What is the treatment approach and regimen for psychodynamic psychotherapy?

Psychodynamic Psychotherapy: Treatment Approach and Regimen

Psychodynamic psychotherapy should be delivered as either time-limited (11-30 sessions) or long-term open-ended treatment, with frequency ranging from once weekly to 4-5 times weekly depending on severity, using a biopsychosocial formulation that integrates psychoanalytic theory to address unconscious conflicts, maladaptive defenses, and relational patterns through the therapeutic relationship. 1

Treatment Framework and Theoretical Foundation

The clinician must formulate a psychodynamic understanding by integrating biological data (genetics, temperament, physical development), psychological data (developmental history, emotional development, personality style, defenses, object representations), and sociological information (family dynamics, peer relations, school functioning, cultural traditions) using psychoanalytic theories including ego psychology, object relations theory, attachment theory, and self psychology. 1

Treatment Spectrum: Supportive to Expressive Modalities

The therapist selects interventions along a spectrum from supportive to expressive based on the patient's psychological capacities and pathology. 1

Supportive Interventions

• Build on existing strengths through encouragement, suggestions, and education 1
• Facilitate development of impulse control, frustration tolerance, affect regulation, and capacity to reflect 1
• Appropriate for severely organically impaired patients, significant mental retardation, psychosis, severe pervasive developmental disorders, and severe conduct disorder without guilt or remorse 1

Expressive Interventions

• Address unconscious conflicts, traumatic memories, maladaptive defense mechanisms, and transference distortions 1
• Aim to rework conflicts, lift unnecessary inhibitions, develop flexible thinking and fantasy access 1
• Increase expression through play and words rather than impulsive actions 1
• Contraindicated for the severe conditions listed above 1

Treatment Regimens

Time-Limited Psychodynamic Psychotherapy (STPP)

For most common mental disorders, time-limited treatment of 11-30 sessions delivered weekly is effective and shows sustained improvement at follow-up. 1, 2

• 11-week combined individual and parent-focused therapy for internalizing disorders shows sustained effects at 2-year follow-up with reduced comorbidity and less frequent mental health service use compared to treatment-as-usual 1
• 24.7 sessions (mean) for major depression and dysthymia in children/adolescents ages 9-15, with 100% no longer clinically depressed at 6-month follow-up 1
• Up to 30 sessions for sexually abused children focusing on transforming trauma experience into memory, with significant symptom reduction and improved relatedness 1
• 45 weekly sessions for toddlers of depressed mothers targeting self and maternal representations, achieving secure attachment equal to toddlers of non-depressed mothers 1

Long-Term Open-Ended Therapy

For complex cases with entrenched conflicts, developmental interferences, and maladaptive personality traits, long-term open-ended psychodynamic psychotherapy is indicated with mean treatment duration of 14 months or longer. 1, 3

• Both frequency and length are critical outcome factors 1
• Children with severe emotional disorders (three or more Axis I diagnoses) show symptom relief and return to non-clinical classification 1
• Continuity of care is essential, with treating clinicians remaining constant for at least the first 18 months 3

Frequency Considerations: A Critical Variable

Higher frequency sessions (4-5 times weekly) produce superior outcomes compared to once-weekly sessions, particularly for children under 12 years and those with conduct problems. 1

Evidence for Frequency Effects

• Children seen 4 times weekly versus once weekly showed equal improvement in reading/spelling initially, but at 18-month follow-up the higher-frequency group demonstrated: 1

  • Higher self-esteem and greater capacity for appropriate peer relations
  • Freer expression of wider variety of affects
  • Greater autonomy and assertiveness
  • Greater capacity to reflect about behavior and motives
  • More balanced, flexible, and mature defense mechanisms

• Children with conduct problems respond poorly to once- or twice-weekly therapy but with greater frequency do almost as well as children with emotional difficulties of equal severity 1

Combination Treatment Approach

When indicated, combine individual psychodynamic psychotherapy with group therapy, family therapy, or psychopharmacology within a biopsychosocial model. 1

Adjunctive Treatments

• Group psychotherapy for difficulties with peer relationships 1
• Family therapy for family dysfunction 1
• Medication adjunctively to relieve symptoms and facilitate ability to work in therapy, targeting symptoms while psychotherapy facilitates healthy character development 1

Critical Medication Considerations

• Account for meanings the child or family may assign to taking medication 1
• Medication and psychotherapy require different timeframes to reach maximum effectiveness 1
• Common pitfall: Parents may discontinue treatment prematurely when medication relieves symptoms before underlying issues are resolved in psychotherapy 1
• Address nonadherence due to fear of drug addiction or safety concerns through collaborative alliance with parents 1

Indications and Patient Selection

Psychodynamic psychotherapy is not diagnosis-specific but is effective for internalizing disorders, mild-to-moderate externalizing disorders, developmental character difficulties, and maladaptive responses to life events. 1

The treatment addresses underlying psychological functions, making it particularly helpful in complex cases. 1

Potential Complications and Management

Transitory deteriorations (regressions) in functioning may occur, including acting-out behaviors or exacerbation of parent-child conflict. 1, 3

Relationship Complications

• Excessive dependence of parents on therapist 1, 3
• Threats of treatment disruption if parents feel criticized or resent therapist's close relationship with child 1
• Management strategy: Consultation with colleague or obtaining second opinion in difficult cases 1

Training Requirements

Psychodynamic psychotherapy requires training in psychodynamic theory and techniques, with knowledge of child development and various psychodynamic theories (ego psychology, object relations theory, attachment theory, self psychology). 1

Clinical experience should be acquired under supervision, optimally including children of both sexes in various developmental phases and with various psychopathologies. 1

Evidence Base and Comparative Effectiveness

Meta-analyses demonstrate that psychodynamic psychotherapy is superior to control conditions and equivalent to established treatments including cognitive-behavioral therapy, with robust within-group effect sizes (g=1.07) that increase at follow-up. 4, 2, 5, 6

The average treated patient is approximately two-thirds of a standard deviation better off than the average nontreated patient, with effects maintained or increasing over time. 1, 2