Psychodynamic psychotherapy

  Psychoanalysis was closely associated with Jewish practitioners in its infancy and became a target for Nazi persecution in the 1930s. As a result most practitioners had to leave and most moved to the US, England, and South America. In all of these places their work and teaching came to have an enormous influence on psychiatry – much more than in their native German-speaking countries.

  The Second World War put extra demands on psychoanalysts who turned their attention to traumatized soldiers and, surprisingly, the understanding of organizations (in particular the army). Out of this arose group analysis and group therapies where patients were treated in small groups of 5–8 so that they benefited from solidarity and support as well as insight. Group work led to the development of the therapeutic community (see Chapter 3) where analytical and psychological insights are applied to running a unit (rather than individual treatments). This informal, communal approach (with staff and patients sharing many of the tasks of running the place) was called ‘sociotherapy’ and has become a standard feature of modern psychiatric practice, drug rehabilitation units, and some prisons.

  The endlessness of classic psychoanalysis (often taking several years at three to five sessions a week) has been strongly criticized. It is prohibitively expensive and many believed that shorter therapies would focus the mind better and improve outcomes. Typical ‘short-term’ therapies now last three to six months with weekly sessions of an hour. Interpersonal therapy focuses on relationships and cognitive analytical therapy uses specific exercises like letter writing and prescription of homework as part of the treatment. While still maintaining strict professional boundaries therapists are increasingly more active.

  These are usually called ‘psychodynamic’ psychotherapies because they attribute such importance to dynamic interactions between the past and the present and between conscious and unconscious processes. The individual’s life story, their ‘narrative’, is central to understanding and resolving their problems. All require the therapist to hold back from giving too much direct advice so that the patient can, with guidance, find their own solutions. These therapies are routinely combined with other psychiatric treatments (antidepressants, hospital care, etc.).

  Non-specific factors in psychotherapy

  Most psychodynamic psychotherapists are intensely loyal to their model, convinced of the specificity of their treatment. Unfortunately the evidence is against them. There is depressingly little research into psychodynamic psychotherapies (unlike cognitive behavioural therapies) but what there is makes interesting reading. Experienced therapists who follow their training closely do much better than novices, or those who apply their model loosely. However, which model doesn’t seem to matter so much – they are all about equally effective. Most of this research confirms the crucial importance of establishing a good therapeutic relationship.

  The qualities of a good therapist transcend the different schools of thought. The essential ingredients are accurate empathy (the therapist must really understand what the patient is going through, it is not enough just to feel sorry for them),unconditional regard (the therapist has to like and respect the patient, you can’t do therapy with someone you really dislike), and non-possessive warmth (the therapist must be able to show warmth without making the patient feel beholden to them). These insights are particularly useful in psychiatric practice. Matching patients and therapists really does matter – not all of us can get on with everyone. To work with violent or sexual offenders, for instance, requires a particularly tolerant and forgiving individual.