Psychoanalytic Contributions to Psychodynamic Psychiatry and Psychotherapy: Erik Erikson's Psychosocial Developmental Theory.

Erik Erikson gives us a comprehensive psychosocial schema encompassing the life cycle from birth to death. In elucidating key issues at each life stage-the epigenetic crises-he defines important parameters of development that distinguish between the normative and the pathologic. Individuals at any developmental stage can be evaluated with respect to these fundamental milestones.

Psychoanalytic Contributions to Psychodynamic Psychiatry: Freud's Anxiety Theory.

In many academic centers a generation of psychiatrists has undergone training with little or no exposure to Freud's contributions to our profession. Our profession is diminished if we ignore Freud's remarkable insights into the human psyche. Not only does Freud give us a comprehensive theory of human nature-of our mental life and its psychopathology-his concepts are foundational to dynamic psychiatry and its psychotherapeutic application. This article describes one of his core concepts: Freud's theory of anxiety.

Psychoanalytic Contributions to Psychodynamic Psychiatry and Psychotherapy: Freud's Structural Hypothesis.

Psychoanalysis has long lost its historical influence on U.S. academic psychiatry. Psychoanalytic theory, however, provides us with a rich and remarkably comprehensive knowledge of human development, both normative and pathologic. This article describes a psychoanalytic concept that enriches our understanding of the mind and its disorders: Freud's structural hypothesis. This core concept provides a theoretical foundation for understanding the clinical features of both neurotic and personality disorders. It also informs a psychodynamic psychotherapy.

The psychodynamics of borderline psychopathology.

The concept of borderline personality disorder (BPD) remains problematic despite psychiatrists' general familiarity with its DSM diagnostic criteria. The diagnosis of BPD is frequently based simply on the DSM checklist of traits and symptoms without knowledge of their origins or significance. Misdiagnosis is common, as is lack of recognition of the full complexity of this severe personality disorder and the nature of the vulnerabilities that underlie its myriad forms of pathology. The stresses of ordinary life are often too much for people with BPD. Knowledge of the nature and origins of their stress points, such as their great fear of loss or rejection, is necessary for adequate diagnosis and treatment. The author addresses how signature features of the disorder relate to psychosocial development, how they correlate with failed developmental milestones, and how they can be understood psychodynamically. This is essential knowledge for psychotherapists because the pathological interpersonal relationships of the borderline patient will be repeated and acted out in the transference, whatever the modality or intensity of treatment.

Ambivalence: its development, mastery, and role in psychopathology.

The term ambivalence-meaning the coexistence of love and hate toward a person or object-is commonly used both in the vernacular and in psychiatry. However, how ambivalence contributes to understanding and treating some important psychiatric disorders has not been well defined. This article reviews Bleuler's original use of the concept, as well as contributions by Freud and other theorists, as background. The author proposes that mastery of ambivalence-depolarization of the primary drive expressions of love and hate so that a degree of ambivalence toward a loved object can be tolerated-is a fundamental developmental task. The significant role that ambivalence plays in some major psychiatric disorders-schizophrenia, borderline personality, and depression-is illustrated with case material and discussed.

Schizophrenia as a human process.

The patient with schizophrenia often appears to be living in an alien world, one of strange voices, bizarre beliefs, and disorganized speech and behavior. It is difficult to empathize with someone suffering from symptoms so remote from one's ordinary experience. However, examination of the disorder reveals not only symptoms of the psychosis itself but also an intensely human struggle against the disintegration of personality it can produce. Furthermore, examination of the individual's attempts to cope with a devastating psychotic process reveals familiar psychodynamic processes and defense mechanisms, however unsuccessful they may be. Knowing that behind the seemingly alien diagnostic features of schizophrenia is a person attempting to preserve his or her self-identity puts a human face on the illness. This article utilizes clinical material to describe some of the psychodynamic processes of schizophrenia. Its purpose is to facilitate understanding of an illness that requires comprehensive biopsychosocial treatment in which a therapeutic doctor-patient relationship is as necessary as antipsychotic medication.

The role of identification in dynamic psychiatry and psychotherapy.

Identification-a psychic process in which a person takes on characteristics of another-is a concept important to the understanding of human nature. It plays an important role in how our personalities develop, in our ability to deal with life's stresses, and in how we interact with other people. Knowledge of its manifestations is essential to dynamic psychiatry and to its applications in psychotherapy. This article defines identification and reviews its role in development and as a defense. It discusses its role in the psychopathology of disorders commonly encountered in psychotherapy practice-depression and anxiety states reactive to losses in life, and borderline states. Clinical vignettes illustrate how identification functions in these conditions, and also how identifications reveal themselves in the transference and are utilized in psychotherapy. A teaching vignette illustrates how important it is that residents learning the art of psychotherapy appreciate the therapeutic potential of identification. The article maintains that, although it often goes unrecognized, identification with the therapist is one of the most effective therapeutic devices in the transference.

The repetition compulsion in psychodynamic psychotherapy.

The repetition compulsion-the propensity to repeat formative early life experiences, for good or ill-is one of psychoanalysis's most important contributions to the understanding of human nature. However, its broader applications to psychodynamic psychiatry and psychotherapy have received little attention. In fact, it is a concept widely applicable to the understanding and treatment of psychiatric disorders, since maladaptive or self-defeating repetitions are the stuff of psychopathology. This article will discuss the repetition compulsion as a core concept of psychodynamic psychiatry. Principles of the compulsion to repeat will be applied to the dynamics of personality disorders, and will be illustrated by discussion of its usefulness in understanding and treating several common and representative psychiatric conditions: reactive depression, punitive superego function, and traumatic neurosis. These conditions illustrate the reparative, retributive, and restorative functions of the compulsion to repeat.

Turning passive into active: a building block of ego and fundamental mechanism of defense.

Turning passive into active is an ego function that plays an important role in managing anxiety associated with passive feelings of helplessness and powerlessness. Its use in childhood aids the ego in constructing a basic sense of mastery, a secure sense of being in control, both of oneself and of one's circumstances. Functioning first as a building block of ego, it subsequently becomes a versatile mechanism of defense with utility throughout the life cycle. This article discusses both the developmental and defensive uses of the passive into active mechanism of defense and illustrates them with clinical examples. Often regarded only as a byproduct of defense, its importance in mastering core developmental anxieties and their adult revivals warrants its inclusion in the glossary of discrete defenses.

A conceptual model of transference and its psychotherapeutic application.

The tendency to repeat formative human relationships in later life, a universal developmental characteristic, is referred to as transference when it occurs in the doctor-patient relationship. Its systematic therapeutic application in psychiatry has historically been associated with classical psychoanalysis. As psychoanalysis has lost its cachet, and as drug treatment has replaced psychotherapy as psychiatry's major treatment modality, the therapeutic potential of transference risks being neglected. This is to the great detriment of psychiatric patients. Knowledge of the power of transference and expertise in its clinical use in psychotherapy should be the most powerful tool in the psychiatric therapeutic armamentarium. This article discusses a concept of transference that the author has found effective, both in clinical practice and in teaching about transference to psychiatric residents. The article delineates a psychology of transference, discusses its universal applicability to the whole of the psychotherapeutic process, and utilizes case material to illustrate principles of its application.

Psychodynamic psychotherapy: a core conceptual model and its application.

Contemporary American psychiatry, influenced by the "biologic revolution" with its emphasis on a brain-disease model of mental illness, and operating in a managed care delivery system, is in danger of relinquishing its listening and talking functions--psychotherapy--in favor of prescribing drugs. However, despite remarkable advances in the neurosciences, there is still no pharmaceutical magic bullet. The author argues for the continued relevancy of psychotherapy and outlines a practical psychodynamic approach that utilizes fundamental analytic concepts. These concepts--transference, the dual theory of drives, the repetition compulsion, and mechanisms of defense--are described and their clinical application is illustrated. This core conceptual model has significant heuristic value in treating patients and in teaching psychotherapy to psychiatric residents. With its emphasis on the power of the doctor-patient relationship, it teaches residents an effective body of knowledge that helps them define their professional identity-as psychiatrists whose most effective therapeutic tool is themselves, not the drugs they dispense.

Medical psychotherapy of schizophrenia--a dynamic/supportive approach.

Split psychiatric treatment-a psychiatrist prescribing medication while a nonphysician provides or coordinates psychosocial treatments-is common practice, especially in the managed care setting. This influence, along with a focus on the biology of mental illness, has shifted the emphasis in psychiatric education and practice away from psychotherapy. In particular, "psychotherapy" of schizophrenia has gotten short shrift. Since our drugs for schizophrenia do not cure, but only ameliorate, it would be unfortunate if psychiatrists were to become marginalized in a largely prescriptive role. This paper discusses medical psychotherapy of schizophrenia-an integrated treatment in which the psychiatrist provides the comprehensive care that such a chronic biopsychosocial illness requires.