Commentary: Psychodynamic Approaches to the Patient

I begin with a tip of the hat to Dr. Paul Chodoff, who on page 1404 offers his reflections on dynamic psychotherapy from the vantage point of more than a half-century of clinical practice. I wish only to add a few comments about psychodynamic approaches to the patient.

First, let us step even further back and acknowledge that Mesmer, Janet, Freud, and the generations of therapists since—no matter how seemingly diverse their methods—have all been borne along by the same psychocultural-historical-scientific river that has carved out many useful interpersonal methods for changing human beings' lived experience, and, a fortiori, their brain function. The dynamic current that crystallized in the form of psychoanalysis was, of course, especially strong for the first three-quarters of the 20th century. Yet a behavioral current has flowed alongside it for at least as long, such as in the work of Pavlov and Watson, if not longer, such as in institutional behavioral approaches to "the insane."

From admixtures of these two great streams have emerged a variety of other clinical methods, especially cognitive-behavioral therapy. We should also acknowledge hypnosis as having nourished these grander flows and, in turn, as having siphoned off a draft of both dynamic and behavioral theory and technique to produce systemic, strategic, and solution-focused therapies. Thus there has always been an intermingling of sources and influences feeding into our reservoir of therapeutic possibilities.

Second, even if the dynamic cataract has been transformed and diverted, and with it some of its therapeutic indications, the ubiquitous use of the new forms it has often assumed—whether some of the brief therapies, supportive therapy, and family or group therapies (1)—has ensured that psychodynamic psychotherapy persists as an intrinsic, vital ingredient in many clinical functions and situations. Even when such clinical focal points do not involve classical, insight-oriented, exploratory, or expressive dynamic psychotherapy, they are almost inevitably psychodynamically informed. Examples include initial case evaluations, assessments of treatment impasse or medication nonadherence, multidisciplinary treatment planning, and therapy and treatment consultations.

Take the example of supportive therapy, which itself embodies a broad palette of diverse and subtly different techniques. As a general rule, psychodynamically aware therapists are most adept at this "complex and often difficult process" (2), which has been too often devalued because in its pure form it deploys little or no interpretation and large doses of suggestion and environmental manipulation, and it does not offer some ultimate dramatic cure through insight (3,4,5,6,7). However, deciding when to use supportive techniques and then wielding them adroitly involve, par excellence, psychodynamic skills in both the formulation of cases and the actual conduct of treatment. Such treatment is not about merely being nice and supportive. As many have noted, supportive therapy and expressive or insight-oriented therapy are each more often than not midwife to the other's emergence at the appropriate times in a treatment. Thus when we acknowledge the presence of supportive psychotherapy in our world of dynamic therapies and their indications, we have vastly broadened our therapeutic horizon.

Third, the sharpening of our capacity to differentiate types of therapy and therapeutic techniques, along with their relevant clinical substrates and goals, has been one of the major works-in-progress of the past half-century of scientific progress in the mental health fields. Even if treatment-matching schemas—prospective attempts to align patients' pathology with our array of treatments, the more efficiently and effectively to assist them—still linger in frustrated statu nascendi, we have learned a great deal about what approach is likely to be useful, even if we don't yet know whether another might be better. The example of neurosis versus personality disorder comes immediately to mind, and within the latter category, the type and severity of personality disorder. The work of Otto Kernberg, Marcia Linehan, Salman Akhtar, Michael Stone, Aaron Beck and colleagues, and many others must be celebrated here. Especially relevant, for example, is Dr. Kernberg's chapter on indications and contraindications for the spectrum of psychodynamically based treatment modalities (5) and Dr. Akhtar's Broken Structures (8).

Fourth, we have the issue of how to define "dynamic psychotherapy." Its traditional core (I'm guessing that this is how Dr. Chodoff learned it) has involved an adeptly erosive laying bare of areas of the dynamic unconscious—if by no means always the bedrock of psychic structure—involved in clinically relevant conflicts, confusions, compromise formations, and other derivatives. This has been an operation performed largely by means of interpretive interventions, which effect enduring change in personality function and—inchoately visualizable through neuroimaging—brain structure.

As I have already suggested regarding supportive therapy, the influence of the dynamic model can be seen clearly even in many widely influential therapies that do not explicitly take the unconscious or psychological structure as their central objects. In this context we might consider the person-centered Rogerian approach, existential therapy, the variety of strategic approaches influenced by Milton Erickson, Moreno's psychodrama, interpersonal therapy as described by Klerman and Weissman, Ellis' rational-emotive therapy, and the cognitive-behavioral therapies (1).

Fifth, we cannot and should not speak of dynamic psychotherapy without invoking psychodynamic formulation—that is, thinking through a case in terms of the apparently simple yet profound question: Why did this particular person (in his or her life-historical uniqueness) develop this particular problem (the life difficulty or disorder) at this particular time (the role of environmental or putatively innate factors), and what factors limit or enhance this person's capacity to move toward better function?

Of course, debate continues in many clinical and academic harbors—buffeted by the torrent of clinical demands—about how best to schematize this theoretic-diagnostic edifice for clinicians' and trainees' optimal understanding, integration, and routine use (9,10,11,12,13,14,15,16). In the current professional epoch, with integrative, antidichotomous, dialectical reasoning finally having found its proper hegemony, at least in the form of active dialogue, debate, and, increasingly, eclectic-transtheoretical practice (17,18,19), we would do well to continue to carve new channels flowing away from using a purely "psycho"-dynamic formulation toward something like a "biopsychosocio(economico)-dynamic formulation" (20). (Does anyone have a better term—perhaps "comprehensive formulation"?)

As we practice and teach, we must continually remind ourselves that in any given clinical case, and in any given moment in the treatment process, one or more of these dimensions (bio-, psycho-, socio-, or even economico-) will bear the greatest load, but the other dimensions will not—and must not—be wholly and unalterably drained or shunted out of our clinical logic or practice (bless you, Adolf Meyer and George Engel) (20).

In some settings, case formulation assumes the guise of parallel pharmacologic-diagnostic and psychotherapeutic-diagnostic exercises (21), but the practical key—and, increasingly, it appears, the most efficacious (22)—involves the artful stirring of these two together to achieve optimal outcome (21,23,24,25). Here again, dynamic principles and practices—for example, in relation to transference-countertransference issues—often carry the day (24).

Indeed, the day has not yet dawned in clinical practice when we can achieve the proper tincture of receptor stimulation or blockade without an interactive moment with this other human being, whom we wish to push and tug toward a more buoyant being in the world. As long as thoughtful and heartfelt clinician-patient interaction remains accessible (21), so too should we who would presume to provide skillful succor to others make sure that we avail ourselves of the fullest spectrum of dynamically interacting biopsychosocial facets. Ultimately and ineffably, this is the very stuff that constitutes us, our patients, and our world. When we take all this into account, then we can honestly take heart in the work we are doing as we blend, mix, and titrate our theories and methods—always, I hope, with the necessary tinctures of respect and devotion so essential in this difficult, noble work.