Psychodynamic Therapy For Personality Disorders

Introduction

Patients who experienced past trauma, anxiety and childhood neglect are often severely affected by it and develop symptoms of personality disorders. These past events may have embedded in the unconscious, a central term in Freudian psychology. A therapist trained in psychodynamic methods enables the patient to get access to the unconscious.

Based on this raised awareness of past issues a patient can now work through these anxieties and improve his/her mental well being. Psychodynamic therapy has a range of treatment tools to offer for the increasing number of individuals who suffer from mental disorders.

Brief understanding of different personality disorders

Borderline personality disorder

About 1% of the population have been diagnosed with Borderline Personality Disorders (BPD). The name stems from a previously held view that BPD is a borderline condition located between neurosis and psychosis. It is characterised by individuals having distinctly different thoughts, feelings, behaviours and relationships if compared to most people. 

Although the symptoms may vary widely they typically include:

• emotional instability
• distorted perception
• disturbed ways of thinking
• Impulsive behaviour
• unstable but intense relationships

The causes of BPD are poorly understood and may be of genetic and environmental origin, however it is conspicuous that many individuals have been exposed to trauma or neglect as children. 

Narcissistic personality disorder

A person with Narcissistic Personality Disorder (NPD) wants to be admired, displays grandiosity and lacks empathy for others.¹ NPD is often hard to diagnose as an individual may also have an antisocial personality disorder, BPD, histrionic or schizotypal personality disorder. 

Structured interviews investigating personality structure, defence mechanisms, coping skills and relationship patterns are the primary diagnostic tool in clinical studies.

No standardised pharmacological or psychological treatments are available and patients are advised that ongoing long-term therapy with a professional therapist may be required.

Avoidant personality disorder(AVPD)

AVPD may develop gradually and can become chronic. Individuals frequently show signs of inferiority complex linked with the fear of rejection, leading to avoidance of social contact.² A repeated history of rejection can lead to a feeling of shame and personal inadequacy, diminished self-esteem and malignant self-regard.

This maladaptive behavioural patterns can be caused by genetic factors (0.64) but also when dismissive actions by caregivers, minimal parental encouragement, neglect and abuse may cause fear of intimacy in childhood.

Treatment is hampered by the fact that the patients are frequently unwilling to take part in talking therapies out of fear of being rejected when revealing their thoughts.

Obsessive-compulsive personality disorder

Obsessive-Compulsive Personality Disorder (OCPD) sounds very similar to Obsessive-Compulsive Personality Disorder (OCD) however, there are distinct differences. OCD includes having unwanted thoughts and behaviours which cause stress. The symptoms can fluctuate. However, OCPD is a different condition where someone always wants to be in control. The persistent symptoms include strict control and orderliness regardless of the impact this may have on others. 

OCPD has only been studied to a limited extent with inconsistent results. There is no single recommended treatment but CBT and Psychodynamic Therapy have successfully been applied.³

Core principles of psychodynamic therapy

Unconscious mind and its role

The unconscious mind includes hidden memories, repressed feelings and thoughts which are not easily accessible. They may be too painful, embarrassing or distressing to be permitted to surface to the conscious mind.

The perception of the unconscious mind has been studied and interpreted in a variety of ways since its Freudian origin.⁴ Simultaneously sources attribute a more flexible, complex, controlling and action orientated role than previously thought. 

The unconscious has a very strong influence on our daily life as it provides a depository of past thoughts, experiences and behavioural patterns. Every day we have to make numerous almost automatic snap judgments based on previous experiences. For example we expect waiters, taxi drivers and librarians to behave in a certain way and judge accordingly.

We may struggle to comprehend that a taxi driver could be a medical doctor unable to work in medicine due to his/her immigration status. Our unconscious mind, although essential in daily life, sometimes requires control by our conscious thoughts.

Importance of early life experiences

The experiences that we have in the formative years and later childhood are essential in the development of our thoughts, emotions and behaviour. A supportive environment, often provided by a family, is important in the healthy development of every child but it becomes of significant importance if a child’s life is affected by trauma.⁵

While positive childhood experiences provide a sound base for a physically and mentally healthy life, being subjected to a lack of care and perhaps even abuse in childhood frequently manifests as psychological disorders later in adulthood.

Development of defence mechanisms

Defence mechanisms are unconscious resources the ego employs to decrease conflict and stress.⁶ Anna Freud, the daughter of Siegmund Freud, initially identified 10 defence mechanisms, this number has substantially increased by other psychoanalysts, including: 

• Acting out
• Avoidance
• Conversion
• Denial
• Identification
• Projection
• Regression
• Repression
• Anticipation
• Compensation
• Displacement
• Humour
• Intellectualization
• Isolation of Affect
• Rationalisation
• Reaction formation
• Sexualization
• Sublimation
• Suppression

Exploration of unconscious conflicts

Unconscious conflicts can occur when fantasies collide.⁷ These are often sexual or aggressive urges which are in conflict with socially acceptable norms and behaviour. Clusters of these are called complexes. A therapist may aim to raise a patient’s awareness of unconscious conflicts and provide an opportunity to address them. 

Psychodynamic techniques in treating personality disorders

Free association

Free association allows the patient to observe thoughts, images, dreams and feelings that may occur when prompted by a therapist. They may provide insights into why a patient feels anger and resentment towards another person. Further discussion may shed light on the wider causes and provide a further step in resolving the resentment.

Dream analysis

Analysing dreams can give a patient access to his unconscious and assist him/her in understanding hidden thoughts, emotions and behaviours. Dream analysis has a very long although fading tradition and is mainly used by psychoanalysts as well as other therapists.⁸

Transference and countertransference

Transference is a process where a patient’s dysfunctional beliefs are directed towards the therapist. Countertransference occurs when a therapist responds complements the patient’s transference which gives insights into his beliefs. Guided discovery, imagery and role-playing techniques are tools to monitor transference and countertransference.⁹

Interpretation of resistance

Resistance to the therapeutic process is frequently encountered during sessions with a therapist. This may mean that the patient stops talking, only makes small talk, doesn’t engage with the therapist’s suggestions, cancels sessions or is not making any progress at all.

Therapists can overcome resistance by e.g. applying a paradoxical approach. Some patients are resistant to change and do the opposite of what the therapist suggests e.g. a patient complains about a sleeping issue, the therapist suggested improvements which were ignored. In the paradoxical approach he/she would recommend to continue watching TV in bed, the patient may now oppose the suggestion and get rid of the TV.

Working through trauma

Trauma is a lasting negative emotional response to extreme events such as experiencing war, violence or disasters. In severe cases trauma can develop into Post Traumatic Stress Syndrome. Symptoms of trauma may include

• flashbacks
• feeling upset
• avoidance of feelings
• loss of memory
• being mentally unbalanced

They may persist for weeks and months and in some cases patients may benefit from therapeutic interventions. Trauma focused therapies may include Cognitive Processing Therapy, Cognitive Behavioural Therapy, Eye Movement Desensitisation and Reprocessing among others.

Challenges and criticisms

There is no doubt that well-established psychotherapies have helped numerous patients over a long period of time. However, questions are emerging that query suitability and even the underlying principles are critically examined. 

All psychodynamic therapies are based on a range of assumptions often deriving from Freud’s historic work which postulates the existence of Id, Ego and Superego, the unconscious, as well as the importance of childhood experiences.

There are doubts about the importance and perhaps even the existence of these fundamentals which underpin psychodynamic principles. Undoubtedly childhood experiences are important but is it overrated? What is the impact that life has on adults? 

Many therapies are time-intensive, costly, and introduce an element of subjectivity by requiring therapists trained in the various treatments.

There are also concerns that certain personality disorders such as obsessive compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) may not be fully addressed by uncovering therapies.

Summary

For many years psychodynamic therapy has successfully helped many patients to overcome the often devastating effects of a number of conditions. Based largely on established Freudian views of the unconscious, treatments options include the famous dream analysis.

During this process a therapist assists and guides a patient through his/her dreams which may indicate past trauma or anxieties. This traditional method has now largely given way to tools such as free association, transference/countertransference and analysis of resistance to therapy. 

Although often successful psychodynamic therapy may be costly, time-consuming, requiring a specially trained therapist and always needs the patient to reveal his innermost thoughts and feelings. This may exclude those who are neither willing nor able to meet all of these requirements which leaves space for further complementary or alternative treatment options currently in development.