Counseling and Psychotherapy. Группа авторов
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between historical processing and current circumstances, thereby synthesizing personality components into one functional unit as the client develops a sense of empowerment (see Sidebar 3.2).
Traditional psychoanalytic theory suggests that all psychological disorders are the result of unconscious conflicts manifesting in emotional dysregulation with behavioral consequences, which cause intrusions of hidden drives into voluntary behavior when defense mechanisms fail. Current approaches consider all presenting symptoms meaningful and relevant to the client’s subjective experience and are therefore useful in treatment. Brief psychodynamic approaches have emerged from traditional psychoanalytic theory with clinical success among populations diagnosed with serious mental health disorders, including chronic depression, borderline personality disorder, and posttraumatic stress disorder. The emphasis on insight varies by client functionality, and the focus remains on transference and countertransference, with consideration placed on the event, neuropsycho-logical function, and current circumstances (Bond, 2006). Current psychodynamic approaches that emphasize time limit, therapeutic focus, and counselor directiveness are particularly relevant for addressing disorders that require intensive intervention (see Sidebar 3.3).
Sidebar 3.2 Psychodynamic Theory and Neuroscience
A strong trend in counseling is a growing interest in the relationship between personality disorders, attachment theory, and links to neuroscience. This relationship is being explored by using neuroimaging techniques to discern the difference between psychodynamics (or the motivational influences that are actively blocked from awareness) and etiology (or causes of pathological behaviors). Counselors may use this information to understand how different brain structures react with incredible precision to a variety of stimuli, whether they are cognitive, pharmacological, or emotional. For example, data acquired from neuroimaging techniques show that explicit memory is defined as conscious memory, whereas implicit memory is defined as unconscious. The hippocampus, which is responsible for coding memory, is directly affected by the amygdala, the emotion center of the brain. Thus, when a client experiences an emotional trauma, the perception of the trauma is coded into memory as conscious or unconscious content (Barry, 2014).
The degree to which structure and support are generally provided by the counselor depends on the functional level of the client. Experienced counselors who have incorporated psychodynamic techniques into their practice with clients with serious mental illness suggest taking the following steps during interventions (Lemma et al., 2011):
1 Identify an attachment-related problem with a specific relational-emotional focus that the client identifies as the cause for diagnostic symptoms.
2 Collaborate with the client to create a concrete conceptualization of interpersonal issues raised by the problem.
3 Attend to the structure of the dialogue between counselor and client and examine transference as a relational theme to generate alternative ways of thinking and feeling.
4 Attend to the therapeutic process and invite the client to evaluate the process of change as it is happening.
5 Provide the client with a written summary of the collaboratively created view of the client’s area of unconscious conflict. This serves as a tangible reference for the client in moments of relapse.
SUPPORTING RESEARCH AND LIMITATIONS
Overview
Psychoanalytic theory has been both acclaimed for its effectiveness and highly criticized for its limitations. Traditional psychoanalysis used structural, developmental, and motivational constructs to describe the complexity of human personality functioning. Many theorists and practitioners focus their criticisms on the lack of specific attention to the present and future and, in particular, on the lack of attention to cross-cultural applications and the potential for bias toward specific client populations. Others favor the theory because of the dynamic foundation of development and structural components used to explain personality development and its contemporary applications to present maladaptive functioning (Petrocelli et al., 2001).
Sidebar 3.3 Psychodynamic Interpersonal Therapy and Major Depressive Disorder
Psychodynamic interpersonal therapy is often used to treat major depressive disorder (MDD). This approach assumes that symptoms reflect a treatable illness that is not the client’s fault and that symptoms arise in an interpersonal context. When treating MDD, counselors frame the disorder in one of four interpersonal contexts: (a) grief (complicated bereavement), (b) a role dispute (struggle with a significant other that the client is invariably losing), (c) a role transition (any life change, such as a geographic move, the onset of medical illness, a marriage or divorce, starting or losing a job), or (d) interpersonal deficits (social isolation). The overall goal in treating MDD within this framework is to resolve the life crisis by helping clients build social skills, communicate their emotions more effectively, and mobilize protective social supports. Randomized controlled trials have provided evidence-based support for this method (Markowitz et al., 2014).
Supporting Research
Psychoanalysis in its classical form has limited current empirical support across contexts and populations and has evolved to meet the changing needs of managed care and community-based programs that emphasize productivity led by evidence-based practices. In its brief form, the efficacy of its techniques is equal to that of other mainstream counseling modalities such as the cognitive behavioral approach (Horvath, 2005; see Sidebar 3.4).
Derived from these techniques, psychodynamic psychotherapy is strongly clinically supported as effective with many diagnoses and populations (Shedler, 2010). Meta-analytic reviews of treatment outcome studies and randomized controlled trials support its efficacy for treating mood and anxiety disorders, somatoform disorders, and schizophrenia. This approach has also been compared with dialectical behavior therapy in its effectiveness and quality of treatment for borderline personality disorder (Seligman & Reichenberg, 2014). In the area of psychoanalytic and psychodynamic research, the trend toward evidence-based support is encouraging counselors to reexamine the use of traditional techniques based on significant results from randomized controlled trials, brain scans, and the measurable effects of talk therapies on behavior, brain activity, and brain function (Sonnenberg, 2011).
Originally intended as an explanation of the effects of childhood trauma in later life, psychoanalysis has evolved to include explanations of personality development and maladaptive behaviors resulting from disturbances in early relationships. Many counselors suggest that psychoanalysis can also be used to describe or explain a vast array of other concepts outside the realm of the psychological field and is a powerful model for understanding the role and impact of early childhood conflicts in clients’ lives. One of the greatest strengths of psychoanalytic theory is the breadth and depth of the explorations into personality development and coping skills, making it a comprehensive theory with much versatility in practical use.
This theory is especially useful in understanding the basis for resistances that may present as missing appointments, refusing to engage in introspection, and being reluctant to examine the use of defenses (Corey, 2021). From a psychoanalytic viewpoint, the client will bring to the session a consistent set of themes rich with content accumulated over their lifetime. And individually or in combination with other theories, psychoanalysis is a valuable tool that counselors may use to develop an effective treatment plan based on the symptoms and patterns of behaviors initially observed within a psychoanalytic framework. Katz-Bearnot (2009) suggested that the psychoanalytic orientation offers the most comprehensive approach to counseling because the theory considers unconscious factors, including transference, enactments, and aspects of the client’s personal relationships.
Sidebar