Comparison of psychodynamic cognitive and interpersonal brief psychotherapies

Interpersonal psychotherapy(28) and cognitive-behavioural psychotherapy (29> derive from the psychodynamic model and therefore share many common elements with brief psychodynamic psychotherapy but with distinct approaches and interventions. All three modalities, interpersonal psychotherapy, cognitive-behavioural therapy, and brief individual psychodynamic psychotherapy, are complex methods of treatment that must be custom-tailored to the individual patient. Brief by definition, they all lack the extended working through and application period of psychoanalysis and intensive (long-term) psychodynamic psychotherapy. All demand a high degree of clinical judgement and considerable experience to acquire competency. The relationship between the therapist and patient and the establishment of a therapeutic alliance are essential (T§ble...,6).

Table 6 Comparison of brief dynamic psychotherapy with cognitive psychotherapy and interpersonal psychotherapy

Sharing explorative and change-oriented goals, they focus on patient's thoughts and feelings, including those involving the therapist. To this end, the therapist maintains an investigative, collaborative, and non-judgemental stance. While sharing many similarities, it is ultimately in the conception of the problem, the goals, and therapeutic interventions that these treatments differ. It is unclear to what extent behavioural changes may be attributed to the similarities or differences between treatments.

Cognitive psychotherapy, a brief method developed from behavioural therapy in the last two decades by Beck, is focused on the thinking patterns of the patient. In brief individual psychodynamic psychotherapy, the process of understanding defences similarly focuses the therapy on the hidden cognitive distortions that result in the patient's faulty perception of the internal and external world. In cognitive-behavioural therapy, these faulty cognitions are seen as the causative agent of the patient's distress. In the dynamic model, defence mechanisms are directed towards the control of anxiety resulting from conflict. The defences, however, distort perception and cognition as is the focus of cognitive therapy. Identification and exploration of these distortions is similar to the interpretation of defences in psychodynamic psychotherapy. Discovery and understanding of these unconscious patterns of behaviour are central to both treatments. The schemas underlying the faulty cognitions of cognitive psychotherapy are unconscious assumptions, which, from a psychodynamic perspective, derive from earlier experience. To the extent that a psychodynamic psychotherapy focuses on the current experience of the patient rather than the reconstruction of the past, the similarity to cognitive therapy increases. Frequently, the understanding of a defensive pattern used to handle ongoing conflict can be the end-point for a well-conducted psychodynamic psychotherapy. As such, the outcomes for both therapies may be quite similar.

Interpersonal psychotherapy, a focused short-term therapy developed originally as a time-limited treatment of non-psychotic unipolar depression by Klerman et al.,(39 is most closely related to the perspective of psychodynamic object relations. Understanding internal objects rests upon understanding the interpersonal relationships of the patient, including the relationship with the doctor. Both interpersonal and psychodynamic psychotherapy share a focus on identifications and transference, which interpersonal psychotherapy defines as 'past models for relationships'. In addition, interpersonal psychotherapy pays particular attention to withdrawal and detachment, areas related to defences in the psychodynamic model, and faulty cognitions in the cognitive model. Emphasizing interpersonal rather than intrapsychic or cognitive events, interpersonal psychotherapy focuses on the same area of disturbance as the other therapies though the identified problem is an interpersonal deficit rather than distorted cognitions or intrapsychic conflict.

All psychotherapies, including brief individual psychodynamic psychotherapy, interpersonal psychotherapy, and cognitive- behavioural therapy teach new skills—problem-solving skills directed at how to resolve interpersonal and emotional problems when they arise. Differences among these psychotherapies in their interventions are more striking than the differences in their goals or the problem areas they identify for therapeutic work. In psychodynamic psychotherapy the structure of the session is determined by the flow of the patient's thoughts and their interaction with the therapist's interpretive comments. In contrast, cognitive and interpersonal psychotherapies use more directive, structured, and behavioural interventions. Whereas the brief individual psychodynamic psychotherapy like other psychodynamic psychotherapies relies on the patient to activate and practice new behaviours without direction. The therapist remains an empathic interpreter, a sharer of the patient's experience and perspective. While in other therapies, especially cognitive, the therapist may direct, prescribe, enjoin, educate, or role play.

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