PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy has the longest organized tradition of the psychotherapies. It is also known as psychoanalytic psychotherapy or expressive psychotherapy.⁷ This psychotherapy can be brief or time-limited, but it is usually open-ended and long-term. Sessions are generally held once or twice per week, with the patient being encouraged to talk about “whatever comes to mind.” This encouragement has been termed the fundamental rule of psychotherapy. The therapist, consequently, is usually nondirective but may encourage the patient to focus on feelings about “whatever comes to mind.” The therapist is empathic, attentive, inquiring, nonjudgmental, and more passive than in other kinds of psychotherapies. The goal of psychodynamic psychotherapy is to recognize, interpret, and work through unconscious feelings that are problematic. Often unconscious feelings are first recognized in transference phenomena. Many psychodynamic psychotherapists choose to ignore positive transference phenomena, but interpret negative phenomena. For example, the patient may express the wish to be the therapist’s friend. The focus would be on the patient’s disappointment and frustration that a friendship cannot occur rather than a focus on the depth of the patient’s longing for a friendship with the therapist. The psychotherapist deliberately avoids answering most questions directly or revealing personal information about himself or herself. This strategy, referred to as the abstinent posture, promotes the emergence of transference phenomena. The abstinent posture leaves a social void that the patient fills with his or her imagination and projections, allowing the therapist access to the patient’s unconscious. The patient will get in touch with intense feelings that have been suppressed or repressed. Catharsis is the “letting go” and expression of these feelings.

At least six major theoretical systems exist under the psychodynamic model; these are summarized in Table 10-1.

Table 10-1 Major Theoretical Systems in the Psychodynamic Model

Psychoanalysis is an intensive form of psychodynamic psychotherapy; several of its characteristics are summarized in Table 10-2. The time and financial cost of psychoanalysis generally puts it out of range for many patients. To date, there is no persuasive evidence that psychoanalysis is more effective than psychodynamic psychotherapy. However, there is emerging evidence that psychodynamic psychotherapy is effective for a number of diagnoses.^13,14

Table 10-2 Characteristics of Psychoanalysis

COGNITIVE-BEHAVIORAL THERAPY

CBT is emerging as a widely practiced psychotherapy for depression, anxiety disorders, and other psychiatric and medical diagnoses. CBT represents a merger of the pioneering work of Aaron Beck¹⁵ (who first developed cognitive therapy for depression in the mid-1960s) and the work of Joseph Wolpe¹⁶ (who, in 1958, described a behavior therapy, reciprocal inhibition, for anxiety disorders).

CBT is built on the assumption that conscious thoughts, feelings, and behaviors interact to create symptoms.¹⁷ In contrast to the psychodynamic model, unconscious inner conflicts and early relationships are considered less important than here-and-now conscious awareness of thoughts, feelings, and behaviors. The therapeutic sessions are structured and collaborative. The therapist defines the goals and methodology of therapy and teaches the patient to observe the interaction of feelings, thoughts, and behaviors. Commonly used cognitive-behavioral techniques are summarized in Table 10-3. There is considerable research support for the effectiveness of CBT for a number of disorders.¹⁸

Table 10-3 Commonly Used Cognitive-Behavioral Techniques

SUPPORTIVE PSYCHOTHERAPY

Supportive psychotherapy has been included in the five core competencies of psychotherapy training. This “user-friendly” psychotherapy has rarely been formally taught in residency or in psychology training programs. In the heyday of psychoanalysis and psychoanalytic psychotherapy during the mid to late twentieth century, advice, suggestion, and encouragement were generally considered unhelpful for most patients with emotional problems. Nevertheless, Wallerstein,¹⁹ reporting on the results of the extensive Menninger Clinic and Foundation Study of Psychoanalysis and Psychotherapy, stated that supportive psychotherapy was often as effective as psychoanalysis at relieving symptoms and achieving enduring structural change.

Supportive psychotherapy is often defined by what it is not. It does not involve analysis of the transference; it does not involve challenging defenses; it does not endeavor to change the structure of personality or character; it does not involve making the unconscious, conscious. Supportive psychotherapy is often indicated to help a patient survive a loss or to get beyond a stressful event. This therapy can be brief but often is long-term. For example, a widow may initially benefit from weekly supportive psychotherapy after the loss of her spouse. After painful grief symptoms have improved, she may see the therapist monthly for an indefinite period for maintenance supportive psychotherapy.

Supportive psychotherapy provides a safe place for the patient to express feelings, to problem-solve, and to reinforce adaptive defenses. Techniques involved in the practice of supportive therapy are summarized in Table 10-4.

Table 10-4 Techniques Involved in the Practice of Supportive Therapy

Hellerstein and colleagues²⁰ suggested that supportive psychotherapy be the default psychotherapy. This “user-friendly” therapy neither generates anxiety nor requires a weekly commitment for an undetermined period of time as with expressive psychodynamic psychotherapy. Research has found supportive psychotherapy to be efficacious. Hellerstein and associates²⁰ proposed a trial of this therapy before the more extensive, more anxiety-provoking expressive psychodynamic psychotherapy.

Several studies of psychotherapy research have found that supportive psychotherapy is effective for a variety of psychiatric diagnoses; Winston and colleagues²¹ have comprehensively reviewed this literature. However, more research is needed to better understand how to integrate supportive psychotherapy with psychopharmacology and with other psychotherapy techniques for specific diagnoses.

BRIEF PSYCHOTHERAPY

Although Olfson and Pincus²² found that the average length of psychotherapy is probably only eight visits, most of these “brief” psychotherapies represent the patient’s unilateral decision to discontinue treatment. Paradoxically, Sledge and colleagues²³ found that if a brief therapy is planned with the patient, twice as many patients continue to the agreed-on endpoint than if no endpoint is agreed on. In other words, having an agreed-on limit to the number of visits reduces the dropout rate by half.

Brief psychotherapy is therefore defined as a psychotherapy with a predetermined endpoint, usually 8 to 12 visits. The theory and technique of brief psychotherapy parallels the established psychotherapy “camps.” Sifneos,²⁴ Malan,²⁵ Davanloo,²⁶ and others describe time-limited psychodynamic psychotherapy. Beck and Greenberg²⁷ have described time-limited cognitive therapy. Klerman’s Interpersonal Psychotherapy (IPT)²⁸ is a time-limited therapy that focuses on here-and-now interpersonal relationships. Budman²⁹ described an eclectic or integrative psychotherapy that includes interpersonal, developmental, and existential issues. Hembree and co-workers³⁰ described a brief behavioral therapy, which includes stress inoculation training and exposure therapy.

Steenbarger³¹ presented six considerations for selection criteria for brief psychotherapy. These six considerations form the acronym DISCUS and are presented in Table 10-5.

Table 10-5 Criteria for Selection for Brief Psychotherapy

Perhaps the most important feature of brief psychotherapy is the activity required of the therapist. The therapist is active in the initial assessment of the patient; active in establishing, early on, the goal of the therapy and the contract for a limited number of sessions; active in keeping the therapy focused on the goals; and active in assigning homework.

There is some controversy concerning the termination of brief psychotherapy. At one extreme, Mann³² advocated a complete termination in order to have the patient confront existentially the meaningful end of the therapy. Mann precluded contact with the patient after termination. At the other extreme is the transition of a weekly 12-session IPT into an indefinite monthly maintenance IPT. Blais and Groves³³ prescribed a recontact after 6 months.

Research evidence for the effectiveness of brief psychotherapy is extensive.^34,35 Brief psychotherapy has been designated by the Psychiatry RRC as one of the five psychotherapies to be included in psychotherapy core competencies. This inclusion, plus mounting pressure from insurers to limit the length of psychotherapy, should lead to more brief psychotherapy. It is also likely that many patients, if given the option, would prefer a time-limited treatment with clear, discrete goals and an active therapist.

PSYCHIATRIC MEDICATION WITH PSYCHOTHERAPY

A patient receiving both psychotherapy and medication becomes part of a complex and multifaceted phenomenon.³⁶ There are two possible approaches to mixing psychopharmacology and psychotherapy: the psychiatrist does both the psychotherapy and psychopharmacology, or the psychiatrist does the psychopharmacology and someone else does the psychotherapy. The former is referred to as integrative treatment, the latter, split treatment. There is virtually no research on whether integrative or split treatment is better for a certain diagnosis or a certain patient. However, there is some research to demonstrate that combining psychopharmacology and psychotherapy is more effective for certain diagnoses than either alone.³⁷ There is also some evidence that it is less expensive for a psychiatrist to provide both the psychopharmacology and the psychotherapy.³⁸

The prevalence of split treatment in the United States is significantly greater than integrative treatment for a number of reasons. First, there is a significant economic incentive for psychiatrists to do psychopharmacology exclusively, either if insurance is used or if patients self-pay. Second, many PCPs refer patients who need psychotherapy to nonmedical therapists. The PCP continues to medicate the patient and a split treatment is established. A third possible reason that split treatment prevails is that recent graduates from psychiatric residency training programs may feel less competent to do psychotherapy than do residents who graduated decades earlier.

There are advantages and disadvantages to integrated care. As mentioned, research has found that integrated care is less expensive for some diagnoses. This finding may be explained by the fact that fewer visits are required with only one practitioner or that medication may be appropriately started sooner if the therapist can also prescribe. Another advantage is the efficiency if all pharmacological and psychosocial issues are known and managed by one clinician (i.e., no time is needed to communicate with another professional). The pitfalls of integrated care include the time pressure to address both psychosocial and pharmacological issues in one visit, as well as the unwitting overemphasis of one modality over the other by the psychotherapist-psychiatrist. For example, a maladaptive response to countertransference issues raised by the patient’s feelings may be to focus more on medicating the feelings than on listening to, and understanding, them.

Split treatment also has advantages and disadvantages. In split treatment, the clinician can focus exclusively on his or her specific expertise. The psychotherapist does not have to reconsider dosages and side effects, and the psychopharmacologist can defer psychosocial issues to the psychotherapist. The pitfalls of split treatment are also significant. The ideal of regular communication between psychotherapist and pharmacotherapist is often hard to accomplish. The shared electronic medical record can accomplish some efficient and constructive communication, but live verbal communication can often capture important nuances that visit notes may not. Another pitfall of split treatment is the expense in terms of time and money. Some insurers will not pay for a psychotherapy visit and a psychopharmacology visit on the same day. So, if both psychotherapist and psychopharmacologist are in the same practice setting, the patient has to come in on separate days. Countertransference can also be a pitfall of split treatments. When the patient is failing, each clinician might unwittingly blame the other clinician and the other modality. Good communication and collaboration between clinicians engender trust and respect, which will benefit the failing patient.

Another pitfall of split treatment is the fact that emergency management or hospitalization often becomes the responsibility of the psychopharmacologist, who sees the patient less frequently and is less aware of psychosocial factors. Better communication and collaboration between clinicians greatly enhances the effectiveness of the psychopharmacologist’s emergency interventions.

A final pitfall of split treatment is that if a bad outcome to the psychotherapy leads to litigation, the psychopharmacologist is almost always included. This cautionary note argues for the psychopharmacologist to know well the psychotherapists with whom he or she is collaborating.

There are important considerations in the sequencing of psychotherapy and pharmacotherapy. For example, Otto and colleagues³⁹ found that adding CBT for a patient with a good response to benzodiazepines for panic disorder improves the success of a subsequent benzodiazepine taper. Marks and co-workers⁴⁰ found that adding a benzodiazepine early in exposure psychotherapy for phobias diminishes the effectiveness of the psychotherapy, presumably by muting the appropriate anxiety provided by graduated exposure.