Psychodynamic Therapy Treatments

In psychodynamic concepts, using anxiety to avoid thinking about other distressing situations is referred to be a defense mechanism. This idea can be traced back to Sigmund Freud’s signal theory of anxiety, which argued that defenses are created to keep us from focusing on more difficult, contested, or stressful events or feelings. According to this signal theory, a small quantity of anxiety induced by a prospective hazard “signals” the ego to be aware of the risk. To keep the threat from getting too dangerous, defense systems are activated. The focus of the treatment was on acquiring insight into the potential harm so that the patient might see that it was not as bad as he or she imagined. There’s a remarkable parallel here with acceptance-based treatment: removing the techniques for suppressing emotions leads to a reduction in anxiety.

However, in addition to avoidance, psychodynamic perspectives on stress and anxiety have focused on additional determinants of elevated anxiety levels (protection). While developing theories of anxiety, many psychodynamic theorists focused on the importance of human interpersonal relationships on psychological development.

Horney (1950) proposed that interactions that harm children’s psychological development (e.g., caregivers who are controlling, overly protective, overly punitive, or insensitive) lead to a lack of trust in oneself and others, a sense of loneliness and hopelessness, and “basic anxiety” in the children. Another interpersonal-psychodynamic hypothesis of anxiety proposed by Sullivan (1953) is that anticipating rejection from the primary caregiver at a young age is a factor. Fairbairn (1952) stressed the anxiety-producing conflict between the child’s sense of dependency on the caretaker and a fear of being smothered and losing identity, while Klein (1975) linked anxiety to the child’s worry of being unable to evoke the caretaker when needed. All of these models have instilled self-and other perceptions that are aroused later in life, influencing ongoing interpersonal connections and causing anxiety. It’s uncertain whether this generalized anxiety correlates to the current DSM-IV GAD diagnosis.

Despite this, our early perspectives informed the development of a brief, focal psychodynamic-interpersonal therapy for generalized anxiety disorder. According to Roemer and Orsillo, Borkovec (1999) has recently added strategies for changing interpersonal issues into CBT for GAD (current issue).

Anxiety can be treated with supportive-expressive psychodynamic therapy. The case for establishing a relations-oriented psychodynamic treatment for Generalized Anxiety Disorder (GAD) arises not only from the historical significance of psychodynamic groups in anxiety but also from fresh empirical findings tying interpersonal components to GAD. For example, Borkovec, Robinson, Pruzinsky, and De Pree (1983) discovered that anxiety was linked to increased interpersonal difficulties. Using retrospective recall techniques, Lichtenstein and Cassidy (1991) discovered that GAD participants reported significantly more attachment troubles with primary caregivers than non-GAD respondents. GAD patients reported higher levels of entanglement and role reversal (i.e., the child taking on parental responsibilities), as well as more preoccupying anger and shifting feelings toward the caregiver. Furthermore, GAD patients experienced more rejection as children than non-GAD patients.

We hypothesize that a set of dangerous or distressing interpersonal experiences results in a set of fundamental wishes/desires, anticipations, belief systems, and thoughts about oneself and other people, based on historical psychodynamic literary works on defenses and early developmental factors in anxiety, as well as recent research on worry as avoidance and interpersonal factors in GAD. These wishes/desires are usually driven by fears of desertion, violence, disappointment, or criticism from others and include getting affection, consistency, or care from others. The anxiety connected with these interpersonal goals and beliefs is so strong that the person with GAD avoids thinking about the wishes, memories, and feelings that led to the worries. To prevent these cravings, sensations, and recollections, one method is to become overly cognitively engaged (worried) with current events. The SE model, in contrast to traditional psychoanalysis, does not limit GAD formation to early childhood events. Interpersonal catastrophes and pressures can strike at any age, but a long period of insecure attachment throughout childhood is more likely to result in unrealistic expectations of others that last far into adulthood.

The set of interpersonal wants, desires, belief systems, and emotions becomes a component of cyclical feedback systems after it has been created, repeating the imagined situations that initially triggered anxiety. The SE model formalizes the core conflictual relationship theme’s (CCRT) cyclical, recurrent relationship patterns, which are made up of three elements: the wish or desire, the apparent or anticipated reaction from the other person, and the self-response. The counselor’s major expressive (exploratory) role in SE treatment is to create a CCRT for each patient and use it to guide therapies. The therapist’s primary support role in SE treatment is to establish and maintain a good therapeutic alliance.

GAD anxiety, according to this theory, can be caused by a variety of factors. The most basic is a persistent fear of not achieving what one desires in relationships. The concern component of anxiety is regarded to be a defensive response, as previously noted. Other anxiety symptoms, such as physical symptoms, can also be a defense mechanism (i.e., focus on bodily symptoms as a way of avoiding emotions). Personal circumstances might sometimes add “realistic” fear to the mix of worries and defenses carried over from past relationships.

To summarize, today’s prevalent SE model resembles Roemer and Orsillo’s comprehensive acceptance-based approach in certain ways. Among these is the concept of worry as a type of avoidance (defense). As previously stated, CBT has a strong emphasis on interpersonal patterns, which is an important part of SE treatment (Borkovec, 1999). Such interpersonal patterns are not included in the therapeutic focus of the Roemer and Orsillo models, indicating a significant departure from the models.

What are the treatment differences between an integrated CBT package that focuses on both cognitive avoidance and interpersonal problems and the brief, focal SE psychodynamic treatment? Assuming that an interpersonal component is included in the Roemer and Orsillo (this issue) model, or that it could easily be added using Borkovec’s alteration of CBT for GAD, what are the treatment differences between an integrated CBT package that focuses on both cognitive avoidance and interpersonal problems and the brief, focal SE psychodynamic treatment? The distinctions boil down to a question of attention for the most part.

Only a small amount of time can be devoted to interpersonal issues within the confines of a brief (e.g., twelve to twenty session) CBT treatment, which may also include setting a session agenda, teaching relaxation skills, monitoring automatic thoughts, examining evidence for the patient’s beliefs, generating various interpretations, and other CBT and acceptance-oriented methods. The idea in traditional psychodynamic therapy, and particularly this specific type of SE therapy, is that patients will need a lot of therapy session time to recollect their interpersonal encounters in-depth memories, feelings, and thoughts of what happened. The therapist remains relatively engaged within a brief treatment paradigm and supports the elicitation of specific narratives surrounding interpersonal encounters, but the unfolding of this information is regarded to be most beneficial when done at the patient’s pace. SE therapy, on the other hand, is less structured than CBT.

SE therapists, on the other hand, are less directive than CBT therapists. Traditional psychoanalysis would almost entirely eschew directive tactics for fear of complicating the therapeutic connection and making it more difficult to distinguish between patient transference reactions to the therapist and an established authority figure position. SE treatment is more open to incorporating directed methods and avoids the “blank screen” stereotype associated with psychoanalysis. However, some patients may not see therapy as a place to discuss their recurring interpersonal challenges that are causing distress after being trained in several different skills (e.g., relaxation treatment, monitoring techniques, meditation exercises, and problem-solving strategies) and a substantial amount of psycho-educational material over time. This concern can be mitigated by achieving a balance between didactic and skill-building components, as well as interpersonal content expression and conversation.