Which type of therapy relies most heavily upon clients becoming conscious of their unconscious conflicts?

XI. Psychoanalytic Psychotherapy

Psychoanalytic psychotherapy is a modified form of psychoanalysis. Its goals are similar in that it tries to achieve relief from mental suffering through a careful understanding of mental functions and contents. Although the goal is the same, the objectives, setting, and technique vary. The objectives are more focused and limited, the setting is once or twice a week with the patient sitting up, and the technique may be very much more active on the part of the therapist.

The indications are generally the same as for psychoanalysis but because the sitting position and active interventions of the therapist often prevent an intense emotional regression, this type of therapy may be better suited to sicker patients whose integrative mental functions cannot yet tolerate a full analysis. In addition, the method may be used when very specific, time-limited objectives are needed by the patient and no personality reconstruction is necessary for those objectives. Some examples of this situation are difficulty in mourning a lost one, panic attacks or social anxiety as isolated symptoms in an otherwise high-functioning person, difficulty adapting to a difficult spouse or boss, or help in understanding a troubled relationship with a child. This kind of therapy is often used in conjunction with medication. Examples are the treatment of depression, panic attacks, or social anxiety situations. The combination is a potent one. The duration of such treatments are weeks to months to a few years. In some situations, generally because of constraints of time or money on the patient's part, such therapy can stretch on for years with the goal of providing a modified psychoanalysis for the treatment of long-standing personality disorders.

The technique generally involves both interpretation of dynamic conflict and support of defenses and of self-esteem. The usual goal is to repair, not reconstruct. However, for those whom the technique is being used as a modified psychoanalysis, interpretation, reconstruction, uncovering, and the intensification of transference and its interpretation are important techniques just as they are in psychoanalysis.

The training of practitioners is difficult for the patient consumer to ascertain because there are few programs specifically teaching dynamic psychotherapy Psychiatrists may learn dynamic psychotherapy in their residencies. Those who are psychoanalytically trained at psychoanalytic institutes after residency training at least are well grounded in the theory and technique of psychoanalysis, which is then applied to psychodynamic psychotherapy. Psychologists and social workers may get specific training in dynamic psychotherapy during the course of their degree programs. Some get further training in the few psychotherapy training programs that exist or go on for full psychoanalytic training themselves.

1.4 Applications

Unlike psychoanalytic psychotherapies, cognitive psychotherapy has developed through its application to conditions in which symptoms or problematic habits are associated with specific patterns of thinking. Its growth since 1970 has been accompanied by progressive developments in psychiatric nosology. The diagnostic and statistical manuals of the American Psychiatric Association chart diagnostic developments which have involved the progressive refinement of diagnoses based on anxiety, depression, psychosis, and distortions of personality, with the effective invention of categories to encompass the so-called somatoform, dissociative, adjustment, and eating disorders (APA 1968, 1980, 1994). These have facilitated understanding of common cognitive patterns associated with these and development of specific treatment techniques. Use of cognitive therapy in depression and anxiety disorders are best established, while diagnostic subclassifications that have clarified the characteristics of bipolar depressive disorder and panic disorder have been followed by specific cognitive techniques for their management. The category of personality disorders has not only been refined through this period, but, with the advent of multiaxial classification, been designated as an independent axis for summary clinical descripton (axis II). Given that the basic difference between disorders of personality from the symptom focused categories of axis I lies in their early onset and relative stability, models of their cognitive pathology have emphasized ‘deep’ cognitions over surface ones, and more recently the early maladaptive schema model of Young. Efforts to link specific personality types with consistent schema formations continue. A further development of particular significance to psychiatrists has been the application of cognitive therapy to schizophrenia. These have included treatments for specific symptoms (delusions and hallucinations) as well as measures to live with the impact of illness and enhance coping capacities (Chadwick et al. 1996).

The vast majority of cognitive therapy is provided as individual therapy. However, group treatments have been pioneered for specific disorders including depressive, anxiety, and eating disorders. Beck has advocated its use with couples experiencing conflict.

More recently, attempts have been made to differentiate between psychological therapies with reference to the strength of independent evidence concerning their clinical effectiveness. An empirically supported treatment is one which is clearly defined and, for a given clinical problem, is consistently more efficacious than placebo treatments on the evidence of controlled clinical trials. On this basis, cognitive therapies have emerged as empirically supported in adults for anxiety disorders (including panic disorder, generalized anxiety disorder, and social phobia); unipolar depression; anorexia nervosa and bulemia nervosa (Roth and Fonagy 1996).

5.09.5.3.2 Short Term Psychoanalytic Psychotherapy (STPP)

Short-Term Psychoanalytic Psychotherapy (STPP) is a relatively brief treatment, delivered over 30 weeks with monthly parent sessions, for adolescents with moderate to severe depression (Cregeen et al., 2016). STPP bears similarities to CAPP in that it proposes that depression stems from common intrapsychic and interpersonal conflicts. For example, depression may arise from conflicted anger (i.e., anger at others which becomes directed at the self, leading to depressive affect), a harsh superego (i.e., feelings of guilt and shame resulting from feelings or wishes of being seen as bad or wrong), or narcissistic vulnerability (i.e., an insecure sense of self resulting in the adolescent's sensitivity to losses and rejection). As in CAPP, the clinician seeks to address the underlying dynamics that give rise to the depressive symptoms, while communicating to the adolescent that their symptoms have meaning and can be understood and anticipated. The aim of STPP is to help the adolescent manage these symptoms, including feelings of aggression, guilt, and self-devaluation, achieve greater agency and a more realistic sense of self, and to enhance resilience by understanding and anticipating situations that evoke depressive symptoms.

In the first of three stages of treatment, the clinician establishes the frame of treatment and forms an alliance with the adolescent and parents, developing a formulation and treatment plan that is integrated with the adolescent's history and life experiences gathered from initial sessions. The clinician might surmise from the vignette above that Shawn's depression stems from narcissistic vulnerability, as he is sensitive to rejection from his peers, triggering harsh self-criticism and subsequent anger and rage at this rejection.

In the second stage, the therapist uses a variety of techniques to emphasize the meaning underlying the adolescent's depression symptoms and strives to connect these to the adolescent's thoughts and feelings. The therapist encourages exploration of feelings and reinforces the adolescent's emergence from apathy and increased feelings of agency and self-esteem. Attempts to avoid or defend against painful feelings or interactions are explored. The therapist and adolescent work to identify patterns in the adolescent's experiences and relationships with others, including these patterns as they manifest in the relationship with the therapist. When successful, the adolescent becomes better able to confront difficult aspects of their inner experience and relationships. The adolescent begins to understand their symptoms in the context of their current and past experiences, leading to a greater sense of control, as the adolescent has a greater understanding of their own vulnerabilities.

STPP emphasizes the importance of the therapist's ability to work with the negative transference. As an inability to manage angry, guilty, and critical feelings and fears of their consequences for interpersonal relationships are central to the underlying dynamics of depressive symptoms, therapists must be able to contain, experience, and respond empathically to the adolescent's anger and pain. The therapist's tolerance of these affects prevents these feelings from being turned inward and provides the opportunity for the adolescent to internalize the therapist's ability to deal with difficult experiences. The ending stage of STPP involves working through endings and helping the adolescent to anticipate future experiences, taking into account both vulnerabilities and newly developed capacities for resilience.

The efficacy of STPP was assessed within a large multicenter randomized controlled trial of 465 adolescents, divided into three groups – a brief psychosocial intervention, CBT, and STPP (Goodyer et al., 2017). Adolescents were treated weekly for approximately four months, although on average adolescents attended a median of 6–11 sessions across groups. Somewhat unusually for studies of psychodynamic youth therapies, sessions were audio-recorded, and treatment fidelity and differentiation between each treatment approach were established (Midgley et al., 2018). Adolescents in all three groups were found to have sustained reductions in depressive symptoms over a year after the conclusion of treatment. STPP, CBT, and the brief psychosocial intervention were found to be equally effective. At 1-year follow-up, 85% of adolescents receiving STPP no longer met criteria for depression. Youth receiving STPP also experienced reduction in other symptoms, including a 59% reduction in anxiety, a 43% reduction in obsessive-compulsive symptoms, and a 45% reduction in functional impairment. Secondary analysis of data from the IMPACT study has demonstrated that STPP had a significant impact on adolescents' “general psychopathology” (the p factor), supporting core psychodynamic ideas that even a treatment targeted at a particular diagnostic group can have an impact on psychopathology more generally (Aitken et al., 2020). A number of further studies of the IMPACT data have examined important issues, such as trajectories of change in therapy (Davies et al., 2019), or prognostic indications for those who drop out of therapy (O’Keeffe et al., 2019a,b).

6.05.2.9.1 Indications for ending treatment

Like much of psychoanalytic psychotherapy, the ending of treatment is often idealized. The desirable final outcome is often stated in terms of the process of treatment. Kennedy and Moran (1991), following Anna Freud, helpfully separate the process aims from the outcome aims of psychodynamic treatment. The former is likely to be stated in theoretical terms (e.g., a move from paranoid to depressive anxieties, an increase in the coherence of the patient's narrative, an increased awareness of impulses and fantasies, a manifestation of genuine concern for others and so on). All these are observed in the context of the treatment and are at best loosely coupled with the goals the patient might have for ending the treatment.

The latter are often external changes such as the decline of symptoms, improvement of relationships, decrease of unpleasant affect, an increased capacity for assertiveness, and so on. These external criteria are sadly regarded by many psychodynamic clinicians as superficial as they can be achieved without fulfilling the process aims of the treatment (Grünbaum, 1984). Evidence will have to be gathered which clearly demonstrates that external change associated with process change is more extensive or longer lasting than external changes achieved in isolation.

Process Development and Identification of Segments for Patient G

Quantitative process analysis of psychoanalytic psychotherapy for Patient G revealed two factors, which were produced by the P-factor analysis of the 17 defense mechanisms on the CADM; they accounted for 9.8 and 9.1 percent of total variance, respectively.

Factor A, which refers to the structural analysis of development, contains immature defense mechanisms related to the superego, such as turning against self, introjection, regression, and predominance of affect equivalents, with respective loadings of 0.53, 0.49, 0.47, and 0.59. Factor B is characterized by mature defense mechanisms and can be designated as related to impulse defense. Loadings for rationalization, isolation, and repression amounted to 0.65, 0.61, 0.47. and 0.58, respectively.

Only through changes in Factor B, which is the mature dimension in this therapy, was it possible to distinguish individual therapy segments (see B in Figure 16.5) After a decrease in mature defenses from Session 1 to 20 in Segment 1, there is change from Session 21 to 34 to a relatively stable high defense level in Segment 2, which between Sessions 34 and 68 gives way to increased fluctuation in Segment 3. From Session 69 to 99 a relatively stable high level of defense is again in evidence in Segment 4. Segment 5 is marked by major fluctuation in Factor 2 while Factor 1 remains largely constant across segments. An inverse relationship has emer between Factors 1 and 2. When the values for Factor 1, indicative of immature defense, are highest, those for Factor 2, on which mature defenses are loaded, are low, and vice versa.

Discussion

The five CPDTs reviewed here—SEPP, PaCT, CAPP, RFP-C, and MBT-C—have certain characteristics in common. Other than SEPP, all are short-term and/or time-limited and identify clear “phases” of therapy. Whether this time-limited element is seen as a necessary evil in the era of managed care (Salyer, 2002) or a positive recognition of the effectiveness of short-term interventions (McLaughlin, Holliday, Clarke, & Ilie, 2013), this aspect of these therapies stands in contrast to the tradition of more open-ended, long-term work in CPDT. Nevertheless, all of these CPDTs use psychodynamic principles to stimulate therapeutic change in the child. These principles include letting the child take the lead, focusing on affects (especially painful affects), helping the child to understand the motivation behind his or her own and others’ behavior, working on the here-and-now of the child’s relationship with the therapist, and soliciting the parents’ active involvement in parallel sessions.

Although all of these approaches refer back to the main traditions in psychodynamic thinking, such as the work of Anna Freud, Melanie Klein, Donald Winnicott and others, they all tend to be more integrative; in particular integrating the findings of developmental (and neuroscientific) research with attachment theory and psychoanalysis as well as features of other forms of child therapy. Three of these five CPDTs (PaCT, CAPP, MBT-C) explicitly rely on mentalization theory to formulate their treatment goals and their underlying theory of change. To what degree is there a shared mechanism of change underlying these different models of contemporary CPDT, or to what degree do they each depend on model-specific therapeutic processes? One hypothesis is that mentalization—the process of interpreting one’s own and others’ behaviors as connected to mental states such as feelings and intentions—is the effective therapeutic ingredient common to all effective psychotherapies (Bateman & Fonagy, 2004a), and this may be especially so in the case of psychodynamic treatments, given the focus on meaning making and unconscious states of mind. According to this hypothesis, “The potential effectiveness of all treatments depends not so much on their frame but on their ability to increase a patient’s capacity to mentalize” (Bateman & Fonagy, 2004a, p. 46). Regarding this hypothesis, analysis of session prototypes of a variety of adult and child treatments ranging from CBT to child-centered play therapy and CPDT indicate that a focus on promoting reflective functioning as the operationalization of the capacity to mentalize is significantly positively correlated with all these prototypes (Goodman, 2013b; Goodman et al., 2016; Prout et al., 2018). A more refined version of this hypothesis, which balances both common and unique factors, draws on the fact that mentalization is a construct that encompasses a number of dimensions: (1) implicit/explicit, (2) self/other, and (3) cognitive/affective (Choi-Kain & Gunderson, 2008). Goodman et al. (2016) have speculated that different treatment models might enhance different dimensions of mentalization.

We might wish to apply these two hypotheses to the five CPDTs reviewed here (three of which explicitly derive inspiration from mentalization theory). Is it possible that the “secret sauce” of all five CPDTs is their effectiveness at enhancing a child’s mentalizing abilities? Or do these five CPDTs go about enhancing different dimensions of mentalization? Goodman et al. (2016) have suggested that while CPDT might enhance self and other mentalization as well as implicit and affective mentalization, CBT might focus on self-mentalization in addition to explicit and cognitive mentalization. Similarly, Hoffman (2015) has suggested that externalizing children exhibit deficits in two domains—negative valence systems and systems for social processes—and that RFP-C addresses primarily the negative valence systems, while MBT-C addresses primarily the systems for social processes. Consistent with this line of thinking, is it possible that especially RFP-C and CAPP, but also PaCT and SEPP, primarily promote implicit, affective, and other dimensions of mentalization, while MBT-C primarily promotes explicit, cognitive, and self dimensions of mentalization?

A related hypothesis concerns the clinical techniques used to enhance these mentalizing processes in children with various diagnostic profiles (e.g., externalizing or internalizing behaviors). For example, RFP-C purportedly targets the defensive processes that prevent the externalizing child from mentalizing his or her own affects, which is understood to reestablish affect regulation. In a sense, one could view RFP-C as a form of graduated exposure to unpleasant affects that gradually become metabolized. By contrast, MBT-C purportedly targets the inhibitions in thinking about others’ (and the child’s own) thoughts about affects and behaviors and their connections to each other, which is also understood to reestablish affect regulation. Under what set of conditions each set of techniques is most therapeutic (e.g., child’s diagnostic profile, length of treatment, child’s developmental level) remains an unanswered question.

Psychotherapy researchers can empirically test these hypotheses, but we first need valid coding systems that can reliably measure Choi-Kain and Gunderson’s (2008) three dimensions of mentalizing (and other as yet unidentified dimensions) in various psychotherapy settings. Therapists could use such instruments to highlight specific mentalization deficits in children seeking treatment, as well as determine which CPDTs are best suited for which children. Finally, additional laboratory and naturalistic studies need to be completed to test the effectiveness of these five CPDTs, which are all based on strong conceptual foundations and integrate knowledge from developmental research with clinical wisdom but as yet have only minimal evidence of clinical- or cost-effectiveness. According to the National Registry of Evidence-Based Programs and Practices (n.d.) (http://nrepp.samhas.gov), none of these CPDTs yet qualifies as a program with “effective” or “promising” outcomes. The current generation of CPDT therapists and researchers need to take on the challenge of establishing and promoting the evidence base if a case is to be made for the contemporary relevance of psychodynamic thinking to therapeutic work with children.

II. Theoretical Bases of the Working Alliance

The concept of working alliance originated in psychoanalytic psychotherapy that is designed to make unconscious conflicts and feelings conscious. The analytic patient relates to the analyst in a distorted manner that mirrors these unconscious conflicts. In 1912, however, Sigmund Freud also posited a positive relationship between the analyst and patient that was based in the reality of their work together. This relationship later became known as the working alliance.

To humanistic therapists who believe that people are capable of helping themselves if they are provided with a facilitating relationship, the working alliance is both necessary and sufficient for client improvement. According to Carl Rogers in 1957, the therapist was responsible for creating this facilitating relationship by demonstrating empathy, genuineness, congruence, and unconditional positive regard toward the client. Within this accepting environment, the client was then able to achieve self-acceptance and self-actualization. This relationship would then generalize to other relationships outside of therapy. Thus, for Rogers, the working relationship was directly responsible for client improvement.

Behavioral and cognitive-behavioral therapy, which are based on learning principles, did not originally address the client–therapist relationship. In 1977, however, the Association for Advancement of Behavior Therapy (AABT) published ethical principles for behavior therapists. These principles emphasized client agreement with the goals and methods of treatments that are important components of the working alliance. Thus, most behaviorists and cognitive behaviorists stress the importance of the working alliance.

The working alliance is just one term for the collaborative relationship between client and therapist. Different theorists highlight different aspects of the alliance, and as a result, it is sometimes referred to as the helping alliance or therapeutic alliance. In 1979, Bordin put all the elements of the working alliance together into one conceptualization that applied to all types of theories and therapies. He defined working alliance as a bond between client and therapist and an agreement on the goals of therapy and the tasks necessary to achieve those goals.

Theoretical Bases of the Working Alliance

The concept of working alliance originated in psychoanalytic psychotherapy, which is designed to make unconscious conflicts and feelings conscious. The analytic patient relates to the analyst in a distorted manner that mirrors these unconscious conflicts. In 1913/1966, however, Sigmund Freud also posited a positive relationship between the analyst and patient that is based in the reality of their work together. This relationship later became known as the working alliance.

To humanistic psychotherapists who believe that people are capable of helping themselves if they are provided with a facilitating relationship, the working alliance is both a necessary and sufficient for client improvement. According to Rogers (1957), the psychotherapist is responsible for creating a facilitating relationship by demonstrating empathy, genuineness, congruence, and unconditional positive regard toward the client. Within this accepting environment, the client is able to achieve self-acceptance and self-actualization. This relationship then generalizes to other relationships outside of therapy. Thus, for Rogers, the working alliance was directly responsible for client improvement.

In contrast, behavior and cognitive-behavioral psychotherapists have historically tended to focus on specific techniques rather than the relationship between psychotherapist and client. In practice, however, behavioral therapies, such as dialectical behavior therapy, acceptance and commitment therapy, and functional analytic psychotherapy, rely heavily on the psychotherapist-client alliance to facilitate client change (Grosse Holtforth and Castonguay, 2005; Lejuez et al., 2005).

The working alliance is just one term for the collaborative relationship between client and therapist. Different theorists highlight different aspects of the alliance, and as a result, it is sometimes referred to as the helping alliance or therapeutic alliance. In 1979, Bordin put all the elements of the working alliance together into one conceptualization that applied to all types of theories and psychotherapies. He defined working alliance as a bond between client and psychotherapist and an agreement on the goals of therapy and the tasks necessary to achieve those goals.

In their 1985 article on the relationship in psychotherapy, Gelso and Carter emphasized the importance of establishing a positive working alliance early in treatment so that the alliance would sustain the relationship through the difficult periods to come in treatment. They believed that the alliance becomes disrupted in the middle phase of therapy when most intense work on behavior and attitude change is undertaken. The alliance was then assumed to recover to more positive levels later in therapy.

2.1.3 Modes of therapeutic action

The primary mode of the therapeutic action of psychoanalytic psychotherapy is considered to be insight. Insight may be defined as the conscious recognition of the role of unconscious factors in current experience and behavior. Unconscious factors encompass unconscious feelings, experiences, and fantasies. Insight is more than mere intellectual knowledge. Thomä and Kächele (1987) consider insight to be equidistant from emotional experience and intellect. Etchegoyen (1991) distinguished descriptive insights from demonstrated (ostensive) insights which represent a more direct form of knowing, implying emotional contact with an event one has experienced previously.

Although specific formulations of the effect of insight depend on the theoretical framework in which explanations are couched, there is general agreement that insight's therapeutic effect is to integrate mental structures in some way (Thomä and Kächele 1987). Kleinian theorists see the healing of defensively created splits in the patient's representation of self and others as crucial. One may be more specific by specifying split or part-objects as isolated representations of intentional beings whose motivation is insufficiently well understood for these to be seen as coherent beings. In this case insight could be seen as a development of the capacity to understand internal and external objects in mental state terms, thus lending them coherence and consistency. The same phenomenon may be described as an increasing willingness on the part of the patient to see the interpersonal world from a third-person perspective.

A simple demonstration to the patient of such an integrated picture of self or others is not thought to be sufficient. The patient needs to work through a newly arrived at integration. Working through is a process of both unlearning and learning: actively discarding prior misconceptions and assimilating learning to work with new constructions. The technique of working through is not well described in the literature, yet it represents the critical advantage of long-term over short-term therapy. Working through should be systematic and much of the advantage of long-term treatment may be lost if the therapist does not follow through insights in a relatively consistent and coherent manner.

In contrast to the emphasis on insight and working through are those clinicians who, as we have seen, emphasize the relationship aspect of psychoanalytic therapy (Balint, Winnicott, Loewald, Mitchell, and many others). This aspect of psychoanalytic therapy was perhaps most eloquently described by Loewald when he wrote about the process of change as: ‘set in motion, not simply by the technical skill of the analyst but by the fact that the analyst makes himself available for the development of a new “object-relationship” between the patient and the analyst …’ (Loewald 1960 pp. 224–5). Sandler and Dreher (1996) have recently observed ‘while insight is aimed for, it is no longer regarded as an absolutely necessary requirement without which the analysis cannot proceed.’ There is general agreement that the past polarization of interpretation and insight on the one hand and bringing about change by presenting the patient with a new relationship on the other was unhelpful. It seems that patients require both and both may be required for either to be effective.

It has been suggested that change in analysis will always be individualized according to the characteristics of the patient or the analyst. For example, Blatt (1992) suggested that patients who were ‘introjective’ (preoccupied with establishing and maintaining a viable self-concept rather than establishing intimacy) were more responsive to interpretation and insight. By contrast, anaclitic patients (more concerned with issues of relatedness than of self-development) were more likely to benefit from the quality of the therapeutic relationship than from interpretation.

IV. Empirical Data

The few studies that deal with the value of psychoanalytic psychotherapy often show that different theoretical orientations have similar results. Thus, it is the interactions between the patient and therapist and not one's orientation that facilitates meaningful psychic change. My focus, for years, has been an intersubjective model, which focuses on the importance of the dyadic interaction. This interest in dyadic interactions has also led me to study the right brain (the old limbic system), where affects, vocal timing, and facial recognition are part of an early, unconscious, action-oriented process. The closer we can recreate these nonverbal right brain interactions between mother and infant in our work, the deeper and more meaningful the psychic changes will be in our patients. This has particular relevance when working with gifted early adolescents. As most early adolescents, in treatment, are depressed, of equal importance is the use of SSRI's. Studies show the value of combining psychotherapy, with medication, to prevent a relapse of their depression.