What is Psychodynamic Therapy?

There are three main orientations of the psychological treatment model for borderline personality disorder, namely psychodynamic orientation, cognitive-behavioral orientation and supportive psychotherapy orientation. Representatives of psychodynamic orientation are Kernberg, Akhtar, Gunderson, M Balint, Seales, Kohut, Fonagy, etc .; representatives of cognitive-behavioral orientation are Linehan, LS Benjamin, A Ryle, Jeff Young, Klerman / Weissman, A Beck & A Freeman, etc .; and the representatives of supportive psychotherapy are Arnold Winston, Larry Rockland, R Wallerstein, Henry Pinsker, etc. Evidence from evidence-based medicine is currently sufficient. Efficacy research evidence focuses on psychodynamic and cognitive-behavioral approaches.

Although many psychiatrists currently follow the habitual use of drugs to treat personality disorders, this operation actually lacks sufficient evidence-based medicine. Soloff et al. Proposed that drug treatment can control patients' anxiety, impulsivity, and psychotic symptoms. There is no evidence that drug treatment can improve overall personality function. (Soloff, 2005)

In addition, borderline personality disorder has poor adherence to drug treatment and high dropout rates are important issues facing psychiatrists. A six-year prospective study found that irrational medications for patients with personality disorders are widespread and used by 40% of patients. More than three major psychiatric medications, 20% use more than four major medications, and 10% of patients even use more than five psychiatric medications. Researchers believe that psychiatrists do not rationally use medications to prevent patients from falling out. And the main reason is to persuade patients to take medication for a long time because of the fear of recurrence. The problem, Bateman believes, is that doctors are caught in countertransference, and prescribe drugs to save the countertransference into action. This problem may also help patients resolve insecurities, improve medication compliance, and resolve the doctor's own countertransference through kinetic therapy. (Bateman, 2004; Zanarini, 2004) ^[1]

Psychodynamic psychology emerged in the 1920s, focusing on the psychological perspectives of studying the motivation and motivation of behavior.

Due to the influence of physiology in the 18th and 19th centuries, German psychologist Feng Te focused on the study of perception and did not pay attention to the dynamic aspects of psychology. However, because evolution theory emphasizes the organism's adaptability to the environment and its driving force, and Freud's motivational role that attaches importance to human behavior, people have gradually become interested in the field of motivation.

Historically, dynamic psychology generally refers to Woodworth's psychology. He is a generalized functional psychologist with a particular interest in the driving forces of behavior. He said in 1896 that he would develop a "motivational science." In 1918 he published the book "Psychology of Psychology", and wrote two papers in 1925 and 1930, giving a clear exposition of dynamic psychology. In 1958, he published the book "Behavioral Dynamics".

Woodworth opposes Tiechenner, Watson and Mai Dugu's bias, and strives to understand the causal mechanism of human consciousness and behavior and the dynamic stimulus or situation that determines the driving force. He put forward the concepts of mechanism and drive in an attempt to explain all human activities. He believes that the mechanism is the external behavior mode that satisfies the driving force, and the driving force is the internal condition of the mechanism.

For behavior, the mechanism is to answer the "how" question; the driving force is to answer the "why" question. The two can be transformed into each other. The mechanism was originally stimulated by external stimuli and continued to move without the need for motivational supplementation, which could itself become a driving force. For example, the mechanism for seeking food can be directly converted into the motivation for seeking food. In this way, habits can be turned into interests.

Pauling devoted a chapter to dynamic psychology in his revised edition of A History of Experimental Psychology. He believes that although dynamic psychology is not a school, it includes many schools. He listed Freud's psychoanalytic school, Mai Dugu's teleological psychology or motivational psychology, Holt's so-called Freud's desire, Tolman's teleological behaviorism, Lewin's topological psychology , As well as Murray s Harvard Psychological Clinic Group and Hull-led Yale System. He also acknowledged that Woodworth should be the pioneer of dynamic psychology.

Pauling also pointed out that any psychology that cares about human nature and personality can be included in dynamic psychology. In this way, modern neo-psychoanalysis, and the humanistic psychology that later emerged in the United States, should be included. The scope of dynamic psychology is indeed very broad.

Motivation is probably one of the most important functions of human beings. Although it has attracted the general attention of western psychologists, there has been a lack of systematic research.

Many modern psychologists studying study, perception and personality have realized that the decisive role of motivation should be valued, but they are still limited to theoretical discussions of individual motivations or minor motivations. Research on the neural mechanisms of motivation has also made some progress. In general, it is difficult to establish a scientific general theory of motivation because it fails to delve into the social and historical nature of motivation. ^[1]

In the field of psychodynamics, there are currently two therapies supported by strong evidence-based medicine (randomized controlled trials), mentalization-based treatment (MBT) and transference-focused psychotherapy (TFP) ), They have both undergone manual work on therapies and randomized controlled trials. MBT has completed randomized controlled trials and the research results have been published. The research report published by TFP is only a case-control study. The results of randomized controlled trials are under review. However, according to the information obtained from the private communication, the results support TFP's effect on borderline personality disorder Effectiveness. (Bateman et al, 1999, 2001, Clarkin et al, 2001)

Empathy focus therapy

Transference focused therapy is a kinetic therapy that is mainly used in the treatment of personality disorders invented by Kernberg. Its initial name is expressive psychotherapy. Later, in the 1990s, Clarkin et al. Systematically and manually treated this therapy, facilitated clinical operations, and renamed it empathy focus therapy, and conducted efficacy studies. From the perspective of clinical application, it is divided into four parts: basic theory, overall treatment strategy, treatment tactics, and treatment technology. The basic theory is mainly Kernberg et al.'S psychoanalytic theory of Borderline personality organization (BPO) and related theories of psychiatry. Strategies of treatment are strategies related to the framework of the entire treatment course. The tactics of treatment are the treatment strategies for each meeting time. The techniques of treatment are the techniques used in the dialogue between the therapist and the patient.

Personality structure is divided into three types according to identity diffusion, reality testing ability, and the extent to which the original defense mechanism exists:

1) Neurotic personality structure (NPO): stable identity, good ability to test reality, the original defense mechanism does not occupy the main position, mainly because the defense mechanism is based on depression. More common in hysteria type personality disorder, obsessive-compulsive personality disorder, and depression (abuse) personality disorder.

2) Marginal Personality Structure (BPO): Diffusion of identity can maintain a certain reality test ability, but the reality test ability loss may occur under stress conditions, and the original defense mechanism is mainly. Including marginal personality disorder, narcissistic personality disorder, split-like and split personality disorder, paranoid personality disorder, performance personality disorder, anti-social personality disorder and dependent personality disorder.

3) Psychotic personality structure (PPO): Except for the loss of ability to test reality, other characteristics are the same as BPO, including patients with severe mental illness such as schizophrenia.

The psychopathological principles of TFP related to BPO patients are briefly summarized as follows:

1) The early traumatic experience caused neurochemical changes in patients, mainly the imbalance of the neurotransmitter system. This makes it easy for patients to activate aggressive and depressive emotions, as well as to be overly sensitive to certain stimuli. These biological changes cast a temperamental basis for patients, and on this basis, the aggressive object relationship between patients and important caregivers was internalized, forming the body and object appearances of BPO patients.

2) The internalized object relationship of aggressive perfusion determines the patient's pre-Oedipal fixation, and mainly uses primitive defense mechanisms such as division and projective identification to protect the self-object from aggressive damage. During the process of psychological development, the symptoms of diffuse identity gradually formed.

3) In this scene here and now, the patient repeatedly internalizes the pathological object relationship, which causes difficulties in interpersonal relationships. Especially in the empathy relationship with the therapist, through the therapist's treatment of empathy, the patient can integrate those psychological components that are split or projected out, so as to recover.

Treatment strategy

The overall goal of TFP therapy is to focus on the resolution and integration of identity diffusion and primitive defense mechanisms. This is mainly through identifying and repairing the original components in the empathy scenario, so that patients gradually integrate and form a normal identity.

This goal is ensured through 4 strategies throughout the treatment process:

1) Strategy 1: Define the main object relationship

This strategy consists of 4 more steps:

The first step is to experience and endure the confusion of the patient's inner world as shown in the empathy;

The second step is to identify the main object relationships.

Ten typical patient-therapist empathy pairs are summarized in the TFP's operation manual, which are--

Destructive bad children-punitive, abusive parents; controlled, irritated children-controlling parents; children whom nobody wants-unconcerned, self-centered parents; defective, Worthless children-parents who look down on others; abusers-abusers; abusers-attackers, rapers; deprived children-selfish parents; runaway, angry children -Incompetent parents; naughty, sexually excited children-castrated parents; dependent, contented children-doting, admiring parents.

The third step is to name the actors in the object relationship.

The fourth step, pay attention to the patient's response

2) Strategy 2: Observe and explain the reversal of patient roles

3) Strategy 3: Observe and explain the pairs of opposing object relationship pairs. If the relationship between the patient and the therapist is sometimes "dependent, contented child-doting, admiring parents", and sometimes the "abuse-abuser attacker" relationship, this needs to be explained The relationship between the two matching modes.

4) Strategy 4: Integrate and split out some objects

The whole strategy is to achieve its goals through repeated treatment interventions.

There are six indicators of patient integration: (1) the patient's statement is an extension or further exploration of the therapist's interpretation; (2) can tolerate or tolerate when aware of hatred; (3) can tolerate fantasy, And open excess space. This is mainly reflected in the fluency of free association; (4) the ability to tolerate and integrate the interpretation of primitive defense mechanisms, especially projective identification; (5) the pathological exaggeration of self-empathy; (6) the main empathy paradigm The transfer.

Treatment strategy in a single meeting

That is treatment tactics. Includes 7 strategies.

1) Select a priority theme.

Every conversation requires attention to the priority of the crisis. You can filter based on the subject priority list in the manual. (See Table 1) When explaining these topics, adhere to the principles of three interpretations, namely:

First, economic principles. The attention and interpretation of treatment should be directed towards the dominant emotions.

Second, the principle of motivation. Consider the power of conflict in the mental system and how they manifest themselves in object-relational pairs. Decide the order of explanation, from shallow to deep, from defensive explanation to motivation explanation to impulse explanation.

Third, structural principles. Comprehensively review the relationship patterns in the main object relationship pairings in the patient's mental system; focus on explaining the structures involved in defense and impulsivity. For the neurotic, these structures are the self, the ego, and the superego; for the marginal, these structures are a form of object relationship pairing that is less clear than the neurotic.

2) The framework of protective treatment: removing secondary benefits and setting limits

The therapist should be careful not to allow the treatment framework to strengthen the secondary benefit of the patient, which is mainly accomplished through the treatment contract in the early stage of treatment. When the patient appears to be assisting, the therapist will explain first, and if the explanation is invalid, a limit will be set.

3) Technical neutrality and its limitations

The therapist exists as a neutral observer, close to the patient's observational self. However, neutrality cannot be maintained in the context of crisis and supportive actions, and restrictive measures need to be taken before returning to technical neutrality.

4) After elaborating the distorted views, then intervene in the common elements of shared reality events.

5) Analyze positive empathy and negative empathy.

6) Analyze the original defense mechanism.

7) Use countertransference.

In a single meeting of the TFP, the therapist also needs to follow two basic principles: 1) the patient decides what the conversation is, the therapist does not set the schedule himself; 2) the therapist pays attention to the therapist's reference Content.

Theme priority ranking table:

1. Topics that prevent empathy exploration

a. Threat of suicide or murder

b. Significantly interferes with ongoing treatment events (such as financial difficulties, preparing to leave the place of residence, requiring less frequent treatment)

c. Disrespectful or intentional speech is reserved. (Such as lying to the therapist, refusing to discuss certain topics, silence during most of the treatment)

d. Break the treatment contract. (If you agree to meet the therapist without going, do not take drugs)

e. Supportive actions during the meeting. (Such as destroying the treatment room equipment, refusing to leave the treatment room at the end of the treatment, roaring)

f. Supporting actions between meetings

g. Non-emotional topics or trivial trivia

2. Obvious empathy

a. Oral discussion involving therapist

b. Supportive actions in the heart (such as poses of obvious seduction)

c. Implied therapist (if referring to other doctors)

3 Non-emotional, less emotional topics

Therapeutic techniques during the talks

During the treatment process, pay attention to the patient's three main channels to communicate with the therapist: 1) verbal communication; 2) non-verbal communication; 3) the therapist's anti-emotional. BPO patients communicate mainly through the latter two channels.

The basic analysis technique is still three steps: clarification, confrontation and interpretation. Interpretation should be carried out in the context of clarification, and follow the aforementioned economic principles, dynamic principles and structural principles to ensure the pertinence of the interpretation. The depth of explanation is divided into three levels--

The first layer explains how put into action and primitive defenses are used by patients to avoid awareness of the inner experience; the second layer explains the current, active object relationship. Describe the self and object appearances and the reversal of roles in the pairing; the third layer explains what kind of object relationship the currently activated object relationship is used to defend against.

The following aspects need to be paid attention to during the explanation process: 1) early interpretation of empathy; 2) explanation of the lack of patient awareness; 3) description of conflicts; 4) confrontation and explanation of contradictions between various communication channels; The meaning of the explanation given to the patient by the teacher; 6) Evaluate the effect of the explanation.

In the process of interpretation, the therapist assumes the role of active interpretation, actively clarifies, confronts and explains, while paying attention to maintaining neutrality and avoiding role deviation. TFP's role as a therapist is also characterized by the lack of supportive treatment techniques for patients. This is because it is believed that such techniques undermine the effectiveness of the transference-anti-transference work and lead to counter-transference assistance actions.

Treatment stages and summary

The entire treatment process is divided into the following stages: assessing the patient, signing a treatment contract, early treatment, mid treatment, and late treatment.

Patients were assessed at two levels, symptom and personality structure. Conduct a psychoanalytic structured interview. There are two components to signing a treatment contract, one that is universally applicable to all patients, and one that is specific to certain behaviors. The treatment frequency of TFP is to meet twice a week. The initial stage of treatment is mainly the therapist's tolerance and treatment of the patient's impulsive behavior. Mid-term treatment often focuses on the interpretation and management of love and sex. Part of the object was repaired in the later stage of treatment. The end of treatment is mainly the management of separation anxiety. At this point, TFP therapists begin to diagnose and manage separation anxiety early in treatment. At the same time, a feature of TFP is not to desensitize patients to the end of treatment by reducing the frequency of treatment, but to maintain the original frequency until the end of treatment. ^[1]

Mentalization-based therapy was invented by Fonagy et al. In the late 1990s. It used to be "psychoanalytical partial hospitalization". After completing its manual treatment and randomized controlled trials, it was renamed as psychological basic therapy.

The goal of MBT treatment is to improve the patient's mentalization. Psychological function refers to the ability of a person to consider the mental state of himself and others, and to be aware that the mental state of himself and others is independent and affects each other. Treatment includes improving psychological functions, tolerating the patient's deficiencies, using empathy, maintaining psychological closeness, and dealing with the current psychological state and other components.

Basic theory

The basic theory of MBT has three basic concepts: psychological equivalence, pretend mode, and mentalization. These three concepts represent the three psychological modes that appear in turn in the process of infant psychological development.

In the mode of spiritual equality, human beings will equate external things with internal experiences, without experiencing their differences. In the camouflage mode, people will completely dismantle external things and mental states, without experiencing their continuity, and some mental states will be separated from other mental parts. In the spiritual equality model, the experience becomes too authentic and drowns people. In camouflage mode, the experience becomes too unreal, separated and isolated. In the former, people are overwhelmed by emotions, experience too much, and patients experience a sense of fragmentation in themselves; in the latter, they experience too little, become rigid, become stuck in the stability of hallucinations, and lack meaning. , Connection, dialogue and flexibility.

The integration of these two models produces a psychological model in which thinking and feelings can be experienced as appearances, and internal and external reality can be seen as both interrelated and separated from each other, rather than either Equalize them completely, or separate them completely. Psychological function requires people to understand the meaning of various psychological states such as desires, behaviors, and emotions of themselves and others, be able to distinguish psychological events, and reflect on the psychological states of themselves and others. This ability is acquired in the first few years of a baby's life and needs to be acquired in the context of a secure care relationship. The emergence of psychological models requires parents of infants to be able to provide complete attachment and interactive transition space. (Fonagy, Target, Gergely, & jurist, 2002)

Psychological ability and its dependent background are the foundation of its own structure. Only in the mirrored and interactive subjective interactions with parents can babies have the opportunity to "observe" themselves, thereby forming and recognizing the inner state and starting symbolic representation process. (Gergely & Watson, 1999) The baby will internalize the caregiver to form its own appearance. If the caregiver is full of anger, hatred and fear, the baby will internalize these parts of the caregiver to form an "alienated self" ( alien self). (Fonagy & Target, 2000) Alienation itself will be rejected by its own structure, because it is persecution. In this process of rejection and alienation, alienation will experience the external world as persecution. Because alienation itself is experienced as external. The existence of alienation, destabilizing self-structure, and the effects of childhood trauma and other factors have caused borderline personality disorders in adulthood.

The core problem of borderline personality disorder is the loss of psychological function, which leads to the lack of cognitive and emotional functions. People with borderline personality disorders need to act to repair their psychological functions and create a sense of self-cohesion. Action is a way to protect the fragile self from continuous and internal attacks and persecution. The patient must externalize this sense of shame and threat to form an aggressiveness to the external object, otherwise suicide is the way he can choose to save himself. Alienation itself is projected outward as part of others. Attacks on others express patients' hopes for reorganizing their structures. When the external interpersonal relationship changes, especially when the separation situation occurs, the alienation itself returns to its own structure, again threatening the stability of its own structure. (Bateman et al, 2004)

treatment method

MBT's psychotherapy setting is twice a week, once for 50 minutes for individual treatment, and once for 90 minutes for group treatment.

In the MBT treatment model, the therapist is required to remain more open and cooperative. The therapist must be what the patient needs him to be, that is, the vehicle of alienation, and at the same time, the therapist must maintain his own clarity and stability, maintaining a balance between the two. Psychological gesture of the therapist. (Bateman & Fonagy, 2003) The therapist keeps the focus on the psychological function by asking the psychology-oriented questions. These questions are often "why do patients say this now?", "Why do patients do this?", " What did I do to explain the patient's current status? "," Why do I feel this way now? "," What happened in the recent treatment relationship to explain the current status? "Etc. This technique runs through the entire treatment process. In group therapy, the therapist encourages the patient to consider the mental state and motivations of themselves and others. Rather than pursuing complex unconscious motivations with patients, therapists use "folk psychology" to help patients understand interpersonal communication in daily life. Researchers believe that even for professional clinical psychologists, people's psychology is mainly used instead of scientific psychology in treatment. (Allen & Fonagy, 2002) MBT focuses on the current psychological process, not the present and past psychological content. Current emotions are calibrated, identified, and explored in the context of interpersonal relationships. The therapist needs to perform the same psychological process on his countertransference in time, rather than put it into action. Therapists cannot presuppose that patients with borderline personality disorder have the ability to deal with conflicts, express emotions through verbal language, use metaphors, refrain from actions and reflect, but therapists are often confused by the intelligence of people with borderline personality disorders. Make a wrong assessment of their capabilities. Once the attachment system is activated, the patient's psychological ability becomes worse. Therefore, the therapist should pay attention to the psychological defects of the patient during the treatment.

Unlike TFP's focus on empathy interpretation as a treatment focus, MBT does not focus on explaining empathy in the first place. The idea is that patients must first establish a safe dependency relationship with the therapist before the projection of alienation itself occurs. Fonagy et al. Believe that the interpretation of empathy is equivalent to allowing the patient to understand another person's point of view. The interpretation of empathy is gradually carried out according to the degree of anxiety of the patient. Premature and direct empathy explanation will make the patient return In camouflage mode. This is different from the style in which TFP explained positive and negative empathy from the beginning.

The focus and main tool of MBT's work is not empathy, but retaining mental closeness. Maintaining psychological closeness is accomplished by accurately presenting the patient's emotions and internal appearances, while avoiding talking about events unrelated to the patient's beliefs, expectations, and emotions. The main task at the beginning of MBT treatment is to stabilize the expression of emotions, and to achieve the purpose of controlling emotions and impulsivity by identifying and expressing emotions. The therapist must be able to distinguish between one's own emotions and those of others, and be able to explain the difference to the patient. The therapist's own emotions cannot be attributed to the patient and explained as such. This repeats the patient's traumatic process, which is to internalize the caregiver's experience as a dissident.

MBT opposes focusing on the past. It believes that this will put the patient into a mode of mental equality or camouflage, confusing the difference between the past and the present. It does not bring the benefits of the treatment, but there is a great risk. Therefore, the treatment dialogue emphasizes the present moment The events here are only concerned with the impact of the past on the present. If the patient keeps remembering the past, the therapist will pull the patient from the past back to the present.

MBT believes that the process of interpretation is the core of the treatment, and the content of the explanation or the style of support is not the core of the treatment. For people with borderline personality disorder, premature and clever interpretation by the therapist will induce camouflage. Mode, thus starting "false treatment". The content of external interpretation is only a tool, and the process of internal interpretation is the true value of treatment.

Psychologizing, according to Fonagy, integrates the physio-psychological processes described by other terms such as empathy, comprehension, self-observation, and introspection. Researchers believe that psychology is the foundation of all effective psychotherapy. ^[1]

The psychoanalytic school has a rich summary of clinical experience in treating borderline personality disorders. These clinical experiences can be traced back to Freud's research on patients with so-called "hysteria" at the time. Some patients in his work Hysteria Study may be borderline personality disorder. Since the 1960s, works on the treatment of marginal personality have been in the psychoanalytic literature. By the 1980s and 1990s, four models of dynamical schools of borderline personality disorder had been presented. .

Kernberg's model

Kerngberg's model, as previously described, evolved into later empathy focus therapy, a model that integrates Freudian and object-relational ideas and techniques.

Apparent defect / self defect model ^[2]

What kind of borderline personality disorder is suitable for various therapies

A solution in this regard may be to achieve the possibility of dialectical treatment through the quantitative evaluation of the patient's dependence model, reflective function, and primitive defense mechanism.

Active ingredients in various composition techniques of each therapy

Manual approach

Although TFP and MBT to some extent solve the problems that have plagued the operability of psychoanalysis for many years. However, its operability is still not comparable to DBT and SFT. It takes a long time for the therapist to master the technology, and it is basically impossible for patients to go home for self-help treatment like DBT or SFT. How to further improve the operability of its technology and reduce the learning cost of such technology is still a problem that the psychological dynamics school faces.

How to verify its basic theory

It is also a problem faced by psychodynamic therapy. Although the emergence of neuropsychoanalysis in 1999 has opened up a path in this area, the current research results in this area are still very limited, and whether it can become the discourse paradigm of the psychoanalytic community also has many controversies and resistances. ^[1]