Psychodynamic Psychotherapy Rationale

Psychodynamic psychotherapy, like CBT, is more accurately understood as a range of approaches with a common origin, namely psychoanalytic psychotherapy, with specific prominence given to object relations theory. The specific focus of attention varies between models but each explores internal conflicts, the early developmental origins of conscious and unconscious defences - particularly those developed to protect against loss, hostility or powerlessness - and their current depressive manifestations. All include explicit reference to and use of the therapeutic relationship, working repeatedly in the transference. The psychodynamic approach aims to promote new experience and to develop new insight into intra-psychic conflicts and enduring maladaptive patterns through empathic listening, emotional catharsis and therapeutic interpretation, to potentially aid resolution. Treatment targets are characterological rather than explicitly symptomatic, ascribing to the idea of depressive personality,rejectedby other models of psychotherapy, and interventions arenon-directive and not skills based. Psychodynamic interpersonal psychotherapy (PIP) (Shapiro etal., 1994) is based on Hobson's conversational model (Hobson, 1985) and offers abridge between psychodynamic psychotherapy and IPT. It relies more heavily on interpretations of the therapeutic relationship than the latter, while working in a time limited and focused way.

Evidence Base

Psychodynamic psychotherapy has been widely criticised for failing to produce empirical evidence to support this form of intervention. Few quality comparative studies exist despite this form of treatment having the longest history of those discussed. The general trend in those studies that have been produced is for better outcome for alternative treatments. Burnand et al. (2002) did, however, report an additive effect for combined therapy over pharmacotherapy with supportive care in symptom reduction, reduced service use and improved cost-effectiveness. However the degree to which the intervention described could be accurately conceptualised as formal psychodynamic psychotherapy is questionable, limiting the support offered by this study. The NICE guidelines (NICE, 2004) failed to find any conclusive empirical data favouring a psychodynamic approach for the treatment of depression.

Shapiro & Firth (1987) and Shapiro & Firth-Cozens (1990) reported on two studies comparing PIP and CBT for professional/ managerial subjects with depression and/or anxiety. The trend across all outcome measures in the first Sheffield study was modestly in favour of prescriptive (CBT) treatment over exploratory (PIP). These differences were, however, noted to be of little clinical significance, with the exception of the SCL-90, where CBT produced twice as much improvement and were also largely attributable to the performance of one therapist (Shaprio, Firth-Cozens & Stiles, 1989). These differences, however, remained stable over a two-year follow-up (Shapiro & Firth-Cozens, 1990). In the second Sheffield study the same treatments were examined but were delivered over different time periods - eight or 16 sessions for CBT and PIP - and to a larger sample. There was little evidence of either treatment performing more effectively or efficiently, although both produced substantial clinical improvement.

Clinical Practice

Psychodynamic interpersonal psychotherapy uses a number of psychodynamic and interpersonal concepts to aid use of the therapeutic relationship as a means of exploring, clarifying and resolving interpersonal problems, which are conceptualised as being at the root of depressive difficulties. The assumption of the interpersonal origins of depressive difficulties aligns this model closely with IPT. The explicit use of the therapy relationship and the dialogue between participants as the vehicle through which understanding and change is achieved testifies to the psychodynamic foundations. The method encourages exploration and is non-directive in character to the extent that questions are avoided in preference to statements and hypotheses to be accepted, revised or rejected. Hypotheses potentially aim to develop understanding, to link different aspects of experience or to provide an explanation for behaviour or experience. In other psychodynamic models such links would be clarified through interpretation. The treatment has a strongly collaborative feel with an extended assessment at the start of treatment and an emphasis on shared language. The treatment focuses on here and now concerns within the session and will examine interpersonal interactions in considerable detail, encouraging and supporting the full experience of affect in the moment, through the use of metaphor. Other forms of psychodynamic therapy would be expected to give more explicit attention to early, formative experiences, through which current interaction could be understood as re-enactments of internalised interpersonal templates. Evidence of transference enactments would be examined in detail to develop insight into conscious and unconscious conflicts and work these through to a more satisfactory resolution. Language and experience take precedence over skills training and problem solving in PIP and other psychodynamic models. Although considerable attention is given to the therapeutic relationship the aim is also to extrapolate from this to other relationships outside of therapy where similar interactions may be enacted. As previously noted the time-limited nature of these interventions maintains attention on the issues on ending throughout the intervention, with more specific attention given to the end of the therapeutic relationship in these transference-based models.

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