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The Psychodynamic Paradigm: Depth Psychology

Natural science combines two worlds, the physical and the psychic. Psycholog}' does this only in so far as it is psychophysiolog}'.

—C. G. Jung

Critiques of psychoanalysis and reformulations of psychodynamic thought have brought about major shifts in theoretical perspectives, empirical research, and therapeutic practice over the last three decades. The growing emphasis on interdisciplinary study, bridging work in science and the humanities, continues to enlarge the scope of understanding. Emerging perspectives have been shaped by empirical findings in the fields of genetics, evolutionary biology, neuroscience, cognitive psycholog}', experimental psycholog}’, developmental psycholog}', personality psychology, social psychology, and cultural anthropolog}'. Some scholars think of psychoanalysis as a science of mind; others view it as an interpretive or hermeneutic discipline. Thinkers have increasingly centered on conceptions of self, relationship, and social life in their reformulations of theory, emphasizing the multiplicity and complexity of human experience. Research findings across the fields of neuroscience and developmental psycholog}' provide strong support for the core propositions of psychodynamic understanding, emphasizing the crucial role of attachment and relational life in the development of the self and the dynamics of unconscious emotional and cognitive processes (Fonagy, Gergely, Jurist & Target, 2018; Glass, 2008; Kandel, 2018; Luborsky & Barrett, 2006; Schore, 2019a, 2019b; Solms, 2018a, 2018b; Westen, 1998, 2005).

Clinical scholars have identified core processes and techniques that distinguish psychodynamic psychotherapy from other forms of therapy explored in the following chapters. Matthew Blagys and Mark Hilsenroth carried out an analysis of empirical studies in the PsychLit database, reviewing session recordings and transcripts, and described the defining features of psychodynamic therapy as follows: 1) focus on emotion and expression of feelings; 2) exploration of attempts to avoid distressing feelings and thoughts; 3) identification of recurring themes and patterns in feelings, thoughts, actions, and relationships; 4) exploration of past experiences in light of current concerns and problems in living; 5) focus on interpersonal experiences; 6) emphasis on the therapeutic relationship and the dynamics of interactive experience; and 7) exploration of subjective experience (Blagys & Hilsenroth, 2000). A group of experienced clinicians corroborated these findings in constructing a prototype of the ideal version of psychodynamic psychotherapy (Shedler, 2010; Solms, 2018b).

In the domain of clinical research, outcome studies continue to document the efficacy and effectiveness of psychodynamic psychotherapy. In an influential review of meta-analyses representing the most rigorous evaluations of psycho-dynamically oriented therapy, Jonathan Shedler reported that the effect sizes are as large as those found for other forms of intervention widely regarded as “empirically supported’’ and “evidence-based” (2010, p. 98). As he details in his account, randomized controlled trials support the efficacy of psychodynamic therapy for a range of conditions, including depression, personality disorders, post-traumatic stress disorder, anxiety and panic disorders, eating disorders, and substance-related disorders (see Blatt, Zuroff & Hawley, 2009; Fonagy, Roth & Higgitt, 2005; Gibbons, Crits-Christoph & Hearon, 2008; Leichsenring, 2009; Leichsenring & Rabung, 2009; Westen, Novotny & Thompson-Brenner, 2004). Further, follow-up studies indicate that patients who receive psychodynamic therapy not only maintain gains over time but continue to improve after treatment ends, whereas the benefits of other forms of therapy tend to decay over time. Recent meta-analyses provide additional support for these findings, showing consistent trends toward larger effect sizes at follow-up, suggesting that psychodynamic approaches engage core processes that continue to foster change and growth after the end of therapy (Solms, 2018b). Clinicians continue to integrate ideas and methods from other paradigms of psychotherapy in their efforts to broaden the scope of practice, engage a more diverse range of patients, strengthen the empirical foundations of therapeutic action, and improve the outcomes of help and care.

Even so, we find surprisingly little consideration of psychodynamic theory, research, or practice methods in advanced training programs across the fields of psychiatry’, psychology, social work, and counseling. Many’ researchers, educators, and practitioners continue to reject psychodynamic perspectives in view of perceived conflicts with scientific conceptions of psychotherapy and the growing emphasis on technical procedures in evidence-based practice. Some clinical scholars have little knowledge of recent developments in psychodynamic theory' and research, and their critiques of the psychoanalytic paradigm fail to reflect the range of empirical findings, relational approaches, social and cultural perspectives, and pragmatic concerns that have shaped contemporary understanding and practice. Widespread ignorance and neglect of research findings corroborating the basic propositions of psychodynamic theory, and the evidence generated by process and outcome research on psychodynamic psychotherapy continues to perpetuate these unfortunate gaps in understanding (Borden, 2009; Borden & Clark, 2012; Shedler, 2006, 2010, 2015; Solms, 2018a, 2018b; Weinberg & Westen, 2001; Westen, 1998, 2005; Westen & Gabbard, 2002a, 2002b).

The Psychodynamic Paradigm: 1 73

Toward the end of the 20th century clinical scholars had come to distinguish two fundamental perspectives in their accounts of psychodynamic thought: the drive paradigm, based on Sigmund Freud’s classical instinct theory, and the relational paradigm, which centers on the fundamental role of attachment, relationship, and social life in human experience (Greenberg & Mitchell, 1983). Although relational perspectives have shaped contemporary’ understanding and practice, the first generation of psychoanalytic thinkers continues to provide crucial points of reference across the broader psychodynamic tradition. As a starting point, accordingly, I explore the depth psychology of Freud and C. G. Jung, outlining the development of their thought and concepts of therapeutic action. I show how they prefigure recent developments in the science of mind and introduce pragmatic principles of clinical practice. I review the emergence of the relational paradigm and concepts of therapeutic action that shape contemporary’ understanding and practice in Chapter 5.

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