthetico-deductive approach of science as outlined in high school textbooks are not the same thing and historically have often been opposed.

"Clinical lore", if based on careful observations, is the essence of empiricism properly speaking. It is nothing more than veridicial accounting of sensory evidence.

It's not rigorous from the perspective of RCTs but it is arguably more empirical in some sense because it makes fewer philosophical and mathematical assumptions.

 

[dl2dp2]

I mean, they can always do that, but I don't see why they would. Discuss the situation with the program director and negotiate a win-win outcome. This is so common as to be not very remarkable an occurrence.

I disagree with this. A lot of the relational stuff is based on attachment theory, which is empirically testable. The idea of following the affect and the holding environment are backed up by scientific evidence and are testable - and in fact there are scientists working precisely on those questions with connection to dynamic theory.

I'd also argue that what people noticed to work in therapy, forming the basis of theoretical foundations, IS empiricism. Perhaps not as rigorous as a clinical trial or something, but it starts from empirical observation. At the end of the day therapy is more of an art than a science but the underlying core themes can and are scientifically put to the test.

Why is the degree of adherence to empiricism necessarily the arbiter of therapeutic value?

Also FYI attachment theory is NOT currently under any sort of systematic scientific test in the framework of federally sponsored research program. Attachment theorists also have zero interest in going into that system. Knowing what I know about the NIH, I don’t necessarily blame them, but let’s not pretend anyone is doing serious science around this. The honest to god truth is psychoanalysts have no interest in engaging the broader biomedical science research community—which is fine, but let’s call a spade a spade.

 

[tr]

Also FYI attachment theory is NOT currently under any sort of systematic scientific test in the framework of federally sponsored research program. Attachment theorists also have zero interest in going into that system.

Ahem. As the proud owner of multiple failed grant submissions in this area, I humbly submit that it is the feds who are not interested in funding that particular line of research. Not the other way around.

Parenthetically, I take exception to the equation of attachment theory with psychodynamic work. Attachment-based concepts and interventions can be implemented in a CBT framework just like everything else. CBT is not at all about content, it can have any content. It's about structure. The thing that differentiates CBT-based from psychodynamic therapies is the explicit delineation of a goal and the structured path to achieving it.

I have no patience with psychodynamic work and therefore I do not do it. It doesn't suit me. That said, I recognize that there have been some attempts to test it empirically, and the upshot is that (for depression) it takes longer to work than CBT but ultimately is about equivalently effective. And also that in the greater scheme of things, the most important factor in therapeutic success is the therapeutic relationship, not the modality.

But I also must say that my experience with psychodynamically oriented supervisors was that there was no structure whatsoever to what they were doing, and they seemed to use the phase 'the holding environment' to encourage newbie supervisees that their blandly supportive comments or their bumbling attempts at incisive interpretation were indeed useful and effective, against all evidence to the contrary. Only the CBT-oriented supervisors had an actual technique to teach and an actual interest in the objective assessment of whether it was effective or not. Hence my impatience with psychodynamic work: I feel there's no 'there' there. Not to say that it can't be effective. Just that I personally find the lack of structure or any bar for progress irritating.

 

[deleted736562]

Why is the degree of adherence to empiricism necessarily the arbiter of therapeutic value?

Also FYI attachment theory is NOT currently under any sort of systematic scientific test in the framework of federally sponsored research program. Attachment theorists also have zero interest in going into that system. Knowing what I know about the NIH, I don’t necessarily blame them, but let’s not pretend anyone is doing serious science around this. The honest to god truth is psychoanalysts have no interest in engaging the broader biomedical science research community—which is fine, but let’s call a spade a spade.

So Beatrice Beebe (a name on top of my head), a professor at Columbia, is not a serious scientist? Does it have to be funded by the NIH to be called science?

The point is that psychodynamic therapy works for a reason. And those reasons can most definitely be scientifically investigated, like everything in nature. If it can't, then I guess you assume it's magic or supernatural or something.

 

[erg923]

The point is that psychodynamic therapy works for a reason. And those reasons can most definitely be scientifically investigated, like everything in nature.

Eh, maybe? Yes, yes, "dynamic" and "analysis" are not the same thing, blah, blah. Point is, misunderstanding of "empirical" and how we currently spend our resources (MONEY!) with regard to OP mental health.

Philosophical Psychology Session #11

Psychoanalysis copyright 1989-2006 Leslie J. Yonce

mediasite.csom.umn.edu

Philosophical Psychology Session #12

Psychoanalysis copyright 1989-2006 Leslie J. Yonce

mediasite.csom.umn.edu

 

[clausewitz2]

Ahem. As the proud owner of multiple failed grant submissions in this area, I humbly submit that it is the feds who are not interested in funding that particular line of research. Not the other way around.

Parenthetically, I take exception to the equation of attachment theory with psychodynamic work. Attachment-based concepts and interventions can be implemented in a CBT framework just like everything else. CBT is not at all about content, it can have any content. It's about structure. The thing that differentiates CBT-based from psychodynamic therapies is the explicit delineation of a goal and the structured path to achieving it.

I have no patience with psychodynamic work and therefore I do not do it. It doesn't suit me. That said, I recognize that there have been some attempts to test it empirically, and the upshot is that (for depression) it takes longer to work than CBT but ultimately is about equivalently effective. And also that in the greater scheme of things, the most important factor in therapeutic success is the therapeutic relationship, not the modality.

But I also must say that my experience with psychodynamically oriented supervisors was that there was no structure whatsoever to what they were doing, and they seemed to use the phase 'the holding environment' to encourage newbie supervisees that their blandly supportive comments or their bumbling attempts at incisive interpretation were indeed useful and effective, against all evidence to the contrary. Only the CBT-oriented supervisors had an actual technique to teach and an actual interest in the objective assessment of whether it was effective or not. Hence my impatience with psychodynamic work: I feel there's no 'there' there. Not to say that it can't be effective. Just that I personally find the lack of structure or any bar for progress irritating.

Also I would say that Meredith Ainsworth, Nathan Fox, and Jude Cassidy are all fairly successful researchers functioning/defining the attachment paradigm who were sure as heck interested in getting grants.

 

[dl2dp2]

Also I would say that Meredith Ainsworth, Nathan Fox, and Jude Cassidy are all fairly successful researchers functioning/defining the attachment paradigm who were sure as heck interested in getting grants.

Not sure about this. People you cite are not really doing “attachment theory” work so much as childhood adverse events. That said, it maybe that they submitted grants under attachment theory umbrella and got rejected. Still my point stands 1) people who are in charge of the purse strings are not interested in this (scientific research on psychodynamics) People who might have an interest in this don’t want to really do funded research. 2) the fact there’s no science on this doesn’t mean it’s not valuable in a very concrete practical way. 3) more importantly, to even attempt to study psychodynamics in a scientific way is in many ways incorrect.

 

[clausewitz2]

Not sure about this. People you cite are not really doing “attachment theory” work so much as childhood adverse events. That said, it maybe that they submitted grants under attachment theory umbrella and got rejected. Still my point stands 1) people who are in charge of the purse strings are not interested in this (scientific research on psychodynamics) People who might have an interest in this don’t want to really do funded research. 2) the fact there’s no science on this doesn’t mean it’s not valuable in a very concrete practical way. 3) more importantly, to even attempt to study psychodynamics in a scientific way is in many ways incorrect.

Meredith Ainsworth invented the strange situation task so I am not sure who qualifies as an attachment researcher if she does not.

 

[deleted736562]

The relational school in psychodynamics owes a great deal to attachment theory and research. The whole idea is that patterns of relationships and attachment in adult life reflect early developmental experience and the therapeutic environment in a way is thought of as a restructuring of hard-wired patterns. Understanding the role of early relationships can actually inform the actual therapy.

Of course the classical edifice has questionable scientific basis, though has to be said there is absolutely nothing preventing research from looking at the influence of unconscious thought on behavior - which actually has and is being done.

I think it would be a mistake to assume "analysis" or whatever you want to call it operates in its own magical world, detached from testable reality. it's epistemologically false. The same way meditation or Buddhist principles are actually rooted in valid scientific principles.