Psychodynamic approaches to intervention and their clinical value

Psychodynamic Approach to Intervention-Reflect on the psychodynamic perspectives presented, and discuss the approach you find most valuable.

Psychodynamic therapy, or insight-oriented therapy, focuses on unconscious processes as they are manifested in a person's present behavior. The goals of psychodynamic therapy are a client's self-awareness and understanding of the influence of the past on present behavior. Briefly saying, a psychodynamic approach enables the client to examine unresolved conflicts and symptoms that arise from past dysfunctional relationships and manifest themselves in present situations. Psychodynamic therapy has roots in the psychoanalytic theory, which presents discrete theories of personality formation, psychopathology formation, and change; techniques by which to conduct therapy; and indications and contraindications for therapy. However, psychodynamic therapy differs from classical psychoanalysis in several ways: it is shorter, need not include all analytic techniques and is not conducted by psychoanalytically trained analysts; moreover in psychodynamic therapy the therapist is much more actively and openly responsive to the client than the psychoanalyst; the client and therapist establish a collaborative approach to the use of interpretation as a means of insight and problem-solving. Psychodynamic therapy proved to be effective in treating a wide variety of conditions. Its approach focuses mainly on aspects of an individual's personality, while also addressing issues in past and present relationships and ongoing patterns that present conflict.

Some of the controversies regarding the theory and practice of psychoanalysis have underlined the role of theory in the practice of psychodynamic therapy. Peter Fonagy suggested that maintaining the illusion of a logical relation between the two "can cause a petrification of practice and ultimately the downfall of a theoretical orientation." and, further on he stated that "the inductive use of clinical experience can generate an excessive number of irreconcilable theoretical ideas, which in turn explains the tendency of psychodynamic clinicians to eschew operationalization and rigorous theory building." The author concludes, however, that "the abandonment of the pretense of a logical relation, by contrast, could lead to a renewed excitement about the development of technique." (Fonagy P., 1999, p. 1). The major point of controversy in the psychodynamic approach is the lack of scientific validation of the theory. Moreover, the same author acknowledges other obstacles in the way of psychodynamic research, including the fragmentation of psychoanalytic theory, "the relative independence of theory from its clinical and empirical base, the predominance of inductive scientific logic, the polymorphous use of terms, the privacy of clinical data, the dominance of the reconstructionist stance, and the isolation of psychoanalysis from psychology and neurobiology." A virulent criticism of psychodynamic paradigm has been the contemporary philosopher Adolph Grunbaum, who attacked psychoanalysis for not meeting the criteria he designates as necessary for an empirical, scientific discipline. He argues that since the analyst's interpretations operate at least partially through suggestion, there is no possibility for testing their validity in any independent fashion. (Mitchell S.A., 1997). Notwithstanding these limitations, core psychoanalytic precepts are consistent with some of the most important advances of the last decade.

In spite of all controversies, what remains, and capture the attention of both scientists and psychodynamic therapists are the complex, conflicting, unconscious representations of mental states. In order to argue this idea, it should be mentioned the fact that, even cognitive-behavioral therapists (CBT) have begun to study a "cognitive unconscious," underlying the invisible and full of impact on human lives unconscious processes. I witnessed the importance of unconscious processes both in my everyday life and in the study of psychological facts and paradigms. The study of unconscious mental processes remains a challenge both for therapy, and research. Unconscious mental processes may play a part in the etiology and development of psychological disorders. Other possible causes of disorders could be stressful life events or a certain state of vulnerability of the person experiencing the event. The stressful life event could produce the disorder by means of reactivation of certain emotions or feelings connected with other stressful situations from the past, having thus a double impact on the person's psyche and provoking the disorder. However, the precise causes of mental disease are unknown yet. In such a context, the psychodynamic approach based on interpretation of past events offers a generous frame and leaves indeed place for interpretation and criticism. Nevertheless, we should be constantly aware of the interaction between biological, psychological, and sociocultural factors. This holds true for health and illness. Different health stages can be influenced by different factors as well as different stages in illness can be accelerated or decelerated by certain factors. In my opinion the current biopsychosocial model of disease, according to which many factors interact to produce disease, can bear a great relevance on disease etiology. The Biopsychosocial Model of Disease (Engel, 1977) is a framework, rather than a set of detailed hypotheses, for understanding health and disease, and unfortunately has no specificity neither for research, nor for therapeutic practice. However, the model has a great potential to become more specific, to become particular for different types of diseases, and therefore, in my opinion appears very promising for therapy. In this context, it seems that the absence of crucial parental provisions can have a very powerful impact on psychopathology. The absence of parental support or even abuse (neglect included) leads to various mental disturbances, such as depression, anxiety etc., or even to the dissociation of personality in extreme cases. It is very interesting to notice the fact that in cases of multiple personality the most efficient form of therapy is the psychoanalytic approach and its psychodynamic modern form. It is extremely interesting how therapy (the therapist / or analyst) can unite ego fragments into one rational instance by descending into the depths of psyche, to analyze trauma and put the pieces back together. The unifying attempt of psychodynamic therapy on ego appears to be one of the most fascinating processes exerted on human psyche.

In what concerns the cause of psychological disorders, Mitchell and Black (1995: 207-8) say: "If we had to select the controversy that has most divided psychoanalytic theorists and clinicians, the single issue that has given rise to the most impassioned, strident, and sharply contrasting beliefs, there is only one candidate, and no close seconds. That issue concerns the cause of psychological disorders: Is psychopathology the result of trauma, healthy development thrown off course by destructive events and actual experiences? Or is it the result of the misinterpretation of early experience due to the warping impact of early childhood fantasy? Psychoanalysts are not alone in struggling with this problem. The psychoanalytic debate between proponents of trauma and proponents of fantasy is a reflection of the much broader philosophical debate concerning nature vs. nurture that has raged throughout the history of Western thought." However, human being is developing continuously. In this context, it is even more difficult to establish what is more crucial to this development: the factors from external reality (relationships, events etc.) subsequently internalized or the endogenous power of the drive? In psychoanalysis Freud emphasized the internal world, the psychical reality, fantasy. However, in my opinion it would be necessary to take into account the factors from real life for an accuracy of treatment, while also monitoring the expression of the psychical reality in the person's life. In such circumstances, the therapeutic situation should allow the free expression of the person's emotions, feelings dreams. However, there are boundaries to be drawn, concerning the time space and duration of therapy (characteristic in each form of therapy). The therapeutic situation should create a private space in which the patient escapes from the current living and problems. More than the feeling of security and privacy, the therapeutic situation should create a therapeutic relationship based on therapeutic alliance and trust. The hallmarks of analysis are making the unconscious conscious and the regressive transference neurosis. However, these two components are possible only in classical therapy. In other forms of psychodynamic therapies, for example in psychodrama, the focus is on process of making the unconscious conscious, of enacting the fantasy.

Psychodrama is a method of group psychotherapy that uses a dramatic format and theatrical terms (Holmes, P., 1991:7). The method was created and developed by J.L Moreno, who described five elements of psychodrama: the protagonist, the director, the auxiliary egos, the audience, the stage. Psychodrama is essentially a theatrical process and the enactment must move rapidly into drama. The protagonist is supposed to enact on the stage area the initial scene that he and the director agreed upon at the beginning. The sharing stage is the final stage of psychodrama in which all the members are encouraged to share their thoughts and feelings, and also their similarities and identifications with the protagonist. What is impressive about psychodrama is the common idea that through the psychodramatic enactment of an individual's life (past, present or future) that individual is able to come to terms with the identified problem and to develop abilities to overcome it.

In my opinion, psychodrama is a very useful approach of intrapsychic conflict when working with children and adolescents, first of all because it is hard for them to express their conflict into words and to enter a therapeutic relationship. On the other hand, I believe it is a more adequate approach because they are more imaginative and engage more readily in the roles they have to enact. And also children and adolescents are more suggestible and ready for role-play or fantasy enactment. However, even adults find it easier to adopt certain roles in order to express their intrapsychic conflicts.