Dr. Thompson is associate clinical professor of psychiatry in the Department of Psychiatry at the UCLA School of Medicine in Los Angeles.
Acknowledgments: The author reports no financial, academic, or other support of this work.
Which patients suffering from anxiety respond to dynamic therapy and how does dynamic therapy effect change? Dynamic therapy can be uniquely helpful to selected patients with anxiety disorders who are often inadequately treated with medication or time-limited treatments. Psychodynamic insight-oriented treatment conceptualizes anxiety not as an isolated symptom, but as a “signal” indicating deeper, more enduring maladaptive character traits and internalized interpersonal reactive patterns. Anxiety is examined concurrently as the patient’s dominant preoccupations, concerns, and relational patterns are identified. Memories and emotions are explored, real versus fantasized dangers are clarified, and different interactive patterns offering more adaptive responses to current life challenges and opportunities are elaborated.
While Freud and other early psychoanalysts were fascinated by anxiety and other neurotic symptoms, the domain of the modern psychodynamic clinician is the study and treatment of personality. Today, insight is achieved not so much by the archeological search for deeply buried memories, but by attempts to understand personality. Personality, contributing to interpersonal relationships with aspects of desire, self-conceptions, views of others, and anticipations, is endlessly played out in interpersonal dramas of everyday life. These internal patterns of interaction, expectation, and defense typically only reinforce existing internal expectations and fears, often resulting in enduring anxiety.
The modern psychodynamic clinician recommends medication or time-limited cognitive-behavioral therapy for many types of anxiety. Yet, many anxious patients respond incompletely or not at all to medication or time-limited therapies. Numerous patients who are left with enduring anxiety inevitably find their way to psychodynamic therapy. There is no shortage of such patients, who come at personal expense, and apply hemselves to a treatment that requires time, commitment, and labor.
Clearly, not all patients will benefit from psychodynamic therapy. The challenge is identifying which ones will. Psychodynamic treatment has been woefully overprescribed in the past, and while a detailed description of patient selection for psychodynamic therapy is beyond the scope of this article, clinical experience and research would suggest that individuals with chronic maladaptive character traits and personality disorders can be greatly helped by psychodynamic therapy, whereas those with Axis I disorders cannot.
Systematic outcome studies of psychodynamic therapy have been difficult because of the complexity of variables inherent in psychodynamic therapy, the time and financial support necessary to conduct such studies, and a seeming lack of interest on the part of psychodynamic clinicians to develop and participate in such studies. In spite of these limitations, existing studies of psychodynamic therapy, comprehensively reviewed by Gabbard,1,2 suggest that it helps improve global functioning, decrease maladaptive character traits, and reduce the frequency of diagnosable personality disorders.3-8 Thus, insight-oriented therapy offers a viable treatment option when anxiety is interwoven with maladaptive personality traits and character patterns. Conversely, a patient who has no obvious personality difficulties, as evidenced by a healthy capacity to work, love, play, and interact, is likely to be more expediently treated with a time-limited treatment or medication.
How does the psychodynamically oriented clinician view anxiety? Anxiety is conceived of as the proverbial “tip of the iceberg.” Thus, anxiety is a barometer reflecting both temperamental and biologic vulnerabilities, but also complex, enduring inner struggles (eg, lack of inner harmony, anticipation of danger, evidence of deprivation, attachment struggles, or consequence of past trauma). Freud,9 who hypothesized that anxiety was the “signal affect,” posited that when a human being is faced with danger in the real world (eg, an enemy troop cresting the ridge), the individual has two options: flight (run with great urgency), or fight (reach for the nearest weapon).
Anxiety serves as a signal for inner, anticipated danger, which in turn activates an internal psychological response—the use of defenses or coping mechanisms.10-15 Once activated, defenses become the means to protect—a way to manage emotions, perceptions, impulses, desires, and, importantly, a way to deal with internal conflict surrounding significant objects in the individual’s internal world or current relationships.16 For instance, seeing one’s alcoholic mother realistically may be too painful; thus, the child subconsciously chooses not to see the mother’s brutality (denial). Should a friend ask the individual whether his mother has a problem with alcohol, the individual may transiently experience anxiety, which in turn activates a defense of denial. The individual shrugs off the question, minimizes the possibility suggested by the friend, and switches the topic to another subject. Any number of reflexive behaviors from simple to complex, whether changing the subject, leaving the room, having a drink, going for a jog, getting busy cleaning, or having an affair, can be defensive reactions.
How is anxiety addressed in the practice of psychodynamic therapy? First, anxiety must be examined in the context of the “company it keeps,” meaning anxiety does not occur in isolation and, thus, all of the patient’s words, concerns, and preoccupations must be considered in relation to how each might be related to the patient’s experience of anxiety. Freud’s notion of “psychic determinism” hypothesizes that every word, thought, and action has meaning. Free association, words, fantasies, thoughts, and particularly nonverbal communications, attitudes, anticipations, and desires, as expressed toward the therapist, are thought to tell a story. For example, the hopeful expectant look, the fearfully lowered eyes, or the angry sullen silence directed toward the therapist (transference) conveys information about the patient’s history. The story enacted in the transference relationship typically finds the same recurring conclusion. The sullen silence eventually arouses the therapist’s frustration and anger, yet at the same time, the patient’s internal narrative seeks a different ending. At some level, the patient hopes the therapist will not respond with anger and will care instead.
How does change in anxiety occur? The therapist offers a benign, empathic, nonjudgmental, supportive relationship and models and encourages curiosity regarding the patient’s feelings and thoughts, without attempting to confront, “reality test” away (discourage or minimize the patient’s perception of reality), or behaviorally negate any of the patient’s perceptions or feelings. The initial goal of dynamic therapy is to find emotional “room” for the patient to allow for and contemplate inner experiences that he or she may otherwise feel is too shameful or guilt-producing to touch. Gradually, a process unfolds where cognitions, visceral reactions, and responses become more available for consideration. As the patient’s ideas, feelings, and perceptions are shared, they can be gradually clarified. The following physician comments may indicate that the patient’s dominant concerns are initially identified: “you seem to be talking about your kids;” “you seem to be sad;” “you seem to be talking about how heartless people can be;” or “you seem to be upset.” Repeatedly clarifying that the patient has a particular feeling or is thinking about a certain topic, allows both the patient and therapist to ponder further.
As the clarification process occurs, attitudes and reactions toward the therapist become more apparent, and the therapist concurrently becomes more aware of his or her attitudes and feelings toward the patient. Wants, expectations, and fears gradually become articulated and tested in the therapeutic relationship. Old internalized interpersonal schemas (eg, rebellious child, angry retaliating parent, needy child, or indifferent/contemptuous parent) are replayed, relived, and hopefully experienced in less painful, maladaptive, and traumatic ways than previously enacted. Fearful anticipations can be addressed and different interactive patterns can be experimented with.
Old experiences often become strikingly clear both in content and in terms of internal persistence and power. For example, one patient always seemed anxious and fearful, particularly in the moment when the therapist began to make a comment. The therapist stated that he “thought the patient felt as if the therapist was going to attack him.” The comment startled the patient, who found himself instantaneously raising his arms as if to protect his face in anticipation of being hit. The patient then immediately recalled how his mother would slap him as a child, often when he would enter the kitchen after coming home from school, and he began to cry. With this incident, the patient saw with evident clarity how fearful he really was.17
Two broad elements of psychodynamic treatment contribute to change. First is the therapist’s interpretation of meaning, ideally in the context of felt experience like the above example (eg, you fear this, you anticipate this, you miss this, you want this). Second, is the noncondemning, empathic relationship, which vigorously attempts not to repeat past painful or traumatic interpersonal ways of relating. This is not easy, as the power of the patient’s expectations, the tendency to indirectly test, challenge, and ultimately sound out the therapist while always keenly anticipating and looking for the therapist to fulfill old frustrating and disappointing patterns, often perpetuates this cycle.
The focus of psychodynamic therapy is the stuff of life, the drama of interpersonal and familial experience, that always occurs in the context of temperament, biologic givens, and one’s own unique developmental experience. These are the concerns of life that are reflected in literature and art. This may be the deprivation of childhood that results in the bitterness and stinginess of Charles Dickens’ Ebenezer Scrooge.18 Or, for example, this may be the toddler’s traumatic life experience who, from a helpless position, witnesses his mother’s death by asphyxiation from tubercular hemoptysis, who is ever after left with a preoccupation with death, dying, and the living death. Thus was the life experience of the writer Edgar Allen Poe, as delineated by Terr,19 which apparently led to his adult preoccupation and repetitive expression in his creative works.
The terrors and fears of human life become woven into the fabric of an individual’s psyche. The goal of psychodynamic therapy is to confront these fears in the light of the present, and in the context of an empathic, desensitizing, and understanding relationship. Decreasing enduring anxiety typically requires time and patience. On occasion, an insight may offer immediate and sustained relief. For instance, an otherwise high-functioning professional woman who was normally mildly anxious, would become intensely anxious, to the point that she would be unable to sleep, when her husband was away on business trips. Through psychodynamic therapy, it became clear that being alone activated ill-defined fears that touched an old traumatic experience where, when alone in the middle of the night as a college student, the patient’s apartment was entered by a stranger and she was raped at knifepoint. As this old trauma was talked about and related to her current situation, her anxiety diminished and she was able to sleep in her husband’s absence.
More typically, as illustrated in the following case, anxiety is not relieved so quickly and simply. A married, 35-year-old mother of two came to therapy complaining of an ill-defined sense of malaise and chronic anxiety. After several months of therapy, she began to share a series of erotic fantasies about several male coworkers. She deemed these fantasies as unacceptable, yet could not help thinking about how appealing these men were. She became more and more anxious, worrying whether she could contain her desire, which made little sense to her as she thought she was in love with her husband, in spite of having been irritated with him recently for unclear reasons.
In the therapy sessions she also appeared increasingly anxious, but simultaneously seemed to flirt with her male therapist. She commented on his attractive style of dress, his tie, and wondering out loud how much fun he must be to be with. The clinician made a tentative comment that she seemed to find her therapist appealing but that at the same time she seemed anxious, and he wondered if this attraction and her anxiety were somehow related. At this remark, the patient appeared visibly more anxious and changed the subject. At the next visit, she reported several elements with little conscious awareness that they might be interrelated. She talked of recent anger with her husband after he approached her sexually and wondered why she felt so intensely about this interaction. She delineated a series of sexual inhibitions she had struggled with for many years—something she had not discussed previously. She then related a memory that she noted she had not thought of in 15 years. The memory was of her father, lying in her bed on a camping trip and fondling her genitals. The memory was evidently distressing to her as she relayed the incident.
While somewhat more dramatic than many memories that surface in the context of therapy, this sequence is fairly typical of interpersonal patterns, anxiety, and memories that become alive and more accessable in insight-oriented therapy. Latent feelings, desires, and fears are rekindled, in part by the proximity of the therapeutic relationship. Certain patterns are activated and addressed, resulting in reappearance of old memories that enlighten the current dilemma. Yet, retrieval of memories alone is usually insufficient for change to occur. For this patient, retrieval of the old disturbing and traumatic memory was only the beginning. Previously, she had idealized her father, who had since come to a sudden and traumatic death.
In her relationships with men, she was often flirtatious, deferential, yet silently angry and self-defeating. She compulsively played out a pattern where she was subtly sexually provocative and would toy with the idea of an affair, yet never followed through, and ultimately felt guilty, anxious, and remained sexually inhibited. The memory described above marked a turning point for her, as her disappointment with her father and with men in general, began to crystallize, and her sexualized, yet self-demeaning pattern of interacting could now be examined openly.19 These patterns with her therapist were enacted with twists and variations as she both mourned the absence of a more supportive and nonabusive father, and experimented with different and more assertive ways of interacting in the context of therapy, with a concomitant decrease in her anxiety. In the process of therapy, the patient discovered feelings, memories, attitudes, and anticipation that heretofore she was only marginally aware of.
In dynamic therapy, the process of discovery occurs repeatedly before awareness of feelings, memories, and inner reactive patterns become fluid and can be accessed with ease. This repetitive process is the work of therapy, allowing for a gradual desensitization of old fears and concerns. Sorting out fantasized dangers from the real dangers of life and ultimately facing the true dangers is an important goal of psychodynamic therapy. An anxious patient may obsess about the risk of contracting acquired immunodeficiency syndrome, which may be a completely unrealistic danger for him. Yet, he may still need to face the true risk—that of being rejected and hurt, should he ask a woman out on a date. Life presents real risks that must be faced to handle adaptive living of life. Dealing with enduring psychological patterns and fears is a daunting task. Psychotherapy cannot undo all traumas and cannot always provide what has been neglected. Nevertheless, dynamic therapy can help in important ways to understand and offer patients a more benign laboratory for new experiences and opportunities to live life in less fearful and less maladaptive ways. PP
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