Practicing Psychoanalysis and Psychodynamic Psychotherapies in Developing Societies

Introduction

By tradition, psychotherapy has been a main segment of postgraduate teaching in psychiatry, though the techniques and styles of implementation have varied over time and amid settings. Essential to the current the practice of psychiatry is the biopsychosocial approach, and psychotherapy has been designated as its indispensable constituent (Denman, 2010). The growth of psychological treatments has led to the foundation of various therapeutic methods, from psychodynamic therapy and cognitive behavioral therapy (CBT) to more recent techniques, such as cognitive analytic therapy (CAT) and dialectical behavioral therapy (DBT). Most techniques undergo enough research to support their usefulness, with some methods acknowledged as being at least as effective as drugs for certain conditions.

During psychiatric residency, future practitioners learn not only how to be proficient in their areas of practice but also what to expect in the future of the business of psychiatric practice. For many years, psychiatric teaching was identical with learning psychotherapy, “in 1952, becoming a psychiatrist meant becoming a psychotherapist” (Target, 2005, p. 161).

Present day psychiatric trainees consider that while their education and practice will present opportunities for incorporating psychotherapy and psychopharmacology, a typical practice is predominantly drug focused. During the last decade, office-based psychiatrists have moved to providing fewer psychotherapy appointments and relying more upon drug prescriptions (Mojtabai & Olfson, 2008). Some psychiatric mentors worried that the reduced commitment to teaching psychotherapy in residency has moved the therapist’s main character away from psychotherapy (Mohl, Lomax, Tasman et al., 1990; Mellman, 2006). But even now, most psychiatric instructors endeavor to transmit the data, abilities, and approaches essential for psychotherapy as an essential part of a psychiatrist’s role (Langsley & Yager, 1988). Furthermore, according to the Accreditation Council for Graduate Medical Education (ACGME), all psychiatry residents “should exhibit proficiency in applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and long-term individual practice, along with to convincing exposure to family, couples, group, and other individual evidence-based psychotherapies”(ACGME, 2015, p. 13). Despite worries about the diminishing role of psychotherapy in the practice of psychiatry, one study noted that most psychiatric residents recognize psychotherapy as fundamental to their professional character and future treatment strategies (Lanouette, Calabrese, Sciolla, et al., 2011).

Psychoanalysis and psychodynamic psychotherapy are significant constituents of psychotherapy. Psychodynamic philosophies believe that initial infantile events are vital in influencing the character. Similarly, psychodynamic psychotherapy explores unconscious struggles and aims to modify patients’ problematic behaviors. The correlation between the analyst and patient, as well, is critically significant. While psychoanalysis and associated insight-oriented methods have been shown to be effective managements in a variety of mental disorders, patient selection is significant, bearing in mind the parameters such as motivation and psychological mindedness of the patient and the interpersonal circumstances of the presenting problem (Fonagy, 2010).

Early introduction to psychotherapy is essential for trainees when choosing whether or not they want to dedicate themselves to psychiatry. Even for psychiatrists who do not go on to focus on psychotherapy, familiarity with it is an important part of their learning. For all therapists, there is likely to be an emotional element to viewing the symptoms of patients in mental health facilities, and there will be significant transference and counter-transference reactions. Therefore, clinicians need to be able to recognize and deal with these aspects of treatment. Psychodynamics are significant in treating various groups so that physicians who can distinguish the dynamics and adjust to them may have better interactions with patients. Another pertinent issue relates to suitable changes in treatment approaches: One method of psychological treatment does not fit each problem or every patient. Psychiatrists are accountable for evaluating a patient, detecting signs and symptoms of illness, and determining the course of treatment, which may be psychological, biological, or both. To evaluate and refer correctly, the responsible psychiatrist must understand the indications for a specific therapy and be aware of its potential for an individual patient. Of these modalities, psychotherapy consumes more assets than other area of post-graduate training in psychiatry. For example, training in psychopharmacology may be fulfilled in a more self-directed way, using published data, while training in psychotherapy requires seeing patients and being directed in their management by expert supervisors. The learner must have enough time for seeing their patients, but this may take the trainee away from systematic medical efforts. Also, suitable facilities must be accessible to the patient and therapist for the therapy to happen, and above all, managerial support is needed. However, in many of developing societies, there is a deficiency in both these requirements. Likewise, the availability of supervision is also a problem. Many beginning therapists work in regions where psychological treatments are unavailable, and there are no expert clinicians to direct training.

Ongoing economic struggles mean that most mental health organizations have made major cuts to their services. Consequently, psychotherapy—principally longer therapeutic methods like psychoanalysis and psychodynamic psychotherapy—may be targeted for condensed services, which leads to further limitations in opportunities to learn. There is no paucity of studies showing that even in industrialized societies apprentice psychiatrists usually feel that they need to “fight” to gain psychotherapy teaching (McCrindle, Wildgoose, & Tillett, 2001; Pretorius & Goldbeck, 2006; Rooney & Kelly, 1999; Kuzman, Jovanović, Vidović, et al. 2009), and that clinicians are often uncertain as to what the actual purposes of that training should be (Oakley Ryan, & McVoy, 2012). Also, a shortage of psychotherapists to harmonize the teaching of psychotherapy has sometimes been mentioned as one the destructive issues (Oakley Ryan, & McVoy, 2012).

Psychoanalysis was a revolution in the practice of psychiatry and was the first systematic approach to psychotherapy. It was a tool for studying the deeply rooted, unconscious mental processes and for managing psychological treatments. But despite its critical place as a part of core curriculum in psychiatry in developed countries, it does not receive the same value in developing countries. Some aspects of this topic have been discussed previously in another article regarding process of appearance and progression of psychoanalysis in Iran, as a prototypical developing society in the Middle East (Shoja Shafti, 2006). In conservative or traditional societies around the world, therapists may encounter similar problems. The scarcity of facilities and lack of funding for psychoanalysis in developing countries often originates from misunderstandings about therapy and flawed viewpoints of institutional administrators and some psychotherapists. While the explicable part of the problem involves a lack of appropriate institutional settings and qualified supervisors, together with troubles regarding monetary issues and financial coverage by insurance companies, perhaps the most the important part of the problem is based on misapprehension or inaccurate interpretations of psychoanalytic theories without any experimental or practical foundation. The result of such a disturbing process is ignorance of this deeply exploratory method. It is replaced with more superficial individual psychotherapeutic methods that remain at conscious and subconscious levels and never penetrate deeply into the human mind. While psychoanalysis probes the district of unconsciousness, with periodic fluctuation in conscious and subconscious levels, other methods begin at conscious layer and reside there or, at best, reside at subconscious level of the mind. For a therapist who has confidence in unconscious processes, this means brief therapeutic interventions will have shortcomings in cases where deep analytic methods are needed. While cultural principles or psychosocial stages of development may work against the progression of psychoanalysis in developing societies, it is indisputable that improper understanding of the matter is just as important. For that reason, some of those communal, but inaccurate assumptions, which are widespread among developing nations, have been represented in Table 1.

Ignoring the Basics

Why are such erroneous assumptions common among psychotherapists in developing countries? It seems due to deviation from fundamental literature, particularly circumvention of Freud’s fundamental writings. Psychoanalysis, introduced to the world in the “studies on hysteria” by Freud and Breuer (1895), extended overseas up to America after about two decades. Their book, with its strong medical outlook for treatment of psychoneuroses, is still the first step of teaching and practicing psychoanalysis. The same holds true for Freud’s other works; they are essential for beginners who wish to understand and practice psychoanalysis and associated methods (Freud, 1900, 1901, 1905, 1909, 1909, 1911, 1911, 1912). Touching and probing the unconsciousness is not practicable without methodical exploration and interpretation of associations, and such a skill is not attainable without resorting to original works. An enthusiastic psychotherapist must be able to differentiate between what may enhance potentiality for interpretation and construction and what that may increase the reader’s psychological knowledge. So then, the first task of every psychotherapist is broadening his or her personal insight. For example, in one unsuccessful training program, which intended to persuade a small group of psychiatric residents to start training in the classical method of analysis, lack of enthusiasm and motivation were more apparent than lack of setting and knowledge. Exaggerated interest in the theoretical aspects of psychoanalysis, instead of its pragmatic aspects, demonstrated an inaccurate understanding of the subject. This state of affairs proves once more that wishing to know and knowledge are not equivalent to capability and talent, and motivation is something different from enthusiasm. Showing a sufficient amount of ambition for performing a job, adequate curiosity for in-depth study of the known psychoanalytic literature (or at least their accessible translated versions) or interest in clinical evaluation of the effectiveness of psychoanalysis can reflect the inner passion of trainees. Moreover, their expressed inclination to applied psychoanalysis could not be easily differentiated from other methods of psychotherapy. Untimely training, much like unsystematic research, may not attain the desired goals.

In another example, in one of the well-known academic centers in this region, the vital techniques of psychoanalysis, such as free association and dream interpretation are being introduced to the trainees as obsolete, and personal analysis of therapist is acknowledged as an optional requirement that belongs to past, not present. Freud’s basic works, such as “studies on hysteria,” “interpretation of dreams,” “psychopathology of everyday life,” and “papers on technique,” and his pragmatic and enlightening case studies (eg., Dora, Little Hans, Ratman, Wolfman, Scherber) are being taught by proponents of “object related theories.” Trainees are being advised they do not need to follow basic procedures of psychoanalysis and related methods. Therefore, no interpretations of dreams, slips, or free associations are carried out at all. Training for promoting a dynamic psychiatry that takes the unconscious into consideration requires the therapist to undergo personal psychoanalysis. The analyst’s analysis has a fundamental place in training, but at the institution in this example (and many other comparable academic centers in this country), analysis of the trainee is not required. Naturally, the analysis of the therapist who wants to practice psychodynamically is a significant issue, and without this analysis, any attempt or initiative to engage in the psychoanalytic method will not work well. In such a situation it is foreseeable that no understanding of the“unconscious” is possible at all, and the result cannot be more than feeling of uselessness. Moreover, there are other academic centers that do not provide even this incomplete level of teaching, and they rely only on discrete theoretical lessons.

Psychoanalytic practice requires that the therapist have “the complete course of education” in this area. It must include the theoretical study of psychoanalysis (and obviously the work of Freud), the supervision of clinical care, and, especially, personal analysis. This requirement aims at the good practice of psychoanalysis and the emotional protection of the therapist. Some of the main differences between developing and developed societies in the training of psychoanalysis and related therapies are shown in Table 2.

It is easy to understand how a psychiatric resident may become confused in facing the numerous psychotherapeutic methods introduced during the educational curriculum. It takes time for trainees to become familiar with all the methods and to choose the technique which best fits his or her character and objectives.

Psychopharmacology First

In developing countries, factors such as the speed of response, cultural background, patient motivation, and therapist personality may have more of an influence on psychiatric residents’ pursuit of psychotherapy than in more developed countries. In more advanced societies, practice of insight-oriented psychotherapies by psychiatrists may be lacking, but other experts in the field of mental health may compensate for this shortcoming. Such a solution does not is not easily achievable in developing societies

since the importance of these experts have not been widely recognized, and their training is not independent from that of general educational policies of their society.

In developed societies, practicing psychotherapy as a basic therapeutic instrument was prevalent before the emergence of pharmacologic treatment for psychological dysfunction. In developing societies, which have become used to the speed of symptom reduction with prescription of antidepressant or antipsychotic medications, the advantage of psychotherapy as a basic therapy is absent.

In practicing psychotherapy, the psychiatrist must first acknowledge it as comparable to a full-time job, not an overtime task or option, and second, the therapist must recognize its phenomenological aspect and the demands for additional insight in accessing the unconscious. Therefore, modification of the clinical perspectives of learners is very important if the educational system wants to support insight-oriented methods in training programs. The “optional” aspect of teaching psychotherapy, which is opposite to obligatory aspect of teaching about drug treatment in psychiatry, acts against its growth in developing countries.

Decreasing Numbers in Developed Countries

Also dissuading interested therapists in developing countries is the decreasing rate of psychotherapy practice by psychiatrists in advanced countries. According to Chisolm (2011), research shows that the exercise of psychotherapy by psychiatrists is seriously reduced. She states that between 1996 and 2005, the proportion of psychiatry office appointments, including psychotherapy, diminished from around 44% to 29%, representing a 35% reduction in less than 10 years (Chisolm, 2011, p. 168). Though the growing accessibility of drugs to manage psychiatric ailments has played a role in this decrease, it is not the solitary cause. The paper appraised the numerous influences for this swing, including insurance reimbursement and movement to a biological emphasis (2011, page 171), and she concluded with a request for further inquiry to avoid unexpected (and hypothetically destructive) consequences to patients and to appraise the sustained role of psychotherapy in residency training (Chisolm, 2011). Another study (Mojtabai &Olfson 2008) analyzed the records of a crosssectional National Ambulatory Medical Care Survey (1996 to 2005) to study tendencies in psychotherapy delivery within nationwide, characteristic samples of visits to office-based psychiatrists. According to the study, there had been a noteworthy reduction in the provision of psychotherapy by psychiatrists in the United States of America. The proportion of appointments, including psychotherapy, dropped significantly from 44.4% in 1996/1997 to 28.9% in 2004/2005 (P < 0.001). The reduction in providing psychotherapy paralleled with a significant lessening in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005. Psychiatrists who delivered psychotherapy to all of their patients depended more extensively on self-pay patients had less managed-care visits and recommended drugs in a smaller amount of their appointments compared with psychiatrists who provided psychotherapy less often. This tendency is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a parallel escalation in those specializing in pharmacotherapy. These changes that were likely inspired by fiscal reasons and developments in drug treatment (Mojtabai &Olfson, 2008, p. 962). This trend conflicts with the academic aspiration of integrating psychotherapy with pharmacotherapy in medical schools training programs and is especially challenging to schools in lesser developed countries.

The Need for Studies

In a recent joint psychoanalysis and psychodynamic psychotherapy symposium—the first such colloquium in Iran—there was one credited psychoanalyst from Germany, and two qualified psychoanalytic psychotherapists from the United States. The rest of the lecturers seemed to address only the abstract and theoretical rather than the tangible and practical. Perhaps, this was the result of the unsystematic approach to psychoanalysis. The only way to support and promote the psychodynamic perspective in developing societies is through methodical study, training, and practice of psychoanalysis as the highest level of insight-oriented approaches.

Despite psychodynamic psychotherapy’s popularity in clinical practice, it is the subject of controversy concerning experimental proof. Insurance companies, lawmakers, and charitable organizations have become more apprehensive about the effectiveness of the psychotherapies. However, at least one randomized controlled trial (RCT) confirmed that psychodynamic psychotherapy was successful in treating depressive disorders, anxiety disorders, posttraumatic stress disorder, somatoform disorder, bulimia nervosa, anorexia nervosa, borderline personality disorder, Cluster C personality disorder, and substance-related disorders (Leichsenring, 2005). According to process research, outcome in psychodynamic psychotherapy is connected with the proficient delivery of therapeutic methods and to the progress of a therapeutic coalition. Controlled quasi-experimental efficacy reviews showed that psychoanalytic psychotherapy is:

Also, a meta-analysis showed that short-term psychodynamic psychotherapy (STPP) yielded substantial and large effect sizes for targeted problems, general psychiatric symptoms, and societal functioning. These effect sizes were steady and inclined to rise at follow-up. The effect sizes of STPP surpassed those of waiting-list controls and those in treatment as usual. No variances were found among STPP and other forms of psychotherapy (Leichsenring, Rabung, Leibing, 2004), a finding similar to the results of another comparable survey (Crits-Christoph, 1992).

Despite waning encounters with basic Freudian psychoanalysis by those who have moved to object related theories or two-person psychologies, some therapists, such as R. Chessick, have tried to restore attentiveness to the significance of Freud’s work for both practice and training (Chessick, 2010). He states, “the identity of psychoanalysis can still be based on Freud’s work, and his approach can form a fundamental center from which there are various channels of divergence that may be useful when the patient seems to need them” (Chessick, 2010, p. 413). According to Chessick, the core of teaching and direction should be the basic doctrines spelled out in Freud’s several books, despite the many variations and inconsistencies and even absolute slips and cultural carelessness he shows in some occasions (Chessick). Also, Chessick proposes the combination of numerous schools of psychoanalysis rather than breaking up of psychoanalytic practice (Chessick, 2014). “Psychoanalysis remains relevant today because it has situated itself among the other disciplines as a hybrid science, not quite a pure hermeneutic on the one hand, and not quite a pure science on the other, while at the same time having proven to be both these things—and in doing so has revolutionized the way we think about human nature” (Fusella, 2014, p. 871).

Conclusion

Psychotherapy training, including psychoanalysis and the psychodynamic psychotherapies, is acknowledged as being a basic constituent of the post-graduate exercise in psychiatry. It is a necessity for psychiatrists to understand psychological methods and psychodynamic aspects in a relationship so that they can use these in their everyday practice. Therapists must also be competent in the psychotherapies so that they may refer patients for such treatments and advise patients about what to anticipate from the treatments. The evidence shows the efficiency of psychoanalytic and psychodynamic treatments, indicating they will remain a crucial part of psychiatric management. There are numerous challenges facing trainees in developing countries in attaining excellent teaching in psychotherapy. Despite the acceptance of written curricula and general agendas by educational administrators in developing countries, an unsystematic approach, lack of facilities and qualified mentors, along with a lack of supporting societies, institutes, and psychotherapeutic departments present obstacles for the practice of psychotherapy by psychiatrists, generally, and psychoanalysis and related insight-oriented methods, specifically. In such unfavorable conditions, the inner passion of the trainee, along with the systematic study of original psychoanalytic writings, and overview of the historical process of progression of techniques helps gain comprehension about the subject. It should be noted that biopsychosocial attitude in modern psychiatry can not be established without reasonable attention to “unconsciousness.”