Psychiatry 73(1) Spring 2010 43

The Future of Psychodynamic PsychotherapyMauricio Cortina

The article reviews the current state and future of psychodynamic psychothera-pies. In the past few decades psychodynamic psychotherapies have fallen intodisrepute due to the fractious and dogmatic nature of different psychodynamicschools of thought and the lack of interest in validating some of its major prem-ises or its effectiveness in comparison with other psychotherapy modalities. De-spite these self-inflicted wounds, psychodynamic theory and treatment is staginga comeback. Many of the major premises that comprise the complex, layeredmodel of the mind that are the basis of psychodynamic treatments have againbegun to be validated. A list of basic psychodynamic concepts is described. Theevidence for each of these concepts varies, but as a whole the evidence is broadand deep for the model of the mind posited by psychoanalysis. This evidence iscoming from many fields of knowledge that are not necessarily influenced by psy-choanalysis. There have also been significant advances in developing methods andtools that can probe systematically into the complex nature of psychodynamictreatment processes. Finally, statistical tools-such as meta-analytic studies-thatcan aggregate and compare many different studies at once are beginning to showthe effectiveness of dynamic psychotherapies in comparison with other modalitiesof treatment.

Psychodynamic psychotherapy finds THE DECLINE OFitself in an ironic situation. The prestige and PSYCHOANALYSISinfiuence of psychoanalysis and dynamicpsychotherapy have been at an all-time lowfor the past few decades. Yet, at the very mo- From its heyday in the decade of thement when the prestige of psychoanalysis is 1940s and 1950s the prestige of psychoanal-so low, there has been accumulating evidence ysis has suffered a precipitous decline. Per-coming from many fields that support the haps one of the most telling indications ofcomplex, layered model of mind posited by this decline is reflected in the dramatic droppsychoanalytic theories. Another important in sales of psychoanalytic books in the Unit-development over the past decade that has ed States (the following data is taken frombeen less noticed is the gradual accumulation chapter 2 of Stepansky, 2009). Books suchof empirical evidence that supports the effec- as Frich Fromm's (1941) Escape from Free-tiveness of dynamic psychotherapies. dom (1941) and The Art of Loving (1956)

Mauricio Cortina, MD, is Director of the Attachment and Human Development Center at the Washington School ofPsychiatry and Faculty at the Institute of Contemporary Psychotherapy and Psychoanalysis in Washington D.C.An earlier version of this article was delivered as the Commencement address to the graduating classes of 2008Washington School of Psychiatry.Address correspondence to Dr. Mauricio Cortina, 8737 Colesville Road, Suite 303, Silver Spring, MD 20910; e-mai:mauriciocortinaOstarpower.net.

44 Cortina

sold milhons of copies in English alone. ErikErikson's Childhood and Society (1950) soldover a million copies. Even books geared toa more professional audience, such as OttoFenichel's The Psychoanalytic Theory ofNeurosis (1945) sold over 80,000 copies. Al-though sale numbers are lost, it is likely thatCharles Brenner's An Elementary Textbookof Psychoanalysis (1955) might have sold1,000,000 copies in its paperback edition.The paperback edition of Sullivan's The In-terpersonal Theory of Psychiatry (1953) soldover 96,000. The last major success of the"glory era" was David Shapiro's NeuroticStyles (1965) which sold 250,000 copies inits paperback edition. Kohut's The Analy-sis of the Self (1971) sold 42,000 copies. Inthe next generation of best-selling psycho-analytic books. Jay Greenberg and StephenMitchell's Object Relations in Psychoana-lytic Theory (1983) sold 49,500 and Chris-topher Bollas's Tbe Shadow of the Object:Psychoanalysis of the Unthought Known(1987) sold 16,00 copies. When we get intothe 1990s, the best-selling professional bookwas Nancy McWilliams's Psychoanalytic Di-agnosis (1994) with 54,000 copies. There area few other books that sold over 20,000 cop-ies and approximately 13 titles that sold alittle over 10,000 copies in the last 25 years.During the previous decade a "best-selling"psychoanalytic book was selling 1,500 to3,000 copies, while in the last few years theaverage competent and well-written bookswas selling fewer than 500 copies. Accord-ing to Stepansky, the era of big sales for psy-choanalytic books is over, and average, com-petent, psychoanalytic books are no longerprofitable enough to keep small publishingcompanies afloat.

The word is out that Freud was wrongabout everything he wrote and that there isno scientific backing for any of his discov-eries.' Freud was indeed wrong about many

issues, but perhaps the science of his day waswoefully inadequate to provide the evidencehe needed. A great deal has changed in thepast 100 years, and armed with more sophis-ticated methods and tools and several keyconceptual revisions, evidence is rapidly ac-cumulating to support many psychoanalyticconcepts. Many contemporary discoveriessuch as the mirror neuron system (Gállese,2006; Gallese, Fadiga, Fogassi, & Rizzolatti,1996; Rizzolatti, Fadiga, Gállese, & Fogas-si, 1996) or the mapping of the emotionalcircuitry of the brain (Panksepp, 1998) goa long way to explain the neurobiologicalmechanisms that make the psycotherapueticdialogue possible. We are no longer limitedto the type of mechanistic models of sciencethat Freud had to draw from to support histheories. Contemporary models of the mindand of psychiatric disorders, such as the oneproposed by distinguished geneticist Ken-neth Kendler (2008) that involves complexinteractions taking place at multiple levels(molecules to mind) which iteratively involveenvironmental factors, are broadly consis-tent with contemporary models of mind thatare proposed by contemporary psychoana-lysts (Mitchell, 1988). Another sample is thework of Nobel prize winner and psychia-trist Eric Kandel, whose seminal work onmemory and his views on the working of themind embrace basic psychoanalytic concepts(Kandel, 2006).

Many of the troubles of the psycho-dynamic tradition have been self-inflicted.With a few exceptions, there have been veryfew attempts to operationaHze and test ba-sic psychoanalytic concepts. One of thesenotable exceptions is Bowlby's effort to testpsychoanalytic theories having to do withthe nature of the infant's bond to his mother,the phenomenon of separation anxiety, andthe effects of loss (Bowlby, 1969/1982,1973,1980),

1. Some of the critiques of Freud and psychoanalysis addressed to the educated lay public have appeared in presti-gious venues. For example, see Frederick Crews's across-the-board attack, The Revenge of the Repressed, in the TheNew York Review of Books, November 11, and December 1, 1994.

45

The failure to test its theories and toform alliances with potential allies withinacademia has further marginalized psycho-analysis from the mainstream. An exceptionto a generally antagonistic attitude towardpsychoanalysis are some English depart-ments. Here Freud and psychoanalysis havesurvived by becoming transformed into apostmodern-deconstructive philosophy thathas very little to do with the real world andis completely opaque but for the initiated.Freud would not have been happy with thislegacy.

At best we have developed a tolerantattitude toward different schools of thought,having reached the conclusion that no brandof psychoanalysis is complete or true andthat many schools of thought have contrib-uted to the richness of psychoanalytic con-cepts. Many institutions that teach psycho-analytic psychotherapy have come to valuethis openness to different ideas and exposestudents to a variety of schools of thought.While there is much to commend this posi-tion, which certainly is better than the typeof dogmatism that was prevalent during theheyday of psychoanalysis, it leaves much tobe desired from a scientific point of view.Perhaps the most important shortcomingis that this new attitude of tolerance is of-ten taken to mean that all psychoanalytictheories are equally valid, and it is a matteror personal taste or style which theory weprefer to use. This leaves the psychoanalyticfield fragmented and without a clear strategyto move forward. Theoretical fragmentationand postmodern relativism flies in the faceof any attempt to advance psychodynamictheory as a science. Some earlier attempts ofcomparative psychoanalysis, such as Green-berg and Mitchell's Object Relations in Psy-choanalytic Theory (1983) were importantsteps forward. More recent systematic at-tempts of comparative psychoanalytic theo-ries are being conducted by the EuropeanPsychoanalytic Federation Working Groupin Comparative Glinical Methods. Thisgroup is engaged in a more systematic ef-fort of identifying and defining core concepts

that are compatible with a variety of theoriesand techniques (Tuckett et al., 2008). This isa daunting task. Psychoanalytic theory hasevolved over the course of 100 years and isrich and complex, and some of the ideas arenot compatible with each other (Stepansky,2009). What is needed is an ongoing effort todefine and operationalize basic psychoana-lytic concepts that have withstood the test oftime. Without vigorously and systematicallyengaging in these tasks, we simply cannotclaim that we are offering treatments that arebased on evidence. Not only is a laissez-faireattitude toward clinical and extra-clinicalvalidation unacceptable, but from a publicrelations standpoint it is a disaster.

To address these issues in new genera-tions of psychotherapists, we have to startfrom within and change a mindset towardresearch and empirical findings. Bornstein(2005) and Luyten, Blatt, and Correlen(2008) provide a road map on how to bridgethe gap between clinicians and researchers.According to these authors, researchers andclinicians belong to two different culturesand approach clinical work with differentassumptions. Psychodynamic clinicians gen-erally have a skeptical if not outright hos-tile attitude toward empirical research anddoubt that scientific findings might be help-ful (Hoffman, 2009). What is to be gained bytrying to live up to the standards of evidencethat are foreign to the field? The prevailingview seems to be content with avoiding holywars so that we can have a dialogue amongclinicians that might inspire or shed somelight on the intricacies of clinical work. Re-searchers are interested in being able to gen-eralize findings and insights that emerge fromindividual case presentations and find theelements in common that may account forthe effectiveness of any given approach withdifferent clinical populations. This is a verytall order, and the methodological challengesare enormous. But in the past few decadesthere have been significant advances. Thereare now many fine examples of qualitativeresearch methodologies that do justice to thecomplexity of clinical work, yet are able to

46 Cortina

approach research systematically with so-phisticated information gathering and statis-tical tools (Levy & Ablon, 2009). These newadvances make psychodynamic clinicians'attitudes toward the science of our craft evenmore unfortunate and self-defeating.

Regrettably, these attitudes, to a largeextent, reflect the way we teach psychody-namic psychotherapy. I will mention threeimportant areas where I think we have fallenshort: 1) We have failed to bring in findingsfrom other fields that support the model ofthe mind on which our work is based; 2) Wehave failed to show how scientific methodscan be tailored to capture some of the com-plexity of our work. This reflects a largerproblem. Research and empirical articles arepublished in journals that clinicians don'tread and are written in a technical languagethat is only understood by other researchersfamiliar with the intricacies of data gather-ing and statistical methods (Luyten et al.,2008); and 3) We have failed to make thepoint that clinical work based on single casestudies (the usual method for teaching psy-chotherapy) and clinical research that triesto generalize beyond single cases are comple-mentary ways of knowing (Borckardt et al.,2008). Both methods enrich our understand-ing. This raises the question of how to beginclosing the gap between the art and scienceof psychotherapy. A good starting point toaddress some of the issues is to make a list ofbasic concepts used in psychodynamic psy-chotherapies and see what kind of evidenceexsists to support them

BASIC PSYCHOANALYTICCONCEPTS

The following is a list of basic psycho-analytic concepts modified from JonathanSchedler's excellent article The Efficacy ofDynamic Psychotherapy (2010).

1. Unconscious processes and moti-vation. Ours is an intentional model of themind that focuses on conscious and uncon-

scious motivation. We pay special attentionto our patients' needs, desires, and wishesthat may not be recognized. As therapists wehelp patients recognize disowned needs orhelp regulate desires and wishes that are all-consuming or overwhelming. We often focuson motivational systems that are in conflictwith each other, such as approach-avoidanceconflict (typical of patients with borderlinepathologies) or superego conflicts, (e.g., aconflict between unbridled ambition and awish to remain true to ourselves or severeself criticism accompanied by idealization ofparental figures).

2. Emotional processes. The psycho-analytic model of the mind focuses on af-fect and emotion. As therapists we help pa-tients recognize and honor their emotionswhether they are pretty or not. We validateemotions that might not have been formu-lated or named, such as profound shame orguilt, unspeakable terror, searing rage, orall-consuming jealousy or revenge. We workwitb contradictory feelings and help regulateemotion.

3. Defensive processes. The psychoan-alytic model of the mind focuses on defensiveprocesses. We explore attempts of patients toavoid certain aspects of experience, such aspainful emotions or threatening situations.We pay attention when patients exclude af-fects or painful events, and we note whenthey become suddenly confused or disori-ented. Dynamic psychotherapists activelyexplore mechanisms of avoidance. We alsonote when patients look at situations in allgood or all bad terms, when they panic andcatastrophize events, or when they obsessendlessly about them and become paralyzed.

4. Developmental processes. The psy-choanalytic model of the mind is profoundlydevelopmental. Human minds, become or-ganized around certain themes, conflicts, orstrategies that are for the most part uncon-scious and that have their origin in develop-ment. We track these themes, make themexplicit, and try to make a connection withthe present. The focus on the past and on de-velopmental issues is not an end in itself, but

47

a means to make clear how the past is aliveand well in the present and how the past af-fects the way we perceive relations and theworld at large.

5. Social processes. Our model of themind is profoundly social. There are at leastthree interlocking dimensions to human so-ciability: attachment and family ties; inter-subjective abilities and communication; andculture.

a) Attachment and family ties. Hu-man personality becomes organized aroundattachment figures that become a haven ofsafety and a secure base from which to ex-plore the world. As dynamic psychothera-pists we try to develop a working alliancewith our patients that will allow the explora-tion of affects, confiicts with a developmentalperspective, by becoming a secure base forthem. Often developing a secure base fromwhich to explore may become a goal in itself,since many patients have never had a secureattachment figure in their life and their abil-ity to trust others is very limited and fraughtwith terror and shame.

b) Intersubjective abilities and com-munication. Most of how we learn to com-municate and the way we know how to bewith others is not conscious. Gestures, turn-taking in conversation, and the ability to rec-ognize emotions and the intentions of othersare intersubjective abilities that are graduallyacquired before language develops by theend of the second year of life. This world of"implicit relational knowing" (Lyons-Ruth,1999; Stern, 2004) is vast and pervasive,and it provides a background to all verbalcommunication. Many forms of unconsciouscommunication that have been described byterms like transference and protective iden-tification can now be better understood interms of intersubjective abilities. Transfer-ence can be understood as expectations andways of relating that are established duringchildhood and are carried forward in devel-opment. We pay very close attention to howthese relational patterns become activated orreenacted in the consulting room. The powerof these expectations offers us a golden op-

portunity to explore them while in the imme-diacy of a therapeutic relationship.

c) Culture. Cultural norms and beliefs,the range of emotions that can be expressedfreely, and proper ways of being with mem-bers of our own group or members of othergroups are learned to a large degree at im-plicit nonverbal (unconscious) levels and arereinforced through language and ritual. Theimpact of culture is ubiquitous and becomesinternalized as interpersonal schémas and so-cial scripts. Because these schémas and scriptsare primarily non-conscious, they become ac-cepted as a natural way of being. Recogniz-ing cultural differences and their imprint onpersonality has been a major theme amongsuch psychoanalysts as Erik Erickson, KarenHorney, Abram Kardiner, and Erich Eromm.Fromm's theory of social character is per-haps the most developed of these approachesto personality and culture. The concept ofsocial character refers to emotionally basedattitudes (character traits) that are shared bythe social group as adaptations to prevailingeconomic and social conditions.^

6. Imagistic processes. With his cre-ative incursion into the world of dreams,Ereud opened up for scientific scrutiny thesignificance of dreams and the role of imagesand fantasy in dreams and in wakeful rev-erie states. Yet many aspects of Ereud's theo-ries of dreams have been questioned withinpsychoanalysis and from systematic studies(Domhoff, 2000). Ereud believed that themanifest content of dreams is invariably dis-torted or disguised to hide how unacceptablehis wishes had become ("dream work"). Inexploring the potential meaning of a dreamthe approximate meaning can be discernedby paying close attention to its manifestcontent, associated imagery, and emotionaltone. The power of dreams is often capturedthrough images that reflect experience withan emotional resonance and vividness that isimmediate and direct. As we put words tothese images, we begin to discover their sa-lience and meaning. As dynamic therapistswe focus on dreams, images, and fantasies asentries into our patients' states of mind.

48 Cortina

EVIDENCE FOR THESE BASICASSUMPTIONS

1. Unconscious processes. In terms ofunconscious processes we now know thatFreud's dynamic (repressed unconscious)is but a very small fraction of what is non-conscious. The vast majority of informationthat is processed out of awareness is not re-pressed, but is encoded at subsymbolic andimplicit levels (Bucci, 1997, 2005; Cortina& Liotti, 2007). The cognitive revolutionbrought with it an understanding of the mindas being parsed in different memory systems(Bucci, 1997; Schacter, Wagner, & Büchner,2000; Schank & Abelson, 1977; Westen,1999; Westen & Gabbard, 2002).

It has been known for several years thatthe mere activation of the idea of engaging inany given behavior begins to move the bodywithout personal awareness (Wegner, 2002).Using a functional MRI, a group of Germanresearchers have shown that unconsciousprocesses involving the prepolar and precu-neus cortex precede awareness of making adecision by 7 to 10 seconds! (Soon, Brass,Jochen Heinze, & Haynes, 2008). Anotherimportant contribution to understanding un-conscious processes has come from the workof subliminal perception (Frdelyi, 1985; Wes-ten, Weinberger, & Bradley, 2007). A recentexample of this type of research shows thatan unconscious (out of awareness) prime haspowerful effects on motivation, particularlywhen the prime has a positive valence (Aarts,Custers, & Marien, 2008).

2. Emotional processes. It used to bethat emotions were ignored by neuroscience.But recently, emotions have become one ofthe most exciting topics in modern neurosci-ence. The switch began in the 1960s with thework of Sylvan Tompkins, but in the last fewdecades Antonio Damasio's Descartes' Er-ror (1994), Joseph LeDoux's The Emotional

Brain (1996), and Jack Panksepp's AffectiveNeuroscience (1998) have put emotion frontand center. We now have a much better un-derstanding of the brain's circuitry involvingthe amygdala and the limbic system, how theycommunicate with the prefrontal cortex andthe temporal lobes through the hypothala-mus, and how emotions are intimately tied tomotivational systems (Panksepp, 1998). Thework of Paul Fkman (2003) has providedcross-cultural evidence of the universality ofsome basic emotions and emotional expres-sions, and a cadre of brilliant psychologists,including Nico Frijda (1986), Carroll Izard(1991), Richard Lazarus (1991), and AlanSroufe (1996), have made substantial con-tributions showing the function of emotions,the relationship between emotion and cog-nition and how emotions become integratedwith cognition, through acquiring explicitmeanings that are only implicit during earlydevelopment (Sroufe, 1996).

3. Defensive processes. Evidence forthe existence of defensive processes has beenaccumulating from many fields in recent de-cades. In the past few years two articles haveappeared in Science (Anderson et al., 2004;Depue, Curran, ôc Banich, 2007) that docu-ment through neuroimaging techniques theexistence of repression of unwanted memo-ries. These defensive processes are orches-trated via a two-phase process: an initialsuppression by the right inferior gyrus (pre-frontal cortex) over sensory components ofmemory and a second phase initiated by theright medial frontal gyrus over the emotionalcomponents involving the amygdala and hip-pocampus.

Bornstein (2005) notes that the studyof defensive processes has often been takenup by academic psychologists without anyreference to Freud. For instance, Aron Beckhas documented and studied cognitive avoid-ance as a defense mechanism in cognitive

2. In the late 1960s, Fromm and Maccoby (1971) set out to rigorously test the theory of social character in a smallMexican village, using in-depth interviews, extensive ethnographic and economic surveys, and sound statisticalanalysis. The study found that the three social character groups found in the village-free peasants, hacienda peons,and the new entrepreneurs—could be clearly understood by examining different historical and social conditions thathad shaped their character orientations.

49

therapy, while Tulving has documented andstudied slips of the tongue and other mecha-nisms of defense as retrieval errors. The repe-tition compulsion has been studied under thename of nuclear scripts by Tompkins. Andon it goes. Perhaps the most comprehen-sive effort to validate empirically the notionof defense mechanisms has been a 20-yearongoing project led by Phebe Cramer (Cra-mer, 2006). Cramer's impressive work hasfocused primarily on three defense mecha-nisms: denial, projection, and identification.She shows that defenses function outside ofawareness, that they are part of normal per-sonality, but increase with stress. Cramer hasalso shown that defenses mobilize negativeemotions and reduce the scope of conscious-ness. Finally, Cramer shows that defenses areconnected with measures of the autonomienervous system, such as blood pressure andskin conduction tests. These are all findingsconsistent with a psychoanalytic model ofthe mind.

4. Developmental processes. Develop-ment and the significance of the past in influ-encing the present ("the child is parent to theman") have had recent and strong evidence.Longitudinal studies are one of the best waysto provide evidence for this key proposition,but they are extremely expensive and hardto do. In the past few decades several longi-tudinal studies—to a great extent inspired bythe work of John Bowlby (1969/1982, 1973,1980) and Mary Ainsworth and her col-leagues (1978)—have undertaken the enor-mous challenge of putting to the test manypsychoanalytic ideas about the importance ofparent-child relationships in influencing thedevelopment of personality. It is impossibleto summarize all these findings, but it is fairto say that there is strong scientific evidencefor several key propositions in regard to therelationship between the past and present. 1)The past, for better or for worse, is alwayswith us; 2) the past influences but does notdetermine the present; 3) the best predictorof outcomes is the cumulative history of howwe manage different developmental tasks;and 4) there are continuities and discontinui-

ties in development, and nonlinear effects arethe norm. An excellent entry into this litera-ture, led by Alan Sroufe and his colleagues(2005), is based on a very comprehensiveand rigorous scientific longitudinal studyin the work of the University of Minnesotagroup (for review of the major longitudinalstudies, see Grossmann, Grossmann, & Wa-ters, 2005).

5. Social processes. The vast litera-ture on attachment theory and research thatspans five decades is one of the main sourcesof evidence that supports the relational turnin psychoanalysis and has added significantlyto our understanding of how social-emotion-al processes mold personality development.This literature cannot be easily summarized,but among its main findings is the discoveryof three basic strategies used by infants toregulate security and exploration; the dis-covery of a frightening and disorganizingdimension to these basic strategies in someinfants; the transformation of these frighten-ing experiences into controlling strategies inmany cases of children with histories of dis-organized attachment; and the discovery (bymeans of the Adult Attachment Interview) ofhow the narratives we use to recall childhoodevents embody more or less open access topainful emotions or defensive maneuvers toward off these painful emotions. A good en-try into this vast literature is the Handbookof Attachment (Cassidy & Shafer, 2008).

This body of knowledge has significantclinical implications. The quality of the ther-apeutic alliance is the single most importantpredictor of the effectiveness of psychother-apy (Ackerman & Hilsenroth, 2003; Hor-vath, 2001). The ability to develop a senseof safety with the therapist from which toexplore issues in therapy is one of the key in-gredients of a good therapeutic alliance. Theconcept of a therapeutic alliance originatedwithin the psychoanalytic literature but isnow a widely used concept in psychotherapyresearch. As therapists we often become at-tachment figures to our patients, particularlyin moments when they feel vulnerable andhelpless. Many schools of thought have con-

50 Cortina

sidered providing safety and containment akey to success, but attachment theory offersa parsimonious and straightforward wayto understand one of the key dimensionsof therapeutic effectiveness. Understandingdefensive processes that regulate security isanother important contribution from attach-ment theory and research that informs ourclinical interventions.

The significance of intersubjectiveabilities and intersubjective communicationhas been another major contribution stem-ming from infant-parent research. Threenames immediately come to mind, ColwynTrevarthen (2005, 1979, 1980, 1988); Tre-varthen & Aitken (1994); Trevarthen &Hubley (1978); Daniel Stern (1985, 2004)and Beatrice Beebe (Beebe, Knoblauch, Rus-tin, 8c Sorter, 2005). These researchers havecontributed enormously to our understand-ing of the world of implicit relational know-ing (Stern, 2006). Implicit or proceduralknowing is unconscious, not because it isrepressed, but because subsymbolic process-ing of information cannot be retrieved con-sciously. This information is carried forwardas powerful expectations and attributions wemake toward others. The power of these ex-pectations and attributions is that they arenot accessible to consciousness. When mal-adaptive, they often get reenacted in destruc-tive and unhelpful ways.

6. Imagistic abilities. It might seem ar-bitrary to lump the study of dreams with thestudy of images, imitation, and imagination.Dreams not only contain images, but theseimages are also embedded in narrative plotsthat contain language. Moreover, dreamsalso evoke strong emotions—mostly nega-tive emotions as shown by systematic studyof the content of dreams (Domhoff, 1999).There are many complex issues involved inthe scientific approach to dreams. Many psy-choanalists belonging to different schools ofthought have noted over many decades thatthe imagery in dreams often has a figurative ormetaphorical meaning. For instance, the im-

age of flying in a dream might be a metaphorfor a state of happiness or euphoria. We alsouse flying images as metaphors during wake-ful states, as in expressions such as "flyinghigh" or being "high as a kite." The image ofbeing naked in a dream is often a metaphorfor shame or embarrassment, and this imageis also captured in the common expressionof being "caught with our pants down." Asthese examples show, images—or " image-schemas" to use the term of the distinguishedlinguist George Lakoff (1980)—are used tocreate metaphors and figures of speech. Lan-guage builds on the meaning inherent inpreverbal image schémas (see below) and ex-pands their meaning by virtue of the powerof language to combine words and sentencesad infinitum. It is reasonable to think thatimages might perform a similar function indreams. Indeed, many clinicians who workwith dreams approach the manifest contentof images and symbols this way, an approachtaken by Erich Fromm (1951) in The Porgot-ten Language. The dream researcher WilliamDomhoff provides support for the hypothe-sis that some images in dreams can be un-derstood as metaphors that have a cognitivefunction (Domhoff, 1996; Domhoff, 2005).

The study of imagistic abilities is avery promising field, one most in need of re-search. Jean Piaget (1962) in his landmarkbook Play, Dreams and Imitation in Child-hood thought that deferred imitation was adevelopmental benchmark that signaled theemergence of symbolic or representationalthought. Deferred imitation is defined by theability to repeat a scene or behavior days orweeks after being exposed to it. The impor-tant point is that deferred imitation impliesthat there is a remembered image of the eventor behavior.̂ According to Piaget, images be-come mental representations or symbols ofsorts, albeit a symbol still tied to a perceptualstimulus. In contrast, abstract symbols (thatmake their first appearance by the middle ofthe second year of life or later) are no longertied directly to an immediate percept. For in-stance the word "animal" refers to the whole

51

category of living creatures that share certaincharacteristics such as spontaneous agencyand motility.

In Piaget's developmental model, repre-sentational thought does not appear until 16to 18 months of age. Before this age infantsdisplay a sensorimotor form of intelligencethat is nonsymbolic or nonrepresentationalin nature (Piaget's sensorimotor intelligenceis now understood as a form of implicit orprocedural knowledge). We now know fromthe work of Patricia Bauer and colleagues(1996; Bauer & Shore, 1987) that deferredimitation appears much earlier than Piagetthought —toward the end of the first yearof life-and that the capacity for imitation isone of the foundations for social cognition(Meltzoff, 2007). The appearance of the ca-pacity for deferred imitation is accompaniedby the emergence of other abilities, such as:

• sharing of interesting events and happen-ings with caregivers by pointing and oth-er gestures beginning around 12 months(Bates, Camaioni, & Volterra, 1975; Toma-sello. Carpenter, &c Liszkowski, 2007;Warneken, Chen, & Tomasello, 2006)

• the ability to achieve a goal through vari-ous means—9 to 12 month-old infants(Piaget, 1952)

• joint intentionality: the ability to under-stand intentions from a first-person per-spective (I) and third-person perspective(others), beginning with 15-month-old in-fants (Tomasello, Carpenter, Call, Behne,&c Henrike, 2005)

• the ability to cooperate with caregivers inreciprocal games and simple tasks, begin-ning soon after the first year of life (Toma-sello, 2007)

• the ability to altruistically help others by 18months, an ability that far surpasses simi-lar bebaviors in chimpanzees (WarnekenSe Tomasello, 2006)

All this suggests that before languageemerges by the end of the second year of life,there is a form of knowing that is already

representational in nature and is marked bythe emergence of images that can be retainedin memory. This cognitive revolution is ac-companied by a revolution in social under-standing that takes off during the secondyear which greatly facilitates the ability ofinfants to cooperate and communicate withcaregivers (intersubjective abilities).

RESEARCH ON DYNAMICPSYCHOTHERAPY

I would like to conclude by making afew more remarks in regard to psychother-apy research. Much of this research is frus-trating because it ends up with the so-calleddodo bird verdict, referring to Alice in Won-derland, where in a contest among birds thequeen decides that "everyone has won andall must have prizes" (Shedler, 2010). Out-comes of different therapies are surprisinglyequivalent, and no form of psychotherapyhas proved more effective than any other.Not surprisingly, when differences are foundfor a certain type of therapy (such as cogni-tive behavioral therapy), the positive findingsalways favor the treatment advocated by theresearchers (Luborsky et al., 1999).

Nonetheless, there is good news onthis front. Some studies are beginning toshow what is called an "incubator effect" ofdynamic psychotherapy. That is to say, thatthe positive effects of psychotherapy contin-ue to accrue after the therapy has terminated(Shedler, 2009). This incubator effect has notbeen shown to be long acting in dialecticalbebavioral therapy (DBT) or in cognitivebehavioral approaches. Another very sugges-tive finding is that to the extent that cognitivebehavioral techniques are useful, they maybe so because they have incorporated psy-chodynamic principles used by experiencedtherapists that deviate from the manualizedtreatment protocol.

With the development of meta-anal-yses, it is possible to accumulate very large

52 Cortina

data sets from many psychotherapy researchstudies. This large pool of data is then scru-tinized with sophisticated statistical methodsand can be compared and evaluated. Meta-analytic studies can also be used to comparehow well these large data sets stack up againstsimilar data sets from different types of psy-chotherapy. Just to get a measure of some ofthese studies and what they mean, an effectsize of 1.0 means that the average patient isone standard deviation healthier in the nor-mal (Bell) distribution curve than the averageuntreated patient. An effect size of 1.0 meansthat the population mean of treated personsis 84 % better than the population mean ofuntreated persons. Anything better than .8 isconsidered a very good effect size. Erom thesemeta-analytic studies, it is becoming clearthat effect sizes of dynamic psychotherapyare comparable, if not superior to other com-mon types of psychotherapy that are general-ly considered to have solid evidence for theirefficacy. Eor instance, a meta-analysis of 12short-term psychodynamic studies showedeffect sizes of .97, (Abbas, Hancock, Hen-derson, & Kisely, 2006), and a meta-analysisof 15 studies of the treatment of personal-ity disorders using long-term psychotherapy(measuring pretreatment and post-treatmenteffects) showed an effect size of 1.46. To gaina comparative perspective of effect sizes, sev-eral studies of cognitive behavioral psycho-therapy have shown effect sizes ranging from.58 to .62. An even more telling perspectiveis to compare effect sizes when only medi-cation is used to treat depression. Commonantidepressants have effect sizes that rangefrom of .31 for citalopram (Celexa), .3 for

duloxetine (Cymbalta) and .24 for sertraline(Zoloft) (Shedler, 2009).

Another encouraging article showingthe effectiveness of long-term treatment overshort-term cognitive and dynamic psycho-therapies appeared recently in the Journalof the American Medical Association (Leich-senring & Rabung, 2008). The authors re-viewed 11 prospective studies that comprised1,053 patients, with diagnoses ranging fromborderline, obsessive, and avoidant personal-ity disorders, to eating disorders mixed withAxis I diagnoses—mainly chronic depressionand anxiety disorders. They compared theeffect of long-term psychoanalytic psycho-therapy (a mean of 95 weeks in treatmentand a followup mean at 93 weeks) with avariety of short-term psychotherapies. Therewere 257 patients enrolled in short-termpsychotherapy. The results showed a robustbetween-group effect size of 1.8 (with a 96% confidence level) in long-term treatmentof patients with complex mental disorders.This means that on average 96% of the pa-tients who received long-term psychotherapywere better off in comparison to groups inshort-term psychotherapies (p = .002). Sub-group analyses showed that long-term psy-chotherapy yielded significant large and sta-ble within-group effect sizes across differentcomplex mental disorders, with effect sizesranging from 0.78 to 1.98. Using a random-ized controlled clinical trial with follow-upevaluation 1 and 3 years after termination,another mainstream article shows sustainedimprovements of transference interpretationswhen used during treatment over and abovethe use of other treatment interventions(Hoglend et al., 2008). The effectiveness of

3. The existence of internal modelling processes in the brain of humans and other primates has been demonstratedby the work of Rizollatti, Gállese and their colleagues (Gállese et al., 1996; Rizzolatti et al., 1996) who have shownthat the same prefrontal cortex motor cells that become active when a subject picks up an object are equally activewhen the subject observes another living agent picking up the same object. These cells have been named mirrorneurons. In another experiment, a group of neurons in the insula were seen to discharge in two emotional condi-tions; when the subject felt disgust at a noxioius smell and when the subject viewed a film of a face showing disgust(Keysers et al., 2003). It is likely that other emotions are activated the same way just by observing them on others(Gazzaniga, 2008, pp. 177-181).

53

transference interpretations was shown in arandomized control study with patients diag-nosed with borderline personality disorder.The study showed statistically significantchanges in attachment patterns (as measuredby the Adult Attachment Interview), using atransference-focused approach to treatmentin comparison with controls (Levy et al.,2006).

CONCLUSION

Despite the low level of prestige ofpsychoanalysis and psychodynamic psycho-therapy, the tide is turning. There is solid evi-dence to support many key premises under-

lying the practice of dynamic psychotherapyand modest but growing evidence to supportthe effectiveness of its treatments. Most post-graduate training of dynamic psychotherapyis based on small independent training insti-tutes that do not have the resources to teachresearch methods and conduct expensiveclinical trials. To train future therapists inthe art and science of dynamic psychother-apy, it is imperative that these independentinstitutes make a concerted effort to bridgethe gap between research and practice. Thisis a difficult undertaking, but there are someareas of the country where local instituteshave banded together to pool resources andshowcase some of the most promising typesof research that speak to clinical concerns."*

REFERENCES

Aarts, H., Custers, R., & Marien, H. (2008).Preparing and motivating behavior outside ofawareness. Science, 319, 1639-1610.

Abbas, A. A., Hancock, J. T., Henderson, J.,&C Kisely, S. (2006). Short-term psychodynamicpsychotherapy for common mental health dis-orders. The Cochrane Database of SystematicReview, 4-CD004887.

Ackerman, S., & Hilsenroth, M. J. (2003). Areview of therapist characteristics and tech-niques positively impacting the therapeutic alli-ance. Clinical Psychology Review, 23, 1-33.

Ainsworth, M. D., Blehar, M. C , Waters, E.,&c Wall, S. (1978). Patterns of attachment. Apsychological study of the strange situation.Hillsdale, NJ: Erlbaum.

Anderson, M. C , Ochsner, K. N., Brice, K.,Cooper, J., Roberston, E., Gabrieli, S. W. etal. (2004). Neural systems underlying the sup-pression of unwanted memories. Science, 303,232-235.

Arbib, M. A. (2005). From monkey-like actionrecognition to human language: An evolution-ary framework for neurolinguistics. Behavioraland Brain Sciences, 28{2), 105-124.

Bates, E., Camaioni, L., & Volterra, E. (1975).The acquisition of performatives prior tospeech. Merril-Palmer Quarterly, 21, 205-226.

Beebe, B., Knoblauch, S., Rustin, J., &c Sorter,D. (2005). Forms of Intersubjectivity in InfantResearch and Adult Treatment. New York:Other Press.

Bollas, C. (1987). The Shadow of the Object:Psychoanalysis of the U nth ought Known. NewYork: Columbia University Press.

Borckardt, J. J., Nash, M. R., Murphy, M. D.,Morre, M., Show, D., & O'Neil, P. (2008).Clinical practice as natural laboratory for psy-chotherapy research. American Psychologist,63, 77-95.

Bornstein, R. F. (2005). Reconnecting psycho-analysis to mainstream psychology. Psychoana-lytic Psychology, 20, 323-340.

Bowlby, J. (1969/1982). Attachment (Vol. I).New York: Basic Books.

Bowlby, J. (1973). Separation, Anxiety and An-ger (Vol. II). New York: Basic Books.

4. In the Washington, D.C. metropolitan area a consortium of twelve psychoanalytic and psychodynamic societieshave been hosting a very successful annual program.

54 Cortina

Bowlby, J. (1980). Attachment and Loss (Vol.III). New York: Basic Books.

Brenner, C. (1955). An Elementary Textbookof Psychoanalysis. New York: InternationalUniversity Press.

Bucci, W. (1997). Psychoanalysis and Cogni-tive Science. New York: Cuilford.

Bucci, W. (2005). The interplay of suhsymbolicand symbolic processes in psychoanalytic treat-ment. Psychoanalytic Dialogues, 855-873.

Cassidy, J., & Shafer, P R. (Eds.). (2008).Handbook of Attachment. Theory, Research,and Clinical Applications. New York: Guil-ford.

Cortina, M., & Liotti, G. (2007). New ap-proaches to understanding unconscious pro-cesses: Implicit and explicit memory systems.International Forum of Psychoanalysis, 16,204-212.

Cramer, P (2006). Protecting the Self DefenseMechanism in Action. New York: Guilford.

Damasio, A. (1994). Descartes' error: Emotion, Reason and the Human Brain. New York:Putnam.

Depue, B. E., Curran, T., & Banich, M. T.(2007). Prefrontal regions orchestrate suppres-sion of emotional memories via a two-phaseprocess. Science, 317, 215-219.

Domhoff, G. W. (1999). New directions inthe study of dream content using the hall andvan de Castle coding system. Dreaming, 9,115-137.

Domhoff, G. W. (2000). Moving Dream The-ory Beyond Freud and jung. Paper presentedto the symposium "Beyond Freud and Jung?"Graduate Theological Union, Berkeley, CA,9/23/2000.

Ekman, P. (2003). Emotions Revealed. NewYork: Holt.

Erdelyi, M. H. (1985). Psychoanalysis: Freud'sCognitive Psychology. New Haven, CT: Free-man.

Erikson, E. (1950). Childhood and Society.New York: Norton.

Fenichel, O. (1945). The psychoanalytic Theo-ry of Neurosis. New York: Norton.

Frijda, N. H. (1986). The Emotions. Cam-bridge: Cambridge University Press.

Fromm, E. (1941). Escape from Freedom. NewYork: Farrar & Rinehart.

Fromm, E. (1956). The Art of Loving. NewYork: Harper & Row.

Fromm, E., & Maccoby, M. (1971). SocialCharacter in a Mexican Village. EnglewoodCliffs, NJ: Prentice-Hall.

Gállese, V. (2006). Intentional attunement: Aneurophysiological perspective on social cog-nition and its disruption in autism. CognitiveBrain Research, 1079, 15-24.

Gállese, V., Fadiga, L., Fogassi, L., & Rizzo-latti, G. (1996). Action recognition in the pre-motor cortex. Brain, 119, 593-609.

Gazzaniga, M. S. (2008). Human. The ScienceBehind What Makes Us Human. New York:HarperCollins

Greenberg, J. R., & Mitchell, S. A. (1983). Ob-ject Relations in Psychoanalytic Theory. Cam-bridge, MA: Harvard University Press.

Grossmann, K. S., Grossmann, K., & Waters,E. (Eds.). (2005). Attachment from Infancy toAdulthood. New York: Guilford.

Hoffman, I. L. (2009). Doublethinking ourway to "scientific" legitimacy: The desiccationof human experience. Journal of tbe AmericanPsychoanalytic Association, 57, 1043-1069.

Hoglend, P, Bogwald, K.-P, Amlo, S., Mar-ble, A., Ulberg, R., Sjaastad, C. et al. (2008).Transference interpretations in dynamic psy-chotherapy. Do they really yield sustained ef-fects? American Journal of Psychiatry, 165,763-771.

Horvath, A. O. (2001). The alliance. Psycho-therapy, 36, 365-372.

55

Kandel, E. R. (2006). In Search of Memory.The Emergence of a New Science of Mind.New York: Norton.

Kendler, K. S. (2008). Explanatory models forpsychiatric illness. American Journal of Psy-chiatry, 165,695-702.

Kohut, H. (1971). The Analysis of the SelfNew York: International University Press.

Lazarus, R. S. (1991). Emotion and Adapta-tion. New York: Oxford University Press.

LeDoux, J. (1996). The Emotional Brain. NewYork: Simon &c Schuster.

Leichsenring, F, & Rabung, S. (2008). Effec-tiveness of long-term psychodynamic psycho-therapy. A meta-analysis. Journal of the Ameri-can Medical Association, 300, 1552-1565.

Levy, K. N., Meehan, K. B., Kelly, K. M., Rey-noso, J. S., M., W., Clarkin, J. F et al. (2006).Changes in attachment patterns and reflectivefunctioning in a randomized control trial oftransference focused psychotherapy for border-line personality à\soïàe.i. Journal of Consultingand Clinical Psychology, 74, 1027-1040.

Levy, R. A., & Ablon, J. S. (Eds.). (2009).Handbook of Evidence-Based PsychodynamicPsychotherapy. Bridging the Cap Between Sci-ence and Practice. New York:

Luborsky, I., Diguer, L., Seligman, D. A.,Rosenthal, R., Krouse, E. D., Johnson, S. et al.(1999). The researchers own therapy allegianc-es. A "wild card" in comparison to treatmentefficacy. Clinical Psychology: Science and Prac-tice, 6, 95-106.

Luyten, R, Blatt, S. J., & Corveleyn, J. (2008).Bridging the gap between psychoanalytic re-search and practice Psychologist-psychoana-lyst.

Lyons-Ruth, K. (1999). Two-person uncon-scious: Intersubjective dialogue, enactive re-lational representation, and the emergence ofnew forms of relational organization. Psycho-analytic Inquiry, 19, 576-617.

McWilliams, N. (1994). Psychoanalytic Diag-nosis: Understanding Personality Structure inthe Clinical Process. New York: Guilford.

Meltzoff, A. N. (2007). "Like me": A founda-tion for social cognition Developmental Sci-ence 19,126-134.

Mitchell, S. A. (1988). Relational Conceptsin Psychoanalysis. Cambridge, MA: HarvardUniversity Press.

Panksepp, J. (1998). Affective Neuroscience.New York: Oxford University Press.

Piaget, J. (1952). The Origins of Intelligence inChildren. New York: International UniversityPress.

Piaget, J. (1962). Play, Dreams and Imitationin Childhood. New York: Norton.

Rizzolatti, G., Fadiga, L., Gállese, V., & Fo-gassi, L. (1996). Premotor cortex and the rec-ognition of motor actions. Cognitive Brain Re-search, 3, 131-141.

Schacter, D. L., Wagner, A. D., & Büchner, R. L.(2000). Memory systems of 1999. In E. Tulving& F M. I. Craik (Eds.), The Oxford Handbookof Memory (pp. 627-643). New York: OxfordUniversity Press.

Schank, R., & Abelson, R. (1977). Scripts,Plans, Goals and Understanding. New York:Wiley.

Shapiro, D. (1965). Neurotic Styles. New York:Basic Books.

Shedler, J. (2010). The efficacy of psychody-namic psychotherapy. American Psychologist,65, 98-109

Soon, C. S., Brass, M., Jochen Heinze, H., &cHaynes, J. D. (2008). Unconscious determi-nants of free decisions in the human brain. Na-ture Neuroscience, 11, 543-545.

Sroufe, L. A. (1996). Emotional Development.The Organization of Emotional Life in theEarly Years. New York: Cambridge UniversityPress.

56 Cortina

Sroufe, L. A., Egeland, B., Carlson, E., & Col-lins, W. A. (2005). The Development of thePerson. The Minnesota Study of Risk and Ad-aptation Prom Birth to Adulthood. New York:Guilford.

Stepansky, P. E. (2009). Psychoanalysis at theMargins. New York: Other Press.

Stern, D. N. (1985). The Interpersonal Worldof the Infant. New York: Basic Books.

Stern, D. N. (2004). The Present Moment inPsychotherapy and Everyday Life. New York:Norton.

Stern, D. N. (2006). Some implications of in-fant research for psychoanalysis. In A. M.Cooper (Ed.), Contemporary Psychoanalysisin America (pp. 637-641). Washington, DC:American Psychiatric Publishing.

Sullivan, H. S. (1953). The Intepersonal Theoryof Psychiatry. New York: W. W. Norton.

Tomasello, M. (2007). Cooperation and com-munication in the 2nd year of life. Child Devel-opment Perspectives, 1, 8-12.

Tomasello, M., Carpenter, M., Call, J., Beh-ne, T., & Henrike, M. (2005). Understandingand sharing intentions: The origins of culturalcognition. Behavioral and Brain Sciences, 28,675-735.

Tomasello, M., Carpenter, M., & Liszkowski,U. (2007). A new look at pointing. Child De-velopment, 78, 705-722.

Trevarthen, C. (1979). Communication andcooperation in early infancy. A description ofprimary intersubjectivity. In M. BuUowa (Ed.),Before Speech: The Beginning of Human Com-munication (pp. 321-346). London: CambridgeUniversity Press.

Trevarthen, C. (1980). The foundations of in-tersubjectivity: The social foundations of lan-guage and thought. In D. R. Olsen (Ed.), TheSocial Poundations of Language and Thought(pp. 316-342). New York: Norton.

Trevarthen, C. (1988). Universal cooperativemotives. How children begin to know languageand skills and culture. Acquiring Culture:

Cross-cultural Studies in Child Development,37-90.

Trevarthen, C , & Aitken, K. J. (1994). Braindevelopment, infant communication, and em-pathy disorders: Intrinsic factors in child men-tal health. Development and Psychopathology,6, 597-633.

Trevarthen, C , & Hubley, P (1978). Second-ary intersubjectivity: Confidence, confiding andacts of meaning in the first year of life. In A.Lock (Ed.), (pp. 183-229). London: AcademicPress.

Tuckett, D., Basile, R., Birksted-Breen, D.,Böhm, T., Denis, P, Ferro, A. et al. (2008). Py-schoanalysis Comparable and Incomparable.New York: Routledge.

Warneken, F., Chen, F., & Tomasello, M.(2006). Cooperative activities in young chil-dren and chimpanzees. Child Development,77, 640-679.

Warneken, F, & Tomasello, M. (2006). Altru-istic helping in human infants and young chim-panzees. Science, 311, 1301-1304.

Wegner, D. (2002). The Illusion of ConsciousWill. Cambridge, MA: MIT Press.

Westen, D. (1999). The scientific status of un-conscious processes. Is Freud really dead?/oMr-nal of the American Psychoanalytic Associa-tion, 44, 1061-1106

Westen, D., & Gabbard, G. O. ( 2002). Devel-opments in cognitive neuroscience: 1. Conflict,compromise and connectionism. Joumal ofthe American Psychoanalytic Association, 50,53-98.

Westen, D., Weinberger, J., & Bradley, R.(2007). Motivation, decision making, and con-sciousness: From psychodynamics to subliminalpriming and emotional constraint satisfaction.In M. Mascovith &c P. D. Zelazo (Eds.), Cam-bridge Handbook of Consciousness (pp. xxx).Cambridge: Cambridge University Press.

Copyright of Psychiatry: Interpersonal & Biological Processes is the property of Guilford Publications Inc. and

its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's

express written permission. However, users may print, download, or email articles for individual use.