Psychodynamic Research
In the following, central concepts of psychodynamic therapy and the availabel evidence will be discussed.
Core Conflictual Relationship Theme (CCRT): The CCRT is a psychotherapy research method and psychotherapeutic technique used to examine patient relationship narratives to understand and explore recurring aspects of interactions and expectations of interactions between the patient and others, More specifically, A CCRT consists of a wish, an expected responses from others and a responses of the self which include the patient’s defense mechanisms and the resulting symptoms (Luborsky, 1984). Thus, the CCRT method allows to operationalize and empirically study Freud´s (1923) concept of symptom formation. The CCRT has been thought of as analogous to Freud’s understanding of transference, that is experiencing another person in way similar to important figures of the past (Luborsky et al, 1994). The CCRT method may also be used as guide to understanding the patient relationship themes as part of psychotherapy (Crits-Cristoph et al, 1988). CCRT’s may change across a course of treatment, suggesting that a client’s self and other representations may also change over the course of treatment (Wiseman & Tishby, 2017). Finally, the CCRT method may also be used to help develop goals, build therapy alliance, and set therapy expectations in psychodynamic psychotherapy (Siefert, 2019).
Defense Mechanisms: Defense mechanisms, first introduced by Freud in 1894, are involuntary psychological coping mechanisms to manage internal conflict or internal or external psychological threat (Perry & Bond, 2017) and are largely out of awareness (Di Giuseppe et al., 2021). Defensive processes are one of the most well-researched psychodynamic concepts with much empirical support (for review see Bond, 2004; Cramer, 2015). Defenses have a developmental trajectory (Cramer, 2015) are adaptive (Di Giuseppe et al. 2021), and can are structured hierarchically based their degree of adaptiveness (Di Giuseppe & Perry, 2021; Hilsenroth, et al., 2003). Lesser or lower adaptive defenses are associated with greater symptom severity poor psychological functioning (Perry & Bond, 2017). Changes in defense mechanism may occur as a result of psychotherapy (Babl et al., 2019; Perry & Bond, 2017; Perry, et al., 2020).
Primary Process: Freud (1895/1950) identified two types of mentation, namely primary process and secondary process. Secondary process is primarily language-based thinking, which focus on meaning whereas primary process mentation is a mode of thinking which is based on association and superficial similarities between thoughts (Bruzelmane et al, 2020). Primary process thinking is thought of developmentally, as the earliest mode of thinking (Robbins, 2018). This type of thinking is characterized by thoughts associated via loose connection. Early empirical research (e.g., Shevrin & Luborsky, 1961) focused on presenting visual stimuli that was, in part, hidden from conscious awareness. Participants were then asked to recount and draw images of their dreams, demonstrating unconscious associations to the hidden visual stimuli. More recent research (for review see: Brakel, 2004; Bazan et al, 2013; Bazan & Brakel, 2023) using categorization tasks specifically independent of the psychoanalytic clinical method demonstrate associative attributions between non-essential visual stimuli in a forced choice situation. Evidence for this type of primary process thinking was found to be greater in psychiatric populations and more specifically in psychotic patients compared to non-psychotic patient (Bazan, et al 2013; Singer & Larson, 1981), as well as able to distinguish individuals with personality pathology individuals with neurotic functioning (Leichsenring, 1991). The Rorschach, the TAT, and the Holtzman Inkblot Technique are all useful assessment tools for both researchers and clinicians interested in understanding primary process and its relationship to patient cognitive and emotional functioning and diagnosis (e.g. Ackerman et al., 1999; Leichsenring, 1991; Singer & Larson, 1981). Primary process is viewed as a critical component of the psychoanalytic process of free association, which allows for the patient to become aware of new meanings (Rabeyron & Massicotte, 2020).
Attachment and Mental Representations: A critical task of early childhood is the development of an attachment to a primary caregiver or caregivers. Attachment refers to the affective bond between a child and caregiver that serves to promote proximity and to protect the child in circumstances of threat or danger (Bowlby, 1982). Attachment is the behavioral manifestation of the mental representations/internal working models that reflect the internalization of these early caregiving relationships (Fonagy et al., 2023). These mental representations that develop in infancy continue to serve as templates that are modifiable throughout life (Doyle & Cicchetti, 2017). The attachment bond with the parent and the subsequent mental representations are heavily influenced by the actual parenting behaviors (Doyle & Cicchetti, 2017) and reflective capacities of the caregivers (Zeegers et al., 2017). Notably, a large body of research has demonstrated that attachment and mental representations are damaged by interpersonal trauma in childhood (Doyle & Cicchetti, 2017; Fonagy et al., 2023). In psychotherapy, the attachment relationship with the therapist has been shown to be related to outcomes (see Slade & Holmes, 2017). Finally, interpretation of the patient’s mental representations of the therapist is the basis of transference interpretation and has long been a foundation of psychodynamic/psychoanalytic psychotherapy.
Reflective Functioning/Mentalization: This is the capacity to understand and interpret one’s own behavior and others’ behaviors as reflecting the existence of the individual’s mental states, including thoughts, feelings, desires, motivations, which includes an implicit understanding that each individual’s mind is separate from all other minds (Katnzelson, 2014). Parental reflective functioning has been shown to influence parenting quality (Stuhrmann et al., 2022). In addition, multiple forms of psychopathology, including personality pathology, autism, mood disorders, and schizophrenia, among others are associated with diminished mentalization capacity (Johnson et al., 2022; Luyten et al., 2020). Improvement of patient mentalization is a common goal in psychotherapy (Ludemann et al., 2021), however, this research has very mixed findings and it is as yet unclear whether RF serves as a moderator or mediator of therapeutic outcomes or can be an outcome of therapy, itself (Katznelson, 2014).
Therapeutic Relationship as a Mechanism of Change: The therapeutic relationship is considered a primary mechanism of change in contemporary psychodynamic psychotherapies (Zilcha-Mano & Errazuriz, 2017). This approach includes a focus on the therapist contribution to this relationship (Lingiardi et al, 2018). Specifically in contemporary psychodynamic psychotherapy, an emphasis is placed on exploring the here-and-now relationship that develops between the client and the therapist, in order to help clients gain therapeutic benefit from identifying and understanding better their internal mental representations. Psychodynamic therapists use a variety of techniques to do this, including, interpretation (Levy et al, 2015), mentalization (De Meulemeester et al., 2018), and rupture and repair (Eubanks et al., 2018). In addition, new research also suggests neurobiological support for the importance of the therapeutic relationship (see review by Zilcha-Mano et al., 2019).
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