CHAPTER 30

Psychodynamic Psychotherapy

Robert J. Ursano, M.D.

Russell B. Carr, M.D

Beginning therapists often do not have the extensive psychoanalytic background that was more typical in previous years. They have limited opportunity during training to learn a particular psychotherapy, such as psycho dynamic therapy, in detail. Yet, as clinicians, they may want to understand and use psychodynamic psychotherapy as a part of their therapeutic armamentarium and also use psychodynamic techniques in the evaluation and treatment of patients for whom a full psychotherapy may not be appropriate or possible.

The Psychiatry Residency Review Committee mandates that psychiatry residency programs in the United States train psychiatry residents in psychodynamic therapy as one of three core competencies in psychotherapy (Gabbard 2010). Developing skills in psychodynamic psychotherapy and its techniques, however, is a lifetime endeavor. This treatment modality provides the clinician a window on the meaning of behaviors that are often inexplicable from other vantage points. Psychodynamic psychotherapy may be brief, long term, or intermittent; although the principles and techniques are similar across these three approaches, each has its advantages and limitations. Psychodynamic psychotherapy requires the therapist to recognize patterns of interpersonal interaction without engaging in the "drama." The psychodynamic psychotherapist comes to recognize and understand his or her own reactions as early indicators of events transpiring in the treatment and as potential roadblocks to successful treatment. This knowledge and skill are also applicable to other psychiatric treatment modalities, including the other psychotherapies, medication management, consultation-liaison psychiatry, outpatient and emergency room assessment and evaluation, and inpatient treatment.

In this chapter we introduce the concepts and techniques of psychoanalytic psychotherapy. The efficacy and cost-effectiveness of psychotherapy in general, and of psychodynamic psychotherapy in particular, are of special concern to the evidence-based practice of medicine and mental health care (Gabbard et al. 2002). "Why psychotherapy?" is a question often asked in the cost-conscious world of present psychiatric care. In addition to understanding the reasons, it is increasingly important to recognize the basic skills and techniques of psychodynamic intervention that are used in treatments other than psychotherapy. Psychodynamic listening and psychodynamic evaluation are two such techniques that are best learned in the context of learning psychodynamic psychotherapy but are applied in many other psychiatric diagnostic, treatment, and prediction methods.

Reasons for Psychotherapy

Psychotherapy has long been a part of the treatment of psychiatric patients. Clinical experience and empirical research have shown psychotherapy to be both efficacious and cost-effective (Shedler 2010, 2012). The effectiveness of psychotherapy has been presented in several ways. A reevaluation of a classic study by Hans Eysenck indicated that psychotherapy accomplishes in 15 sessions what spontaneous remission takes 2 years to do (McNeilly and Howard 1991). Smith et al. (1980) found an average effect size of 0.68; this means that after treatment with psychotherapy, the average treated person was better off than 75% of the untreated sample. The effect size found by Smith et al. is larger than the effect sizes for some other medical treatment trials; in fact, Smith et al. stopped their trials before completion because the data indicated the treatment was efficacious enough that it would be unethical to withhold treatment (Rosenthal 1990). Similarly, such effect sizes are the equivalent of a surgeon's saying that 66% of patients will survive with the surgery but only 34% will survive without it (Rosenthal and Rubin 1982). Is there any question about whether to have such a surgery? Similar effect sizes have been found for psychodynamic psychotherapy (Bond and Perry 2004; Shedler 2010), and in particular for long-term psychodynamic psychotherapy, for complex mental disorders (multiple diagnoses) and increased utilization of health care resources (Leichsenring and Rabung 2008; Rabung and Leichsenring 2012).

Psychiatric illness is not uncommon. There are psychiatric "common colds" as well as psychiatric "cancers." When considering community health needs as a whole, one often forgets the range of psychiatric illnesses and therefore the range of interventions—including psychotherapy—that are needed. Because of this range of psychiatric disorders and their effects on health, there appears to be substantial economic advantage in including psychotherapy benefits in all health insurance plans, not only for those with primary psychiatric illness but also for those with medical illness and accompanying psychiatric problems.

Contribution of Psychotherapy

Psychotherapy is essential to the care of many diagnostic groups of psychiatric patients. It can be crucial for many depressed patients, especially for those who cannot take antidepressant medication, such as pregnant and nursing mothers, some elderly depressed patients, and some depressed patients with concomitant medical illnesses. Approximately 3% of the U.S. population receives psychotherapy each year (Weissman et al. 2006). From 1987 to 1997, access to psychotherapy remained constant in the United States, but the number of visits per patient decreased. In 1997, the percentage of patients having 20 visits or more was 10.3%, compared with 15.7% in 1987. In 1997, nearly 10 million Americans spent $5.7 billion on outpatient psychotherapy (Olfson et al. 2002).

Psychotherapy in general, and psychodynamic psychotherapy in particular, improves interpersonal and selfesteem symptoms (DiMascio et al. 1979; Klerman et al. 1974). A recent meta-analysis indicates the substantial effect size of psychodynamic psychotherapy across numerous mental disorders and in patients with complex mental disorders (Rabung and Leichsenring 2012). Studies have indicated that extended dynamic psychotherapy may be more efficacious for perfectionistic depressed patients than are other treatment approaches, including medication (Blatt et al. 1995; Mil-rod et al. 2000; Rabung and Leichsenring 2012). One year of dynamic psychotherapy has been shown to ameliorate nausea, pain, depression, and anxiety in metastatic breast cancer patients and has been reported to lead to a substantially increased survival rate (Spiegel et al. 1989). The use of psychodynamic psychotherapy in patients with borderline personality disorder also has a growing evidence base, both of treatment and of cost-benefit outcomes (Clarkin et al. 2001; Hall et al. 2001). Briefer psychotherapy has been related to increased survival in patients with malignant melanoma (Fawzy et al. 1990, 1993). Similarly, children with diabetes given psychotherapy have a more stable medical course and better diabetic control than do control-group patients not given psychotherapy (Moran et al. 1991; Winkley et al. 2006).

In a study of patients with previously unresponsive mental health problems, those randomized to psychodynamic interpersonal psychotherapy had significantly greater improvement than control patients in psychological distress and social function 6 months after the trial. The cost of psychotherapy was recouped in 6 months from decreased health care use (Guthrie et al. 1999).

Data on the specific and differential effects of various types of psychotherapy are generally limited, with most empirical studies being of cognitive-behavioral psychotherapies. Given the complicated nature of studies of psychodynamic psychotherapy in particular, such studies may remain limited for some time. However, available data on long-term psychodynamic psychotherapy with some diagnostic groups, on brief psychodynamic psychotherapy, on interpersonal psychotherapy derived from psychodynamic psychotherapy, and on supportive psychotherapy derived from the application of psychodynamic principles indicate that psychodynamic psychotherapy is an important, valuable, and cost-effective part of the clinician's armamentarium (Lazar 1997; Leichsenring 2005; Perry and Bond 2012). Skills in this modality should be an important part of every clinician's training.

Basic Principles

Behaviors, which include thoughts, feelings, fantasies, and actions, have both direct and indirect effects on health. Psychiatric illnesses are behavioral disturbances that result in increased levels of morbidity and mortality. Psychopathology usually limits the individual's ability to see options and exercise choice. Feelings, thoughts, and actions are frequently restricted, painful, and repetitive. Psychotherapy, the "talking cure," is the medical treatment directed toward changing behavior through verbal means. Through talk, psychotherapy provides understanding, support, and new experiences that can result in learning. The goal of all psychotherapies is to increase the range of behaviors available to the patient and, in this way, to relieve symptoms and alter patterns that have created increased morbidity and potential mortality.

A broad and comprehensive view of health and disease is needed to understand the relationship between behavior and health. The target organ of psychotherapeutic treatment is the brain. Feelings, thoughts, and behaviors are basic brain functions. Therefore, if psychotherapy is to change behavior, it must at some basic level alter brain function and organization (Buchheim et al. 2012; Kan-del 1999). If a particular behavior is the result of neuron A firing to neuron B, then for change to occur, neuron A must now fire to neuron C. This simplistic example underscores the importance of recognizing the complex biological results of psychotherapeutic work (Etkin et al. 2005; Gerber 2012).

Behavioral change can be the result of direct biological effects at the brain level (e.g., toxins, tumors), the unfolding of biology in maturation, or the effect of past and present life experiences interacting with biological givens. Psychotherapy itself is a life experience and can become a means by which what is "outside" changes what is "inside." Our understanding of how our environment and experience ("outside") changes our brain and behavior ("inside") is a growing area of recent knowledge (Huttenlocher 2002; McEwen 2001; Ursano and Fullerton 1991).

Recall, for example, when you last looked at a gestalt diagram, such as the one of the beautiful woman-ugly witch. At first, perhaps the beautiful woman was the only clear image, but after certain shaded areas were pointed out, you were able to discern the chin of a witch rather than the face of the beautiful woman. Nothing had changed in the amount of visual information that was reaching your brain; rather, what changed was how it was organized, allowing a fuller range of meanings to be experienced and behaviors to be expressed.

Various infant systems (activity level, arousal, and brain neurochemistry) are regulated by the mother-infant interaction and can be profoundly affected by it (Gerber 2012; Flofer 1984; Meaney 2001). In adults as well, the extent of social relatedness has been repeatedly shown to affect behavior as well as morbidity and mortality (House et al. 1988). For example, a common observation is that a patient with a phobia will frequently approach the phobic object when with a supportive other. How has the presence of another person altered brain function to allow this profound yet everyday change in behavior? Mental, symbolic, and representational events—including hopes, fears, memories, expectations, and fantasies—also serve as important biological regulators in the same way as do actual life events.

Understanding of how the outside world (psychotherapy) can change the inside world (biology) is growing but is still in its infancy. The basic sciences of psychotherapy have changed the question from whether organization, meaning, memory, expectations, and interpersonal contact influence health and behavior to how they influence them and to what extent.

Focus of Psychodynamic Psychotherapy

The different psychotherapies target different aspects of psychological functioning for change. Psychodynamic (psycho-analytically oriented) psychotherapy focuses primarily on the effects of past experience on molding patterns of behavior and expectations through particular cognitions (defenses) and interpersonal styles of interaction and perception (transference) that have become repetitive and that interfere with health (Table 30-1).

An individual's past exists in the present through memory and biology. Expectations—the anticipated present and future—are formed by one's past experiences and biology. Likewise, the way in which language is used metaphorically by a patient may reflect a particular organization (cluster of feelings, thoughts, and behaviors) formed in the past and affecting present perception and behavior. By exploring the past and present meaning of events and their context, the psychodynamic psychotherapist aims to alter the organizers of behavior, restructuring how information and experience are organized.

Psychodynamic psychotherapy (also called psychoanalytic psychotherapy, exploratory psychotherapy, or insight-oriented psychotherapy) is a method of treatment for psychiatric disorders that uses words exchanged between two people to effect changes in behavior. Psychodynamic psychotherapy shares with the other psychotherapies a general definition: a two-person interaction, primarily verbal, in which one person is designated the help giver and the other the help receiver. The goal is to elucidate the patient's characteristic problems of living; the hope is to achieve behavioral change. Psychodynamic psychotherapy uses specific techniques and a particular understanding of mental functioning to guide and direct the treatment and the therapist's interventions. As in other medical treatments, there are both indications and contraindications to this form of treatment.

Although the strategic goals of a psychodynamic treatment are to alter symptoms and change behavior to alleviate pain and suffering and to decrease morbidity and mortality, the tactical moment-to-moment objectives vary. As in surgery, in which the strategic goal is to remove disease, stop bleeding, and eliminate pain, it is not the strategic goals that direct the actual operation itself. The surgeon sometimes causes bleeding and pain and is directed by technical procedures to accomplish the overall goal. Similarly, in psychodynamic psychotherapy, the tactical moment-to-moment process of treatment is directed by the therapist's understanding of what is causing the disease, and of how a particular intervention will affect the recovery in the long run.

Psychodynamic psychotherapy is based on the principles of mental functioning and the psychotherapeutic techniques originally developed by Sigmund Freud. Freud began his work by using hypnosis; he later turned to free association as the method by which to understand the unrecognized (unconscious) conflicts that arose from development and continued into adult life. Such conflicts are patterns of behavior—that is, patterns of feelings, thoughts, and behaviors laid down in the brain during childhood. These patterns are the result of the individual's developmental history and biological givens.

Typically, these unconscious conflicts are between libidinal or aggressive desires (wishes) and the fear of loss, the fear of retaliation, the limits imposed by the real world, or the opposition of conflicting desires. Libidinal wishes are best thought of as longings for sexual and emotional gratification. Aggressive wishes, on the other hand, are destructive wishes that either are primary or are the result of perceived frustration or deprivation (Ursano et al. 1990). The beginning therapist frequently confuses the old terminology of libidinal wishes with the idea of specifically genital feelings. Sexual gratification in psychodynamic work refers to the broad concept of bodily pleasure—the states of excitement and pleasure experienced since infancy. The patient talking about happiness, excitement, pleasure, anticipation, love, or longing is describing libidinal wishes. The desire to destroy or the experience of pleasure in anger, hate, and pain is usually the expression of aggressive wishes.

Neurotic conflict (i.e., conflicted feelings/ambivalence derived from past [usually childhood] experiences and usually out of awareness) can result in anxiety, depression, and somatic symptoms; work, social, or sexual inhibitions; or maladaptive interpersonal relations. These unconscious conflicts from past experiences are evident as patterns of behavior: feelings, thoughts, fantasies, and actions. These patterns, learned in childhood, may at one time have been appropriate to the patient's childhood view of the world and may have been adaptive or even necessary for survival. Even though these behaviors are not evident to the patient initially, through the psychotherapeutic work they become clear, and their many ramifications for the patient's life become evident.

Psychodynamic psychotherapy is more focused than psychoanalysis, per se, and somewhat more oriented to the here and now. However, both these techniques share the goal of understanding the nature of the patient's conflicts—maladaptive patterns of behavior derived from childhood (also called the infantile neurosis)—and their effects in adult life.

Setting of Psychodynamic Psychotherapy

Psychodynamic psychotherapy may be brief (see Chapter 29, "Brief Psychotherapies"), intermittent, or long term. The norm is intermittent psychotherapy, in which episodes of brief or time-limited psychodynamic psychotherapy are given to a patient over a longer period of time. Intermittent psychotherapy may also be necessary due to resources of time or money, or the patient's unwillingness to undertake longer-term treatment. Intermittent psychotherapy can also be planned after the initial evaluation as a joint plan of the therapist and patient. As the therapy unfolds over time, it may often include medication treatment. This type of psychotherapy is now quite common as a treatment but is rarely studied—a regrettable omission, because research using intermittent psychodynamic psychotherapy is needed to obtain a better understanding of its unique opportunities and limitations.

Psychodynamic psychotherapy may take months or years. Typically, a longer-term treatment is open-ended; no termination date is set at the beginning of treatment. The length of treatment depends on the number of conflict areas to be addressed and the course of the treatment. Psychotherapy sessions are usually held one, two, or three times a week, although in brief treatments once a week is the norm. The frequent meetings permit a more detailed exploration of the patient's inner life and of the transference (for an explanation of transference, see the section "Transference, Defense Mechanisms, and Resistance" later in this chapter). The frequent meetings also support the patient during the treatment process.

Medications are used as needed with patients in psychodynamic psychotherapy. Medications may relieve biological symptoms or regulation disruptions that evidence shows do not respond to psychotherapy. In addition, medication may alleviate persistent and impairing symptoms and, thereby, allow the patient to participate in psychotherapy to learn new behaviors and avoid old impairing behaviors while experiencing a fuller range of affect. In some disorders, medication may alleviate a biological disease process so that the psychotherapy can address the illness-onset conditions; facilitate the patient's readjustment, recovery, and integration into family and community; and prevent relapse. All of these benefits of psychotherapy decrease the risk of morbidity and mortality. The meaning to the patient of the medication he or she may be taking is also an important area for exploration during the psychotherapy, particularly when lack of adherence is an issue or when it is time to discontinue use of the medication (Kay 2009).

Technique of Psychodynamic Psychotherapy

Behavioral change occurs in psychodynamic psychotherapy primarily through two processes of treatment: understanding the cognitive and affective patterns derived from childhood (defense mechanisms) and understanding the conflicted relationship(s) one had with one's childhood significant figures as they are reexperienced in the doctor-patient relationship (transference). The recovery and understanding of these feelings and perceptions are the focus of treatment. The treatment setting is designed to facilitate the emergence of these patterns in a way that allows them to be analyzed rather than being confused with the reality of the doctor-patient relationship or being dismissed as trivial (Gabbard 2009).

Primary to the success of psychoanalytically oriented psychotherapy is the need for the patient to feel engaged in the work and to trust the relationship with the therapist. This therapeutic alliance is built on the reality-based elements of the treatment, such as the mutual working together toward a common goal and the consistency and reliability of the therapist (Bruch 1974). Only in contrast to a good therapeutic alliance can the patient view the transference feelings and experience the distortion that the transference reveals.

The clinician empathically hears what the patient says in order to understand what an experience means to the patient (Fromm-Reichmann 1950). What the patient is able to bring into focus is what is dealt with in the treatment (Coleman 1968). The depth of interpretation and exploration is always at the point of urgency for the patient, not ahead of or behind the patient's thoughts and feelings. Beginning therapists often think that as soon as they see something, it is time to tell the patient. The timing of when to tell the patient is the essence of the skill of the therapist; careful thought and planning are needed to determine the appropriate time. Although the actual event of interpreting—explaining a piece of behavior in the context of the present and past and in relation to transference elements—is spontaneous, it is "spontaneous" after much preparation. When to tell the patient a new piece of information is determined by when the patient can hear and understand what the therapist has to say.

The patient's free association—that is, speaking without censoring or inhibiting his or her thoughts—is encouraged. This encouragement can be as simple as telling a patient that she is free to talk about whatever she wishes. The therapist's main task is to listen to the undercurrents of the patient's associations. Frequently, this involves wondering about the connection between one vignette and the next or listening for how the patient is experiencing a particular person she describes or a particular interaction with the therapist. Often, listening to the ambiguity in a patient's associations may open the door to the unconscious conflict and the person from the past to whom it relates.

For example, one patient came into a psychotherapy session shortly after breaking up with his girlfriend, saying, "I want to get her back." If one hears the double meaning in the sentence—to be back with her or to take revenge on her—it will not be surprising to learn that although the patient thought he was only talking about wanting to get back together with his girlfriend, by the end of the session he was describing his particular revenge fantasy. (This patient's fantasy derived from an old movie. He fantasized about "smushing" a grapefruit in his girlfriend's face.) The conflicted feelings—longing for and hating—were foretold in the opening of the session. This long-held pattern of response to rejections matched his early experiences with a mother who would alternately see him as having exactly the same feelings as she did and later chase him with a knife. He was not yet ready to hear this connection, but it was already becoming evident. The pattern could now be watched, and the patient's awareness of it slowly increased.

The transference may be experienced by the therapist as a pressure to act in a certain way toward the patient. More often than not, the beginning therapist may identify this pull to respond in a certain way by noticing—much like a person learning to ski—the direction in which he or she is about to fall. The transference is a specific example of the tendency of the brain to see the past in the present, to make use of old patterns of perception and response, and to exclude new information. When the transference is alive, it is very real to the patient, and contradictory information is disregarded. For the new therapist it is often difficult to see the irrational elements in the patient's feelings and perceptions about the therapist. Often, the transference is built on a seed of accurate perception about the therapist. It is the elaboration of this seed that makes the unconscious evident. The therapist may experience the accuracy of the patient's perceptions and fail to listen to the elements of the past that may be appearing.

Exploring the transference is just a special case in the ongoing work of examining the patterns of relationships that the patient experiences. This is all part of the attempt to understand the inner world of the patient—the world of how the patient sees and experiences people and events, the world of psychic reality. Transference is not unique to the psychotherapeutic setting. It occurs throughout life and in medical treatments of all kinds. In fact, asking someone to come into a hospital (an unfamiliar setting) and take off his clothes, have no one know who he is, and be required to eat when told and go where told is a very powerful way to induce transferences. What is unique to psychodynamic therapy is the attempt to understand the transference and to examine it when it occurs rather than to try to undo it (Gabbard 2005; Luborsky and Crits-Christoph 1998).

The therapist may also experience feelings toward the patient that come from the therapist's past. This is called countertransference. The countertransference is increased during times of stressful events and unresolved conflicts in the life of the therapist. The countertransference can be a friend, guiding the therapist to see subtle aspects of the doctor-patient relationship that may have gone unnoticed. It can also be a block to a successful treatment, causing the therapist to misperceive and mishear the patient.

Evaluation

Assessment, Diagnosis, and Prescription of Brief, Intermittent, or Long-Term Psychodynamic Psychotherapy

Psychiatric evaluation is critical to the assessment of a patient for psychotherapy, just as it is for the patient who is to be seen for medication management (Ursano and Silberman 1988). The prescription of psychotherapy can be the outcome of the psychiatric evaluation. The therapist must consider the advantages, disadvantages, target symptoms, course of treatment, and contraindications for psychodynamic psychotherapy, as for any other prescription.

Psychodynamic psychotherapy may be brief (see Chapter 29, "Brief Psychotherapies"), long term, or intermittent. The structure of each of these formats requires consideration and planning of goals and targets of treatment. At present it is not uncommon for a patient to have a brief psychodynamic psychotherapy as his or her first psychotherapy. If that is not sufficient, the patient may be seen in a longer-term treatment or an additional brief treatment, or intermittently to work on focused areas that may have become evident during the first treatment. The choice of brief, intermittent, or long-term treatment is determined by the patient, type of problems (recent precipitant vs. character related), degree of social supports to aid treatment responsiveness, extent of the disorder (multifocal vs. unifocal conflict), and practical issues of patient availability and preferences.

As part of the evaluation for psychodynamic psychotherapy, the clinician must assess the presence or absence of organic causes for the patient's psychiatric disturbance, the need for medication, the risk of untoward outcomes (suicide, homicide, divorce, work disruption), and the possibility that the patient's condition will worsen. At times, the beginning therapist starting work in a busy outpatient service may neglect to consider the option that the patient assigned for psychotherapy was evaluated incorrectly and that individual psychodynamic psychotherapy is not the appropriate treatment or that no treatment is indicated.

The psychiatric assessment for psychodynamic psychotherapy includes the use of two important techniques: psychodynamic listening (Chessick 2000) and the psychodynamic assessment or evaluation. The two are important to distinguish as techniques because they are applicable to many types of treatment and intervention, not only to psychodynamic psychotherapy. The use of psychodynamic listening and evaluation can be critical in medication management, consultation-liaison evaluation, and inpatient treatment, to name a few.

Psychodynamic listening (Mohl 2003) puts the psychiatrist in an attitude of curious inquiry, listening to the meanings, metaphors, developmental sequencing, and interpersonal nuances of the patient's story and of the doctor-patient interaction (Edelson 1993). Particular attention is paid to stories, present and past, about 1) feelings and wishes; 2) the management of various feelings through the life cycle (e.g., defense mechanisms and cognitive style) and areas of healthy interaction with the world; 3) self-esteem regulation; and 4) interpersonal relationships (Table 30-2). These four areas reflect the four traditional psychodynamic perspectives on psychopathology—drives, ego function, self psychology, and object relations (Pine 1988)—and two additional perspectives have recently emerged as contemporary psychodynamic theories of pathology—intersubjective systems theory and attachment theory. (The focus of each of these six theories is stated in Table 30-3.) The latter two, intersubjective systems theory and attachment theory, are often seen as related most closely to self psychology and object relations.

The psychodynamic assessment or evaluation uses the data obtained from questioning and from psychodynamic listening (MacKinnon et al. 2006; Sullivan 1954; Table 30-4). The evaluation aims to integrate the patient's chief complaint; history of present illness; past history; family history; developmental history, including any traumatic events or deviations from usual developmental patterns; mental status examination; style of doctor-patient interaction; and transference and the psychiatrist's countertransference feelings. The outcome of this evaluation is a psychodynamic understanding of the patient's past and present experiences from the patient's subjective viewpoint. This psychodynamic formulation provides an integrated understanding through the patient's life cycle from the psychodynamic perspectives listed in Table 30-3 on the past and present experiences of the patient. Through this understanding, the therapist can then make predictions of potential doctor-patient interactions, including the patient's patterns of defense mechanisms and transference reactions in future therapy sessions.

In this way, the evaluation phase provides information for the assessment of the type and degree of psychiatric illness and impairment, the selection of treatment modality, and the conduct of psychotherapy itself. After a well-conducted evaluation, the patient feels respected and safe, believes that his or her best interests are the primary concern of the clinician, and feels that any topic can be talked about (Levinson et al. 1967).

The therapist's asking about medical signs and symptoms and suicidal and homicidal thoughts and actions frequently relieves the patient of the feeling that he or she is the only one worried about these areas. Often, the patient wonders whether the doctor will ask about these issues. The patient may use whether the therapist inquires about these particular areas as a way to assess whether the therapist is serious about listening and being concerned about the patient. If the therapist omits medical or safety issues, the patient might conclude that the clinician feels that these topics are irrelevant or too dangerous to talk about. "VIP" and physician patients in particular are alert to whether the therapist is thorough in the evaluation. The patient who feels that all areas—medical as well as behavioral—and all risks and concerns have been forthrightly and empathically explored will feel the beginning of a working relationship centered on trust and mutual respect. The beginning of the psychotherapy in the evaluation phase is critical to the psychotherapeutic work to follow, which can include many distortions of the doctor-patient relationship. Commonly, long after a therapy has started—and frequently in its termination phase—a patient may reveal, for example, the one question the therapist asked, or the particular way in which the therapist greeted him or her at the door, that led to the feeling that working together would be possible.

Beginning the Evaluation

The evaluation begins when the therapist meets the patient (Lazare and Eisenthal 1989a, 1989b). In the outpatient setting, it is best for the therapist to introduce himself or herself and explain to the patient what the therapist knows about the patient's problems. The clinician should not assume that a patient knows that a session is an evaluation. Rather, the therapist should establish the context of the meeting, explaining that he or she would like to spend some time getting to know the nature of the patient's difficulties and inviting the patient to tell more (Table 30-5).

The number of evaluation sessions usually ranges from one to four, but more sessions may be needed. The length of the evaluation is determined by the amount of time required to collect the information for the diagnostic and psychodynamic assessment and to address the practical issues of beginning treatment. Usually, the beginning therapist errs on the side of short evaluations and an incomplete assessment. Table 30-6 includes helpful hints for the evaluation.

The clinician uses two methods for data collection during the evaluation: asking questions and listening unobtrusively (Silberman and Certa 2003). Both styles must be used to collect the needed information. No patient should leave the first evaluation session without the clinician's knowing the risk of suicide. This topic usually requires at least some direct questioning. Life-threatening issues must be dealt with early so the therapist can gather the needed diagnostic information. However, other historical information can be collected as part of the patient's story (Horowitz et al. 1995; Perry et al. 1987). By the end of the first session, the clinician should have answers to the questions posed in Table 30-7.

Frequently, the skill of the therapist lies in how he or she collects the history and diagnostic information. The more skilled the therapist, the more able he or she is to understand—that is, to reach—and therefore to work with a wider range of patients. The skilled therapist can establish a rapport across a wide array of socioeconomic classes and sexual, racial, religious, cultural, and emotional differences.

In the first session, the therapist should listen for the patient's fears about starting psychotherapy. These fears should be explored early, as they appear and are articulated by the patient. The patient will feel safer and be more interested in continuing the evaluation and the treatment when these fears have been heard, respected, and explored by the therapist. In addition, airing these fears will leave the therapist in a better position to interpret any precipitous stopping of the treatment. It is not unusual for a patient to drop out during the evaluation phase before beginning treatment. That is one reason to view this phase as the candidacy stage. (In clinic settings, about 50% of patients stop before the fifth session [Malan et al. 1975].)

Indications and Selection Criteria

Psychodynamic psychotherapy has its best outcomes with what have been called "neurotic-level disorders." Individuals with these disorders have conflicts that are primarily oedipal in nature (e.g., competition, guilt, independence, adult sexuality and intimacy parental loss and identification) and that are experienced as internal by the patient. Although the diagnoses in DSM-5 (American Psychiatric Association 2013) are not organized by their developmental conflict level (or level of maturity of defenses), some of the disorders are more likely than others to present with a primarily neurotic-level conflict. DSM-5 disorders that frequently involve a primarily neurotic conflict include obsessive-compulsive disorder, anxiety disorders (Bond and Perry 2004), conversion disorder, psychological factors affecting other medical conditions, dysthymia, mild to moderate depressive disorders (Bond 2006), adjustment disorders, and mild to moderate personality disorders (Gabbard et al. 2002; Leichsenring 2005; Leichsenring and Leibing 2003). Patients who are psychologically minded, who are able to observe feelings without acting on them, and who can obtain symptom relief through understanding may benefit from psychodynamic psychotherapy. The patient who has a supportive environment—family, friends, and work—usually does better because he or she is able to use the therapy in a more intensive manner. Such a patient does not need the therapist to be a primary reality support in order to weather the stresses of life or the treatment.

When not in the acute phase of illness and when dealing with rehabilitation, adjustment, and recovery, more seriously disturbed patients—those with moderate to severe major depression, schizophrenia, or borderline personality disorder—can also be treated in psycho-dynamically informed psychotherapy, with the addition of psychosocial supports and interventions as needed (Blatt and Shahar 2004; Fonagy et al. 2005). For these patients, the treatment is usually directed toward modifying the illness-onset conditions and facilitating readjustment, recovery, and integration into the community. Supportive treatment, derived from many principles of psychodynamic psychotherapy, is the primary treatment in the acute phase of these illnesses (see Chapter 33, "Supportive Psychotherapy"). The regressive tendencies of such patients are managed in psychodynamic psychotherapy with the use of medication and with greater support and reality feedback through face-to-face meetings with the therapist (Gabbard 2005).

Patients with severe preoedipal pathology are not good candidates for psychodynamic psychotherapy. This type of pathology is manifested by an inability to form a supportive dyadic relationship, the presence of severely exploitative relationships, a chaotic lifestyle, or substantial (or dangerous) acting out. The basic requirements of psychodynamic psychotherapy—that the patient have a strong observing ego (ability to be introspective) and an ability to form a supportive therapeutic relationship—are very difficult tasks for these patients.

Although psychological mindedness is important, intelligence per se is not a selection criterion; in fact, intelligence can reflect a highly organized obsessional character structure that may be very difficult to treat. Socioeconomic class is also not a good predictor of success in treatment. Rather, the ability to work with patients from diverse socioeconomic classes is usually a part of the therapist's task and skill: to span a range of life experiences and accurately empathize with the patient's world. The patient-therapist match is therefore very important, especially to the opening phase of treatment and the establishment of the therapeutic alliance.

In general, patients who like their therapists, who have had a shorter duration of symptoms, and who are seeking understanding of their problems as well as symptom relief have the best outcomes. The use of a trial interpretation during the evaluation phase can provide much useful information on how the patient makes use of understanding to modify symptoms and to what extent the patient experiences understanding provided through interpretation as supportive and helpful (Malan 1999).

Treatment

Psychodynamic psychotherapy is usually not a familiar form of medical treatment to the patient who is about to begin psychotherapy. At the end of the evaluation, the clinician discusses with the patient alternative forms of treatment that might in various ways be of benefit. In addition, the clinician must discuss with the patient how each of these treatments, including psychodynamic psychotherapy, works. Psychodynamic psychotherapy can be explained to the patient as a process for learning a new method of problem solving based on an understanding of the personal life history, the workings of the mind that are outside conscious awareness, and the personal view of the world—one's psychic reality. The individual's psychic reality hinges on the way in which past experience is used as an unconscious template for present behaviors—feelings, thoughts, fantasies, and actions.

Teaching the patient about the goals and process of psychodynamic psychotherapy is very important to the successful beginning of the psychotherapy. One way to conceptualize this phase of treatment is creating an atmosphere of safety. Although this may seem an imposing task, it is similar to the physician's task in many situations. For example, when the family practitioner finds that an otherwise healthy patient has a high cholesterol level, he or she must educate the patient and develop a cooperative working relationship so that together they can begin a treatment to counteract the potential ill effects of this silent condition.

In the opening phase of the treatment, the patient learns that psychodynamic psychotherapy will work because in the relationship with the therapist, the patient will reexperience the past in the present through the transference relationship. By examining feelings in the therapy setting, the patient develops an understanding of how his or her personal past is continually reexperienced in life. The patient will then begin to understand that psychological pain can result from symbolically reliving the past in the here and now, causing the reawakening of the conflicted feelings and anxieties of childhood. The patient also learns by experience that through recognizing these unconscious processes, the painful feelings diminish and new behaviors are possible.

The patient is educated directly both through teaching and explanation and through example. At times, the clinician should explain very directly and supportively to the patient the process of the treatment. When this has been done, it is best not to continue to repeat the explanations but instead to change into a mode of understanding rather than teaching, listening to the patient's possible emotional blocks to understanding. The skilled clinician is always making decisions early in treatment about whether this is a time to educate or a time to listen to more material from the patient, delaying any further instructive comments. Generally, the new therapist struggles with how much to educate and how much to listen in the opening sessions. Later in treatment, after explanations have been given clearly, the therapist can assume that cognitive education is not the difficulty the patient is having. However, the therapist cannot assume this in the opening phase, particularly with the naïve patient. Understanding the goals and processes of treatment is important to the patient's feeling safe and comfortable enough to explore and tolerate the anxiety that arises in the treatment setting (Sonnenberg et al. 1996, 2003).

Abstinence, Neutrality, and Free Association

After the patient has begun to understand the process of treatment, the therapist will, over time, become somewhat less verbally active in order to hear more about how the patient organizes his or her psychological world. Technically, this is called being abstinent (Gabbard 2009). The therapist may need to explain this to the patient if he or she asks about the therapist's silence. The therapist might say, "I am listening to you very closely. I want to be able to best understand how you see the world and not interfere with what you are telling me." The therapist also encourages the patient to speak as freely as possible and to suspend judgment about the accuracy or logic of what is said. This may be explained to the patient in the following manner: "You are free to say whatever you would like. In fact, it is most helpful if you say whatever comes to mind. I know that is difficult to do." The therapist helps the patient say whatever comes to mind—to speak without editing thoughts—even though the patient may say things that he or she fears would be untrue or hurtful to the therapist or to loved ones.

This method of communication is known as free association. It is characteristic of the mode of thinking and talking used by the patient in classical psychoanalysis, although free association in classical psychoanalysis is much freer because of the other elements of the psychoanalytic treatment (Freud 1917/1963). However, the psychodynamic psychotherapy patient will come fairly close to that same mode of expression.

Inevitably, free association is only relative, and the unconscious conflicts the patient experiences are the major forces that block the free expression of thoughts, feelings, and fantasies. The therapist, in collaboration with the patient, listens for clues to what may be outside the patient's awareness and may appear as a block to the free expression of thoughts. These ways of thinking that block uncomfortable feelings and conflicts from being experienced are called defense mechanisms. The therapist carefully observes, and at the right time shares with the patient, the patterns the patient shows in his or her thoughts and feelings and the blocks to these thoughts and feelings. The therapist observes the changes in the patient's thoughts and feelings and any movement away from the treatment. The therapist experiences the patient's defense mechanisms as a resistance to the work. Through the process of understanding how the resistances—the patient's defense mechanisms—operate, the transference emerges later in treatment.

The clinician and patient work together to recognize the patterns of the patient's thoughts and feelings. This collaborative work allows the patient to experience this task as one that he or she can eventually assume, rather than as something magical. This task—the analysis of defenses—forms the basis on which the patient can eventually choose alternative behaviors. At times the enthusiasm of the new therapist can lead to wanting to tell the patient a pattern without working together with the patient to identify it. This can lead to the therapist's being seen as very powerful by the patient and often will create problems later in treatment.

The patient at times experiences feelings of frustration because of the clinician's relative silence. However, the patient should, overall, experience the therapist as standing with him or her, as an ally with whom the patient can master the forces that keep so much outside consciousness (Schafer 1983). Helping the patient understand this during the opening phase of treatment is essential.

In therapy, what the patient says is met with an effort to understand, not with judgment or criticism. The therapist maintains neutrality. The job of the psychodynamic psychotherapist does not involve managing the patient's life (one reason why patient selection is so important) or judging its worth or the value of the way in which it is conducted (Poland 1984).

The therapist's abstinent, neutral demeanor in the therapeutic setting is, in part, a technique, a special form of behavior designed to offer the patient the opportunity to experience his or her own feelings, thoughts, and fantasies. Partly as a result of this unique aspect of the psychotherapeutic setting and partly because of the normal course of life, the patient is able to think in a less well-organized, less structured fashion, giving access to more unconscious feelings and thoughts and thereby acting on the psychotherapeutic stage. Over time, the therapy becomes a laboratory in which the patient can examine in detail the feelings, thoughts, and fantasies that he or she experiences toward another person (the therapist) within the safety of the therapeutic alliance (Bender 2005).

Although this goal requires the therapist to be relatively passive and silent, this technical stance is not meant to be harsh or depriving. The collaboration develops in part through the clinician's appropriate concern and through explanations of the special kind of team effort and working together that are a part of the therapy. The therapist and the patient work together to understand the patient's experience, which in turn leads to the amelioration of the patient's psychic pain. The therapist and the patient are more accurately described as trying to develop a working (Greenson 1965) or therapeutic alliance (Curtis 1979; Zetzel 1956).

The psychiatrist doing this form of therapy works from the perspective of the concerned physician, with gentleness and an awareness of the patient's pain (Schafer 1983; Stone 1981). Over and over again, through working together, the physician conveys the awareness that the patient is experiencing psychological pain not only in life outside the therapy but, because of reexperiencing the past, in life inside the therapy as well. The psychiatrist conveys respect for the patient's efforts to understand himself or herself and to keep going in therapy in spite of the pain.

Transference, Defense Mechanisms, and Resistance

Transference

Transference is at the core of how psychodynamic psychotherapy works (Table 30-8), but it is never easily understood by the patient. Freud developed the idea that all human relationships are transference relationships. By this, he meant that all human beings experience others by way of their perceptions of figures from the past. Today, although within psychoanalysis there exists a range of views on the nature of transference, it is generally felt that memories of the past are activated in all relationships. To some extent, each individual unconsciously plays out in current relationships certain aspects of important past relationships.

The psychodynamic psychotherapist attempts to be abstinent and not share details of his or her personal life with the patient as much as possible. The therapist thus creates a kind of blank screen on which the patient may paint a transference picture of his or her own design. Therapists, however, inevitably disclose something about themselves, even through nonverbal means such as body language. The transference, therefore, never purely derives only from the patient. Rather, both participants codetermine its content. It is built upon some small "grain of truth" about the therapist. Understanding the part of it that comes from the patient's past becomes the focus of therapy. Early in the therapy this becomes apparent. By pointing it out, the therapist and the patient create a common focus of attention. In this way the patient's understanding of how therapy works is also deepened.

People form transferences in all relationships. This is because people use the past as a pattern for understanding the present and because all people seem to have a psychological need to repeat the past in an effort to master that which was difficult or emotionally painful. Therefore, not only in psychoanalysis and psychodynamic psychotherapy but everywhere, people construct their relationships in the present by reproducing emotionally important aspects of their past relationships (Freud 1912/1958; McLaughlin 1981).

One way to vividly imagine the impact of transference is to imagine a series of transparent plastic pages in an anatomy textbook. When the book is first opened, the reader sees the surface of the body. When the first page is turned, the muscles are seen, with the major blood vessels barely visible beneath them. As the reader turns to the next page, the blood vessels and the major nerves are seen. The bones are visible beneath. Finally when the last page is turned, the bones come into full view. Transference is much the same in that memories of various relationships are superimposed one on another and what is observed on the surface is determined by the subtleties beneath the surface, out of conscious awareness.

Another way of conceptualizing transference is to think of the human mind as made up, in part, of sets of memories of important individuals from a person's past. These organized sets of memories are called object representations. Whenever a person meets someone new, he or she begins to form a new object representation. Obviously, this process proceeds to a significant extent only when the new person is of some importance to the observer; whenever the process takes place, the observer, in an effort to understand a new acquaintance, scans his or her memories for standards against which to measure and compare the new individual. Soon, new and old object representations are psychologically connected in response to the observer's need for familiarity and to other psychological needs. The newcomer is on the receiving end of ideas, thoughts, and feelings that were originally directed toward the old friend, relative, loved one, or enemy.

What we see when we observe individuals and talk with them about their present life or current relationships is the surface of their psychological life. Beneath that surface are the memories of their important past relationships, which—like the muscles, nerves, and bones beneath the skin—constitute vital parts of the organic whole of their interpersonal world, in the present as well as the past (Goldstein and Goldberg 2003; Sandler et al. 1973). The individual, however, perceives his or her current relationship as the whole. The connections of the current relationship to an old relationship and the way in which the present is serving as a vehicle for working out old relationships remain outside conscious awareness. Therefore, the therapist may experience the transference in the therapy as pressure to behave in a certain way toward the patient that is reminiscent of a previous relationship the patient had in childhood.

In psychodynamic psychotherapy, the therapist, through his or her neutrality, abstinence, and encouraging of free association, creates an environment in which conscious transference responses are relatively more intense than in typical relationships (although they are less intense than in a classical psychoanalysis). The development and understanding of the transference is one of the therapist's most important tools. It is the vehicle for bringing alive—in the consulting room—the patient's difficulties and for examining these in depth in an existentially meaningful environment. In fact, it is this process that, more than anything else, distinguishes psychodynamic psychotherapy from other forms of treatment.

From another perspective, the transference is the way the patient remembers what he or she has forgotten—what is unconscious and the source of psychological pain. In popular caricatures of psychiatric treatment, the patient remembers dramatic childhood events in a melodramatic fashion. In reality, this remembering occurs as a result of detailed effort to dissect the frequently small memories of long-forgotten, sometimes repetitively experienced parts of the past as they present in the transference relationship. Through the transference the patient develops an understanding of what was experienced in the past and how that experience lives on in the here and now. To help the patient understand transference and begin to develop the ability to work with it, the therapist must direct the patient's attention to this dimension of his or her thoughts. Thus, the therapist may ask the patient to describe what he or she is thinking or feeling about the therapist when it appears that may be in the patient's awareness (Ogden 1995).

Defense Mechanisms and Resistance

At times the psychotherapist attempts to clarify the patient's feelings and the meaning of what the patient is trying to say. At other times the therapist may supportively confront the patient with attitudes the patient has disavowed but clearly demonstrates. In both cases the therapist is hoping to point out the kinds of thoughts and feelings that the patient obscures and the ways they are obscured, defended against, and kept unconscious. Throughout this process the patient's defensive ways of thinking are elucidated.

In the opening phase the therapist will have the opportunity to identify patterns of defense and resistance and must orient the patient to how awareness of these patterns can be used to advance the patient's knowledge of himself or herself (Loewald 1960).

Resistance is a general term referring to all the forces in the patient that oppose the painful work of therapy. There are many different categories of resistance, including general fear of any change, an overly harsh conscience that punishes a patient with the continuation of suffering, and insistence on the gratification of childish impulses that forms part of an emotional illness. All people, including patients in therapy, employ mechanisms of defense to keep painful feelings and memories outside conscious awareness. These defense mechanisms are specific, discrete maneuvers or ways of thinking that the mind employs to avoid painful emotional material (Nemiah 1961; Shapiro 1965).

Whenever a patient is manifesting resistance, in whatever form, it is because the patient is protecting himself or herself from experiencing, including remembering or reliving, the old dangers and fears associated with the childhood conflicts and developmental difficulties of his or her life. Character (the set of expectable responses from a person in a given setting) is in great part a result of the defense mechanisms each person characteristically uses. Defenses are cognitive mechanisms of structuring mental and emotional experience to keep psychic pain at a minimum and to bring interpersonal and intrapsychic functioning and relationships into some congruence with external reality

The patient's defense mechanisms are an important source of resistance in psychotherapy. In 1936, Anna Freud, in The Ego and the Mechanisms of Defense (Freud 1966), outlined the functioning of many of these defense maneuvers. Since that time, the list of defense mechanisms has grown and been elaborated upon (Table 30-9). Several common and important mechanisms of defense are defined in Table 30-10. There are also more primitive mechanisms of defense—splitting, projection, projective identification, omnipotence, devaluing, and primitive identification and idealization—that are seen in severe personality disorders such as borderline personality disorder and in psychotic disorders (Kernberg 1975).

In psychotherapy the therapist strives to help the patient understand the origins and functions of his or her defenses (i.e., the therapist interprets the defenses) so that the patient can become aware of the feelings, thoughts, and fantasies that the patient fears from the conflicts of long ago.

Use of Dreams

The therapist also attends to the dream life of the patient (Brenner 1976; Freud 1900/1953). Not all patients in psychotherapy work extensively with dreams, but many do, and for those who can, the work is an important tool. Every patient should be given the opportunity to work with dreams. It is in the opening phase that this road to understanding is introduced and learned. Frequently, dreams reported early in treatment are particularly revealing of the core conflicts of the patient. Dreams can reveal something that the patient's mind is trying to process and understand (Fosshage 1997). Dreams can be presented to the patient as thoughts and concerns the patient is having while asleep, although the rules for how these thoughts and concerns are created during sleep (i.e., through primary process thinking) are different from how they are created during waking life (i.e., through secondary process thinking) (Reiser 1994).

Countertransference

Countertransference is the emotional reaction of the therapist to the patient. Historically, countertransference was limited in meaning to the therapist's transference onto the patient. This was felt to be a response to the patient's transference. Like all transferences, the therapist's countertransference was the result of unconscious conflicts; however, these unresolved conflicts were those of the therapist rather than those of the patient. This countertransference was thought to obscure the therapist's judgment in conducting the therapy (Gabbard 1995; Gabbard and Wilkinson 2001).

Countertransferences are many and varied. Often, they are the result of events occurring in the therapist's life that may make him or her more sensitive to certain themes in the patient's associations. The developmental period of the therapist's life—involving issues of intimacy, achievement, or old age, for example—may also affect how the therapist hears the patient. Intense transferences of all kinds—erotic, aggressive, devaluing, idealizing, and others—are ripe for serving as stimuli to awaken in the therapist elements of his or her own past (Mitchell and Aron 1999).

When all of one's patients seem to be talking about feeling overworked, or angry, or sad, the therapist can reflect on these feelings and wonder whether this theme is being selected by him or her rather than being the central issue for all of his or her patients. A common countertransference issue in training occurs at the end of training when both the therapist and the patient are dealing with termination. For the patient it is the end of treatment; for the therapist it is both the end of a treatment and the end of a stage of life, usually accompanied by a move and loss of colleagues and friends, as well as a sense of new achievement.

The clinician may first note a patient's core conflictual issue through observing subtle emotional reactions stirred in himself or herself (Kernberg 1976; Searles 1979). The clinician can then explore these feelings, through self-analysis, as possible reverberations from the unconscious but also as emerging concerns of the patient that may be hidden in the patient's language, behavior, or fantasies.

The psychodynamic psychotherapist observes his or her own emotional reactions and values and processes them as possible windows into the patient's experience. Frequently, the more intense and even embarrassing the therapist's responses, the more likely they are to reflect a crucial, hidden, conflicted state residing within the patient. There are generally two types of countertransference reactions: concordant and complementary (Racker 1968; Table 30-11).

Termination

Often, psychodynamic psychotherapy is conducted in an open-ended fashion regardless of whether it is to be short or longer term. At the beginning of the treatment, the therapist explained to the patient that the treatment would take as long as required to discover and resolve the patient's unconscious core conflicts and for the patient to understand the workings of his or her mind.

There comes a time, however, when the patient and the psychiatrist agree that it is time to end the treatment. At this juncture the troublesome areas of the patient's personality seem to be separate from the core of the patient's sense of self (Alexander 1941). What was once central to the patient's presenting difficulties is now experienced as alien. The patient has learned to use intellect and perception in an affectively rich manner in the service of self-awareness (Dewald 1982).

The therapist must remember and the patient must come to realize that treatment goals are related to, but different from, the patient's life goals (Ticho 1972). Treatment goals are always dependent to some extent on life's demands and possibilities—what is possible at a given time of life and in a given context. Termination does not mean that a patient has realized all of his or her hopes and wishes. Rather, the patient entering the end phase of treatment after a successful treatment has experienced substantial relief from psychological suffering, and this relief is evident to both the patient and the therapist. In addition, the internal conflicts of the patient, as well as the presenting symptoms, have been resolved, and reasonably permanent changes in behavior have occurred. The patient shows a detailed understanding of the working of his or her mind and is beginning to use self-inquiry as a method of problem solving. Often, there have been gains in most of these areas of the treatment goals, but not necessarily all. The gains are observed by the therapist and shared with the patient as part of the patient's increasing awareness of new areas of strength and conflict resolution. Table 30-12 lists the criteria for termination. The termination phase has its own tasks to consolidate the treatment and facilitate leave taking while maintaining the therapeutic relationship (Table 30-13).

Conclusion

Psychodynamic psychotherapy is now more than 100 years old. What began as so-called studies on hysteria has broadened into the investigation and treatment of emotional illness throughout the human life cycle. Psychodynamic psychotherapy explores the subtleties of the effect of the mind-body connection. It examines the interaction of neurobiology with experiences across the life cycle and the effects on behavior and internal as well as interpersonal lives. The patterns of early childhood—laid down on the basis of one's biological givens, early familial experiences, and interpersonal world—form the lenses through which one views the world throughout life and gives meaning to adult experiences. Psychodynamic psychotherapy looks to change current maladaptive patterns of behavior through understanding the relationship of present symptomatic behaviors to past experiences that have provided the templates for these behaviors and for adult cognitive and emotional perception.

Further research is needed to develop the evidence base for better understanding the role of psychodynamic psychotherapy in the psychotherapy treatment armamentarium. In addition, the core concepts of psychodynamic psychotherapy—the role of conflict in feelings, thoughts, and behaviors; the interaction of neurobiology with experiences throughout development and particularly in childhood; and the fact that people have feelings and thoughts outside of awareness—require study across a wide array of health-related behaviors to identify new psychodynamically informed interventions and treatments.

Key Clinical Points

• Psychodynamic psychotherapy is as effective as many other medical interventions.
• Early childhood development structures brain development and results in patterns of feelings, thoughts, behaviors, and interpersonal relating.
• Psychotherapy changes brain activity as part of changing symptoms and behaviors.
• Psychodynamic psychotherapy focuses on the effects of past experience in producing present symptoms and behaviors (e.g., cognitions, affects, fantasies, actions).
• Expectations (e.g., the anticipated present and future) are formed by one's past experience and one's biology.
• Mental conflicts can be out of awareness and derived from childhood experiences.
• Transference occurs in all interpersonal relationships.
• Defense mechanisms are cognitive mechanisms to decrease anxiety and other distressing feelings.
• The working, reality-based relationship with the patient is called the therapeutic alliance.
• Psychodynamic psychotherapy may be brief, intermittent, or longer term.
• The principles of psychodynamic psychotherapy are used in many doctor-patient interactions other than psychodynamic psychotherapy.

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Suggested Readings

Buirski P, Haglund P: Making Sense Together: The Intersubjective Approach to Psychotherapy. Northvale, NJ, Jason Aronson, 2001

ColumbiaNews: A conversation with Nobel laureate Eric Kandel, who continues to look forward to 80. November 23, 2009. Available at: www.youtube.com/watch? v=zuZjOwd7HLk&feature= related. Accessed November 9, 2012.

Cummings CA: Elyn Saks, Eric Kandel, and Kay Jamison discuss importance of psychodynamic psychotherapy. September 10, 2010. Available at: www.youtube.com/watch?v=3xzuS7qfGZE. Accessed November 9, 2012.

Freud S: The interpretation of dreams (1900), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vols 4 and 5. Translated and edited by Strachey J. London, Hogarth Press, 1953

Gabbard GO: Long-Term Psychodynamic Psychotherapy: A Basic Text, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2010

Gabbard GO, Gabbard K: Psychiatry and the Cinema, 2nd Edition. Washington, DC, American Psychiatric Press, 1999

Levy RA, Ablon JS, Kachele H (eds): Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence. New York, Humana, 2012

Mitchell SA, Black MJ: Freud and Beyond: A History of Modern Psychoanalytic Thought. New York, Basic Books, 1995

Stern DN: The Interpersonal World of the Infant: A View From Psychoanalysis and Developmental Psychology. New York, Basic Books, 2000

Stolorow RB: Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections. New York, Psychoanalytic Press, 2007

Ursano RJ, Sonnenberg SM, Lazar SG: Concise Guide to Psychodynamic Psychotherapy: Principles and Techniques of Brief, Intermittent, and Long-Term Psychodynamic Psychotherapy. Washington, DC, American Psychiatric Publishing, 2004