The Future of Psychodynamic Psychotherapy

Psychiatry 73(1) Spring 2010
43
The Future of Psychodynamic Psychotherapy
Mauricio Cortina
The article reviews the current state and future of psychodynamic psychotherapies. In the past few decades psychodynamic psychotherapies have fallen into
disrepute due to the fractious and dogmatic nature of different psychodynamic
schools of thought and the lack of interest in validating some of its major premises or its effectiveness in comparison with other psychotherapy modalities. Despite these self-inflicted wounds, psychodynamic theory and treatment is staging
a comeback. Many of the major premises that comprise the complex, layered
model of the mind that are the basis of psychodynamic treatments have again
begun to be validated. A list of basic psychodynamic concepts is described. The
evidence for each of these concepts varies, but as a whole the evidence is broad
and deep for the model of the mind posited by psychoanalysis. This evidence is
coming from many fields of knowledge that are not necessarily influenced by psychoanalysis. There have also been significant advances in developing methods and
tools that can probe systematically into the complex nature of psychodynamic
treatment processes. Finally, statistical tools-such as meta-analytic studies-that
can aggregate and compare many different studies at once are beginning to show
the effectiveness of dynamic psychotherapies in comparison with other modalities
of treatment.
Psychodynamic psychotherapy
finds
THE DECLINE OF
itself in an ironic situation. The prestige and
PSYCHOANALYSIS
infiuence of psychoanalysis and dynamic
psychotherapy have been at an all-time low
for the past few decades. Yet, at the very moFrom its heyday in the decade of the
ment when the prestige of psychoanalysis is 1940s and 1950s the prestige of psychoanalso low, there has been accumulating evidence ysis has suffered a precipitous decline. Percoming from many fields that support the haps one of the most telling indications of
complex, layered model of mind posited by this decline is reflected in the dramatic drop
psychoanalytic theories. Another important in sales of psychoanalytic books in the Unitdevelopment over the past decade that has ed States (the following data is taken from
been less noticed is the gradual accumulation chapter 2 of Stepansky, 2009). Books such
of empirical evidence that supports the effec- as Frich Fromm's (1941) Escape from Freetiveness of dynamic psychotherapies.
dom (1941) and The Art of Loving (1956)
Mauricio Cortina, MD, is Director of the Attachment and Human Development Center at the Washington School of
Psychiatry and Faculty at the Institute of Contemporary Psychotherapy and Psychoanalysis in Washington D.C.
An earlier version of this article was delivered as the Commencement address to the graduating classes of 2008
Washington School of Psychiatry.
Address correspondence to Dr. Mauricio Cortina, 8737 Colesville Road, Suite 303, Silver Spring, MD 20910; e-mai:
mauriciocortinaOstarpower.net.
44
sold milhons of copies in English alone. Erik
Erikson's Childhood and Society (1950) sold
over a million copies. Even books geared to
a more professional audience, such as Otto
Fenichel's The Psychoanalytic Theory of
Neurosis (1945) sold over 80,000 copies. Although sale numbers are lost, it is likely that
Charles Brenner's An Elementary Textbook
of Psychoanalysis (1955) might have sold
1,000,000 copies in its paperback edition.
The paperback edition of Sullivan's The Interpersonal Theory of Psychiatry (1953) sold
over 96,000. The last major success of the
"glory era" was David Shapiro's Neurotic
Styles (1965) which sold 250,000 copies in
its paperback edition. Kohut's The Analysis of the Self (1971) sold 42,000 copies. In
the next generation of best-selling psychoanalytic books. Jay Greenberg and Stephen
Mitchell's Object Relations in Psychoanalytic Theory (1983) sold 49,500 and Christopher Bollas's Tbe Shadow of the Object:
Psychoanalysis of the Unthought Known
(1987) sold 16,00 copies. When we get into
the 1990s, the best-selling professional book
was Nancy McWilliams's Psychoanalytic Diagnosis (1994) with 54,000 copies. There are
a few other books that sold over 20,000 copies and approximately 13 titles that sold a
little over 10,000 copies in the last 25 years.
During the previous decade a "best-selling"
psychoanalytic book was selling 1,500 to
3,000 copies, while in the last few years the
average competent and well-written books
was selling fewer than 500 copies. According to Stepansky, the era of big sales for psychoanalytic books is over, and average, competent, psychoanalytic books are no longer
profitable enough to keep small publishing
companies afloat.
The word is out that Freud was wrong
about everything he wrote and that there is
no scientific backing for any of his discoveries.' Freud was indeed wrong about many
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issues, but perhaps the science of his day was
woefully inadequate to provide the evidence
he needed. A great deal has changed in the
past 100 years, and armed with more sophisticated methods and tools and several key
conceptual revisions, evidence is rapidly accumulating to support many psychoanalytic
concepts. Many contemporary discoveries
such as the mirror neuron system (Gállese,
2006; Gallese, Fadiga, Fogassi, & Rizzolatti,
1996; Rizzolatti, Fadiga, Gállese, & Fogassi, 1996) or the mapping of the emotional
circuitry of the brain (Panksepp, 1998) go
a long way to explain the neurobiological
mechanisms that make the psycotherapuetic
dialogue possible. We are no longer limited
to the type of mechanistic models of science
that Freud had to draw from to support his
theories. Contemporary models of the mind
and of psychiatric disorders, such as the one
proposed by distinguished geneticist Kenneth Kendler (2008) that involves complex
interactions taking place at multiple levels
(molecules to mind) which iteratively involve
environmental factors, are broadly consistent with contemporary models of mind that
are proposed by contemporary psychoanalysts (Mitchell, 1988). Another sample is the
work of Nobel prize winner and psychiatrist Eric Kandel, whose seminal work on
memory and his views on the working of the
mind embrace basic psychoanalytic concepts
(Kandel, 2006).
Many of the troubles of the psychodynamic tradition have been self-inflicted.
With a few exceptions, there have been very
few attempts to operationaHze and test basic psychoanalytic concepts. One of these
notable exceptions is Bowlby's effort to test
psychoanalytic theories having to do with
the nature of the infant's bond to his mother,
the phenomenon of separation anxiety, and
the effects of loss (Bowlby, 1969/1982,1973,
1980),
1. Some of the critiques of Freud and psychoanalysis addressed to the educated lay public have appeared in prestigious venues. For example, see Frederick Crews's across-the-board attack, The Revenge of the Repressed, in the The
New York Review of Books, November 11, and December 1, 1994.
45
The failure to test its theories and to
form alliances with potential allies within
academia has further marginalized psychoanalysis from the mainstream. An exception
to a generally antagonistic attitude toward
psychoanalysis are some English departments. Here Freud and psychoanalysis have
survived by becoming transformed into a
postmodern-deconstructive philosophy that
has very little to do with the real world and
is completely opaque but for the initiated.
Freud would not have been happy with this
legacy.
At best we have developed a tolerant
attitude toward different schools of thought,
having reached the conclusion that no brand
of psychoanalysis is complete or true and
that many schools of thought have contributed to the richness of psychoanalytic concepts. Many institutions that teach psychoanalytic psychotherapy have come to value
this openness to different ideas and expose
students to a variety of schools of thought.
While there is much to commend this position, which certainly is better than the type
of dogmatism that was prevalent during the
heyday of psychoanalysis, it leaves much to
be desired from a scientific point of view.
Perhaps the most important shortcoming
is that this new attitude of tolerance is often taken to mean that all psychoanalytic
theories are equally valid, and it is a matter
or personal taste or style which theory we
prefer to use. This leaves the psychoanalytic
field fragmented and without a clear strategy
to move forward. Theoretical fragmentation
and postmodern relativism flies in the face
of any attempt to advance psychodynamic
theory as a science. Some earlier attempts of
comparative psychoanalysis, such as Greenberg and Mitchell's Object Relations in Psychoanalytic Theory (1983) were important
steps forward. More recent systematic attempts of comparative psychoanalytic theories are being conducted by the European
Psychoanalytic Federation Working Group
in Comparative Glinical Methods. This
group is engaged in a more systematic effort of identifying and defining core concepts
that are compatible with a variety of theories
and techniques (Tuckett et al., 2008). This is
a daunting task. Psychoanalytic theory has
evolved over the course of 100 years and is
rich and complex, and some of the ideas are
not compatible with each other (Stepansky,
2009). What is needed is an ongoing effort to
define and operationalize basic psychoanalytic concepts that have withstood the test of
time. Without vigorously and systematically
engaging in these tasks, we simply cannot
claim that we are offering treatments that are
based on evidence. Not only is a laissez-faire
attitude toward clinical and extra-clinical
validation unacceptable, but from a public
relations standpoint it is a disaster.
To address these issues in new generations of psychotherapists, we have to start
from within and change a mindset toward
research and empirical findings. Bornstein
(2005) and Luyten, Blatt, and Correlen
(2008) provide a road map on how to bridge
the gap between clinicians and researchers.
According to these authors, researchers and
clinicians belong to two different cultures
and approach clinical work with different
assumptions. Psychodynamic clinicians generally have a skeptical if not outright hostile attitude toward empirical research and
doubt that scientific findings might be helpful (Hoffman, 2009). What is to be gained by
trying to live up to the standards of evidence
that are foreign to the field? The prevailing
view seems to be content with avoiding holy
wars so that we can have a dialogue among
clinicians that might inspire or shed some
light on the intricacies of clinical work. Researchers are interested in being able to generalizefindingsand insights that emerge from
individual case presentations and find the
elements in common that may account for
the effectiveness of any given approach with
different clinical populations. This is a very
tall order, and the methodological challenges
are enormous. But in the past few decades
there have been significant advances. There
are now many fine examples of qualitative
research methodologies that do justice to the
complexity of clinical work, yet are able to
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46
approach research systematically with sophisticated information gathering and statistical tools (Levy & Ablon, 2009). These new
advances make psychodynamic clinicians'
attitudes toward the science of our craft even
more unfortunate and self-defeating.
Regrettably, these attitudes, to a large
extent, reflect the way we teach psychodynamic psychotherapy. I will mention three
important areas where I think we have fallen
short: 1) We have failed to bring in findings
from other fields that support the model of
the mind on which our work is based; 2) We
have failed to show how scientific methods
can be tailored to capture some of the complexity of our work. This reflects a larger
problem. Research and empirical articles are
published in journals that clinicians don't
read and are written in a technical language
that is only understood by other researchers
familiar with the intricacies of data gathering and statistical methods (Luyten et al.,
2008); and 3) We have failed to make the
point that clinical work based on single case
studies (the usual method for teaching psychotherapy) and clinical research that tries
to generalize beyond single cases are complementary ways of knowing (Borckardt et al.,
2008). Both methods enrich our understanding. This raises the question of how to begin
closing the gap between the art and science
of psychotherapy. A good starting point to
address some of the issues is to make a list of
basic concepts used in psychodynamic psychotherapies and see what kind of evidence
exsists to support them
BASIC PSYCHOANALYTIC
CONCEPTS
The following is a list of basic psychoanalytic concepts modified from Jonathan
Schedler's excellent article The Efficacy of
Dynamic Psychotherapy (2010).
1. Unconscious processes and motivation. Ours is an intentional model of the
mind that focuses on conscious and uncon-
scious motivation. We pay special attention
to our patients' needs, desires, and wishes
that may not be recognized. As therapists we
help patients recognize disowned needs or
help regulate desires and wishes that are allconsuming or overwhelming. We often focus
on motivational systems that are in conflict
with each other, such as approach-avoidance
conflict (typical of patients with borderline
pathologies) or superego conflicts, (e.g., a
conflict between unbridled ambition and a
wish to remain true to ourselves or severe
self criticism accompanied by idealization of
parental figures).
2. Emotional processes. The psychoanalytic model of the mind focuses on affect and emotion. As therapists we help patients recognize and honor their emotions
whether they are pretty or not. We validate
emotions that might not have been formulated or named, such as profound shame or
guilt, unspeakable terror, searing rage, or
all-consuming jealousy or revenge. We work
witb contradictory feelings and help regulate
emotion.
3. Defensive processes. The psychoanalytic model of the mind focuses on defensive
processes. We explore attempts of patients to
avoid certain aspects of experience, such as
painful emotions or threatening situations.
We pay attention when patients exclude affects or painful events, and we note when
they become suddenly confused or disoriented. Dynamic psychotherapists actively
explore mechanisms of avoidance. We also
note when patients look at situations in all
good or all bad terms, when they panic and
catastrophize events, or when they obsess
endlessly about them and become paralyzed.
4. Developmental processes. The psychoanalytic model of the mind is profoundly
developmental. Human minds, become organized around certain themes, conflicts, or
strategies that are for the most part unconscious and that have their origin in development. We track these themes, make them
explicit, and try to make a connection with
the present. The focus on the past and on developmental issues is not an end in itself, but
47
a means to make clear how the past is alive
and well in the present and how the past affects the way we perceive relations and the
world at large.
5. Social processes. Our model of the
mind is profoundly social. There are at least
three interlocking dimensions to human sociability: attachment and family ties; intersubjective abilities and communication; and
culture.
a) Attachment and family ties. Human personality becomes organized around
attachment figures that become a haven of
safety and a secure base from which to explore the world. As dynamic psychotherapists we try to develop a working alliance
with our patients that will allow the exploration of affects, confiicts with a developmental
perspective, by becoming a secure base for
them. Often developing a secure base from
which to explore may become a goal in itself,
since many patients have never had a secure
attachment figure in their life and their ability to trust others is very limited and fraught
with terror and shame.
b) Intersubjective abilities and communication. Most of how we learn to communicate and the way we know how to be
with others is not conscious. Gestures, turntaking in conversation, and the ability to recognize emotions and the intentions of others
are intersubjective abilities that are gradually
acquired before language develops by the
end of the second year of life. This world of
"implicit relational knowing" (Lyons-Ruth,
1999; Stern, 2004) is vast and pervasive,
and it provides a background to all verbal
communication. Many forms of unconscious
communication that have been described by
terms like transference and protective identification can now be better understood in
terms of intersubjective abilities. Transference can be understood as expectations and
ways of relating that are established during
childhood and are carried forward in development. We pay very close attention to how
these relational patterns become activated or
reenacted in the consulting room. The power
of these expectations offers us a golden op-
portunity to explore them while in the immediacy of a therapeutic relationship.
c) Culture. Cultural norms and beliefs,
the range of emotions that can be expressed
freely, and proper ways of being with members of our own group or members of other
groups are learned to a large degree at implicit nonverbal (unconscious) levels and are
reinforced through language and ritual. The
impact of culture is ubiquitous and becomes
internalized as interpersonal schémas and social scripts. Because these schémas and scripts
are primarily non-conscious, they become accepted as a natural way of being. Recognizing cultural differences and their imprint on
personality has been a major theme among
such psychoanalysts as Erik Erickson, Karen
Horney, Abram Kardiner, and Erich Eromm.
Fromm's theory of social character is perhaps the most developed of these approaches
to personality and culture. The concept of
social character refers to emotionally based
attitudes (character traits) that are shared by
the social group as adaptations to prevailing
economic and social conditions.^
6. Imagistic processes. With his creative incursion into the world of dreams,
Ereud opened up for scientific scrutiny the
significance of dreams and the role of images
and fantasy in dreams and in wakeful reverie states. Yet many aspects of Ereud's theories of dreams have been questioned within
psychoanalysis and from systematic studies
(Domhoff, 2000). Ereud believed that the
manifest content of dreams is invariably distorted or disguised to hide how unacceptable
his wishes had become ("dream work"). In
exploring the potential meaning of a dream
the approximate meaning can be discerned
by paying close attention to its manifest
content, associated imagery, and emotional
tone. The power of dreams is often captured
through images that reflect experience with
an emotional resonance and vividness that is
immediate and direct. As we put words to
these images, we begin to discover their salience and meaning. As dynamic therapists
we focus on dreams, images, and fantasies as
entries into our patients' states of mind.
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48
EVIDENCE FOR THESE BASIC
ASSUMPTIONS
1. Unconscious processes. In terms of
unconscious processes we now know that
Freud's dynamic (repressed unconscious)
is but a very small fraction of what is nonconscious. The vast majority of information
that is processed out of awareness is not repressed, but is encoded at subsymbolic and
implicit levels (Bucci, 1997, 2005; Cortina
& Liotti, 2007). The cognitive revolution
brought with it an understanding of the mind
as being parsed in different memory systems
(Bucci, 1997; Schacter, Wagner, & Büchner,
2000; Schank & Abelson, 1977; Westen,
1999; Westen & Gabbard, 2002).
It has been known for several years that
the mere activation of the idea of engaging in
any given behavior begins to move the body
without personal awareness (Wegner, 2002).
Using a functional MRI, a group of German
researchers have shown that unconscious
processes involving the prepolar and precuneus cortex precede awareness of making a
decision by 7 to 10 seconds! (Soon, Brass,
Jochen Heinze, & Haynes, 2008). Another
important contribution to understanding unconscious processes has come from the work
of subliminal perception (Frdelyi, 1985; Westen, Weinberger, & Bradley, 2007). A recent
example of this type of research shows that
an unconscious (out of awareness) prime has
powerful effects on motivation, particularly
when the prime has a positive valence (Aarts,
Custers, & Marien, 2008).
2. Emotional processes. It used to be
that emotions were ignored by neuroscience.
But recently, emotions have become one of
the most exciting topics in modern neuroscience. The switch began in the 1960s with the
work of Sylvan Tompkins, but in the last few
decades Antonio Damasio's Descartes' Error (1994), Joseph LeDoux's The Emotional
Brain (1996), and Jack Panksepp's Affective
Neuroscience (1998) have put emotion front
and center. We now have a much better understanding of the brain's circuitry involving
the amygdala and the limbic system, how they
communicate with the prefrontal cortex and
the temporal lobes through the hypothalamus, and how emotions are intimately tied to
motivational systems (Panksepp, 1998). The
work of Paul Fkman (2003) has provided
cross-cultural evidence of the universality of
some basic emotions and emotional expressions, and a cadre of brilliant psychologists,
including Nico Frijda (1986), Carroll Izard
(1991), Richard Lazarus (1991), and Alan
Sroufe (1996), have made substantial contributions showing the function of emotions,
the relationship between emotion and cognition and how emotions become integrated
with cognition, through acquiring explicit
meanings that are only implicit during early
development (Sroufe, 1996).
3. Defensive processes. Evidence for
the existence of defensive processes has been
accumulating from many fields in recent decades. In the past few years two articles have
appeared in Science (Anderson et al., 2004;
Depue, Curran, ôc Banich, 2007) that document through neuroimaging techniques the
existence of repression of unwanted memories. These defensive processes are orchestrated via a two-phase process: an initial
suppression by the right inferior gyrus (prefrontal cortex) over sensory components of
memory and a second phase initiated by the
right medial frontal gyrus over the emotional
components involving the amygdala and hippocampus.
Bornstein (2005) notes that the study
of defensive processes has often been taken
up by academic psychologists without any
reference to Freud. For instance, Aron Beck
has documented and studied cognitive avoidance as a defense mechanism in cognitive
2. In the late 1960s, Fromm and Maccoby (1971) set out to rigorously test the theory of social character in a small
Mexican village, using in-depth interviews, extensive ethnographic and economic surveys, and sound statistical
analysis. The study found that the three social character groups found in the village-free peasants, hacienda peons,
and the new entrepreneurs—could be clearly understood by examining different historical and social conditions that
had shaped their character orientations.
49
therapy, while Tulving has documented and
studied slips of the tongue and other mechanisms of defense as retrieval errors. The repetition compulsion has been studied under the
name of nuclear scripts by Tompkins. And
on it goes. Perhaps the most comprehensive effort to validate empirically the notion
of defense mechanisms has been a 20-year
ongoing project led by Phebe Cramer (Cramer, 2006). Cramer's impressive work has
focused primarily on three defense mechanisms: denial, projection, and identification.
She shows that defenses function outside of
awareness, that they are part of normal personality, but increase with stress. Cramer has
also shown that defenses mobilize negative
emotions and reduce the scope of consciousness. Finally, Cramer shows that defenses are
connected with measures of the autonomie
nervous system, such as blood pressure and
skin conduction tests. These are all findings
consistent with a psychoanalytic model of
the mind.
4. Developmental processes. Development and the significance of the past in influencing the present ("the child is parent to the
man") have had recent and strong evidence.
Longitudinal studies are one of the best ways
to provide evidence for this key proposition,
but they are extremely expensive and hard
to do. In the past few decades several longitudinal studies—to a great extent inspired by
the work of John Bowlby (1969/1982, 1973,
1980) and Mary Ainsworth and her colleagues (1978)—have undertaken the enormous challenge of putting to the test many
psychoanalytic ideas about the importance of
parent-child relationships in influencing the
development of personality. It is impossible
to summarize all these findings, but it is fair
to say that there is strong scientific evidence
for several key propositions in regard to the
relationship between the past and present. 1)
The past, for better or for worse, is always
with us; 2) the past influences but does not
determine the present; 3) the best predictor
of outcomes is the cumulative history of how
we manage different developmental tasks;
and 4) there are continuities and discontinui-
ties in development, and nonlinear effects are
the norm. An excellent entry into this literature, led by Alan Sroufe and his colleagues
(2005), is based on a very comprehensive
and rigorous scientific longitudinal study
in the work of the University of Minnesota
group (for review of the major longitudinal
studies, see Grossmann, Grossmann, & Waters, 2005).
5. Social processes. The vast literature on attachment theory and research that
spans five decades is one of the main sources
of evidence that supports the relational turn
in psychoanalysis and has added significantly
to our understanding of how social-emotional processes mold personality development.
This literature cannot be easily summarized,
but among its main findings is the discovery
of three basic strategies used by infants to
regulate security and exploration; the discovery of a frightening and disorganizing
dimension to these basic strategies in some
infants; the transformation of these frightening experiences into controlling strategies in
many cases of children with histories of disorganized attachment; and the discovery (by
means of the Adult Attachment Interview) of
how the narratives we use to recall childhood
events embody more or less open access to
painful emotions or defensive maneuvers to
ward off these painful emotions. A good entry into this vast literature is the Handbook
of Attachment (Cassidy & Shafer, 2008).
This body of knowledge has significant
clinical implications. The quality of the therapeutic alliance is the single most important
predictor of the effectiveness of psychotherapy (Ackerman & Hilsenroth, 2003; Horvath, 2001). The ability to develop a sense
of safety with the therapist from which to
explore issues in therapy is one of the key ingredients of a good therapeutic alliance. The
concept of a therapeutic alliance originated
within the psychoanalytic literature but is
now a widely used concept in psychotherapy
research. As therapists we often become attachment figures to our patients, particularly
in moments when they feel vulnerable and
helpless. Many schools of thought have con-
50
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age offlyingin a dream might be a metaphor
for a state of happiness or euphoria. We also
useflyingimages as metaphors during wakeful states, as in expressions such as "flying
high" or being "high as a kite." The image of
being naked in a dream is often a metaphor
for shame or embarrassment, and this image
is also captured in the common expression
of being "caught with our pants down." As
these examples show, images—or " imageThe significance of intersubjective schemas" to use the term of the distinguished
abilities and intersubjective communication linguist George Lakoff (1980)—are used to
has been another major contribution stem- create metaphors and figures of speech. Lanming from infant-parent research. Three guage builds on the meaning inherent in
names immediately come to mind, Colwyn preverbal image schémas (see below) and exTrevarthen (2005, 1979, 1980, 1988); Tre- pands their meaning by virtue of the power
varthen & Aitken (1994); Trevarthen & of language to combine words and sentences
Hubley (1978); Daniel Stern (1985, 2004) ad infinitum. It is reasonable to think that
and Beatrice Beebe (Beebe, Knoblauch, Rus- images might perform a similar function in
tin, 8c Sorter, 2005). These researchers have dreams. Indeed, many clinicians who work
contributed enormously to our understand- with dreams approach the manifest content
ing of the world of implicit relational know- of images and symbols this way, an approach
ing (Stern, 2006). Implicit or procedural taken by Erich Fromm (1951) in The Porgotknowing is unconscious, not because it is ten Language. The dream researcher William
repressed, but because subsymbolic process- Domhoff provides support for the hypotheing of information cannot be retrieved con- sis that some images in dreams can be unsciously. This information is carried forward derstood as metaphors that have a cognitive
as powerful expectations and attributions we function (Domhoff, 1996; Domhoff, 2005).
The study of imagistic abilities is a
make toward others. The power of these exvery
promising
field, one most in need of repectations and attributions is that they are
search.
Jean
Piaget
(1962) in his landmark
not accessible to consciousness. When malbook
Play,
Dreams
and
Imitation in Childadaptive, they often get reenacted in destruchood
thought
that
deferred
imitation was a
tive and unhelpful ways.
developmental benchmark that signaled the
6. Imagistic abilities. It might seem ar- emergence of symbolic or representational
bitrary to lump the study of dreams with the thought. Deferred imitation is defined by the
study of images, imitation, and imagination. ability to repeat a scene or behavior days or
Dreams not only contain images, but these weeks after being exposed to it. The imporimages are also embedded in narrative plots tant point is that deferred imitation implies
that contain language. Moreover, dreams that there is a remembered image of the event
also evoke strong emotions—mostly nega- or behavior.^ According to Piaget, images betive emotions as shown by systematic study come mental representations or symbols of
of the content of dreams (Domhoff, 1999). sorts, albeit a symbol still tied to a perceptual
There are many complex issues involved in stimulus. In contrast, abstract symbols (that
the scientific approach to dreams. Many psy- make their first appearance by the middle of
choanalists belonging to different schools of the second year of life or later) are no longer
thought have noted over many decades that tied directly to an immediate percept. For inthe imagery in dreams often has afigurativeor stance the word "animal" refers to the whole
metaphorical meaning. For instance, the im-
sidered providing safety and containment a
key to success, but attachment theory offers
a parsimonious and straightforward way
to understand one of the key dimensions
of therapeutic effectiveness. Understanding
defensive processes that regulate security is
another important contribution from attachment theory and research that informs our
clinical interventions.
51
category of living creatures that share certain
characteristics such as spontaneous agency
and motility.
In Piaget's developmental model, representational thought does not appear until 16
to 18 months of age. Before this age infants
display a sensorimotor form of intelligence
that is nonsymbolic or nonrepresentational
in nature (Piaget's sensorimotor intelligence
is now understood as a form of implicit or
procedural knowledge). We now know from
the work of Patricia Bauer and colleagues
(1996; Bauer & Shore, 1987) that deferred
imitation appears much earlier than Piaget
thought —toward the end of the first year
of life-and that the capacity for imitation is
one of the foundations for social cognition
(Meltzoff, 2007). The appearance of the capacity for deferred imitation is accompanied
by the emergence of other abilities, such as:
• sharing of interesting events and happenings with caregivers by pointing and other gestures beginning around 12 months
(Bates, Camaioni, & Volterra, 1975; Tomasello. Carpenter, &c Liszkowski, 2007;
Warneken, Chen, & Tomasello, 2006)
• the ability to achieve a goal through various means—9 to 12 month-old infants
(Piaget, 1952)
• joint intentionality: the ability to understand intentions from a first-person perspective (I) and third-person perspective
(others), beginning with 15-month-old infants (Tomasello, Carpenter, Call, Behne,
&c Henrike, 2005)
• the ability to cooperate with caregivers in
reciprocal games and simple tasks, beginning soon after the first year of life (Tomasello, 2007)
• the ability to altruistically help others by 18
months, an ability that far surpasses similar bebaviors in chimpanzees (Warneken
Se Tomasello, 2006)
All this suggests that before language
emerges by the end of the second year of life,
there is a form of knowing that is already
representational in nature and is marked by
the emergence of images that can be retained
in memory. This cognitive revolution is accompanied by a revolution in social understanding that takes off during the second
year which greatly facilitates the ability of
infants to cooperate and communicate with
caregivers (intersubjective abilities).
RESEARCH ON DYNAMIC
PSYCHOTHERAPY
I would like to conclude by making a
few more remarks in regard to psychotherapy research. Much of this research is frustrating because it ends up with the so-called
dodo bird verdict, referring to Alice in Wonderland, where in a contest among birds the
queen decides that "everyone has won and
all must have prizes" (Shedler, 2010). Outcomes of different therapies are surprisingly
equivalent, and no form of psychotherapy
has proved more effective than any other.
Not surprisingly, when differences are found
for a certain type of therapy (such as cognitive behavioral therapy), the positive findings
always favor the treatment advocated by the
researchers (Luborsky et al., 1999).
Nonetheless, there is good news on
this front. Some studies are beginning to
show what is called an "incubator effect" of
dynamic psychotherapy. That is to say, that
the positive effects of psychotherapy continue to accrue after the therapy has terminated
(Shedler, 2009). This incubator effect has not
been shown to be long acting in dialectical
bebavioral therapy (DBT) or in cognitive
behavioral approaches. Another very suggestivefindingis that to the extent that cognitive
behavioral techniques are useful, they may
be so because they have incorporated psychodynamic principles used by experienced
therapists that deviate from the manualized
treatment protocol.
With the development of meta-analyses, it is possible to accumulate very large
52
data sets from many psychotherapy research
studies. This large pool of data is then scrutinized with sophisticated statistical methods
and can be compared and evaluated. Metaanalytic studies can also be used to compare
how well these large data sets stack up against
similar data sets from different types of psychotherapy. Just to get a measure of some of
these studies and what they mean, an effect
size of 1.0 means that the average patient is
one standard deviation healthier in the normal (Bell) distribution curve than the average
untreated patient. An effect size of 1.0 means
that the population mean of treated persons
is 84 % better than the population mean of
untreated persons. Anything better than .8 is
considered a very good effect size. Erom these
meta-analytic studies, it is becoming clear
that effect sizes of dynamic psychotherapy
are comparable, if not superior to other common types of psychotherapy that are generally considered to have solid evidence for their
efficacy. Eor instance, a meta-analysis of 12
short-term psychodynamic studies showed
effect sizes of .97, (Abbas, Hancock, Henderson, & Kisely, 2006), and a meta-analysis
of 15 studies of the treatment of personality disorders using long-term psychotherapy
(measuring pretreatment and post-treatment
effects) showed an effect size of 1.46. To gain
a comparative perspective of effect sizes, several studies of cognitive behavioral psychotherapy have shown effect sizes ranging from
.58 to .62. An even more telling perspective
is to compare effect sizes when only medication is used to treat depression. Common
antidepressants have effect sizes that range
from of .31 for citalopram (Celexa), .3 for
Cortina
duloxetine (Cymbalta) and .24 for sertraline
(Zoloft) (Shedler, 2009).
Another encouraging article showing
the effectiveness of long-term treatment over
short-term cognitive and dynamic psychotherapies appeared recently in the Journal
of the American Medical Association (Leichsenring & Rabung, 2008). The authors reviewed 11 prospective studies that comprised
1,053 patients, with diagnoses ranging from
borderline, obsessive, and avoidant personality disorders, to eating disorders mixed with
Axis I diagnoses—mainly chronic depression
and anxiety disorders. They compared the
effect of long-term psychoanalytic psychotherapy (a mean of 95 weeks in treatment
and a followup mean at 93 weeks) with a
variety of short-term psychotherapies. There
were 257 patients enrolled in short-term
psychotherapy. The results showed a robust
between-group effect size of 1.8 (with a 96
% confidence level) in long-term treatment
of patients with complex mental disorders.
This means that on average 96% of the patients who received long-term psychotherapy
were better off in comparison to groups in
short-term psychotherapies (p = .002). Subgroup analyses showed that long-term psychotherapy yielded significant large and stable within-group effect sizes across different
complex mental disorders, with effect sizes
ranging from 0.78 to 1.98. Using a randomized controlled clinical trial with follow-up
evaluation 1 and 3 years after termination,
another mainstream article shows sustained
improvements of transference interpretations
when used during treatment over and above
the use of other treatment interventions
(Hoglend et al., 2008). The effectiveness of
3. The existence of internal modelling processes in the brain of humans and other primates has been demonstrated
by the work of Rizollatti, Gállese and their colleagues (Gállese et al., 1996; Rizzolatti et al., 1996) who have shown
that the same prefrontal cortex motor cells that become active when a subject picks up an object are equally active
when the subject observes another living agent picking up the same object. These cells have been named mirror
neurons. In another experiment, a group of neurons in the insula were seen to discharge in two emotional conditions; when the subject felt disgust at a noxioius smell and when the subject viewed a film of a face showing disgust
(Keysers et al., 2003). It is likely that other emotions are activated the same way just by observing them on others
(Gazzaniga, 2008, pp. 177-181).
53
transference interpretations was shown in a
randomized control study with patients diagnosed with borderline personality disorder.
The study showed statistically significant
changes in attachment patterns (as measured
by the Adult Attachment Interview), using a
transference-focused approach to treatment
in comparison with controls (Levy et al.,
2006).
CONCLUSION
Despite the low level of prestige of
psychoanalysis and psychodynamic psychotherapy, the tide is turning. There is solid evidence to support many key premises under-
lying the practice of dynamic psychotherapy
and modest but growing evidence to support
the effectiveness of its treatments. Most postgraduate training of dynamic psychotherapy
is based on small independent training institutes that do not have the resources to teach
research methods and conduct expensive
clinical trials. To train future therapists in
the art and science of dynamic psychotherapy, it is imperative that these independent
institutes make a concerted effort to bridge
the gap between research and practice. This
is a difficult undertaking, but there are some
areas of the country where local institutes
have banded together to pool resources and
showcase some of the most promising types
of research that speak to clinical concerns."*
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