I have finally found a book about psychodynamic psychotherapy that I actually understand: Individual Psychotherapy and the Science of Psychodynamics by David Malan.

(I’m only on page 54 of 255 pages, so there is plenty of time for my comprehension to fizzle away.)

I am reading the first edition of the text (from 1979; the second edition came out in 1995!); I’d like to purchase my own copy so I can scribble stuff on the pages. This is in contrast to the other psychodynamic books I have tried to read, where I don’t understand the language enough to write anything meaningful on the pages (except for question marks).

It’s not that I have developed a new fondness for psychodynamic psychotherapy (which is related to Freud’s psychoanalytic psychotherapy—you know, with the couch and whatnot)—how could I, when the writings in this field made little, if any, sense to me? As I progress in my residency training, however, I have wondered more and more about the theory and approaches of psychodynamics—I want to be comfortable and familiar with this model as another way to understand human behavior.

And, truth be told, some of the best behaviorists and not-psychodynamic psychiatrists (who hold strong opinions against the practice of psychoanalysis) use psychodynamic theory to inform their own practices. Although all forms of therapy look “deeper” into human behavior (e.g. what thoughts resulted in that behavior? what function does that behavior serve? what other meanings could that statement have?), psychodynamic psychotherapy, by its very nature (”dynamics”), compels people to consider more covert possibilities to explain thoughts and behaviors. (This, however, is also my novice opinion, since I currently have very little theoretical or practical experience with this branch of therapy. It’s a coastal thing.)

Early in his text (page 15), Malan introduces the idea of the “triangle of conflict” as an important tenet in psychodynamics:

One of the main tasks of the psychotherapist is therefore to analyse in his own mind, and then to interpret to the patient, the end-product of these mechanisms, in terms of (a) the devices adopted for avoiding mental pain, conflict, or unacceptable feelings (the defence [sic–the guy is British]); (b) the feared consequences of expressing these hidden feelings (the anxiety); and (c) the nature of the hidden feelings themselves.

For example, according to this theory, someone may complain of feeling anxious (b), particularly around bakeries (I can relate cookies to everything). As a result, this person may make a point of avoiding bakeries and all places that sell confections—maybe he can’t even really talk about cookies or look at images of cookies in magazines or on the internet (a). He rarely goes to restaurants because of the severe discomfort he feels upon seeing cookies. This avoidance is interfering with his relationships; his friends don’t understand why he refuses to socialize—”what is so wrong with bakeries?”—and he doesn’t have much time to do anything but work (because he walks an extra three miles to avoid walking past coffee shops, bakeries, and restaurants on his way to and from work). What is the underlying cause of this behavior (the only thing we can quantify)? Perhaps it is because he lost his virginity in a bakery at the age of 13—except he lost it to his older sister. (Just work with me.) At that age, he knew about the prohibitions about intercourse within the family—this event disgusted him… and he liked it. Thus, this disgust and pleasure are the hidden feelings (c) that he cannot express.

The idea, then, is that upon discussing this situation and facilitating a space where the patient can reveal his hidden feelings (with the assistance of interpretations from the therapist—because, remember, the patient cannot initiate this discussion himself), the patient becomes aware (or gains insight) into his symptoms and their cause, thereby alleviating his anxiety and eliminating the need of defenses.

I can see how that makes sense. We’ve all felt better after sharing our mental and emotional burdens with other people. Talking things over can be therapeutic.

Psychodynamics, however, is not amenable to evidence-based practice. After all, how can we measure “hidden feelings”? Is there a way for us to design experiments where we can demonstrate with laboratory instruments (or questionnaires) that it is the actual discussion of hidden feelings (rather than cookies or sexual relations with different people or avoidance) that results in symptom relief? How do we know that interpretations actually facilitate the clarification of “hidden feelings”? Perhaps the “hidden feelings” would have come up themselves without the use of interpretations. Or, perhaps there is some subtle hypnosis (again, just work with me) occurring that induces the patient to agree with the therapist’s interpretations—loss of patient autonomy, if you will.

This lack of evidence is what causes a lot of people to regard psychodynamics with skepticism—particularly given the usual time course of therapy (years!). Other therapies (such as CBT, DBT, and CBASP) have more measurable outcomes because these therapies incorporate definite goals: “I want to stop cutting.” “I want to take plane rides without freaking out.” “I want to feel less anxious.” (There are validated questionnaires that can quantify anxiety, depression, etc.) These therapies also don’t focus on the “why” of symptoms (though they do not ignore possible reasons); they focus more on increasing function or reducing symptoms in measurable ways.

Psychodynamics, as demonstrated above, attempts to address the “why” of things.

(Tangent: A study recently came out that demonstrated the efficacy of psychodynamic therapy for the treatment of panic disorder. This is big news because there is very, very little data to support the utility of psychodynamic psychotherapy. There are several flaws with the study, but it is a data point for psychodynamics. You can read the New York Times article here or the original study here.)

Although I don’t foresee myself ever becoming an analyst, I still want to add psychodynamic skills into my repertoire to further improve my delivery of patient care. I have already incorporated the “triangle of conflict” model into my skill set to help formulate patients—and, if for nothing else, it has helped me to think more deeply and carefully about the manifestations, functions, and consequences of human behavior.