Psychoanalytic Therapy

Naveen Sharma; Philip Spiro

Psychoanalytic Therapy

Author: Naveen P. Sharma Editor: Philip M. Spiro Updated: 8/2/2023 8:52:10 AM

Introduction

Psychoanalytic or psychodynamic psychotherapy is an umbrella term that describes the psychotherapeutic clinical application of a larger group of theories and principles stemming from psychoanalysis. Psychoanalysis began as the work of Sigmund Freud and quickly expanded through the work of his contemporaries, including Sandor Ferenczi, Carl Jung, Otto Rank, and Alfred Adler. The term "psychoanalytic psychotherapy" is often used interchangeably with "psychodynamic psychotherapy," but these terms are distinguished from psychoanalysis.[1][2]

Psychoanalysis and psychodynamic psychotherapy use similar techniques, theories, and approaches to listening and understanding. Notable differences are intensity, frequency, and length of the treatment, whereas psychoanalysis is more intensive and of longer duration.[3] In addition, the term "evidence-based psychotherapy" (EBP) is defined as psychotherapy that utilizes published findings to inform clinical decision-making.[4]

Cognitive behavioral therapy (CBT) is frequently considered the prime exemplar of EBP, and psychodynamic psychotherapy has been historically excluded from this list of EBPs. Recent literature, however, has suggested that this distinction may be outdated and inaccurate, as emerging research on psychodynamic psychotherapies has demonstrated efficacy and effectiveness for various conditions.[4]

Several forms of psychodynamic psychotherapies derive from their associated theories. Theorists include:

Freud[5]
Ferenczi[6]
Adler[7]
Jung[8]
Stack Sullivan
Kohut[9]
Kernberg[10]
Balint[11][12]
Erikson[13]
Klein[14]
Sharpe[15]
Bowlby[16]
Winnicott[17]
Ainsworth[18]
McWilliams[19]

Associated theories include drive theory, ego psychology, object relations theory, interpersonal psychoanalysis, self-psychology, and others. During the initial development period of psychoanalysis, Sigmund Freud was the primary contributor and leader of the movement, and many of the significant initial discoveries and methods developed are attributed to Freud. In his position as the leader and progenitor, Freud attempted to curate and develop psychoanalysis carefully, often requiring other theorists to follow his primary tenets or be expelled from the movement.[20][21]

After Freud's passing, the field grew in a varied manner, with theorists and followers developing unique theories, lexicons, schools, and organizations.[22] The following table provides a non-exhaustive list of theorists and their associated contributions, which often overlap with one another, given the collaboration—for example, multiple personality theories developed as a result of each theorist's formulation. Modern psychodynamic psychotherapy may utilize one or several of these theories to develop case formulations.

Theorist by chronological order	Contributions
Sigmund Freud[23]	Founder of the principles, theory, and practice of psychoanalysis Drive theory and Oedipus complex Dream analysis Topographical (conscious, preconscious, unconscious) and Structural (Id, ego, and superego) models
Carl Jung[24][25]	Jungian psychology Archetypal phenomena Collective unconscious Psychological complex Extraversion and introversion
Sandor Ferenczi[26]	Here-and-now psychotherapy Relational psychoanalysis and empathy in psychoanalysis Origins of family therapy Countertransference as a therapeutic tool, mutuality, and intersubjectivity Psychoanalytic theories of war neuroses (war trauma)
Alfred Adler[27]	Individual psychology Inferiority complex and superiority/inferiority dynamic Social interest (contributing to others) Discarded the analytic couch in favor of two chairs to create a more dyadic interaction
Otto Rank[28]	Existential psychoanalysis Separation anxiety Trauma of birth
Girindrasekhar Bose[29][30]	First Indian Psychoanalyst Founder of the Indian Psychoanalytic Society Integration of Hinduism and psychoanalysis Concept of Repression
Harry Stack-Sullivan[31][32]	Interpersonal psychoanalysis Psychotherapist as participant-observer Social psychiatry Self-system One of the founders of the journal Psychiatry and William Alanson White Institute
Anna Freud[33]	Ego psychology Defense mechanisms Child psychoanalysis Theories of child development
Karen Horney[34][35]	Feminine psychology Theories of neurosis Theories of narcissism Categories of needs
Ronald Fairbairn[36]	Object relations theory Theory of attachment
Melanie Klein[14]	Kleinian psychoanalysis Child analysis Projective identification Contributions to object relations theory
Ella Sharpe[15]	Role of symbolism in the human psyche Integration of various psychoanalytical thoughts
Kosawa Heisaku[37]	First Japanese psychoanalyst Integration of Buddhism and psychoanalysis
Michael Balint[12][38]	Focal psychotherapy Primary love and interdependence of mother and infant
Erik Erikson[39]	Eight stages of human psychological development Identity crisis
John Bowlby[40]	Maternal deprivation Attachment theory Psychoanalysis and ethology
Donald Winnicott[41][17]	Object relations theory The true and false self Good enough mother
Bingham Dai[42]	One of the first Chinese psychoanalysts Integration of Confucianism and Taoism and psychoanalysis Contributions to whole health emphasis and psychotherapy led by the patient
Wilfred Bion[43][44]	Group dynamics Theory of thinking Capacity for thought One of several key contributors to systems psychodynamics
Jacques Lacan[45]	Mirror stage Variable length sessions "Return to Freud" Challenges to previous psychoanalytic concepts, including object relations Language and its relation to the unconscious
Mary Ainsworth[18]	Formalized attachment theory Anxious-Avoidant Attachment, Secure Attachment, Anxious-Resistant Attachment, Disorganized/Disoriented Attachment Strange situation procedure
Heinz Kohut[36]	Self-psychology Narcissistic personality organization
Otto Kernberg[46][47]	Object relations theory Transference-focused psychotherapy Borderline and narcissistic personality organization
Nancy McWilliams[19]	Psychoanalytic diagnosis Integration of feminism and psychoanalysis Personality structures and disorders Humanistic traditions in psychotherapy

Of note, the foundations of various other forms of psychotherapy, including humanistic, existential, and cognitive-behavioral, can be traced to the psychoanalytic movement.[48][49]

Historically, each psychoanalytic theory and its associated school developed and operated independently, and as such, a unified definition of psychodynamic psychotherapy is difficult to identify. This is further clouded by the development of various other psychotherapies, which resulted in reciprocal influence.[50][51][52][53] To remedy this, recent definitions have been proposed in the primary literature, where the principles of psychodynamic psychotherapy may number between four and seven features.

By one definition, as introduced by Otto Kernberg, the psychoanalytic technique consists of interpretation, analysis of transference and countertransference, and technical neutrality.[54]

Transference is considered the "unconscious repetition in the here and now of pathogenic conflicts from the past" for the patient within the session. Analyzing the transference is considered in this definition as the primary source of change.
Countertransference is considered "the analyst's total, moment-to-moment emotional reaction to the patient and to the particular material that the patient presents." Tolerance of countertransference is considered necessary for high-fidelity treatment. Understanding the countertransference can provide important information for the treatment.
Technical neutrality refers to the therapist abstaining from personal gratification obtained through the therapeutic relationship, along with a natural and sincere approach to the treatment. This is as opposed to the concept of anonymity, where the analyst is considered a "blank slate" on which the patient places all their emotions and thoughts.
Interpretation is a blanket term for the specific verbal communication from the analyst to the patient. Interpretation within this definition is classified as "clarification," "confrontation," and "interpretation proper." Clarification seeks to elucidate the patient's conscious thoughts; confrontation seeks to tactfully bring unconscious thoughts, emotions, or behaviors into the patient's awareness; and interpretation attempts to provide a hypothesis to bring together all aspects of the patient's communication.

Paulina Kernberg published an article outlining empirically supported postulates of psychodynamic psychotherapy with children, which can be extrapolated for adults:[55]

Complex, unconscious processes lead to conscious thought and behavior deterministically.
Internal representations of one's experience with important people and the external world shape the person's foundational assumptions and expectations.
Observable thoughts and behaviors arise from more than a single unconscious origin. An individual's spoken language can have multiple meanings.
Conflict within the psyche is often present and a part of normal development. Conflicts are either external or internal. External conflicts happen between the needs of the person and the needs of the environment. Internal conflicts happen within the mind, such as between the person's impulses or desires and internalized societal prohibitions.
Defenses are mental processes that alleviate anxiety and maintain the individual's homeostasis. Defenses change throughout development from initial immature to mature defenses. Rigid defenses can prevent further development.
Resistance to change maintains stability but can slow the therapeutic process.
Transference provides an opportunity to understand and change internalized relational patterns.
Therapist neutrality establishes a safe setting for the therapeutic relationship by aiming to allow free expression by the patient. The therapist seeks to follow the individual's lead. In this case, neutrality is defined as "the [therapist's] cultivation of a non-judgmental, respectful, empathic, supportive attitude toward the patient."
The therapist must recognize and understand their countertransference, which may provide insight into the patient's internal conflicts. Awareness of countertransference is also key to maintaining the therapist's neutrality which should not be affected.

Another third definition introduced by Jonathan Shedler discusses seven features that distinguish psychodynamic psychotherapy from other psychotherapy modalities.[2] These are the following:

Emphasis on emotion and its expression
Exploration of avoidance attempts from thoughts and feelings
Identifying recurrent patterns or themes
Discussing past experiences
Emphasis on interpersonal relations
Emphasis on the therapy relationship
Exploring fantasy life

Transference and countertransference similarly have varying definitions. Sigmund Freud's original definition of transference and countertransference was that both occur within the bounds of the therapeutic relationship.[56][57]

The patient experienced transference, and the therapist experienced countertransference. Both were considered impediments to treatment that required "working through." Their respective definitions have since expanded to encompass the patient's and provider's emotions, behaviors, thoughts, biases, and all other individual contributions to the therapeutic relationship. Transference and countertransference reactions are no longer considered pathological unless they negatively impact relationships or the fulfillment of needs.[58]

Additionally, transference and countertransference are now considered integral parts of all relationships and are particularly important to attend to within the therapeutic relationship. Transference phenomena have also been discussed in the context of medical practice.[58]

Some practitioners of CBT consider forms of countertransference and transference as key concepts to be explored within the treatment and in therapy supervision.[59] Practitioners of CBT formulate transference and countertransference differently from practitioners of psychodynamic psychotherapy. Most notably, practitioners of CBT use CBT-related terms, such as automatic thoughts and cognitive distortions, to define the concepts. Aaron Beck described transference in publications from the 1970s and following as a "schematic response." Discussions within CBT have also noted the importance of analyzing the therapeutic relationship in individuals with personality disorders.[59]

Issues of Concern

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Issues of Concern

Psychodynamic psychotherapies derive from psychoanalytic principles and theories. Primary schools of psychoanalytic theory currently considered to inform psychodynamic theory are Drive Psychology, Ego Psychology, Object Relations and Attachment Theories, Interpersonal Psychoanalysis, and Self Psychology.[60] These theories all attempt to map the territory of the human psyche, both in health and in illness, but each focuses on a different aspect of personality as most central to theoretical and clinical concern.

Drive Psychology

Drive Psychology emerged from Freud's early theory around 1905, wherein human behavior is "driven" by unconscious aggression and sexuality.[5] Freud introduced the concept of the Oedipal complex and analysis of dreams. Drawing upon ancient Greek myths, which he believed represented universal human struggles, Freud formulated the concept of the Oedipal complex and focused on analyzing dreams as central to understanding the human condition. He also introduced the topographical and structural models of the mind.

The topographical model divided the human psyche into three parts - the conscious, preconscious, and unconscious - depending on the level of awareness of the ordinary conscious mind. The conscious mind is that part of the mind that every human is always aware of. The preconscious is part of the mind that is immediately out of awareness but can be brought into the conscious mind by the individual with relative ease.[61] The unconscious mind is part of the psyche that can be accessed only through free association, psychoanalysis, and indirect mechanisms such as dreams and parapraxes (so-called Freudian slips).[61]

Later in his elucidation of psychoanalytic theory and practice, Freud developed the so-called structural model, where he considered the distinction between the id, ego, and superego.[62][63] The id is the unconscious part of the mind, characterized by the unconscious drives as above; the superego is the internalization of moral constraints; and the ego is the mediator between the two.[64][65]

More specifically, the ego is considered the mediator between reality and the person's experience. The id is considered entirely unconscious and can only be brought into consciousness through analysis. Both the superego and ego have conscious, preconscious, and unconscious parts.[66]

Ego Psychology

Ego Psychology focuses on treating and analyzing the ego, understanding ego defenses, and reality testing. Freud and his contemporaries initially considered the ego an impediment to treatment, as the ego prevented access to the id, which was considered the primary focus of treatment.[67]

Later, Sigmund Freud published two additional works on the ego, followed by his daughter Anna Freud in 1936 and Heinz Hartmann in 1939. These works encouraged clinicians to identify and analyze ego structure and defenses as equally important to the id.[68][69] Anna Freud described ten primary defense mechanisms: regression, reaction-formation, isolation, undoing, repression, projection, introjection, turning against the self, reversal, and sublimation.

Anna Freud described these defense mechanisms as initially to protect the ego from underlying id drives, and later Heinz Hartmann proposed that instead, ego defenses protect the ego in the face of external adversity and experience.[67] Ego psychology thus focuses on fostering healthy defenses and ameliorating unhealthy defenses resulting from greater functioning.[69]

Object Relations Theory

Object relations theory began as a movement in Britain and is considered to have emerged from the "controversial discussions." [70][71] These (sometimes heated) "discussions" occurred at the British Psychoanalytical Society from 1943 to 1944. They occurred between Anna Freud and Melanie Klein along with respective followers, called, respectively, the "A" group (followers of Anna Freud) and the "B" group (followers of Melanie Klein). The primary topic of debate was the nature of ego development and psychoanalytic technique.[71] A third group called the "middle" or "independent" group, emerged from these discussions, consisting of Ronald Fairbairn, Michael Balint, John Bowlby, Donald Winnicott, and later, Harry Guntrip. The independent group developed theories derived from Kleinian theory which became recognized as object relations theory.[72]

Melanie Klein is thus considered a pivotal figure in the development of Object Relations theory, as she and her theory facilitated a significant theoretical and practical divergence from Freud within the field of psychoanalysis.[73] In addition, Ronald Fairbairn is credited with coining the term "Object Relatedness" or Object Relations. He defined this as the developmental drive coming from an "innate need for emotional attachment to an object" rather than pleasure-seeking, in direct opposition to the central tenets of drive theory.[74]

Several theorists contributed to this collection of theories, which all utilize the fundamental concept that humans develop primarily through interaction with other humans around them, especially those closest to the individual. These other humans are subsequently viewed and internalized as "objects." These internalized "objects," in turn, impact the individual's self-view and relationships with others throughout life.[60]

Object relations theory was later developed, applied, and integrated with prior and emerging theories in the United States. These included theorists such as Otto Kernberg, Heinz Kohut, Glen Gabbard, and James Masterson.[75][76][75]

Attachment Theory

An offshoot of object relations theory is attachment theory. Attachment theory was developed initially by John Bowlby and Mary Ainsworth through their collective work; it is considered a part of object relations with empirical support through the research work of Mary Ainsworth. John Bowlby worked with emotionally disturbed children in the 1930s and published his seminal paper summarizing his findings in 1958 in a paper titled "The Nature of the Child's Tie to His Mother," followed by four additional papers in short succession. Mary Ainsworth's research with infants identified four attachment styles, published in her work, Patterns of Attachment (1978): Secure Attachment, Anxious-Avoidant Insecure Attachment, Anxious-Resistant Insecure Attachment, and Disorganized/Disoriented Attachment.[77] Attachment theory provided a way to understand children's relationships and later adult relationships.

Interpersonal Psychoanalysis

In the 1920s and 1930s, Harry Stack Sullivan, who is considered the first psychoanalytic theorist in America, developed Interpersonal Psychoanalysis.[78] This theory involves a focus on the interpersonal relationship as a means to change an individual's relational patterns, which are shaped by prior and recent experiences.[79]

Harry Stack Sullivan is also considered to have brought together social science and psychiatry to create "social psychiatry" in collaboration with Adolf Meyer in the 1920s. Their work was supported by the National Insititute of Mental Health and the Group for the Advancement of Psychiatry and emphasized a paradigm of a biopsychosocial approach to psychiatric treatment.[80]

Harry Stack Sullivan also conducted research at Sheppard and Enoch Pratt Hospital focused on individuals with schizophrenia and severe borderline personality in 1923 on a specialized unit.[81] He identified the role of the psychiatrist as a "person among other persons" within the patient's social circle and that each individual has several interpersonal relationships, and the individual's "self" may differ between each.[82]

Self Psychology

Self-psychology was developed in Chicago by Heinz Kohut in the late 1960s to mid-1970s.[83] Kohut studied narcissism and its developmental precursors and published his first book, The Analysis of the Self (1971), in which he discussed the theory. The central tenet of self-psychology is an emphasis on a new interpersonal experience within the therapeutic relationship, and the development of the self requires empathy, mirroring, idealizing, and twinship.[9]

In the presence of these four, the self can then develop naturally through experiences in life, including disappointments and difficulties, and over time the healthy self will establish boundaries with others and differentiate. Deficits of the self can occur with insufficiencies in mirroring, idealizing, and twinship, and treatment focuses on supplementing these insufficiencies.

Clinical Significance

Psychodynamic psychotherapies provide a framework for understanding individuals from various considerations, with the overall goal of providing symptom remission, increased functioning, and greater fulfillment. These treatments can be used in concert with biological approaches to treatment and behavioral, social, and other treatment approaches.[84] Psychodynamic psychotherapies are tailored to understanding the person and their unique experience, in contrast to biological models, which seek to identify similar symptom clusters and associated etiologies and treatments.[85]

Medication management sessions that utilize psychodynamic psychotherapy techniques can often give providers a framework to understand the causes of resistance to treatment, negative reactions to medications, and other complicating factors in prescribing.[86][87]

Short-term vs. Long-Term Psychodynamic Psychotherapy

Modern psychodynamic psychotherapy has also taken different forms, which are often separated into Long-Term and Short-Term Psychodynamic Psychotherapies. Long-term psychodynamic psychotherapy is generally considered open-ended, whereas short-term psychodynamic psychotherapies typically last 12 to 15 sessions per treatment course and no greater than 40 sessions.[88]

Short-term psychodynamic psychotherapy is often focused on a specific presenting problem, and the practitioner strives to keep the psychotherapy focused on this specific problem. There are several models of short-term psychodynamic psychotherapy, including Time-Limited Psychotherapy, Short-Term Anxiety-Provoking Psychotherapy, Intensive Short-Term Dynamic Psychotherapy, Supportive-Expressive Therapy, and Brief Dynamic Interpersonal Therapy, among several others.[89]

ISTDP was developed by Habib Davanloo from the 1960s to the 90s. Davanloo initially developed short-term dynamic psychotherapy that he subsequently refined into intensive short-term dynamic psychotherapy through video recordings and study. The goal of ISTDP is to rapidly facilitate access to unconscious emotions by focusing on and overcoming resistance and defense. ISTDP has been studied in a wide variety of disorders and has also shown cost-effectiveness.[90]

Supportive-Expressive therapy (SE therapy) helps facilitate an understanding of relationship patterns within a therapeutic relationship. SE therapy has also shown benefits for various disorders, including depression, generalized anxiety disorder, opiate dependence, and cocaine abuse. Supportive techniques are used to strengthen the therapeutic relationship, and various interpretations are provided to increase the patient's self-understanding.[91] A Cochrane review of short-term psychodynamic psychotherapies has shown "modest to large" gains for several individuals and conditions.[92]

Evidence-based Medicine and Psychodynamic Psychotherapy

As noted earlier, psychodynamic psychotherapy is often criticized for having a limited evidence base.[93] Historically psychodynamic psychotherapies developed within siloed schools of thought and often eschewed the scientific process in favor of theoretical development through case studies and analysis.[94]

Evidence-based medicine developed from the work of three major influencers: Alexander Flexner, Archibald Cochrane, and David Sackett. In 1910, Flexner published a comprehensive review of medical schools in the United States, critiquing many schools' models of medical education using a variety of metrics. His fundamental notion was that physicians should be trained with a strong foundation in science and the scientific method.[95]

Later, Cochrane became interested in empirically studying and demonstrating treatment efficacy after he experienced ineffective treatment for his sexual dysfunction. He had pursued psychoanalysis for personal study and initial treatment of this dysfunction, which was later concluded to be likely secondary to tuberculosis or porphyria (or some combination thereof).[96] After this experience, he advocated for the necessity of randomized-controlled trials (RCT), cost-effectiveness, and the scientific approach to medicine. He conducted much of his work from the 1930s through the 1980s before passing in 1988.[96]

Beginning in 1981, Sackett, a clinical epidemiologist at McMaster University in Ontario, Canada, led a group that advocated for evidence-based medicine and scoring evidence by levels of strength. He also recommended the following key components of evidence-based medicine: "the patient's expectations and wishes, the provider's clinical skills, and the best available evidence."[97][98]

All three individuals contributed significantly to advancing science and medicine, along with greater effectiveness and public trust in medical treatments. However, psychoanalysis was marginalized in this era of empiricism due to the inherent challenges of studying it in an empirical setting. These challenges arose both from psychoanalysis' self-isolation from empiricism and the limitation that many of its hypotheses are unfalsifiable and challenging to prove or subject to an RCT.[99]

Cognitive-behavioral therapy (CBT), which originally developed from cognitive therapy (Beck) and rational emotive behavior therapy (Albert Ellis), provided more easily testable and falsifiable hypotheses and methods, which later demonstrated effectiveness in studies. As such, CBT and related therapies quickly gained traction as evidence-based treatments.[100][101] The development of psychodynamic psychotherapies led to similarly testable methods and hypotheses, and many subsequent studies and meta-analyses have since described its effectiveness in various conditions.[102]

CBT and psychodynamic therapy have been compared in head-to-head studies, many of which have shown positive results from both treatments. An RCT comparing CBT and short-term psychodynamic supportive psychotherapy conducted similarly to supportive-expressive therapy demonstrated no significant difference in outcome measures on HAM-D scoring.[103] Subsequent meta-analyses have shown similar efficacy between CBT and psychodynamic psychotherapy, with some authors suggesting that the effects of psychodynamic psychotherapy last longer and may even increase after the completion of treatment.[104]

Another study comparing panic-focused psychodynamic psychotherapy and CBT for panic disorder showed similar results between both. However, the earlier age of onset of panic disorder as well as a lower expectancy of the patient for meaningful change, predicted worse outcomes for both treatments, with panic-focused psychodynamic psychotherapy being more affected.[105] Further research remains underway and is required to substantiate psychodynamic psychotherapy as an evidence-based treatment.[106]

Psychodynamic psychotherapy has demonstrated neurological changes in specific brain regions, particularly the right superior and inferior frontal gyri and the putamen.[105] These are hypothesized to perform language functions and coordinate a wide range of neuropsychological processes. Other psychotherapies have also demonstrated similar changes in the brain, which may provide biological evidence for the effectiveness of psychotherapy and the common factors of psychotherapy.[105]

The transdiagnostic application of CBT modalities emerged from individual, diagnosis-based protocols. This movement led to the development of a Unified Protocol, interpreted as the end of CBT-centric psychotherapy and the resurgence of psychodynamic psychotherapies, with a de-emphasis on diagnostic stratification and increased emphasis on principle-based treatment.[107]

Enhancing Healthcare Team Outcomes

Modern-day psychiatric treatment often involves teams nested within larger systems.[108] Traditionally psychodynamic psychotherapy has been delivered as a physician-driven treatment; however, principles of psychodynamic psychotherapy can be used by all treatment team members to provide more comprehensive treatment. A nuanced understanding of a patient's underlying emotions, recurrent themes, unconscious behaviors, and team members' countertransference can augment treatment by providing more focused and patient-centered care.

Transference issues between provider and patient may influence interactions with other providers on the treatment team. Patients may view their treatment team as a surrogate family, which can be a conscious or unconscious process. Team members' awareness of the patient's family of origin and transference can provide context for a patient's differential reaction to individual providers.[109] Demonstrating a compassionate, unified front can provide the patient with a sense of unity and safety. To foster such an environment, each team member can benefit from gaining awareness of their own families of origin and how these experiences may influence their role and interactions within the team. Team discussions about and awareness of a patient's transference reaction can help inform future interactions with other team members. [Level 4]

The following case example may serve to illustrate these points: a patient, who was raised by an abusive parent, experiences a transference reaction towards their advanced practice provider (APP) as a similarly domineering and abusive parent. During the session, the patient appears curt with the APP, despite the prompt diagnosis, medication recommendation, and prescription. Both patient and provider remain unaware of the patient's transference. While at the pharmacy, the patient perceives the pharmacist as similar to their benevolent sibling from their family of origin, who was a strong support during the abuse. The pharmacist provides a list of common side effects for the patient during a brief medication education session.

The patient begins the medication and experiences similar side effects. Because of the initial negative transference to the prescriber, the patient experiences these side effects as "abuse" by the APP, and the patient feels unsafe discussing this with the APP, as they did with their abusive parent. Instead, the patient speaks with the pharmacist, criticizing the APP's decision-making and competence. The patient praises the pharmacist for warning about these potential side effects. Unaware of their countertransference reaction, the pharmacist feels flattered and unknowingly contributes to a split within the treatment team. Also unaware of the complicated emotional territory they are in, the pharmacist does not reach out to the APP and begins to question the provider's competence.

Over time the patient continues to privately devalue the APP and becomes nonadherent with the treatment. Since the patient does not disclose their misgivings about treatment to the APP, the prescriber is unable to address the emotional issues in the background. After several months the pharmacist becomes aware of the patient's nonadherence and attempts to confront it. The patient feels betrayed and isolated by the pharmacist's actions, perceiving this as their once-supportive sibling taking the side of their abusive parent. The patient subsequently attempts self-harm, leading to psychiatric hospitalization.

This case provides an example of the so-called "drama triangle," as first described in the 1960s by Stephen Karpman.[110] This triangle is derived from two psychoanalytic theories: transactional psychoanalysis, developed by Eric Berne in the 1950s, and thematic analysis, developed by Stephen Karpman in the 1960s. The triangle describes a complex transactional interaction between a persecutor, victim, and rescuer. In this case, the APP is the persecutor, the patient the victim, and the pharmacist the rescuer. To break this triangle, individuals within the triangle will need to develop self-awareness of their respective position and understand how unexplored transference/countertransference dynamics can lead to the perpetuation of destructive interpersonal dynamics.

In this case, the lack of awareness of transference and countertransference led to an adverse outcome and aided a lack of communication in this case. Earlier intervention at several points could have prevented this outcome. Attention to transference may have led to the APP focusing first on therapeutic alliance and addressing the transference before initiating medication. The pharmacist's recognition of their countertransference may have led to recognizing a split sooner, and in turn, the pharmacist may have reached out to the APP to collaborate openly. The pharmacist could then empathically facilitate a discussion between the APP and the patient. Pharmacists are essential intermediaries between patients and providers.[111]

APP could also have recommended therapy before starting the medication, where the patient's transferential reaction is explored. Many other team members can utilize these techniques, including psychiatrists, psychologists, social workers, nursing staff, case managers, sitters, front desk staff, concierge, and security staff. [Level 4]

Providing treatment that facilitates emotional expression from the patient can augment treatment effectiveness and outcomes.[112] [Level 2] Managing countertransference can also augment the effectiveness of treatment.[112] [Level 3] Also, team members who are attuned to each patient can better provide personalized care. Patients in various settings can induce strong countertransference reactions in providers.[113]

Awareness and management of these countertransference reactions can facilitate bonding between providers and patients, reduce confrontation and increase patient satisfaction. Consultation between providers about countertransference reactions can provide support for each healthcare team member, enhance an understanding of the patient and presenting issues, and facilitate a unified front.

Systems psychodynamics is another field that discusses psychodynamic principles and how they may apply in various systems. Systems psychodynamics combines the practice of psychodynamics along with group relations theory and perspectives on open systems; it was initially developed in the late 1800s and early 1900s using these developing theories and practices, with open systems theory having origins at least as far back as Plato's Republic.[114]

According to this theory, transference and defense mechanisms can interact between each individual in the organization and towards leadership, which can subsequently affect individuals in other parts of the organization. Unconscious processes can therefore impact others in a group. A proposed view of residential treatment from a systems psychodynamics approach has been discussed in the literature.[109]

In this model of care, each provider works individually with the patient and collectively as a group to deliver thoughtful, empathic care. Providers in this model include therapists, social workers, nurses, activity program managers, dietary staff, and support staff. This model has been proposed to help with treatment-resistant patients and has shown benefits in case studies. [Level 5]

Systems psychodynamics has also been used to help augment nursing students' experiences with preceptorship via an understanding of conscious personal and professional development as well as unconscious contributors to difficulties in taking on professional roles.[115] [Level 5] Psychodynamic approaches have also been proposed as an important and useful approach to understanding various psychological aspects of the COVID-19 pandemic on an individual, group, and systems level.[116] [Level 5]

Nursing practice that is informed by transference can help foster nurse-patient relationships. This has been primarily discussed in the context of psychiatric nursing and can also be applied to medical-surgical floors.[117][118][119]

There is evidence that psychodynamic psychotherapy may help reduce healthcare utilization and cost.[120] A study in Israel showed that the initiation of psychodynamic psychotherapy led to a 10% decrease in total costs and a decreased use of healthcare services, the latter of which was maintained for two additional years. Further study is required to establish a causal relationship.

Integration of psychodynamics and neuroscience has also been offered as a method to provide holistic and antireductionistic education to psychiatry residents.[121] Neuropsychodynamics is a related, emerging field that combines neuroscientific and psychodynamic approaches, thus providing a biological basis for psychodynamic treatment. A neuropsychodynamic approach to depression has been proposed in the literature.[122]

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