Defending and demonstrating the psychodynamic orientation in psychiatry

Psychoanalytic theory and practice are arguably much less central and influential in psychiatric practice today than at the height of their influence in the mid-20th century, when many leaders and influential institutions were simultaneously psychoanalytic and psychiatric. Yet, where would we be today, as training and practicing psychiatrists, without a psychodynamic orientation to our work? When we treat our patients, we attempt to understand their issues and problems, develop helpful and healing relationships with them, communicate with them and sometimes other treaters and carers, all the while reflecting on the position we hold as the treater, and the role we are playing in a certain context, whether this is in a clinic or institution. The more reflective and insightful we are about the treatment situation, the more effective we can be. We rely on models of understanding, and as medical specialists we are influenced strongly by Engel’s (1977) biopsychosocial model, along with the psychodynamic orientation, which I would argue is a fruitful legacy of the influence of psychoanalysis upon the formation of modern psychiatry through the 20th century, as diffuse and complex as this influence may be.

Elaborating upon the psychodynamic orientation, we can draw reference to a group of basic assumptions:

• That the individual’s past continues to have an active part to play in ongoing adaptation, maturational development and biopsychosocial functioning throughout life.

• That experiences can lead to significant impact, as key life events or traumata, that affect emotional development, the development of personality or a sense of self, and may remain unresolved for the individual and lead to conflicts and defensive positions in their interpersonal functioning that repeat in their present-day life.

• That the mind or psyche is structured in a way that many aspects of the individual’s sense of self and way of relating to others is unconscious or not in the person’s conscious awareness. This includes the person’s patterns of relating to others, experiencing emotions and experiencing themselves.

• That every individual attempts to understand their relationships, themselves, their past and their broader existence in many ways, through memories, narratives and beliefs, and that these can be explored and discussed in a clinical situation.

• That clinical problems in psychiatry can often be an interplay between biological, psychological and social factors and that the psychodynamic approach can assist in understanding and formulating the interplay of these factors.

• That conflicts, defensive positions and distortions in the individual’s psychological functioning are amenable to clinical exploration and intervention by engaging the individual in therapeutic dialogue and relationship.

As such, a psychodynamic approach to clinical work involves the clinician paying attention to a range of issues when he or she sees a patient (see Shedler, 2010: 99–100). This includes an exploration of the person’s developmental history and the identification of recurring themes and patterns in the individual’s narrative accounts of past experiences. It involves a focus on affect, emotional expression and the person’s inner life (wishes and fantasies). It also involves a focus on the relationships in the individual’s life, both inside the room with the clinician, and outside, past and present. And finally, it involves the exploration of any attempts to avoid distressing thoughts and feelings.

When training psychiatrists learn about psychodynamics, there may be some trepidation and ambivalence. In Australia and New Zealand, trainees undertake a ‘long case’, where they deliver a weekly psychodynamic psychotherapy treatment for nearly a year, fitting this in alongside their regular training role. These training psychiatrists might have negative perceptions or feelings about this: the complexity and depth of the work, the peripheral or obscure place it seems to hold in relation to their broader training role, the seemingly antiquated or esoteric body of theory with which they are confronted. But these trainees might also welcome the opportunity to be more reflective, in-depth and relational in their treatment, undertaking a process of experiential learning supported by an experienced supervisor. They will learn ways to reflect on their own emotional responses to their patient (countertransference), the patterns of emotional relating that govern that patient’s life, both in the treating room (transference) and in that patient’s present-day life, all the while informed by an in-depth exploration of the patient’s developmental history.

This therapeutic process will open up a myriad of perspectives used to understand the patient’s problems or issues: the unresolved traumas and conflicts the patient continues to suffer from day to day, as well as the psychological defences the patient has characteristically developed to adapt emotionally and relationally. And most importantly, the training psychiatrist will understand and experience how the therapeutic process helps the patient to work through their issues. The patient will begin to change as a person and develop insight about their issues. It is not uncommon for training psychiatrists to undertake their own personal psychotherapy treatment in parallel, to better understand themselves, work on their own personal issues and problems, and understand how these impact their clinical work.

The trepidation trainees might feel about their long case experience has parallels with perceptions that practicing and academic psychiatrists might have in relation to their psychoanalytic psychotherapist colleagues. The work of these colleagues might be seen as antiquated or peripheral, too caught up in complexity, obscurity and esotericism, or somehow non-targeted, open-ended, unsubstantiated or even a purposeless cultivation of dependence.

And yet we are aware that the psychodynamic orientation exists in psychiatry on a continuum, moving from the general principles and approaches outlined above towards more specialised forms of training, research and practice, including a particular school of thought (e.g. Self Psychology); an emerging integrative theory based on new empirical research (e.g. Attachment Theory); a manualised practice or application (e.g. Mentalisation-Based Treatment); a hybrid model (e.g. Cognitive Analytic Therapy); or a certain psychotherapeutic institution (e.g. The Personality Disorders Institute, Weill-Cornell Medical College, New York).

We are also aware that the psychodynamic orientation, for psychiatrists, will always coexist with the biopsychosocial model, both of which are ineliminable in psychiatric practice: if we practice as a psychiatrist we cannot escape the medical specialist roles we are entrusted to perform, nor can we escape the necessity to consider the broader biological and social elements that impact our assessments and treatments beyond purely psychodynamically informed formulation and therapy. The interrelationships between these approaches, when applied to clinical practice, can be rich, complex and cohesive, or potentially messy and fraught with tensions.

Consider how a biopsychosocial orientation might assume a positivistic and empirical stance to evidence-based practice, at the same time upholding a certain treatment attitude as a medical expert in the hospital or clinic. Here, the psychiatrist may assume more biomedical orientation to prescribing and administering treatments like medications and neurostimulation to alleviate symptoms and resolve illness episodes. This orientation will attempt to reconcile this treatment orientation with a more holistic formulation of the interplay of biological, psychological and social factors that is recovery-oriented, trauma-informed, integrative and promoting of a broader well-being. Practice, here, might involve team leadership or consultation rather than an ongoing treatment relationship per se.

Then consider alongside this, how the psychodynamic orientation might place more of a focus upon the complexity, uniqueness and specificity of each case (the idiographic approach); the interpretation of the meaning of symptoms, behaviours and spoken narratives (hermeneutics); as well as a focus on the developmental issues and relationship dynamics at play. Psychodynamic thinking may focus on contributing factors including developmental psychopathology, complex trauma and personality disorder, alongside the use of the interactions with the patient, paying attention to the treatment relationship and setting as the key therapeutic ingredients. It will promote the clinician’s own reflective practice incorporating self-understanding so that clinicians think about why they do the work they do, what their blind spots are and where their fallibilities are found, and how they work in a team.

Difficulties in incorporating or appreciating these differing but complementary perspectives seemed evident in the content of the recent RANZCP Mood Disorder Clinical Practice Guideline (CPG, Malhi et al., 2021). When the psychodynamic orientation is mentioned in the CPG, a positive and accurate focus is placed on the evidence and role for manualised forms of Short Term Psychodynamic Psychotherapy. However, there is arguably an underemphasis on the role of psychodynamic case formulation and techniques in clinical practice, and a negative focus is placed on psychodynamic treatments more broadly, where clinicians are encouraged ‘to remain skeptical about the evidence base generally’, with cautions about ‘suboptimal occasions of care’ where ‘not all depressive presentations benefit from this therapeutic approach’ (pp. 42–44). These types of cautions could be applied to all of the other treatment modalities covered in the CPG, but the stronger negative focus on psychodynamic approaches clearly reflects a more suspicious and critical attitude to psychodynamic approaches. In Box 14, page 44, on treatments of ‘acute depression’, Malhi et al. (2021) offer ‘there is no evidence to support open-ended or long term psychodynamic psychotherapy’. While it could be claimed this is an accurate statement regarding applications in ‘acute depression’ (if this has, indeed, been defined clearly), it is inappropriate to include evaluation of a long-term treatment in an acute treatment section and adds to a critical and arguably biased portrayal of psychodynamic treatments in general. The authors ultimately seem more comfortable introducing a novel conceptual model of mood disorders, the ACE Model, even though this model is not currently utilised by the psychiatric community, rather than attempt to adopt and conceptualise the broader biopsychosocial and psychodynamic orientations described here, which have been foundational and well-established approaches in psychiatry for decades.

Some responses to the Guideline have been critical and impassioned (e.g. Anaf et al., 2021; Leichsenring et al., 2021). Leichsenring et al. (2021) comprehensively rebut ‘factual errors’ in the CPG in its discussion of evidence for different types of psychodynamic psychotherapy, and its misrepresentation or oversimplification of regression and insight formation in psychodynamic treatments. Anaf et al. (2021) offer related criticisms and express concerns about the processes that led to the CPG’s creation, emphasising the negative implications the CPG could have for clinical practice in Australia and New Zealand.

In some ways, one of the strongest responses to the Guideline could be to remind ourselves of the centrality and utility of the psychodynamic orientation to psychiatry, something which, I would argue, Harari and Grant (2022) do admirably well in this edition. Harari and Grant (2022), both seniors in the field, offer a well-articulated and sophisticated description of the utility and richness of psychodynamic thinking, both looking forward and back, integrating a wealth of ideas from the past century with an ever-evolving field of contemporary psychodynamic research and practice. They focus on a number of key themes in the psychodynamic orientation:

• An empirical basis, both in outcomes research, and through its incorporation of findings in novel biological and other empirical research leading to novel fields like neuropsychoanalysis and affective neuroscience.

• A focus on the development of selfhood and subjectivity and psychopathological variants that can help us to understand frank disturbances with personality functioning, depression, aggression and sexuality.

• A focus on developmental trauma and trauma transmission, where traumatic attachment, childhood trauma and intergenerational trauma lead to significant psychopathologies and relational disturbances.

• A focus on the treatment context (the relationships and settings in which treatment is provided, the training of staff) where psychodynamic understanding acts as a holding environment for the patient.

Ultimately, Harari and Grant (2022) simultaneously defend and demonstrate psychodynamic thinking through this form of integrative research article. They interpret and find meaning in contemporary empirical research (which is rich, well developed and justifies psychodynamic approaches). They discuss how to apply psychodynamic thinking in practical ways, demonstrating the importance of keeping up to date, by being active, attentive and reflective about the field. I would encourage readers to pay close attention to what Harari and Grant (2022) have covered, and how they have discussed it. As we know, most psychiatrists aren’t psychoanalysts or psychoanalytic therapists, but most psychiatrists do appreciate the foundational tenets of the psychodynamic orientation, and use these to maintain and augment their practice in a variety of ways, often accessing supervision and sometimes their own treatment. A good psychiatrist knows what is helpful and relevant and is drawn to what is sophisticated and innovative in theory and research, always with a view to enhancing their clinical work. It is for these reasons that the psychodynamic orientation will remain relevant for all psychiatrists, and will continue to adapt and evolve, incorporating innovations, appraising developments, while maintaining standards and earlier discoveries that remain relevant moving forward into the future.