Introduction
The basic concepts of
person-centered psychodynamics have been developed within the framework of
psychoanalysis beyond an orthodox biological thrive theory perspective. These
developments are characterized by an interpersonal approach with an
intra-psychic and inter-psychic interaction within its total context, by the object
relation theory [e.g.1,2], by an empathic therapeutic approach (instead of
neutrality) [e.g.3,4], and by the inclusion of current results of attachment
theory [e.g.5,6], and of brain research [e.g.7-10].
The Berlin School of Dynamic Psychiatry [11,12], to which
the author belongs, has integrated these newer developments of psychoanalysis
and includes furthermore the concept of group dynamics being useful not only
for individual but also for group treatment as well as for communication in
general with access to underlying unconscious dynamics. This concept has been
applied by a diverse range of mental health professionals within the World
Association of Dynamic Psychiatry (WADP) which is an international organization
with the aim of applying and promoting a psychodynamic approach in psychiatry
and other mental health areas. The WADP was founded in 1980 and is an
affiliated member of the World Psychiatric Association (WPA).
A psychodynamic approach is person-centered in its deepest sense
A psychodynamic approach is
person-centred in its deep sense as it applies to the person with his/her
unique personality and unique life history. A psycho-dynamically oriented
professional understands symptoms not just as dysfunctions and deficits, but as
dynamic phenomena with their own understandable function and logic. It is
argued that it is not the main goal to diagnose a psychiatric disorder
according to symptoms, course and history, but rather to understand the person
with the disorder and the person’s capacity to recover from the disorder [13].
In simple words: If it is possible to understand and analyze the underlying
logic of a patient’s symptom, the symptom may disappear, because it will lose
its necessity [4,11].
A psychodynamic expertise helps to deal with complex decisions in diagnosis
and treatment
In clinical diagnosis, it is
important for the clinician to listen well to the patient’s presentation of his
current problems, why he/she asks for professional help at this moment of his/her
life, to be attentive to non-verbal communication, to pay attention to the
patient’s own understanding of his/her problems as well as to his/her self-help
potential. Jacobson and Cooper [14] from Cornell University Medical Center, New
York, define a psychodynamic diagnosis in the following way:
“Psychodynamic diagnosis, while taking full account of
descriptive diagnostic data, attends as well to unconscious mental processes
and the severity of maladaptation. It classifies core aspects of character,
personality, and adaptation to life as they are revealed in different modes of
relating and representing self and others, both consciously and unconsciously.
(…) Psychoanalytic diagnosis is derived from the phenomenology of the
interaction between analyst and patient, as well as from historical data of the
life narrative.”
This way, psychodynamic diagnosis could be understood as a
“joint interactive reconstruction process” [15] in which subjective suffering
as well as positive mental health have their central place opposed to standardized
classification systems [16,17]. In recent years, innovative psychodynamic
diagnostic instruments have been developed [e.g. 18; in German speaking
countries 19] in order to enhance the knowledge and the understanding of a
patient’s complex problem. The OPD, developed for German speaking countries,
provides useful operationalisations of psychodynamic concepts and categories in
order to assess patients’ illness behaviour, their behaviour in interpersonal
relationships, inner conflicts and the level of the personality structure.
Concerning treatment, it can be said in very general terms
that by developing insight into the unconscious functions of symptoms and
problems, the patient will be able to deal more successfully with life’s
problems, such as relationship problems, anxieties, adaptation or dependency
conflicts. A psychodynamic treatment is a complex process and often needs more
time than just symptom-oriented and behaviour-oriented treatments, especially
for personality disorders [20-23]. We can say that a sophisticated knowledge of
transference, counter-transference, and resistance is extraordinarily helpful
in clinical work, including the practice of pharmacotherapy [4].
Psychodynamic therapists [e.g.4,12,24] have pointed out that
the effectiveness of treatment is impaired when team members respond in the
same manner as though they are the patient’s parents. It is well-known that
hospitalized psychiatric patients are significantly more stressed than
outpatients, they tend to employ more immature defence mechanisms like
splitting, projective identification than mature ones. The patients
unconsciously repeat and direct their internalized object relations and
conflicts to the persons in the psychiatric milieu. Therapists with clinical
experience and with a psychodynamic background know that dealing with these
defence mechanisms and transference feelings is quite challenging, even more
for residents at the beginning of their career.
Furthermore, there are essential preventive aspects in
applying a psychodynamic approach. Since a psychodynamic treatment has its
focus on the development of the patient’s personality, it could prevent
patients from having relapses, from discontinuing their treatment, and from
developing a chronic and severe psychopathology. Staff members working in
demanding and challenging psychiatric wards could benefit from a psychodynamic
understanding of complex clinical problems and be prevented from developing a burnout
syndrome [25].
A psychodynamic approach is also context-related
A psychodynamic approach is
context-oriented as it provides a perspective to the interpersonal complexity
of a clinical care situation. A psychodynamic approach can be understood as a
way of thinking by the therapist, not only about one’s patients, but also about
oneself in the interpersonal field between patient and the treating
professional or between the patient and the treatment staff as a whole.
Unconscious processes and communication take place virtually everywhere in
different clinical settings, e.g. in the therapist-patient relationship, in the
whole atmosphere of a hospital unit, and among colleagues. Therefore, it is
useful to understand difficult situations and communication problems in daily
clinical work by applying psychodynamic and group-dynamic skills, for example,
through self-reflection and self-monitoring of transference and
counter-transference feelings [26]. The application of a psychodynamic
perspective is not only useful in the classical treatment situation, but also
in supervision groups, in case conferences or staff meetings of an
interdisciplinary team in medical settings, such as surgical, emergency unit,
in general medical, liaison medicine, and psychiatric settings.
Peykan Gökalp from the Bakirkoy Hospital for Psychiatry,
Istanbul, organized an interesting symposium in Thessaloniki, Greece, in
September 2007, on the topic “Psychoanalytic perspectives in different
settings”. The authors of this symposium presented their views about the
application of psychodynamic concepts to patients of a general hospital, to
patients and staff members of a large psychiatric hospital, to the treatment of
psychotic patients and eating disorder patients. In her paper, Peykan Gökalp
[26] pointed out that, sometimes, therapeutic teams or single staff members may
have unconscious, idealized wishes towards their institution or towards the
medical director of a large psychiatric hospital who should manage everything
ideally like an omnipotent father figure and if their expectations are not
fulfilled they may react with disappointment, frustration, or anger.
Outside of a definitive individual psychotherapy setting, we
daily observe unconscious communication between health professionals and
patients. Especially in stress situations or in interaction with a patient who
is expressing intense feelings, negative chain reactions between a patient and
a therapeutic team could be the consequence of their communication. Often
transference and counter-transference occur in such situations. Transference
feelings are unconscious feelings (positive or negative ones) of the patient
towards the therapist which originally have been directed to persons in early
childhood, e.g. to the patient’s parents. Working with transference feelings
belongs to the therapist’s basic tools. However, transference feelings which
take place outside of a patient-therapist relationship, for example of a team
member, could have quite destructive consequences for clinical decisions, when
this team member directs his other hostile feelings towards his superior.
The unconscious response to these transference feelings is
called counter-transference. This term means the totality of unconscious
reactions of the therapist to his patient, particularly to his transference
feelings. Volkan Topcuoglu [27], from the Marmara University School of
Medicine, Istanbul, suggests a broader definition of counter-transference,
since it is beneficial for both psychiatrists and psychiatry residents as a
major diagnostic and therapeutic tool. By comprehending his
counter-transference towards the patient, a psychiatry resident can understand
a great deal about the patient’s internal world. Furthermore he would be able
to explore further the possible reactions of ‘significant others’ towards the
patient. The ongoing task for a psychiatry resident during a psychiatric
treatment should therefore be to recognize and to monitor continuously his own
counter-transference feelings. If this does not happen, a therapist is likely
to overreact to his patients or to make clinical decisions with negative
results (e.g., forgetting appointments, labelling a patient as “non-compliant”
or “anti-social”). Another example could be over-medication as a consequence of
unconscious and not realized counter-transference feelings of a therapist (such
as helplessness) towards a patient who is not cooperative.
In any case, a psycho-dynamically oriented supervision
should be provided in each therapeutic team. It could be beneficially educative
for residents in order to raise awareness and to gain control in complex
situations. Since the provision of supervision is not always available,
residents will experience their counter-transference feelings as uncomfortable
and as disruptive elements in their therapeutic work. The consequence may be
that they inevitably withdraw and possibly avoid psychodynamic concepts and
psychotherapies. Sadly in times of cost-effective treatment, and pharmacotherapy,
and time-limited therapy settings, such incidents of withdrawal and avoidance
are far more likely to take place.
Conclusions
In recent years, we have observed an
interesting emergence of theoretical perspectives in various schools of
psychotherapy. Clinicians with a great deal of therapeutic experience appear to
have come to the conclusion that the sharp demarcation between the concepts of
psychotherapeutic schools is no longer useful. They seem to appreciate that
clinicians of different psychotherapeutic schools may benefit from each other’s
experience and knowledge. For example, psychoanalytic clinicians recognize that
a personality change at the end of a successful course of psychotherapy may
also imply a change of the person’s behaviour. And, vice versa,
cognitive behaviour therapists recognize that the patient-therapist
relationship and unconscious dynamics play an important role in
psychotherapeutic treatment.
From a clinical and training point of view, there is no
doubt that a psychodynamic perspective is useful in clinical settings, in
interdisciplinary staff meetings and for effective communication in mental
health institutions and in health institutions in general. Future plans and
designs for quality improvement could be the following:
·
The development of a curriculum to teach person-centred
psychodynamics
·
Teaching interdisciplinary staff members of a medical,
psychosomatic or psychiatric hospital unit or of medical private practices
·
Providing supervision to health care workers on the basis of psycho-
and group-dynamic principles
·
A possible collaboration project between the International
Network of Person-Centered Medicine (INPCM), WADP and the Section on
“Psychoanalysis in Psychiatry” of the World Psychiatric Association (WPA).
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