Mauricio Cortina *

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EL ARTICULO EXPLICA EXPONE LOS FUNDAMENTOS CIENTIFICOS DE LA PSICOTERPIA DINAMICA

EL FUTURO DE LA PSICOTERAPIA DINAMICA

*Mauricio Cortina
describe para SIIC los aspectos relevantes de su trabajo
THE FUTURE OF PSYCHODYNAMIC PSYCHOTHERAPY
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*Washinton School Of Psychiatry, Washington D.c., Estados Unidos
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The Future of Psychodynamic Psychotherapy




Mauricio Cortina M.D
Director, Attachment and Human Development Center, Washington School of Psychiatry, Faculty, Institute of Contemporary Psychotherapy and Psychoanalysis, Washington D.C.
























Abstract


The article reviews the current state and future of psychodynamic psychotherapies. In the past few decades psychodynamic psychotherapies have fallen into disrepute due to the fractious and dogmatic nature of different psychodynamic schools of thought, and the lack of interest in validating some of its major premises or its effectiveness in comparison with other psychotherapy modalities. Despite these self-inflicted wounds, psychodynamic theory and treatment is staging a comeback. In the past few decades many of the major premises that comprise the complex, layered model of the mind that are the basis of psychodynamic treatments have begun to be validated. A list of basic psychodynamic concepts is described. The evidence for each of these concepts varies, but as a whole the evidence is broad and deep for the model of the mind posited by psychoanalysis. This evidence is coming from many fields of knowledge that are not necessarily influenced by psychoanalysis. There have also been significant advances in developing methods and tools that can probe systematically into the complex nature of psychodynamic treatment processes. Finally statistical tools, such as meta-analytic studies, that can aggregate and compare many different studies at once, are beginning to show the effectiveness of dynamic psychotherapies in comparison with other modalities of treatment.






Introduction

Psychodynamic psychotherapy finds itself in an ironic situation. The prestige and influence of psychoanalysis and dynamic psychotherapy have been at an all time low for the past few decades. Yet, at the very moment when the prestige of psychoanalysis is so low, there has been accumulating evidence coming from many fields that support the complex, layered model of mind posited by psychoanalytic theories. Another important development over the past decade that has been less noticed is the gradual accumulation of empirical evidence that supports the effectiveness of dynamic psychotherapies.

The Decline of Psychoanalysis
From its heyday in the decade of the 1940’s and 1950s the prestige of psychoanalysis has suffered a precipitous decline. Perhaps one of the most telling indications of this decline is reflected in the dramatic drop in sales of psychoanalytic books in the United States (the following data if taken from chapter 2 of Stepansky, 2009). Books such as Erich Fromm’s (1941) Escape from Freedom, The Art of Loving (1956) sold millions of copies in English alone. Erik Erikson’s (1950) Childhood and Society sold over a million copies. Even books geared to a more professional audience, such as Otto Fenichel's (1945) Psychoanalytic Theory of Neurosis sold over 80,000 copies. Although sale numbers are lost, it is likely that Charles Brenner’s An Elementary Textbook of Psychoanalysis (1955) might have sold 1,000,000 copies in its paperback edition. The paper back edition of Sullivan's Interpersonal Theory of Psychiatry (1953) sold over 96,000. The last major success of the "glory era" was David Shapiro's Neurotic Styles (1965) sold 250,000 copies in its paperback edition. Kohut’s Analysis of the Self (1971) sold 42,000 copies. The next generation of best-selling psychoanalytic books such as Jay Greenberg’s and Stephen Mitchell’s (1983) Object Relations in Psychoanalytic Theory sold 49,500 or Christopher Bollas’ The Shadow of the Object: Psychoanalysis of the Unthought Known (Bollas, 1987) sold 16,00 copies. When we get into the 90s the best selling professional book was Nancy McWilliams' (1994) Psychoanalytic Diagnosis, with 54,000 copies. There are a few other books that sold over 20,000 copies and approximately 13 titles sold a little over 10,000 copies in the last 25 years. During the last decade a "best-selling" psychoanalytic book is selling 1,500 to 3,000 copies, while in the last few years the average competent and well written books is selling lass than 500 copies According to Stepansky the era a big sales for psychoanalytic books is over and average, competent, psychoanalytic books are no longer profitable enough to keep small publishing companies afloat.
The word is out that Freud was wrong about everything he wrote and that there is no scientific backing for any of his discoveries . Freud was indeed wrong about many issues, but perhaps more importantly the science of his day was woefully inadequate to provide the evidence he needed. A great deal has changed in the past 100 years and armed with more sophisticated methods and tools and several key conceptual revisions, evidence is rapidly accumulating to support many psychoanalytic concepts (see below). Many contemporary discoveries such as the mirror neuron system (Gallese, 2006; Gallese, Fadiga, Fogassi, & Rizzolatti, 1996; Rizzolatti, Fadiga, Gallese, & Fogassi, 1996) or the mapping of the emotional circuitry of the brain (Panksepp, 1998) go a long way to explain the neurobiological mechanisms that make the psycotherapuetic dialogue possible. We are no longer limited to the type of mechanistic models of science that Freud had to draw from to support his theories. Contemporary models of the mind and of psychiatric disorder such as the one proposed distinguished geneticist Kenneth Kendler (2008) –that involves complex interactions taking place at multiple levels (molecules to mind) that iteratively involve environmental factors – are broadly consistent contemporary models of mind that proposed by contemporary psychoanalysts(Mitchell, 1988). Another sample is the work of Nobel prize winner and psychiatrists Eric Kandel, whose seminal work on memory and his views on the working of the mind embrace basic psychoanalytic concepts (Kandel, 2006).
Many of the troubles of the psychodynamic tradition have been self inflicted. With a few exceptions there have been very few attempts to operationalize and test basic psychoanalytic concepts. One of these notable exceptions is Bowlby’s effort to test psychoanalytic theories having to do with nature of the infants bond to his mother, the phenomena of separation anxiety and the effects of loss (Bowlby, 1969/1982, 1973, 1980),
The failure to test its theories and to form alliances with potential allies within academia, has further marginalized psychoanalysis from the mainstream. An exception to a generally antagonistic attitude toward psychoanalysis are some English departments. Here Freud and psychoanalysis have survived by becoming transformed into a postmodern-deconstructive philosophy that has very little to do with the real world and is completely opaque but for the initiated. Freud would not have been happy with this legacy.
At best we have developed a tolerant attitude toward different schools of thought, having reached the conclusion that no brand of psychoanalysis is complete or true and many schools of thought have contributed to the richness of psychoanalytic concepts. Many institutions that teach psychoanalytic psychotherapy have come to value this openness to different ideas and expose students to a variety of schools of thought. While there is much to commend this position, certainly better than the type of dogmatism that was prevalent during the heyday of psychoanalysis, it leaves much to be desired from a scientific point of view. Perhaps the most important shortcoming is that this new attitude of tolerance is often taken to mean that all psychoanalytic theories are equally valid, and it is a matter or personal taste or style which theory we prefer to use. This leaves the psychoanalytic field fragmented and without and clear strategy to move forward. Theoretical fragmentation and postmodern relativism flies in the face of any attempt to advance psychodynamic theory as a science. Some earlier attempts of comparative psychoanalysis such as Greenberg and Mitchell’s (1983) Object Relations in Psychoanalytic Theory where important steps forward. More recent systematic attempts of comparative psychoanalytic theories are being conducted by the European Psychoanalytic Federation Working Group in Comparative Clinical Methods. This group is engaged in a more systematic effort of identifying and defining core concepts that are compatible with a variety of theories and techniques (Tuckett, et al., 2008). This is daunting task. Psychoanalytic theory has evolved over the course of 100 years and is rich and complex and some of the ideas are not compatible with each other (Stepansky, 2009). What is needed is an ongoing effort to define and operationalize basic psychoanalytic concepts that have withstood the test of time. Without vigorously and systematically engaging in these tasks, we simply cannot claim that we are offering treatments that are based on evidence. Not only is a laisser-faire attitude toward clinical and extra clinical validation unacceptable, but from a public relations standpoint it is a disaster.
To address these issues in new generations of psychotherapists we have to start from within, and change a mind set toward research and empirical findings. Bornstein (2005) and Luyten (2008) provide a road map on how bridge the gap between clinicians and researchers. According to these authors researchers and clinicians belong to two different cultures and approach clinical work with different assumptions. Psychodynamic clinicians generally have a skeptic if not outright hostile attitude toward empirical research and doubt that scientific findings might be helpful (Hoffman, 2009). What is to be gained by trying to live up to the standards of evidence that are foreign to the field? The prevailing view seems to be content with avoiding holy wars so that we can have a dialogue among clinicians that might inspire, or shed some light on the intricacies of clinical work. Researchers are interested in being able to generalize findings and insights that emerge form individual case presentations and find the elements in common that may account for the effectiveness of any given approach with different clinical populations. This is a very tall order and the methodological challenges are enormous. But in the past few decades there have been significant advances. There are now many fine examples of qualitative research methodologies that do justice to the complexity of clinical work, yet are able to approach research systematically with sophisticated information gathering and statistical tools (Levy & Ablon, 2009). These new advances make psychodynamic clinicians attitude toward the science of our craft even more unfortunate and self defeating.
Regrettably these attitudes, to large extent, reflect the way we teach psychodynamic psychotherapy. I will mention three important areas were I think we have fallen short. 1) We have failed to bring in findings from other fields that support the model of the mind on which our work is based. 2) We have failed to show how scientific methods can be tailored to capture some of the complexity of our work. This failure reflects a larger problem. Research and empirical articles are published in journals that clinicians don’t read and are written in a technical language that is only understood by other researchers familiar with the intricacies of data gathering and statistical methods (Luyten, et al., 2008). 3). We have failed in making the point that clinical work based on single case studies (the usual method for teaching psychotherapy) and clinical research that tries to generalize beyond single cases are complementary ways of knowing (Borckardt, et al., 2008). Both methods enrich our understanding. This raises the question of how to begin to close the gap between the art and science of psychotherapy. A good staring point to address some of the issues is to make a list of basic concepts used in psychodynamic psychotherapies and see what kind of evidence exsists to support these basic concepts

Basic Psychoanalytic concepts

The following is a list of basic psychoanalytic concepts modified from Jonathan Schedler’s excellent article (2009) The Efficacy of Dynamic Psychotherapy.

1. Unconscious processes and motivation. Ours is an intentional model of the mind that focuses on conscious and unconscious motivation. We pay special attention to our patients’ needs, desires and wishes that may not be recognized. As therapists we help patients recognize disowned needs or help regulate desires and wishes that are all consuming or overwhelming. We often focus on motivational systems that are in conflict with each other, such as an approach-avoidance conflict (typical of patients with borderline pathologies), or “superego conflicts” such as a conflict between unbridled ambition and a wish to remain true to ourselves or severe self criticism accompanied by idealization of parental figures.
2. Emotional processes. The psychoanalytic model of mind focuses on affect and emotion. As therapists we help patients recognize and honor their emotions whether they are pretty or not. We validate emotions that might not have been formulated or named, such as profound shame or guilt, unspeakable terror, searing rage or all consuming jealousy or revenge. We work with contradictory feelings and we help regulate emotion
3. Defensive processes. The psychoanalytic model of mind focuses on defensive processes. We explore attempts of patients to avoid certain aspects of experience, such as painful emotions, or situations that are threatening. We pay attention when patients exclude affects or painful events, and we note when they become suddenly confused or disoriented. Dynamic psychotherapists actively explore mechanisms of avoidance. We also note when patients look at situations in all good or all bad terms, when they panic and catastrophize events, or when they obsess endlessly about them and become paralyzed.

4. Developmental processes. The psychoanalytic model of the mind is profoundly developmental. Human minds become organized around certain themes, conflicts or “strategies” that are for the most part unconscious and that have their origin in development. We track these themes, make them explicit and try to make a connection with the present. The focus on the past and on developmental issues is not an end in itself, but a means to make clear how the past is alive and well in the present and how the past has effects on the way we perceive relations and the world at large.
5. Social processes. Our model of mind is profoundly social. There are at least three interlocking dimensions to human sociability: attachment and family ties, intersubjective abilities and culture.
Attachment and family ties. Human personality becomes organized around attachment figures that become a haven of safety and a secure base from which to explore the world. As dynamic psychotherapists we try to develop a working alliance with our patients that will allow the exploration of affects, conflicts with a developmental perspective, by becoming a secure base for them. Often developing a secure base from which to explore may become a goal in itself, since many patients have never had a secure attachment figure in their life and the ability to trust others is very limited and fraught with terror and shame.
Intersubjective abilities and communication. Most of how we learn to communicate and the way we know how to be with others is not conscious. Gestures turn taking in conversations, the ability to recognize emotions and intentions of others are intersubjective abilities that are gradually acquired before language develops by the end of the second year of life. This world of “implicit relational knowing ” (Lyons-Ruth, 1999; Stern, 2004) is vast and pervasive and provides a background to all verbal communication. Many forms of unconscious communication that have been described by terms like transference and projective identification can now be more understood in terms of intersubjective abilities. Transference can be understood as expectations and ways of relating that are established during childhood and are carried forward in development. We pay very close attention to how these relational patterns become activated or reenacted in the consulting room. The power of these expectations offers us a golden opportunity to explore them while in the immediacy of a therapeutic relationship.
Culture. Cultural norms and beliefs, the range of emotions that are allowed to be expressed freely, proper ways of being with members of our own group or members of other groups are learned to a large degree at implicit nonverbal (unconscious) levels and are reinforced through language and ritual. The impact of culture is ubiquitous and becomes internalized as interpersonal schemas and social scripts. Because these schemas and scripts are primarily non-conscious they become accepted as a natural way of being. Recognizing cultural differences and their imprint on personality has been a major theme among some psychoanalysts such as Erik Erickson, Karen Horney, Abram Kardiner and Erich Fromm. Fromm’s theory of social character is perhaps the most developed of these approaches to personality and culture. The concept of social character refers to emotionally based attitudes (character traits) that are shared by social group as adaptations to prevailing economic and social conditions .
Imagistic processes. With his creative incursion into the world of dreams, Freud opened up for scientific scrutiny the significance of dreams and the role of images and fantasy in dreams and in wakeful reverie states. Yet many aspects of Freud’s theories of dreams have been questioned within psychoanalysis and from systematic studies (Domhoff, 2000). Freud’s belief the manifest content of dreams is invariable distorted or disguised to hide unacceptable has wishes became (“dream work”) became an obstackle in exploring the potential meaning of a dream. Often the approximate meaning of a dream can be discerned by paying close attention to its manifest content and associated imagery and emotional tone. The power of dreams is often captured through images that reflect experience with an emotional resonance and vivedenss that is immediate and direct. As we put words to these images we begin to discover their salience and meaning. As dynamic therapists we focus on dreams, images and fantasies as entries into our patients’ states of mind.

Evidence for each one of these basic assumptions

1. Unconscious processes. In terms of unconscious processes we now know that Freud’s dynamic (repressed unconscious) is but a very small fraction of what is nonconscious. The vast majority of information that is processed out of awareness is not repressed, but is encoded at subsymbolic and implicit levels (Bucci, 1997, 2005; Cortina & Liotti, 2007). The cognitive revolution brought with it an understanding of the mind as being parsed in different memory systems (Bucci, 1997; Schacter, Wagner, & Buchner, 2000; Schank & Abelson, 1977; Westen, 1999; Westen & Gabbard, 2002).
It has been known for several years that the mere activation of the idea of engaging in any given behavior begins to move the body without personal awareness (Wegner, 2002). Using a functional MRI, a group of German researchers have shown that unconscious processes involving the prepolar and precuneus cortex precede awareness of making a decision by 7 to 10 seconds! (Soon, Brass, Jochen Heinze, & Haynes, 2008). Another important contribution to understanding unconscious processes has come from the work of subliminal perception (Erdelyi, 1985; Westen, Weinberger, & Bradley, 2007). A recent example of this type of research shows that an unconscious (out of awareness) prime has powerful effects on motivation, particularly when the prime has a positive valence (Aarts, Custers, & Marien, 2008).
2. Emotional processes. It used to be that emotions were ignored by neuroscience. But more recently, emotions have become one of the most exciting topics in modern neuroscience. The switch began in the 60’s with the work of Sylvan Tompkins, but in the last few decades the work of Antonio Damasio’s Descartes’ Error (1994), Joseph LeDoux’s The Emotional Brain (1996) and Jack Panksepp’s Affective Neuroscience (Panksepp, 1998) have put emotion front and center. We now have a much better knowledge of the brain’s circuitry involving the amygdala and the limbic system and how they communicate with the prefrontal cortex and the temporal lobes through the hypothalamus , and how emotions are intimately tied to motivational systems (Panksepp, 1998). The work of Paul Ekman (2003) has provided cross cultural evidence of the universality of some basic emotions and emotional expressions, and a cadre of brilliant psychologists including Nico Frijda (1986), Carroll Izard (1991) Richard Lazarus (1991) and Alan Sroufe (Sroufe, 1996) have made substantial contributions showing the function of emotions, the relationship between emotion and cognition and how emotions become integrated with cognition through acquiring explicit meanings that are only implicit during early development develop (Sroufe, 1996).
3. Defensive processes. Evidence for the existence of defensive processes has been accumulating from many fields over the past few decades. In the past few years two articles have appeared in Science (Anderson, et al., 2004; Depue, Curran, & Banich, 2007) that document through neuroimaging techniques the existence of repression of unwanted memories. These defensive processes are orchestrated via a two-phase process. An initial suppression by the right inferior gyrus (prefrontal cortex) over sensory components of memory, and a second phase initiated by the right medial frontal gyrus over the emotional components involving the amygdala and hippocampus.
Bornstein (2005) notes that the study of defensive processes has often been taken up by academic psychologists without any reference to Freud. For instance Aron Beck has documented and studied cognitive avoidance as a defense mechanism in cognitive therapy, while Tulving has documented and studied slips of the tongue and other mechanisms of defense as retrieval errors. The repetition compulsion has been studied under the name of nuclear scripts by Tompkins. And on it goes. Perhaps the most comprehensive effort to validate empirically the notion of defense mechanisms has been a 20 year on going project led by Phebe Cramer (Cramer, 2006). Cramer’s impressive work has focused primarily on three defense mechanisms: denial, projection and identification. She shows that defenses function outside of awareness, that they are part of normal personality, but increase with stress. Cramer has also shown that defenses mobilize negative emotions and reduce the scope of consciousness. Finally Cramer shows that defenses are connected with measures of the autonomous nervous system such as blood pressure and skin conduction tests. These are all findings consistent with a psychoanalytic model of the mind.
4. Developmental processes. Development and the significance of the past in influencing the present (“the child is parent to the man”) have recent and strong evidence. Longitudinal studies are one of the best ways to provide evidence for this key proposition, but they are extremely expensive and hard to do. In the past few decades several longitudinal studies, to a great extent inspired by the work of John Bowlby (1969/1982, 1973, 1980) and Mary Ainsworth (1978), have undertaken the enormous challenge of putting to test many psychoanalytic ideas about the importance of parent-child relationships in influencing the development of personality. It is impossible to summarize these findings, but it is fair to say that there is strong scientific evidence for several key propositions in regard to the relationship between the past and present. 1) The past, for better or for worse, is always with us 2) the past influences but does not determine the present 3) the best predictor of outcomes is the cumulative history of how we manage different developmental tasks 4) there are continuities and discontinuities in development, and nonlinear effects are the norm. An excellent entry into this literature, led by Alan Sroufe (2005) is based on a very comprehensive and rigorous scientific longitudinal study is the work of the University of Minnesota group (for review of the major longitudinal studies see Grossmann, Grossmann, & Waters, 2005)
5. Social processes. The vast literature on attachment theory and research that spans five decades is one of the main sources of evidence that supports the relational turn in psychoanalysis and has added significantly to our understanding of how social-emotional processes mold personality development. This literature cannot be easily summarized, but some of its main findings are the discovery of three basic strategies used by infants to regulate security and exploration, the discovery of a frightening and disorganizing dimension to these basic strategies in some infants, the transformation of these frightening experiences into controlling strategies in many cases of children with histories of disorganized attachment, and the discovery (by means of the Adult Attachment Interview) of how the narratives we use to recall childhood events embody more or less open access to painful emotions or defensive maneuvers to ward off these painful emotions. A good entry into this vast literature is the Handbook of Attachment (Cassidy & Shafer, 2008).
This body of knowledge has significant clinical implications. The quality of the therapeutic alliance is the single most important predictor of the effectiveness of psychotherapy (Ackerman & Hilsenroth, 2003; Horvath, 2001). The ability to develop a sense of safety with the therapist from which to explore issues in therapy is one of the key ingredients of a good therapeutic alliance. The concept of a therapeutic alliance originated within the psychoanalytic literature but is now a widely used concept in psychotherapy research. As therapists we often become attachment figures to our patients, particularly in moments when they feel vulnerable and helpless. Many schools of thought have considered providing safety and containment a key to success, but attachment theory offers a parsimonious and straightforward way to understand one of the key dimensions of therapeutic effectiveness. Understanding defensive processes that regulate security is another important contribution from attachment theory and research that informs our clinical interventions.

The significance of intersubjective abilities and intersubjective communication has been another major contribution stemming from infant-parent research. Three names immediately come to mind, Colwyn Trevarthen (2005; 1979, 1980, 1988; 1994; Trevarthen & Hubley, 1978), Daniel Stern (Stern, 1985, 2004) and Beatrice Beebe (Beebe, Knoblauch, Rustin, & Sorter, 2005). These researchers have contributed enormously to our understanding to the world of implicit relational knowing (Stern, 2006). Implicit or procedural knowing is unconscious, not because it is repressed, but because subsymbolic processing of information cannot be retrieved consciously. This information is carried forward as powerful expectations and attributions we make toward others. The power of these expectations and attributions is that they are not accessible to consciousness. When maladaptive, they often get reenacted in destructive and unhelpful ways.
6. Imagistic abilities. It might seem arbitrary to lump the study of dreams with the study of images, imitation and imagination. Dreams not only contain images, but these images are also embedded in narrative plots that contain language. Moreover, dreams also evoke strong emotions--mostly negative emotions as shown by systematic study of the content of dreams (Domhoff, 1999). There are many complex issues involved in the scientific approach to dreams. Many psychoanalists belonging to different schools of thought have noted over many decades that the imagery in dreams often has a figurative or metaphorical meaning. For instance, the image of flying in a dream might be a metaphor for a state of happiness or euphoria. We also use flying images as metaphors during wakeful states as in expressions such as “flying high” or being “high as a kite”. The image of being naked in a dream is often a metaphor for shame or embarrassment, and this image is also captured in the common expression of being “caught with our pants down”. As these examples show, images—or “ image-schemas” to use the term of the distinguished linguist George Lakoff (1980)—are used to create metaphors and figures of speech. Language builds on the meaning inherent in preverbal image schemas (see below) and expands their meaning by virtue of the power of language to combine words and sentences ad infinitum. It is reasonable to think that images might perform a similar function in dreams. Indeed, many clinicians who work with dreams approach the manifest content of images and symbols this way, an approach taken by Erich Fromm (1951) in The Forgotten Language. The dream researcher William Domhoff provides support for the hypothesis that some images in dreams can be understood as metaphors that have a cognitive function (Domhoff, 1996; Domhoff, 2005).
The study of imagistic abilities is a very promising field, one most in need of research. Jean Piaget (1962) in his landmark book Play, Dreams and Imitation in Childhood thought that deferred imitation was a developmental benchmark that signaled the emergence of symbolic or representational thought. Deferred imitation is defined by the ability to repeat a scene or behavior days or weeks after being exposed to it. The important point is that deferred imitation implies that there is a remembered image of the event or behavior . According to Piaget, images become mental representations or symbols of sorts, albeit a symbol still tied to a perceptual stimulus. In contrast, abstract symbols (that make their first appearance by the middle of the second year of life or later) are no longer tied directly to an immediate percept. For instance the word “animal” refers to the whole category of living creatures that share certain characteristics such as spontaneous agency and motility.
In Piaget’s developmental model, representational thought does no appear until 16 to 18 months of age. Before this age infants display a sensorimotor form of intelligence that is nonsymbolic or nonrepresentational in nature (Piaget’s sensorimotor intelligence is now understood as a form of implicit or procedural knowledge). We now know from the work of Patricia Bauer and colleagues (1996; Bauer & Shore, 1987) that deferred imitation appears much earlier than Piaget thought--toward the end of the first year of life and that the capacity for imitation is one of the foundations for social cognition (Meltzoff, 2007) The appearance of the capacity for deferred imitation is accompanied by the emergence of other abilities such as:
• sharing of interesting events and happenings with caregivers by pointing and other gestures beginning around 12 months (Bates, Camaioni, & Volterra, 1975; Tomasello, Carpenter, & Liszkowski, 2007; Warneken, Chen, & Tomasello, 2006)
• the ability to achieve a goal through various mean—9 to 12 month-old infants (Piaget, 1952)
• joint intentionality (the ability to understand intentions from a first person perspective (I) and third person perspective (others) beginning with 15-month-old infants (Tomasello, Carpenter, Call, Behne, & Henrike, 2005)
• the ability to cooperate with caregivers in reciprocal games and simple tasks beginning soon after the first year of life (Tomasello, 2007)
• the ability to altruistically help others by 18 months, an ability that far surpasses similar behaviors in chimpanzees (Warneken & Tomasello, 2006)
All this suggests that before language emerges by the end of the second year of life, there is a form of knowing that is already representational in nature and is marked by the emergence of images that can be retained in memory. This cognitive revolution is accompanied by a revolution in social understanding that takes off during the second year which greatly facilitates the ability of infants to cooperate and communicate with caregivers (intersubjective abilities).

Research on dynamic psychotherapy

I would like to conclude by making a few more remarks in regard to psychotherapy research. Much of this research is frustrating because it ends up with the so called Dodo bird verdict. This verdict refers to Alice in Wonderland, where in a contest among birds the queen decides that “everyone has won and all must have prices” (Shedler, 2009). Outcomes of different therapies are surprisingly equivalent, and no form of psychotherapy has proved more effective than any other. Not surprisingly, when differences are found for a certain type of therapy (such as cognitive behavioral therapy) the positive findings always favor the treatment advocated by the researchers (Luborsky, et al., 1999).
Nonetheless, there is good news on this front. Some studies are beginning to show what is called an “incubator effect” of dynamic psychotherapy. That is to say, that the positive effects of psychotherapy continue to accrue after the therapy has terminated (Shedler, 2009).This incubator effect has not been shown to be so long acting in dialectical behavioral therapy (DBT) or cognitive behavioral approaches. Another very suggestive finding is that to the extent that cognitive behavioral techniques are useful, they may be so because they have incorporated psychodynamic principles used by experienced therapists that deviate from the manualized treatment protocol.
With the development of meta-analyses, it is possible to accumulate very large data sets from many psychotherapy research studies. This large pool of data is then scrutinized with sophisticated statistical methods and can be compared and evaluated. Meta analytic studies can also be used to compare how well these large data sets stack up against similar data sets from different types of psychotherapy. Just to get a measure of some of these studies and what they mean, an effect size of 1.0 means that the average patient is one standard deviation healthier in the normal (Bell) distribution curve than the average untreated patient. An effect size of 1.0 means that the population mean of treated persons are 84 % better than the population mean of untreated persons. Anything better than .8 is considered a very good effect size. From these meta-analytic studies it is becoming clear that effect sizes of dynamic psychotherapy are comparable, if not superior to other common types of psychotherapy that are generally considered to have solid evidence for their efficacy. For instance, a meta-analysis of 12 short-term psychodynamic studies showed effect sizes of .97, (Abbas, Hancock, Henderson, & Kisely, 2006), and a meta-analysis of 15 studies of the treatment of personality disorders using long term psychotherapy (measuring pretreatment and post-treatment effects) showed an effect size of 1.46. To gain a comparative perspective of effect sizes, several studies of cognitive behavioral psychotherapy have shown effect sizes ranging from .58 to .62. An even more telling perspective is to compare effect sizes when only medication is used to treat depression. Common antidepressants have effect sizes that range from of .31 for citalopram (Celexa), .3 for duloxetine (Cymbalta) and .24 for sertraline (Zoloft) (Shedler, 2009)
Another encouraging article showing the effectiveness of long term treatment over short term cognitive and dynamic psychotherapies appeared recently in the Journal of the American Medical Association (Leichsenring & Rabung, 2008). The authors reviewed 11 prospective studies that comprised 1053 patients with diagnosis ranging form borderline, obsessive and avoidant personality disorders, to eating disorders mixed with Axis I diagnosis –mainly chronic depression and anxiety disorders. They compared the effect long term psychoanalytic psychotherapy (a mean of 95 weeks in treatment and a follow up mean at 93 weeks) a variety of short term psychotherapies There were 257 patients enrolled in short term psychotherapy. The result showed robust between-group effect size of 1.8 (with a 96 % confidence level) after treatment with long term treatment of patients with complex mental disorders. This means that on average 96% of the patients of patient who received long term psychotherapy were better off in the comparison groups of short term psychotherapies (P=.002). Subgroup analyses showed that long term psychotherapy yielded significant large and stable within-group effect sizes across different complex mental disorders with effect sizes ranging from 0.78-1.98. Using a randomized controlled clinical trial with follow-up evaluation 1 and 3 years after termination a recent article appearing in another main stream article shows sustained improvements of transference interpretations when used during treatment over and above the use of other treatment interventions (Hoglend, et al., 2008). The effectiveness of transference interpretations was as shown in a randomized control study with patients diagnosed with borderline personality disorder. The study showed statistically significant changes in attachment (as measured by the Adult Attachment Interview) patterns using a transference focused approach to treatment in comparison with controls (Levy, et al., 2006).
Conclusion

Despite the low level of prestige of psychoanalysis and psychodynamic psychotherapy, the tide is turning. There is solid evidence to support many key premises underlying the practice of dynamic psychotherapy, and modest but growing evidence to support the effectiveness of its treatments. Most postgraduate training of dynamic psychotherapy is based on small independent training institutes that do not have the resources to teach research methods and conduct expensive clinical trials. To train future therapists in the art and the science of dynamic psychotherapy it is imperative that these independent institutes make a concerted effort to bridge the gap between research and practice. This is a difficult undertaking, but there are examples in some areas of the country where local institutes have banded together to pull resources and showcase some of the most promising examples of types of research that is that speaks to clinical concerns .




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Otros artículos de Mauricio Cortina

Cortina, M. (1999). Causality, adaptation and meaning. A perspective from attachment theory and research. Psychoanalytic Dialogues, 9, 257-296.

Cortina, M. (2001). Sullivan's contributions to understanding personality development in light of attachment theory and contemporary models of the mind. Contemporary Psychoanalysis, 37, 193-238.

Cortina, M. , & Marrone, M. (2004). Reclaiming Bowlby's Contribution to Psychoanalysis. International Forum of Psychoanalysis, 13, 133-146.

Cortina, M., & Liotti, G (2003). Hacia un modelo multi-motivational de la naturaleza humana Aperturas psicoanaliticas, 15(November),

Cortina, M., & Liotti, G (2007). New approaches to understanding unconscious processes: Implicit and explicit memory systems. International Forum of Psychoanalysis, 16, 204-212.

Cortina, M., & Liotti, G (in press). Attachment is About Safety and Protection. Intersubjectivity is About Social Understanding and Sharing. Psychoanalytic Psychology.

Cortina, M., & Liotti, G. (2010). The intersubjective origins of consciousness. The Journal of the American Academy of Dynamic Psychotherapy and Psychoanalysis, 38, 291-314.

Cortina, M., & Marrone, M. (Eds.). (2003). Attachment Theory and the Psychoanalytic Process. London: Whurr.

Para comunicarse con Mauricio Cortina mencionar a SIIC como referencia:
mcortina@wspdc.org

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Acerca del trabajo completo

EL FUTURO DE LA PSICOTERAPIA DINAMICA

Título original en castellano
EL FUTURO DE LA PSICIOTERAPIA DINAMICA

Autor
Mauricio Cortina¹
1 Medico, Washinton School Of Psychiatry, Washington D.c., Estados Unidos, Director Centro de Apego y Desarollo Hum

Acceso a la fuente original
Psychiatry-Interpersonal and Biological Processes
http://www.guilford.com/cgi-bin/cartscript.cgi?page=periodicals/jnps.htm&cart_id=3

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