PSYCHOANALYTIC ALTERNATIVES:EGO ANALYSIS, CURATIVE FACTORS

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Clinical Psychology (PSY401)

LESSON 30

PSYCHOANALYTIC ALTERNATIVES

Psychoanalytic theory underwent considerable modification by the Neo-Freudians, Alfred Adler, Carl Jung,

Otto-Rank, the ego analysts and others. The seminal contributions of Freud remained, but the emphases

often changed. Jung made much more of dreams and symbolic processes. Rank elevated the birth trauma to

a preeminent position. Adler and the neo-Freudians stressed the importance of culture, learning, and social

relationships instead of instinctual forces.

Such variations would be expected to influence the methods of therapy. However, these changes often did

little to alter the critical roles of free association, dream analysis, interpretation, transference, and resistance.

The supreme role of insight was little changed. In sight came about through traditional psychoanalytic

methods, but now it was the insight of Horney or Fromm or-Sullivan. The neurotic symptom was seen as

rooted not only in repressed sexual or aggressive urges; it now became the outgrowth of a fear of being

alone or of the insecurity that goes along with the adult role. In most of these early variants of

psychoanalysis, interpretation remained the essential therapeutic ingredient. What distinguished these

variants was often the content of the interpretation-the different ways in which unconscious material was

construed by the analyst.

Over the years, enough changes have been made in traditional psychoanalysis that those who no longer

practice the strict Freudian techniques are often said to be practicing "psychoanalytically oriented" therapy.

These changes involve many factors. In some cases, the number of analytic sessions is reduced from five

per week to three, and the entire treatment process may last but a year and a half (Alexander & French,

1946). The therapist is no longer inevitably seated behind the patient's couch but now often sits at a desk

with the patient seated in a facing chair. Perhaps the easiest way to characterize these and other

modifications is to say that greater flexibility has been introduced. Although basic Freudian tenets are still

observed, the overall context is not so rigid. For example, free association is no longer absolutely required

by these psychoanalytically oriented therapists. The importance of dreams may be downplayed somewhat.

Drugs and even hypnosis may be used.

For many years, the therapy room was like an inner sanctum. The therapist talked with the patient and no

one else. Now, family members or a spouse are often consulted, or sometimes therapy is conducted with the

family as a unit. There tends to be much less emphasis on the past (childhood) and a more active confronta-

tion with the present. Even the nature of the clientele has changed a bit. Clinics or institutes now provide

some therapeutic services to aging clients, minority group clients, and others who have not traditionally

received psychoanalytic treatment. They have tried to open up therapy to nontraditional populations. Again,

none of this is meant to be a denial of Freudian principles; rather, it is a demonstration that traditional

Freudian treatment procedures are not the only therapeutic techniques that can be deduced from Freudian

psychoanalytic theory.

EGO ANALYSIS:

The ego analysis movement originating from within the framework of traditional psychoanalysis rather than

as a splinter group, held that classical psychoanalysis overemphasized unconscious of ego processes. This

group of theorists accepted the role of the ego in mediating the conflict between the id and the real world

but believed that the ego also performed other extremely important functions. They emphasized the

adaptive, "conflict-free" functions of the ego, including memory, learning, and perception. These theorists

include Hartmann (1939), Anna Freud (1946a), Kris (1950), Erikson (1956), and Rapaport_ (1953).

Ego-analytic psychotherapy has not departed from the usual therapy methods except in degree. In a sense,

the ego analysts seem to prefer reeducative goals rather than the reconstructive goals of orthodox

psychoanalysis. The exploration of infantile experience and the induction of a transference neurosis seem to

be less common in ego-analytic therapy than in classical psychoanalysis. Ego-analytic therapy focuses more

on contemporary problems in living than on a massive examination and reinstatement of the past. Also, the

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therapist must understand not only the neurotic aspects of the patient's personality but also the effective

parts and how they interact with those neurotic trends.

The ego-analytic approach has also tended to emphasize the importance of building the patient's trust

through "reparenting" in the therapy relationship. This approach sometimes even views transference as an

impediment to therapy and works toward building adaptive defenses in the patient (Blanck & Blanck,

1974).

OTHER CONTEMPORARY DEVELOPMENTS:

In particular, the work of Horney, Sullivan, and Adler has been important in giving a new spin to

psychoanalysis. Likewise, ego psychology and theories of object relations have encouraged an emphasis on

the manner in which the patient relates to other people, rather than on conflicts among-, instinctual forces.

For example, object relations theorists see the need to form relationships with others as a primary influence

on human behavior. Therefore, these theorists focus more on the role of love and hate, as well as autonomy

and dependency, in the development of the self. In the self psychology of Kohut (1977), the central task of

maturation is not the successful negotiation of the psychosexual stages but the development of an integrated

self.

Discussions of changes in psychoanalytic therapies emphasize a shift in the therapeutic focus to the "here

and now" and to the interpersonal exchanges that occur within it (Henry, Strupp, Schacht, & Gaston, 1994).

Strupp and Binder (1984) have synthesized some of the more critical developmental changes in

psychoanalytic practice. They emphasize a movement away from the recovery of childhood memories and

their analysis toward-a focus on the corrective emotional experiences that occur through the agency of the

therapeutic relationship. The transference relationship as it occurs now helps provide the means for

constructive changes in interpersonal relations outside the therapy room.

BRIEF PSYCHODYNAMIC PSYCHOTHERAPY:

Perhaps the chief practical thrust of recent years is psychodynamic therapy has been the development of

brief methods (Goldfried, Greenberg, & Manna), 1990, Koss, Butcher, & Strupp, 1986). Many of these

brief therapies retain their psychodynamic identity even as they are employed in emergency, crisis-oriented

situations. This allows the therapist to capitalize on the patient's heightened motivation and also to depend

on the transference relationship (Goldfried et al., 1990).

Although it would be nice to believe that theory and/or research considerations have dictated the shift

toward briefer psychotherapies, this is not entirely the case. An important driving force has been the

increasing focus on cost containment in health care systems (Cummings, 1986). Insurers have been cutting

the number of visits for which they will reimburse therapists. Cost containment has also provided indirect

competition from psychiatrists, who frequently prescribe medications rather than psychotherapy. The net

effect has been a turn to brief psychotherapy to remain economically competitive.

There are now several hundred different brands of brief therapy. In fact, the widespread availability of these

treatments has diminished the exclusive role of psychiatrists and brought many non medical therapists into

the arena. Not all of these briefer therapies could be labeled psychodynamic. In some cases, briefer

therapies are highly similar to crisis intervention techniques. Finally, many forms of brief psychotherapy are

quite eclectic in their approach (Garfield. 1989).

Although some define 25 sessions as the upper limit of brief therapy, others indicate that the range can be

from one session to 40 or 50. However, the issue seems less the number of sessions than the rationing of

time allotted to therapy (Budman & Gunman, 1983) and the state of mind in patient and therapist alike.

Events move rapidly in crisis-oriented therapy. Thus, the quest for insight is not the leisurely process that it

is in traditional forms of psychotherapy. The entire working through process is accelerated. The ultimate

goal is not reconstruction of the personality, but the development of a benign cycle of functioning and the

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Clinical Psychology (PSY401)

better handling of day to day problems in living. Transference is encouraged, but mainly as a means of

ensuring that the therapist will be perceived as helpful, competent, and active.

Specific techniques in brief therapy are numerous. However, the maintenance of a clear and specific focus

on realistic goals is important. Usually, the level of therapist activity is high, and both therapist and patient

are keenly aware of the element of time. The therapist is likely to use homework assignments for the

patient. To involve relatives or significant others in the treatment plan. Supportive activities outside therapy

are likely to be used well (for example, exercise, Overeaters Anonymous). There tends to be a great deal of

flexibility in treatment activities that take brief therapy beyond the strict psychodynamic perspective.

Research evidence attests to the efficacy of brief forms of psychotherapy across a number of clinical

conditions (Koss & Shiang, 1994), and evidence suggests- that brief psychodynamic psychotherapy may be

as effective as traditional time unlimited psychoanalysis.

INTERPERSONAL PSYCHOTHERAPY; AN EMPIRICALLY SUPPORTED TREATMENT:

A particular form of brief therapy that is psychodynamic in flavor deserves mention. It has received a great

deal of attention from psychotherapy researchers, and it has been highlighted in several practice guidelines.

Interpersonal psychotherapy or IPT is a brief insight oriented approach that has been applied primarily to

depressive disorders although it has been_ modified for use in the treatment of other disorders (such as

substance abuse and bulimia) as well. When used to treat depression, IPT involves thorough assessment of

depressive symptoms, targeting a major problem area (such as delayed grief, role transitions or disputes, or

interpersonal deficits), and alleviating depressive symptoms by improving relationships with other

improving communication skills and social skills). IPT has been shown to be effective in treating acute

depressive episodes and in preventing or delaying the recurrence of depressive episodes. Given below are

the major features and characteristics of IPT.

FEATURES OF INTERPERSONAL PSYCHOTHERAPY:

IPT is a brief form of psychodynamic psychotherapy that has been used in numerous research studies. It is

one of the treatments cited as examples of empirically validated/ supported treatments by the Division 12

Task Force of the American Psychological Association. Weissman and Markowitz (1998) discuss the

primary features of IPT.

Focus:

IPT focuses on the connection between onset of clinical problems and current interpersonal problems (with

friends, partners, and relatives). Current social problems are addressed, not enduring personality traits or

styles.

Length: Typically 12-16 weeks.

Role Of The IPT Therapist:

IPT therapists are active, no neutral, and supportive. They use realism and optimism to counter patients'

typically negative and pessimistic outlook. Therapists emphasize the possibility for change and highlight

options that may effect positive change.

PHASE OF TREATMENT:

1. First phase (up to 3 sessions): This includes a diagnostic evaluation and psychiatric history, an

interpersonal functioning assessment, and patient education about the nature of the clinical condition (such

as depression). The therapist provides a clinical formulation of the patient's difficulties by linking symptoms

to current interpersonal problems, issues, and situations.

2. Second phase: Depending on which interpersonal problem area has been chosen (for example, grief, role

disputes, role transition, and interpersonal deficits), specific strategies and goals are pursued. For example,

treatment focusing on role disputes would aim to help the patient explore the problematic relationships, the

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Clinical Psychology (PSY401)

nature of the problems, and the options for resolving them. If an impasse has been reached in a relationship,

the therapist helps the patient find ways to circumvent whatever is hindering progress or to end the

relationship.

3. Third phase (last 2-3 sessions): The patient's progress and mastery experiences are reinforced and

consolidated. The IPT therapist reinforces the patient's sense of confidence and autonomy. Methods of

dealing with a recurrence of clinical symptoms are discussed.

EVALUATION OF PSYCHODYNAMIC PSYCHOTHERAPY:

In this section, we will review the available empirical evaluations and offer some general observations

about those psychotherapeutic practices that trace their origins to the psychoanalytic method.

DOES PSYCHODYNAMIC PSYCHOTHERAPY WORKS?

What evidence is there that the psychodynamic approach is effective? We know the widely known meta-

analytic study by Smith, Glass, and Miller (1980) that examined the effectiveness of psychotherapy. In

addition to examining the effects of psychotherapy in general, these authors also reported effects separately

for different types of psychological intervention. They found that the average patient who had received

psychodynamic psychotherapy was functioning better than 75%, of those who had received no treatment.

Two recent meta-analyses of studies examining the effectiveness of brief psychodynamic psychotherapy

have produced conflicting results, with one supporting the efficacy of brief psychodynamic treatment (Crits-

Christoph, 1992) but the other not (Svartberg & Stiles, 1991). Based on these and other results, we offer the

tentative conclusion that there appears to be at least modest support for the effectiveness of psychodynamic

psychotherapy. However, a number of thorny methodological issues plague research on psychodynamic

therapy (for example, appropriate outcome measures, length of treatment), and additional investigations are

warranted.

INTERPRETATION AND INSIGHT:

A wide range of current psychotherapies depend to a greater or lesser extent on the patient's achieving

insight through therapist interpretation. Psychoanalysis seems to retain its total commitment to insight as the

supreme means for solving problems in living. When understanding is complete enough, it is believed that

the patients' symptoms will be ameliorated, or even disappear entirely.

This emphasis on the pursuit of understanding has great appeal to many people. For example, although

many people who are sad may seek the therapeutic goal of happiness, most of them are not content just to

become happy they also want to know why they are sad. The commitment of psychoanalysis and its

psychotherapeutic heirs to insight and understanding is their greatest asset, but it also contains the seeds of

their failures. Especially in the case of psychoanalysis, reconstruction of the personality through insight and

understanding can lead to a nearly interminable and sometimes exhausting examination of the past and

analysis of motives. Although one can hardly fault psychoanalysis for teaching the importance of the past in

shaping the present, there can be too much of a good thing. At times, it almost seems that the patient can use

the need for understanding and the pursuit of the past as reasons not to come to grips with current problems.

The endless analysis of conflicts and motives and of their childhood origins can easily replace the need to

find solutions and behavioral alternatives to problems in living. Although learning the reasons for one's

problems may be important (and ultimately efficient if one is to attain generalized rather than piecemeal

solutions), the failure to emphasize alternative ways of behaving can be a major shortcoming of traditional

psychoanalysis.

Psychoanalysis often appears to involve a tacit assumption that more adaptive behavior will occur

automatically once insight is achieved by the working through process that behavioral change will surely

follow insight. However, the evidence for this assumption is exceedingly sparse. In fact, it has been argued

for some time that the true course of events follows_ a reverse pattern that insight is brought about by

behavioral change (Alexander & French, 1946).

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One of the chief methods used by psychodynamic clinicians to facilitate patient insight is the interpretation

of transference. A recent review of empirical studies that examined transference interpretation in

psychodynamic psychotherapy (W. P. Henry et al., 1994) offers the following general conclusions:

1. The frequency of interpretations made is not related to better outcome. Indeed, some studies have found

that a higher frequency of interpretation is related to poorer outcome.

2. Transference interpretations do not result in a greater degree of affective experience in the patient as

compared with other types of interpretations or other types of interventions. When followed by affective

responses, however, transference interpretations appear to be related to positive outcome.

3. Interpretations by the therapist are more likely to result in defensive responding on the part of the patient

than are other types of interventions. Frequent transference interpretations may damage the therapeutic rela-

tionship.

4. Clinicians' accuracy of interpretations may be lower than was previously believed.

The authors summarize: "The available findings challenge some clearly held beliefs. In short, transference

interpretations do not seem uniquely effective, may pose greater process risks, and may be counter

therapeutic under certain conditions" (W. P. Henry et al., 1994, p. 479).

This is not to say that transference interpretations are always harmful and should be avoided. Rather, the

existing research suggests that the relationship between interpretation and outcome is a complex one that is

likely to depend on factors such as patient characteristics, clinician interpersonal style, timing of interpre-

tations, and accuracy of interpretations (W. P. Henry et al., 1994).

CURATIVE FACTORS:

What, then, seems to be responsible for positive outcomes following psychodynamic psychotherapy? The

empirical evidence points to the, strength of the therapeutic alliance (W.-P. Henry et al., 1994). Although

the quality of the therapeutic alliance is related to outcome across a number of therapeutic modalities (for

example,

client-centered,

cognitive-behavioral),

it is interesting to note that the importance of the clinician-patient relationship was recognized by Freud

(1912/1966). Although various definitions of the therapeutic alliance have been proposed, this term is

generally used to refer to the patient's affective bond to the therapist. A positive relationship or strong bond

facilitates self examination by the patient and permits interpretation. Presumably, a strong therapeutic

alliance makes it less likely that a patient will react defensively to interpretations by the clinician. Research

evidence suggests a direct link between alliance and outcome, whether short-term or long-term

psychodynamic treatments are examined and regardless of the particular outcome measure used M. P.

Henry et al., 1994).

THE LACK OF EMPHASIS ON BEHAVIOR:

The stereotypic practitioner of psychoanalytic psychotherapy plays a relatively passive role except for

interpretation. The failure to deal_ with behavior to make suggestions or to adopt a generally more activist

posture would seem to prolong psychotherapy unnecessarily. For example, it may be true that a male

patient's unhappy heterosexual adjustment or lack of skills with women stems from unconscious

generalizations from past unfavorable comparisons with a dominant brother. But simple insight into the

childhood origins of the problem does not provide the skills that are lacking. The patient's expectations for

success in establishing relationships with women will continue to be low and a source of anxiety until a

heterosexual behavioral repertoire is established. An active therapist who not only provides interpretations

that will lead to insight but also guides the patient into new learning situations seems more likely_ to

achieve lasting solutions to the patient's problems than does a therapist who relies solely on insight. (Or

solely on behavior, for that matter).

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It seems clear that a major reason for the rapid rise of the behavioral therapies was the failure of so many

psychotherapists to deal directly with the specific problems of the patient. The approach inevitably seemed

to be one of relegating the presenting problem to the status of a "symptom of something deeper." The

therapist then began working with that "something deeper" while clinging to the abiding belief that once the

patient understood it, the symptom or deficit would disappear. Unfortunately, things did not work out that

way often enough. In any case, more and more therapists are trying to foster both insight and behavioral

alternatives in their patients.

THE ECONOMICS OF PSYCHOTHERAPY:

By its very nature (reconstruction of the personality), psychoanalysis is a long and costly procedure. Its

course over three to five years and the long and costly preparation of its practitioners ensure that it will be

an expensive undertaking. Consequently, it has become a therapy for the affluent for those who have both

the money and the time to pursue the resolution of their neuroses. Moreover, the procedures of psycho-

analysis are such that only relatively intelligent, sophisticated, and educated groups are likely to be able to

accept the therapeutic demands it makes. For all these reasons, only a small portion of those in need of

psychotherapy are likely to be reached by traditional psychoanalysis. The poor, the undereducated, minority

groups, older populations, the severely disturbed, and those beset by reality burdens of living for which they

are woefully unprepared will in all likelihood not become psychoanalytic patients.

For these reasons alone, many regard psychoanalysis as a failure. It is inherently incapable of putting even a

dent in the mental health problems of the nation. Yet, for persons who have the necessary personal qualities

and financial resources, psychoanalysis has been helpful, particularly for those whose problems can best be

met through the development of understanding.

Psychoanalytic techniques seem to have helped many patients, and as a theory of therapy, psychoanalysis

undergirds many forms of psychotherapy. Yet many clinicians still question whether, after all these years,

there is really much in the way of definitive research evidence for its effectiveness. These sentiments are

echoed by Wolpe (1981). Although hardly unbiased, Wolpe is particularly critical of a method that can

allow patients to remain so long in therapy, often with little evidence of improvement. Wolpe cites ex-

amples offered by Schmideberg (1970). In one case, a 54-year-old man had been in psychoanalysis for 30

years without noticeable improvement. A woman who began psychoanalysis with no specific symptoms

later developed agoraphobia and after 12 years of therapy was worse than when she began. Admittedly,

nearly every brand of therapy contains its share of horror stories. But lengthy therapy combined with little

improvement does raise questions.

It is encouraging, however, that brief forms of psychodynamic psychotherapy have been developed. Crits-

Christoph (1992) meta-analysis indicates that brief psychodynamic treatments that incorporate the use of

manuals show stronger treatment effects (versus psychodynamic treatments that do not use manuals) and in

some cases may be equivalent to other forms of brief psychological treatment. In addition to providing

encouragement to psycho dynamically oriented clinicians, this finding should serve to impel them toward

mastery and use of manual based, empirically supported brief psychodynamic treatments, such as

interpersonal psychotherapy (Markowitz, 1998). This approach is both scientifically defensible and

appealing to managed care companies.

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