Download The Spectrum of Psychoanalytic Therapies

Journal of Psychiatric Practice
Psychotherapy Columns
Norman A. Clemens, M.D.
The Spectrum of Psychoanalytic Therapies:
For the Person Behind the Diagnosis
Abstract: Psychoanalytic therapies are individualized to the unique needs of each
patient. They are best viewed on a continuum, a spectrum of approaches that are
modulated according to the difficulties and the character structure of each
person as they manifest themselves at that moment in the person’s history. As
people change over the course of treatment, the treatment modality may evolve
accordingly. The many elements of a psychoanalytic therapy move along that
continuum in a way better calibrated on an analogic curve than on a digital scale
with discrete gradations. This requires attunement on the part of the analyst or
therapist to the subtle shifts in the dynamic equilibrium of the patient’s mental
life. Psychoanalysis and psychodynamic psychotherapy are distinct macro ways
to categorize and code for psychoanalytic treatments that operate at different but
overlapping micro ranges of the analogic continuum.
Key words: psychoanalysis, psychodynamic psychotherapy, psychoanalytic
psychotherapy, personality, character, ego structure
Human beings are rounded and lumpy. Their surfaces are curved, even those of the
most muscle-bound athletes. They don’t fit well into rectangular boxes with sharp
angles. The same goes with their minds. The broad categories of DSM-51 may cover
interrelated groups of phenomena with three or four entries to fashion a diagnosis, but
they do not capture the person. The multi-dimensional Alternative DSM-5 Model for
Personality Disorders of DSM-V or the similar Psychoanalytic Diagnostic Manual2 do a
more finely tuned task of assessment, but the product remains an abstract set of
numbers outlining many functional traits. It is useful for diagnosis, treatment selection,
research, and tracking progress, but it is of little use when it comes the minute-to-minute
management of the patient. Only the intuitive human sensitivity of one person engaging
with another person allows entry into the other’s unique inner world and determines the
nuances of the therapist’s response. The entry is on many levels – cognitive, sensory,
emotional, pre-verbal, and to a large degree unconscious. Empathy and the complex,
subjective experience of relatedness are essential to facilitating that person’s growth
and mastery. Greenson3 and McWilliams4 describe it as a particular kind of love often
called transference love. These are the same essential ingredients that facilitated
healthy psychic and neuronal growth and development earlier in the patient’s life -- or in
their absence failed to do so.
The psychoanalytic way of thinking and relating to patients addresses these dimensions
of our patient’s lives. It was illustrated by Paul Summergrad at the May, 2015, meeting
of the American Psychiatric Association. Dr. Summergrad is a psychoanalyst and
prominent academic psychiatrist at Tufts in Boston who was completing his term as
1
president of the American Psychiatric Association. In his outgoing address he covered
many aspects of the field including neurobiology, parity of insurance coverage, and the
development of new ways of delivering mental health care. However, the headline of
Psychiatry News’ report of his message was that “the scrutiny and criticism that the
mental health field occasionally receives is related to the fact that psychiatric illnesses
involve those capacities – feeling, think, and perceiving – that make us human.”5
The advantage of psychoanalytic thought and therapy is that they are wide-ranging and
flexible. They address many dimensions of human life, some of which were only
discovered, made explicit, and explored in a scientific way by psychoanalysts over the
last 120 years. They lend themselves to individualization of therapeutic approach, and
modification as patients change and evolve.
Somewhat arbitrarily, treatment can be divided into psychodynamic (or psychoanalytic)
psychotherapy and formal psychoanalysis. Psychodynamic psychotherapy can range
from deep insight work to ego-supportive interventions that are attuned to helping the
patient get through a major loss or crisis. Other patients of this sort may be dealing with
a chronic physical illness or an entrenched, severe mental illness that is mitigated by
medications. Psychodynamic therapy may be immensely helpful to a bipolar patient in
managing life stresses and relationships – fortifying the healthier part of the patient as it
resists being drawn into the biological dysfunction of the illness. However,
psychodynamic therapy may also be beneficial to patients who could gain great benefit
from full-scale psychoanalysis, but are not ready or motivated to make such a
commitment.
Some patients enter psychotherapy in a formal way, with full explanation of how the
treatment works and a commitment to a set routine of regular sessions. This usually
follows a short period of evaluation visits to get to know the patient and get a sense of
how he or she would engage in therapy. This degree of preparation is likely to be more
highly structured for psychoanalysis, but some degree of preparation and education is
helpful in any psychotherapy, especially preparing the patient for the fact that the
therapist or analyst does not behave or react as one would in ordinary social situations.
However, some patients seem to slide into therapy from what started out as medication
management or crisis management and may need help along the way to understand
what is happening.
Psychoanalysis entails commitment to three to five times a week of regular sessions
and generally (but not always) places the patient on a couch with the analyst seated
above the head. The very frequent sessions and the lack of face-to-face contact are
conducive to greater freedom of associative connections in the patient’s thought,
allowing patients to move into parts of their emotional lives of which they had been
previously unaware. The analyst uses a sense of where the patient is cognitively and
emotionally to assess whether to interrupt the flow of associations with observations
and efforts to help the patient or client (also called an analysand) understand what is
going on. In modern psychoanalysis analysts are likely to be somewhat more active and
to be more open about the feelings and thoughts stirred by the analysand’s thoughts
2
and behavior, in the service of enhancing understanding. Although these countertransference phenomena have been deemed to be important since early in the history
of psychoanalysis, the shift is sometimes characterized as a transition from a oneperson psychology to a two-person psychology.
In the abstract there is a clear difference between psychoanalysis and psychodynamic
psychotherapy. In real life with real people the lines become blurred. Psychoanalysts
are sometime supportive with patients in psychoanalysis during a crisis in their life
situation or at the time of a painful breakthrough in understanding. Psychotherapists
sometimes find that their patients are awakening to an unexpected level of interest in
learning more about themselves and making substantive growth in their level of psychic
functioning. Another variable is time in the life cycle. Turning points such as having a
child or a career crisis or a major illness or aging may open the door to maturational
steps and greater depth of understanding at any stage of life. Therapists understand
these developmental steps in building fundamental ego strengths, finding a secure
sense of self and empathic understanding of others, coming to grips with sadistic
consciences or the shame of failing to meet unrealistically high expectations of oneself,
and finding pleasure in loving relationships while living with the eventuality of
separation, loss, and death. Skillful therapy senses all these variables in each individual
and responds accordingly. Every patient is different; in a half century of being a
psychiatrist I have never found two patients who were very much alike. Each case was
a learning experience, and some were memorable. Most were personally part of my
own growth.
Psychoanalytic psychotherapy can occur in a few sessions or last over decades. I saw a
few patients for 30 or 40 years spanning much of their life cycle and mine. Over that
span the frequency might begin at twice a week and eventually dwindle to once a year.
The treatment relationships were deeply meaningful.
A young woman came to psychotherapy overwhelmed with anxiety at the
prospect of moving away from her family to a new job situation. Under her
clinging dependency and neediness it became increasingly clear that she was
deeply angry with her mother about perceived self-centeredness and neglect of
her children. However, the dependency gradually gave way to an interest in
understanding herself. Even though she was in psychotherapy once or twice a
week, she chose to use the couch and associate more freely. She then obtained
more advanced education and pursued a career that made good use of her
empathy and insightfulness towards others. She continued to use therapy to
manage the transition to marriage and motherhood, in which she found great
satisfaction. She had the strength ultimately to withstand severe marital problems
and disillusionment with her husband, whose career ended in disgrace. She
managed divorce and later career stresses. Her task became to work through her
dependency on her therapist and carry on without therapy, which she did. The
therapist’s task throughout was to sense the nuances of change and adjust the
therapeutic approach accordingly, using their two-person relationship as the
barometer and the facilitator of growth.
3
No one has figured out how ethically or practically to conduct a “gold standard”
randomized, double-blind, manual-driven, controlled trial on psychoanalysis lasting an
average of five years. The evidence base for psychoanalysis is a wealth of individual
case studies leading to observations that have been vigorously and contentiously
discussed in scientific meetings since the early 1900s. There is a broad consensus in
the field about fundamental concepts, but psychoanalysis has evolved dramatically as
new ways of understanding clinical experience have emerged. It is a science of
subjective mental life that cannot be measured or calibrated because it emerges wholly
from the human experience of living.
However, several psychoanalytically based therapies have been developed and studied
by means that meet the criteria of evidence-based medicine. They are more time-limited
and focused on particular treatment emphases. Milrod6 and associates have developed
a short-term panic-focused psychodynamic psychotherapy that is demonstrably
efficacious. Transference-focused psychotherapy (TFPP)7 and mentalization-based
therapy (MBT)8 have both been found effective in the treatment of borderline personality
disorder. A meta-analysis by Leichsenrung et al.9,10 of well-designed outcome studies
has shown that long-term psychodynamic psychotherapy leads to better outcomes in
mixed, severe chronic mental disorders, and in contrast to comparison treatments the
improved outcome endures after treatment ends. Measurement and statistics clearly are
important on the macro level.
On the micro level, however, the fine points of the therapeutic process are not
measurable on a digital scale. They are not like the digitally self-tuning radios that go
from one station to another precisely on the required FM frequency of 90.3 or 104.9.
They are more like the old analogue radios where you tweaked the dial back and forth
along an infinite series of variables until the signal was clear. That’s how humans tune
in to each other.
1
American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5). Washington DC and London: American Psychiatric Publishing
2
PDM Task Force. (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic
Organizations
3
Greenson R. (1967) The Technique and Practice of Psychoanalysis. New York: International Universities Press, pp.
388-396
4
McWilliams N. (2004) Psychoanalytic Psychotherapy: a Practitioner’s Guide. New York and London: Guilford
Press, pp. 40-41, 157-161
5
Moran M. (2015) “Summergrad advises the ‘long game’ in period of change, challenge.” Psychiatric News 50(12),
June 19, 2015, pp. 1,5
6
Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., et al.
(2007). A randomized controlled clinical trial of psychoanalytic psychotherapy
for panic disorder. American Journal of Psychiatry, 164(2), 265-272.
7
Kernberg, O. F., Yeomans, F. E., Clarkin, J. F., & Levy, K. N. (2008). Transference focused
psychotherapy: Overview and update. The International Journal of Psychoanalysis,
89(3), 601-620.
8
Fonagy, P., & Bateman, A. W. (2006) Mechanisms of change in mentalization-based
treatment of BPD. Journal of Clinical Psychology, 62, 411-430.
9 Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic
4
psychotherapy: A meta-analysis. Journal of the American Medical Association,
300, 1551-1565.
10
Leichsenring, F., & Rabung, S. (2011). Long-term psychodynamic psychotherapy in
complex mental disorders: Update of a meta-analysis. British Journal of Psychiatry,
199, 15-22.
5