Psychiatry (3)

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Psychiatry

Christian Jonathan Haverkampf M.D.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Working on internal and external communication is a central focus in psychiatric treatment.

Keywords: psychiatry, psychotherapy, communication, medicine

Contents

Introduction. 3

Communication. 4

Biological and Social Science. 5

Approaches. 5

Software and Hardware. 5

The biopsychosocial Model 6

Diagnostic systems. 6

Diagnostic manuals. 7

Assessment. 8

Medication. 8

Psychotherapy. 9

Medication and Psychotherapy. 10

Ethics. 10

Health. 11

Into the Future. 11

References. 12

Introduction

The question what psychiatry is begins with the definition of the term ‘psyche’. The term “psychiatry” was first coined by the German physician Johann Christian Reil in 1808. The ancient Greek term ‘psyche’ is often translated as ‘soul’. However, it can also mean ‘butterfly’. While psychiatry was up until about a century ago more an occult art than a science, this has changed dramatically in the twentieth century. Within the last century, psychiatry began to make its terms, observations and inquiry much more structured and ‘scientific’.

Psychiatric illnesses all have in common that communication with others and the own person is disturbed. (Haverkampf, 2010b) These maladaptive communication patterns lead to the symptoms which are commonly observed. For example, in a case of schizophrenia the source of incoming information can no longer be correctly attributed to the outside world or the inside, and in a case of anxiety emotional signals are no longer correctly identified and processed. Communication, the transmission of messages, adheres to rules like any other natural phenomena and is relied on in nature from information carried in a beam of light to cells exchanging DNA. Humans can observe and reflect on these flows of information, also on information flows within themselves. The sense of self and the attribution of a mind to someone or oneself is a result of the ability to observe these flows of information, and as such of the communication one has with oneself or the world around.

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It is devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Psychiatry focuses on the interaction between patients and therapists in a way, which no other medical specialty does. While it is true that psychiatry has become more biologically based over the last century, it has also begun to look at the finer details of information transmission in the neuronal networks of the brain. Fortunately, gone are the times of lobotomies, where parts of the brain were removed, to make way for much more specific and finer treatment interventions, whether with psychotherapy or medication that works on specific neurotransmitter receptors or mimics certain neurotransmitters. The elaboration of the information transmission at the synaptic level has given us clues on how psychiatric illness is maintained, and medication works, within the larger system of an individual’s neuronal network.

The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of “nerves”, and psychiatry linked up with neurology and neuropsychiatry. Sigmund Freud, who early in his career searched intensively for explanations of psychiatric phenomena on a neuronal level, initiated the development of psychoanalysis, which shifted the emphasis on communication as an important instrument in the healing process. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices at a time when effective psychiatric medication was still in its infancy.

Psychopharmacology became an integral part of psychiatry starting with Otto Loewi’s discovery of the neuromodulatory properties of acetylcholine, which became the first neurotransmitter to be described. The discovery of chlorpromazine’s effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate’s ability to stabilize mood highs and lows in bipolar disorder in 1948. Neuroimaging became an investigatory tool in psychiatry in the 1980s.

Communication

Psychopharmacological changes in the neurotransmission systems, the information interfaces where electrical signals are translated into chemical signals, and back again, affect how and what information is being transmitted. This in turn has an effect on a person’s internal communication and his or her communication with the external world, which are also the target of psychotherapy. (Haverkampf, 2010a, 2017c) Medication and psychotherapy can thus work together synergistically.

Unlike physicians in other medical specialties, psychiatrists specialize in the doctor–patient relationship and should be trained extensively in the use of psychotherapy and other therapeutic communication techniques. Unfortunately, this is not always the case, which can reduce the effectiveness in treating a mental health condition significantly, because treatment of a mental health condition implies working with and understanding communication on different levels. The patient uses communication with other people and the self-talk with him or herself to meat own needs, values, wishes, desires and aspirations, requiring a holistic approach to the communication patterns and mechanisms a patient uses.

Since communication plays such a central role in psychiatric treatment, the author has developed communication-focused therapy (CFT), which focuses on internal and external communication patterns to relieve the symptoms of a wide variety of mental health conditions (Haverkampf, 2017a, 2018c).

Biological and Social Science

Psychiatry is the most multidisciplinary medical specialty using research in the field of neuroscience, psychology, medicine, biology, biochemistry, even physics, and pharmacology. Since psychiatry looks at the patient who is interacting with the larger world around, the social and communication sciences, including even behavioural economics, and the humanities can make important contributions to the field of psychiatry. If one considers psychiatry as a specialty that focuses on improving meaningful communication within wider information systems, the biological and social viewpoints merely represent looking at the same processes with different magnifications.

Psychiatry addresses internal and external communication issues, which are usually multifactorial in their aetiology. Compliance and the effects of medication and psychotherapy depend on the interactions between the patient and the environment. There are branches of psychiatry which look at different environments and how they influence the mental well-being of a patient. Unfortunately, psychiatric hospitals and various public health clinics have been notoriously slow at implementing any recommendations from this research.

Approaches

Psychiatric illnesses can be conceptualized in several different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. However, unlike the other fields of medicine, psychiatric diagnoses say little about underlying causes on a biological level but are mostly groupings of symptoms which seem to appear together. This is not to say that such groupings are not helpful. They can make it easier to describe conditions and often make it easier to pick specific therapeutic approaches and types of medication. However, since individual symptoms overlap and due to the complexity of the neural networks, it is usually not possible to follow a group of symptoms back to a specific biological variation. Since the brain is highly plastic, synapses rearrange their connections with each other all the time and assign varying weights to them. This means that a symptom of anxiety, for example, can be triggered by information stored over millions of nerve cells, and merely understanding how a biological component, such as a receptor, works does not help in understanding or treating the symptom.

Software and Hardware

Psychiatry is both ‘software’ and ‘hardware’ oriented, where ‘software’ refers to the information stored in the neural network and ‘hardware’ to the cellular network on a biological level. In the latter, there is an overlap with neurology and other medical sciences. What sets psychiatry apart is particularly the concern with information, the flows of information and how information is processed. New diagnostic systems and schemata have been developed on the psychotherapy side, which pay greater attention to the information dynamics. These models and systems can provide additional information to an experienced clinician who can then integrate these additional aspects with the diagnostic systems from the traditional medico-psychiatric side.

The biopsychosocial Model

The biopsychosocial model is commonly used to describe the three factors that play a role in the development and maintenance of a psychiatric condition:

  • Biology
  • Psychology
  • Environment (social)

What is striking about these three domains is that all consist of the transmission of information in one way or another. Some describe more the internal communication (biology, neuroscience, psychology), while others describe the external communication (psychology, sociology, economics and others), but all work in parallel all of the time. Psychiatry thus works with very complex systems, which are much more elaborate than in any other field of medicine. This may also be the reasons why psychiatry was the field within medicine to develop rather late, because it uses the insight gained in several other fields.

Diagnostic systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole, this remains a research topic.

The problem with most diagnostic systems in psychiatry is that they do not address the underlying causes of an illness but focus instead on bundles of symptoms. As a descriptive system this makes sense in many instances. However, from a treatment perspective this is often unhelpful. Since medication works on underlying neurotransmission system within a vast network of interconnected neurons, a system that makes diagnosis based on properties within that system and on the individual neuronal level would be more helpful. From a psychotherapeutic perspective, a focus on internal and external communication would be helpful. Both perspectives could lead to systems that would be compatible with each other or even to one system that combines features of the two.

Diagnostic manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The International Classification of Diseases (ICD-10) is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V), produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States, although the ICD-10 has official status there as well. It is currently in its fifth revised edition and is also used worldwide. As already mentioned, the diagnostic systems are based on bundles of symptoms. Psychiatry has “a syndrome-based disease classification, which is not based on mechanisms and does not guide treatment, which largely depends on trial and error” (Stephan et al., 2016). The author of this article would not go so far. Greater clarity about a diagnosis or several diagnoses, even if we do not understand fully the underlying biological and psychological mechanisms, can be an important tool in formulating a treatment plan, which often also includes medication (Haverkampf, 2018a)

The diagnostic manuals overlap to a significant degree. One reason is that they describe groups of symptoms which are often seen together, and over time the use of their diagnostic terms has made it easier to provide treatment and conduct research. However, both suffer from the critiques mentioned above. They can give a rough idea of the symptoms, a suitable therapy and the prognosis. However, since the diagnostic systems say nothing about the underlying causes, the actual therapy needs to be individualized and its success depends on several factors inside the person and in the environment. Looking at the patient’s internal and external communication can help individualize the therapy. (Haverkampf, 2010b, 2012, 2013a, 2013b)

It is important to keep in mind the purpose served by diagnosis. It is ultimately to help a patient and raise his or her quality of life. While there may be other uses of it for forensic, insurance or other purposes, they should not lead to a different interpretation of what a diagnosis is for in a treatment context. Diagnoses can at least help to raise the probability that a specific medication or group of medication will alleviate certain symptoms (Haverkampf, 2018a, 2018f).

Assessment

The first step in treatment is traditionally assessment. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

However, especially in psychotherapeutic treatment, assessment can still take place after the therapy has commenced. While it is important to have a working hypothesis for the condition, it is important to remain open to any new insights gained from observing and interacting with the patient over time. For this, it is important to be in the interaction with the patient, yet also to be able to take a step outside of the interaction and reflect on the communication dynamics.

Assessment with a focus on the internal and external communication can identify problems which are leading to the symptoms. This information is then helpful to make better decisions with respect to medication and psychotherapy. Communication-Focused Therapy, as developed by the author, focuses on communication patterns an individual uses, whether in everyday life or in a therapeutic setting (Haverkampf, 2010b, 2017a). Rather than looking primarily at the content of what is being communicated, the how it is communicated assumes an additional particularly important role. Since people, and all other living organisms, meet their needs and aspirations through the exchange of information withing themselves and with the world, it is important to encourage awareness, reflection and experimentation with communication to make it more efficient and satisfying for the individual. As life aligns more with the basic parameters, the needs, values and aspirations, as a result of better communication, the symptoms of a mental health condition often receded (Haverkampf, 2017f, 2017b, 2017d) .

Medication

Psychiatric medication represents a very heterogenous group of substances, which are among the most widely prescribe in the world. Psychiatric medication was usually available before one had an understanding for its effects on a cellular or neural network level. However, in all cases it has been shown that psychiatric medication affects the information transmission in the brain. This is a point where psychotherapy and medication could go well with each other hand in hand (Haverkampf, 2018f).

The efficacy of medication can often very significantly among individuals. One antidepressant from the most popular group of antidepressants, the selective serotonin reuptake inhibitor (SSRI), for example, may help against the symptoms of depression and anxiety, while another from the same group does not work in the same patient. The outcome is not always easy to predict, although one can have a sense of the medication that is most likely to work. It requires a proper assessment in the first place, but also a solid understanding of the desired changes and the expectations of the patient.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance, full blood counts serum drug levels, renal function, liver function, and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for severe and disabling conditions, such as those unresponsive to medication. Although the literature reports on successes in treatment-resistant cases, its use remains controversial. Often, the available treatment options with medication and psychotherapy have not been fully exhausted when considering ECT.

To summarize, one may say that the support available form medication can be life-changing in some cases and increase the quality of life significantly. In contrast, in others, it may do little or lead to side effects, or there can be both positive and negative effects side by side. Several parameters have been studied to shape the recommendations of the professional. For example, in a study on the variables that could predict a successful treatment outcome in depression, chronic depression, older age, and lower intelligence, each predicted relatively weak response across psychotherapy and medication. On the other hand, marriage, unemployment, and having experienced a higher number of recent life events each predicted superior response to cognitive therapy relative to antidepressant medications (Fournier et al., 2009).

Psychotherapy

As already mentioned, increasingly psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of “talk therapy.” This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.

However, this approach is short-sighted. It may be easier to prescribe medication, which is a concept familiar to most patients, than to explain how psychotherapy works, whose basic premises, tools and approaches are less well known. Psychotherapy often delivers a lasting effect in the long-term in cases of anxiety, mild to moderate depression and several other conditions, which goes beyond the ongoing support medication can offer (Haverkampf, 2017a). The reason is that changes in the internal and external communications usually bring about changes in a patient’s symptoms (Haverkampf, 2018d). While medication also has an effect on these communication patterns and, through learning effects, it can even last for some time after the drug is discontinued, the changes are usually less specifically tailored to the needs and personal history of the patient.

Medication and Psychotherapy

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. In many cases, a combination of psychotherapy and medication can prevent relapse longer than either treatment type on its own. (Haverkampf, 2018f, 2018e) There is a substantial synergism between the two. Medication can provide the support which facilitates psychotherapy, while psychotherapy can increase the compliance with medication.

Ethics

Most unethical treatments in psychiatry have been a result of neglecting the importance of communication in treatment and seeing properties of interactions as being localized in a particular area of the brain rather than occurring in a network internally and through interactions with the world externally. Much unethical behaviour in psychiatry can be summarised by saying that the physician failed to interact, communicate and understand a patient in any meaningful way. When knowledge about psychiatric conditions is seen separate from the interaction with the patient, it becomes akin to playing the lottery of sorts. Treatment requires a focus on how the patient communicates internally and externally and how the world responds to these messages.

When a psychiatrist is connected on emotional and cognitive levels with himself or herself as well as the patient and has healthy boundaries in place, ethical lapses become less likely. However, this often requires substantial experience and skills in a psychotherapeutic technique that focuses on insight. It requires an interest in and experience with human communication.

Health

To have a definition of illness, one needs a definition of health. Psychiatry is not only concerned with psychiatric illness but largely also with the maintenance of mental health. Insight into the aetiology and pathogenesis of burnout, for example, helps to prevent it, (Haverkampf, 2013a, 2013c, 2017g, 2018b) which is not only good for the individual but society and the economy as a whole. (Haverkampf, 2013c) Knowledge about which work and communication environments are helpful in preventing a relapse of psychosis can help a person arrange life in ways which keep him or her mentally healthy for as long as possible. (Haverkampf, 2017e) Skills in connecting with oneself can help to understand the information contained in emotional signals underlying episodes of anxiety. (Haverkampf, 2012)

Into the Future

The biopsychosocial model reduces to the communication model. Internal communication and external communication are, to some extent, arbitrary distinctions because communication still adheres to the basic rules and laws of communication, whether it unfolds in a person or without. However, this requires an integrated and more universal view of mental health. What makes us all human are the mental processes which give us the ability to observe and reflect on these flows of information. Psychotherapy and medication are the tools to bring about change in these communication patterns, internal and external ones. Other supportive therapies, such as occupational therapy, meditation and various forms of bodywork, can provide crucial additional support towards a satisfied, content and happy life, one in which personal needs, values, wishes, desires and aspirations can be met.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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CBT and Psychodynamic Psychotherapy

CBT-and-Psychodynamic-Psychotherapy-Christian-Jonathan-Haverkampf-2-psychotherapy-series

CBT and Psychodynamic Psychotherapy

Christian Jonathan Haverkampf, M.D.

Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy, apart from interpersonal therapy (IPT) models.

Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.

Keywords: CBT, psychodynamic psychotherapy, Communication-Focused Therapy, CFT, communication, psychotherapy, psychiatry

Table of Contents

Introduction. 3

Philosophical Differences. 3

Practical Differences. 4

Example: Obsessive-Compulsive Disorder (OCD) 5

Example: Depression. 6

Into the Future. 7

References. 9

Introduction

Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy (see Lambert and Bergin, 1994), apart from interpersonal therapy (IPT) models.

Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ (Breuer et al, 2000)  in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.

Philosophical Differences

The late nineteenth century with new discoveries in biological medicine and neurology and the emergence of Darwinian evolution provided the background for psychoanalysis. Psychoanalysis regards the mind as a complex yet structured system that produces and is affected by communication and meaningful information, not unlike individual cells in an organism. The patient’s free associations  are reflected upon by patient and analyst to explore and resolve intrapsychic conflicts and their defences, which cause ‘neurotic’ symptoms, such as anxiety, OCD, depression. Symptoms contain not only hints of repressed feelings and emotions, but also information about the patient’s authentic wishes and desires for individual growth.

CBT delivers a more action-oriented and problem-focused approach, in which treatment plans and goals are formulated without a prior analysis of the meaning of the symptoms.  CBT goes back to a merger of the behaviourism based on studies on conditioning and learning  and studies into cognitive processes by students of Freud , who believed cognitive processes to be closer to consciousness than their mentor. CBT focuses on an understanding of the mechanisms of present thoughts and behaviours rather than their pathogenesis. Both, however, teach their patients to become experts in their respective skills.

In psychodynamic theory, the development stages in childhood play an important role,  as do other past experiences, which are largely organised around interpersonal relations. In CBT, the focus is on conscious processes and the present. Psychoanalysis assumes that communication phenomena  between therapist and patient allow insight into partly unconscious intrapsychic processes, which are organised in a structured system (such as the tri-partite model of ego, superego and id) .

From a CBT perspective, distorted thought processes and maladaptive behaviours are direct causes of mental health symptoms (Hollon and Beck, 1994),  in psychodynamic theory they are ‘only’ symptoms and not to be confused with the underlying causes.  In CBT, logic, for example in the form of the Socratic dialogue, can be used to identify and discard false beliefs that cause unwanted thoughts and emotions (Beck at al, 1979). Psychodynamic therapy enables reason (the ego) to break down the defences, which protect from underlying conflicts.

In CBT, unhelpful thought patterns are made clear in the beginning (assessment phase), which, however, requires a norm  of ‘helpful thinking’ (Fancher, 1995). In psychodynamic psychotherapy, what is ‘helpful’ depends on the individual and has to be worked out in the exploratory process.

Both therapeutic approaches are growing organically, though unfortunately with less than optimal cross fertilisation. Emotional, motivational and relational aspects have been added to CBT.  Neural networks and neural computation models are used in psychodynamic research (Peled, 2008), as well as in the cognitive sciences which underlie CBT. The neurosciences , infant research , neurobiology , attachment psychology and other fields have contributed significantly to psychodynamic theory.

Practical Differences

Treatment in CBT is usually shorter, often below twenty sessions, and with longer inter-session intervals.   There is an evidence-based short-term psychodynamic psychotherapy (STPP) which, however, has in a meta-analysis shown to be “significantly” less effective than the longer version (LTPP) (Leichsenring and Rabung (2008).

Both therapies transfer skills. In CBT the therapist is “very active” (Hofmann, 2011) and the approach is highly structured (Gatchel, 2008) , often with homework and including an initial assessment, education on the course of therapy (Hofmann, 2011), a reconceptualization of the problem, skills acquisition, skills training, generalisation and maintenance, and another assessment. In psychodynamic psychotherapy, patients learn in the therapist-patient interaction to gain insight into their unconscious dynamics and to become their own analysts.

Since CBT assigns lower priority to the specific thought content and the communication dynamics between patient and therapist and defines problems more narrowly, psychoeducation and ‘manualisation’  are easier to integrate, particularly in clearly defined situations, such as drug addiction (Carroll, 1998) . CBT also lends itself better to conduct therapy over a distance (Weiss et al, 2012; Himle et al., 2006) , including the use of e-mail therapy (Vernmark et al, 2010). Computer programmes (CCBT) can make therapy available to millions of previously underserved populations. 

Both, CBT and psychodynamic psychotherapy have proven their effectiveness in numerous studies and large meta-analyses.  However, direct comparisons of the effectiveness of CBT and psychodynamic psychotherapy can be flawed by design if the two therapies are complementary and conceptually related. Bram and Björgvinsson (2004), for example, have successfully integrated exposure-response prevention into their psychodynamic therapies. Measuring success in completed therapy phases seems equally problematic, but is still often used.

CBT is likely to deliver quicker results in motivated patients with clearly defined symptoms, low resistance levels and relatively intact personality structures (with the exception of borderline personality disorder and DBT). Psychodynamic psychotherapy may have advantages in dealing directly with personality disorders,  which are traditionally derived from psychodynamic models.

Leichsenring and Leibling (2003) demonstrated in a meta-analysis a better long-time effectiveness of psychodynamic psychotherapy than CBT, while CBT on its own has shown to prevent relapses in the long-run (Driessen et al, 2013). Much of the apparent diversity in opinion may depend on the specific diagnosis in question.

CBT may have higher drop-out rates (Cuijpers et al, 2008; Whittal et al, 1999). Motivation seems more external in CBT (see Haddock et al, 2012) than in psychodynamic psychotherapy with its emphasis on the therapeutic relationship  and the integration of the more recent motivational systems research (see Lichtenberg at al, 2016). Adding these psychodynamic elements in CBT therapies may lead to better outcomes.

Example: Obsessive-Compulsive Disorder (OCD)

In psychodynamic theory, the anxiety underlying OCD is a result of conflicting dynamics (including emotions), often with a strong relationship component. A conflict may arise in an unstable relationship to an important other, such as a primary caretaker in early childhood, as the feelings of love for the idealised mental representation of the other (longing for attachment) and the frustration, sadness and/or abandonment about the reality of this person’s unpredictability or unreliability cannot be resolved by the child.  Higher levels of aggression and distrust in other people have indeed been found in OCD (Moritz, 2011), and infant research has demonstrated how the interaction between primary caretaker and child can affect the child’s evolving sense of self and feeling of secure attachment . Obsessive thoughts and compulsive rituals are aimed at temporary relief from the heightened anxiety in present situations which trigger the situational and associated emotional memory systems of previous situations . Awareness of the underlying emotional conflict, which manifests through the symptoms, helps the patient to recognise, identify the ‘free-floating’ anxiety in the past experience, which reduces the anxiety from experienced emotional uncertainty and the OCD symptoms in the present.

                The cognitive-affective schemata of newer developments in psychodynamic theory  have considerable overlap with CBT concepts of the effect of learned cognitive schemata. From a CBT perspective, obsessive thoughts are otherwise ‘normal’  negative thoughts which may be misinterpreted as personally significant (Rachman, 1997) or as a potentially dangerous situation for which the patient feels responsible (Salkovskis, 1985), response patterns which are largely learned (Taylor and Jang, 2011). Compulsive rituals are efforts to control these intrusive thoughts. After performing the rituals, individuals usually report a temporary decrease in their obsessional distress (Rachman and Hodgson, 1980), which negatively reinforces these behaviours, a mechanism similar to CBT models on addiction.

Exposure and Response Prevention (ERP)  tries to break this cycle of negative reinforcement, in which the patient is repeatedly exposed to an anxiety-provoking thought or situation stimulus, but the self-calming ritual is reduced or suppressed. The anxiety may increase in the beginning, but then reach a peak and fade away.  Exposure necessarily leads to an involvement of the patient’s emotional memory and an emotional processing of the anxiety (Foa and Kozak, 1986), which seems a point where CBT and psychodynamic psychotherapy again intersect. Basically, both approaches try to give patients a greater sense of positive control over their lives.

Example: Depression

                Freud considered the internalisation of object loss as a normal part of life, and depression as a reaction formation in the face of a particularly severe super-ego , which holds in check our basic desires and wishes (the ‘id’) with the help of conscious cognitive functions (reason, the ‘ego’). In CBT, the super-ego could be compared to the messages we learn over time and the believes we construct of how we ‘should’ live our lives. And similar to the concept of limited cognitive resources in CBT, the rational ‘ego’ function in psychodynamic theory may get overwhelmed in stressful and traumatic situations and become unable to reconcile the super-ego and the id, leaving an unresolved emotional conflict,  which the ego (reason) needs to defend against. Loss and the emotions associated with this conflict (such as anger, sadness or helplessness) are important themes. Anxiety and avoidance have been shown to be greater in people with more insecure attachment (Bateman & Fonagy, 2012),  who are often more dependent and self-criticising, eliciting responses from others that confirm their fears of rejection and abandonment (see Blatt, 1974; Blatt, 1992). The negative emotions then lead to a ‘withdrawal’ from one’s own emotions (repression), reminiscent of learned helplessness in CBT. Awareness of the underlying dynamics and their origin in the past, helps the patient to understand and integrate them in the present.

                In CBT, thoughts, behaviours and feelings are directly interrelated, which can lead to a circularity that is in psychodynamic theory ‘impossible’. Negative thoughts can lead to depressed feelings, which again lead to negative thoughts and ‘depressed’ behaviour, such as social withdrawal, reinforcing the depression. Maladaptive cognitive patterns, such as negative thinking about oneself and one’s experiences (McGinn, 2000), increase the vulnerability for depression.   In learned helplessness, for example, the sense of low self-efficacy brings about behaviour that just reaffirms the low self-efficacy.

In the cognitive aspect of CBT, a person learns to recognize and turn negative automatic thoughts into realistic  beliefs. More realistic beliefs lead to more adaptive thoughts and less depressed feelings. Patients are taught to deconstruct problems into the actual situation, and the thoughts, feelings and behaviours that occur before, during and after the situation, an external correlate to the internal deconstructive process in psychodynamic psychotherapy. In Mindfulness CBT (MCBT)  the emphasis is on experiencing one’s thoughts as mental events rather than interpreting them as representations of oneself or reality. This detachment from negative thoughts and feelings is also useful in preventing relapse (Teasdale, 1999).

Into the Future

The aim of psychotherapy is not merely to eliminate suffering (WHO, 1946), but to help patients develop as humans. The primary tool is communication, in CBT to provide information that generates change and in psychodynamic psychotherapy to reveal the information that brings about change.  There are synergistic effects from using both. Zipfel et al (2014) showed in a large sample of anorexic patients, that CBT was associated with weight gain, while psychodynamic psychotherapy with lower relapse rates at the 12-month follow-up. McFall and Wollersheim (1979) in an early study successfully used a combination of CBT and psychodynamic psychotherapy in anxiety . Given the widely-perceived need for multimodal approaches , it is difficult to comprehend that this should not apply to the most important therapeutic models we have. In ancient Greece, knowing oneself (γνῶθι σεαυτόν, “know thyself”) and the process of the Socratic dialogue were inextricably linked. Psychodynamic psychotherapy and CBT should be viewed as complementary rather than substitutes.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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Across the Seven Seas – Exploration as Therapy (3)

Exploring new contacts and new situations can have a therapeutic effect if it leads to a greater perception of meaning. This can be helpful in depression, anxiety, burnout, eating disorders, ADHD and many other mental health conditions. Communication-Focused Therapy (CFT) focuses on how communication patterns and the exposure to new meaningful information can lead to more adaptive and helpful adjustments of own communication patterns and to more success in meeting own needs, values and aspirations.

Keywords: exploration, communication-focused therapy, CFT, communication, psychotherapy, psychiatry

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© 2019 Christian Jonathan Haverkampf

Communication-Focused Therapy® (CFT) for Anxiety and Panic Attacks (3)

Communication-Focused Therapy (CFT) is a psychotherapy developed by the author, which can be applied to a number of mental health conditions, including anxiety disorder and panic attacks. It focuses on creating greater awareness and insight into internal and external communication patterns and making changes to them. This also helps gain insight into the basic parameters, the needs, values and aspirations which are important for motivation and the direction of changes, behaviors and interactions with oneself and others.

Keywords: anxiety, panic attacks, communication-focused therapy, CFT, communication, psychotherapy, treatment

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Pure ‘O’ OCD and Psychotherapy (2)

Abstract – Obsessive-Compulsive Disorder (OCD) is a condition in which people feel the need to check things repeatedly, perform certain routines repeatedly (‘rituals’), or have certain thoughts repeatedly. People are unable to control either the thoughts or the activities for any longer periods of time. Suppressing the behavior or thoughts often causes intense feelings of anxiety, tension, nervousness and fear. OCD is quite common, and it is mostly treated with a combination of psychotherapy and medication. There is some discussion as to whether categorizations of OCD into heterogeneous forms, including a pure obsessive form, make sense. However, there are common themes and mechanisms underlying any form of OCD.

Keywords: OCD, obsessive-compulsive disorder, communication, psychotherapy, psychiatry

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Pure ‘O’ OCD and Psychotherapy (2) Christian Jonathan Haverkampf – psychotherapy series

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