Analytic vs. Dynamic Psychotherapy in the Era of Managed Care

The main difference between dynamically oriented psychotherapy and analytically oriented psychotherapy is downplaying transference as a therapeutic modality in the latter. Although transference reactions are noted, especially when they occur as resistances, the elaboration of the transference is not a major ingredient in this form of psychotherapy.

Rather, therapists and patients focus more exclusively on present-day interactions and relationships, and their correlation to the patients' past. Patients and therapists work together to try to understand these present-day interactions on the basis of each patient's sensitivities, vulnerabilities and distortions, which originate in the past. A positive therapeutic alliance is fostered, and therapists are sometimes mildly idealized. Occasional suggestions, education and other supportive techniques are employed, along with the insight-oriented interventions of clarification, confrontation and interpretation. Supportive interventions include suggestion, therapeutic manipulation, abreaction, advice, reassurance, education, limit setting, reality testing, and giving encouragement and praise.

Analytically oriented psychotherapy is the preferred treatment for those patients who can form an intense transference in psychotherapy, and then use that transference constructively without regression. Some healthier (i.e., neurotic) patients can form an intense transference in psychotherapy, but many have difficulty accomplishing this. Psychoanalysis proper (with the use of the couch, free association and the increased number of sessions) is especially designed to help induce an intense (and regressed) transference in neurotic patients. Only psychoanalysis can attain this result for many neurotic individuals, to whom intensity and regression do not come naturally.

When psychoanalysis-for whatever reason-is excluded, one faces the question of which kind of psychotherapy to pursue. There are two contrasting opinions. One opinion favors simulating analysis as much as possible, with an all-out attempt to establish and utilize an intense transference. A second opinion, emphasizing the difficulty in attaining transference regression with neurotic patients in psychotherapy, favors using a dynamically oriented approach. Many therapists lean toward an analytically oriented modality for those neurotic patients (often hysterical in personality type) who can form a somewhat intense transference in psychotherapy. These therapists would employ a dynamically oriented model for other neurotic patients (often more obsessive in personality type) who have greater difficulty regressing.

The typical borderline patient, in contrast to the neurotic, has little difficulty forming an intense and regressed transference in the psychotherapy situation. In fact, the rapid mobilization of transference often distinguishes the borderline individual from the neurotic. Thus, analytically oriented psychotherapy is usually the treatment of choice. The common problem with these patients is in containing the transference regression.

With this in mind, modifications in technique (from the pure form of analytically oriented psychotherapy) are needed. Modifications include continual focus on the working alliance, more supportive interventions and alterations in style (such as more attention to an empathic and affirmative stance, the use of preparatory comments and the use of increased input from the patient). Elaboration of these modifications are described elsewhere (Goldstein, 1996).

For psychotic patients, to whom intense transferences can be clearly disruptive, the dynamically oriented approach is recommended. With these patients, supportive interventions predominate over insight-oriented ones.

When recommending either analytically oriented or dynamically oriented psychotherapy, one must often contemplate a long-term proposal. With managed health care, where duration of treatment is vastly limited, a long-term model rarely fits. Yet this kind of treatment is highly valued and desired by many individuals. Studies (Lazar, 1997; Stevenson and Meares, 1992) demonstrate the clear worth of such therapy and its necessity for certain groups of patients. One answer is to go outside of the managed health care system.

Some individuals are able to pay out-of-pocket; others can find good therapists who will charge lower fees when longer-term therapy is indicated. In the District of Columbia area, I am almost always able to place very motivated patients in a reduced-fee setting with a reasonably experienced therapist; I do not know how easily this can be accomplished in other areas.

Being familiar with the details and nuances of analytically oriented and dynamically oriented psychotherapy is an advantage even to therapists who operate within the managed health care system. Although modifications are often needed, many of the strategies and therapeutic techniques of dynamically informed psychotherapy are applicable to shorter-term work. Additionally, there is an expanding literature on dynamically informed short-term approaches. In my opinion, it behooves the managed health care therapist to learn traditional psychotherapy first, then to supplement this knowledge with that of the shorter-term approaches.

Dr. Goldstein is a teaching analyst and the director of the Adult Psychotherapy Training Program at the Baltimore-Washington Institute for Psychoanalysis, as well as clinical professor of psychiatry at the Georgetown University Medical Center. He has written extensively in professional journals and has published three books: An Introduction to the Borderline Conditions (Jason Aronson 1985), Dynamic Psychotherapy with the Borderline Patient (Jason Aronson 1996), and A Primer for Beginning Psychotherapy (Brunner/Mazel 1998).