Analytic vs. Dynamic Psychotherapy in the Era of Managed Care

The dynamically informed psychotherapies can be thought to occur on a continuum, with the most insight-oriented and exploratory types at one end and the most supportive types at the other (Goldstein, 1998). Psychoanalysis proper stands at the end of this continuum, followed by analytically oriented psychotherapy, then dynamically oriented psychotherapy. Within this classification, I view analytically oriented psychotherapy and dynamically oriented psychotherapy as two quite distinct, yet related, forms of therapy.

Differentiation between these two types, although not routinely advocated, provides a useful conceptual framework for psychotherapists. This framework is helpful for correlating types of psychotherapy (i.e., analytic versus dynamic) with types of patients (i.e., neurotic versus borderline versus psychotic), and for providing a structure for selection of therapeutic strategies and interventions.

Dynamically informed therapists generally utilize one of these two types of therapy, although they do not necessarily acknowledge this. Although various combinations of the two can be utilized, the pure forms will be described in this article.

The trappings of both analytically oriented psychotherapy and dynamically oriented psychotherapy involve regularly scheduled sessions, usually one to three times a week, held for varying periods of time. The greater the frequency of the sessions, the greater the intensity and continuity. Thus, more (rather than fewer) sessions are often recommended, especially in the analytically oriented modality.

Typically, there is no contact between patient and psychotherapist outside of the appointments. Sessions are conducted with the patient and therapist sitting across from each other in comfortable chairs. Patients are usually told that the sessions are theirs, and that they can talk about whatever they choose. In addition, patients are sometimes encouraged to report seemingly extraneous thoughts and fantasies that may occur during a session. Areas of resistance to such discussion are often mentioned.

Initial Guidelines

Regarding initial guidelines, I recommend a more elaborate version of those mentioned in the last paragraph for all forms of dynamically informed psychotherapy. I spell out specific guidelines, thus establishing a much desired frame for the therapy that can be returned to whenever there is any deviation. Like Gray (1994), I do not present the guidelines as instructions or rules, as I find this is too authoritarian and rigid. It is puzzling to me that although such guidelines are standard for psychoanalysis, few therapists refer to them for psychotherapy. Kernberg (1989) is one clear exception.

A standard psychotherapy presentation that is useful for most patients is as follows: "The sessions are yours, to talk about anything you want. It will be up to you to choose the topics. Often there will be topics on your mind that you very much want to talk about. At times when you do not have topics of pressing importance, it is helpful to talk freely about anything that comes to mind. There are certain thoughts that some people find difficult to talk about and are tempted to omit. I want to urge you to do your best not to omit those types of thoughts. These include thoughts that cause uncomfortable feelings, such as anxiety, anger, embarrassment or shame, ones that you view as silly or irrelevant, ones that you are fearful that I will disapprove of, and any thoughts, positive or negative, that refer to the therapy or to me personally."

Analytically Oriented Therapy

The analytically oriented therapist attempts to conduct the sessions in a manner as similar as possible to psychoanalysis. He tries to maintain some neutrality, relies on clarifications and interpretations as much as possible, and tries to make maximum therapeutic use of the transference. He comments on resistances, tries to correlate the transference with current interactions and significant childhood relationships, and attempts to help patients to gradually understand those aspects of themselves about which they are unaware.

As in psychoanalysis, the therapist looks to the elaboration and working through of the transference to be the principal vehicle for both insight and change. This is analytically oriented psychotherapy in its pure form.

Neutrality

Traditionally, the neutral therapist has acted as anonymously as possible, striving to serve as a "blank screen," to provide a setting conducive for the displacement of the patient's feelings. The maintenance of neutrality was considered most important in those therapies emphasizing the transference.

The concept of neutrality has since become controversial. Many contemporary therapists view it as a theoretical ideal, impossible to attain in actuality. Nevertheless, some favor attempting to approximate this unattainable ideal, while others (e.g., Renik, 1996) view the concept as antiquated, advocating instead the acceptance of the "non-neutral" subjective therapist. Analytically oriented psychotherapy is similar to psychoanalysis regarding neutrality, its emphasis on insight-oriented techniques, and its focus on the establishment and unfolding of the transference. Differences from psychoanalysis include the use of the chair versus the couch, the lesser frequency of sessions, and the relative de-emphasis of free association.

Dynamically Oriented Therapy

The main difference between dynamically oriented psychotherapy and analytically oriented psychotherapy is downplaying transference as a therapeutic modality in the latter. Although transference reactions are noted, especially when they occur as resistances, the elaboration of the transference is not a major ingredient in this form of psychotherapy.

Rather, therapists and patients focus more exclusively on present-day interactions and relationships, and their correlation to the patients' past. Patients and therapists work together to try to understand these present-day interactions on the basis of each patient's sensitivities, vulnerabilities and distortions, which originate in the past. A positive therapeutic alliance is fostered, and therapists are sometimes mildly idealized. Occasional suggestions, education and other supportive techniques are employed, along with the insight-oriented interventions of clarification, confrontation and interpretation. Supportive interventions include suggestion, therapeutic manipulation, abreaction, advice, reassurance, education, limit setting, reality testing, and giving encouragement and praise.

Therapy and the Neurotic Patient

Analytically oriented psychotherapy is the preferred treatment for those patients who can form an intense transference in psychotherapy, and then use that transference constructively without regression. Some healthier (i.e., neurotic) patients can form an intense transference in psychotherapy, but many have difficulty accomplishing this. Psychoanalysis proper (with the use of the couch, free association and the increased number of sessions) is especially designed to help induce an intense (and regressed) transference in neurotic patients. Only psychoanalysis can attain this result for many neurotic individuals, to whom intensity and regression do not come naturally.

When psychoanalysis-for whatever reason-is excluded, one faces the question of which kind of psychotherapy to pursue. There are two contrasting opinions. One opinion favors simulating analysis as much as possible, with an all-out attempt to establish and utilize an intense transference. A second opinion, emphasizing the difficulty in attaining transference regression with neurotic patients in psychotherapy, favors using a dynamically oriented approach. Many therapists lean toward an analytically oriented modality for those neurotic patients (often hysterical in personality type) who can form a somewhat intense transference in psychotherapy. These therapists would employ a dynamically oriented model for other neurotic patients (often more obsessive in personality type) who have greater difficulty regressing.

The Borderline Patient

The typical borderline patient, in contrast to the neurotic, has little difficulty forming an intense and regressed transference in the psychotherapy situation. In fact, the rapid mobilization of transference often distinguishes the borderline individual from the neurotic. Thus, analytically oriented psychotherapy is usually the treatment of choice. The common problem with these patients is in containing the transference regression.

With this in mind, modifications in technique (from the pure form of analytically oriented psychotherapy) are needed. Modifications include continual focus on the working alliance, more supportive interventions and alterations in style (such as more attention to an empathic and affirmative stance, the use of preparatory comments and the use of increased input from the patient). Elaboration of these modifications are described elsewhere (Goldstein, 1996).

The Psychotic Patient

For psychotic patients, to whom intense transferences can be clearly disruptive, the dynamically oriented approach is recommended. With these patients, supportive interventions predominate over insight-oriented ones.

Managed Health Care

When recommending either analytically oriented or dynamically oriented psychotherapy, one must often contemplate a long-term proposal. With managed health care, where duration of treatment is vastly limited, a long-term model rarely fits. Yet this kind of treatment is highly valued and desired by many individuals. Studies (Lazar, 1997; Stevenson and Meares, 1992) demonstrate the clear worth of such therapy and its necessity for certain groups of patients. One answer is to go outside of the managed health care system.

Some individuals are able to pay out-of-pocket; others can find good therapists who will charge lower fees when longer-term therapy is indicated. In the District of Columbia area, I am almost always able to place very motivated patients in a reduced-fee setting with a reasonably experienced therapist; I do not know how easily this can be accomplished in other areas.

Being familiar with the details and nuances of analytically oriented and dynamically oriented psychotherapy is an advantage even to therapists who operate within the managed health care system. Although modifications are often needed, many of the strategies and therapeutic techniques of dynamically informed psychotherapy are applicable to shorter-term work. Additionally, there is an expanding literature on dynamically informed short-term approaches. In my opinion, it behooves the managed health care therapist to learn traditional psychotherapy first, then to supplement this knowledge with that of the shorter-term approaches.

Dr. Goldstein is a teaching analyst and the director of the Adult Psychotherapy Training Program at the Baltimore-Washington Institute for Psychoanalysis, as well as clinical professor of psychiatry at the Georgetown University Medical Center. He has written extensively in professional journals and has published three books: An Introduction to the Borderline Conditions (Jason Aronson 1985), Dynamic Psychotherapy with the Borderline Patient (Jason Aronson 1996), and A Primer for Beginning Psychotherapy (Brunner/Mazel 1998).

References:

References

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Goldstein W (1998), A primer for beginning psychotherapy. Washington, D.C.: Brunner/Mazel.

2.

Goldstein W (1996), Dynamic psychotherapy with borderline patients. Northvale, N.J.: Jason Aronson Inc.

3.

Gray P (1994), The ego and analysis of defense. Northvale, N.J.: Jason Aronson Inc.

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Kernberg OF, Seltzer MA, Koenigsberg H et al. (1989), Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.

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Renik O (1996), The perils of neutrality. Psychoanal Q 65(3)495-517.

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Lazar S, ed. (1997), Extended dynamic psychothera-py: making the case in an era of managed care. Psychoanalytic Inquiry supplement issue.

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Stevenson J, Meares R (1992), An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 149(2):358-362. See comments.