The psychodynamic model in general and psychoanalysis in particular have
the most developed and elaborated theoretical psychotherapeutic model,
one capable of describing and explaining (more thoroughly than other
psychotherapies) all the nuances of both the clearly pathological and
habitual “normal” psychic manifestations. It was the very first
psychotherapeutic model, and founders and developers of the
psychotherapies that emerged later (with the exception of behavioral
therapy) based their models on it. The appearance and development of
psychoanalytical theory started the differentiation between
psychotherapeutic and psychiatric medical concepts of psyche, and their
interaction began to take shape. The issue of the interaction between
psychiatry and psychotherapy has been approached in various ways in
different countries. In the USA, a certain conjoint, unified model has
been developed that combines both the medical and the psychoanalytical
(psychotherapeutic) approaches into a single system in which
psychoanalytical concepts are pronounced to such an extent that they
sometimes cast the biological precursors of the disorders described into
the background (Stone, M.H., 1986 b).
In European countries, especially in Great Britain (Stone, M.H., 1986 a)
and Germany (Stone, M.H., 1986 b), psychoanalysis (as well as
psychotherapy in general) and its associated terminology have been
developing relatively independently from biological psychiatry, a field
of medical science with its own language.
In the USSR, as in the USA, a unified model combining psychiatry and
psychotherapy into a single system was developed; this remains true to a
certain extent for present day Russia. But unlike in the USA, it was
built on the platform of the psychiatric medical paradigm, which
significantly prevailed over the psychotherapeutic model. In Russian
psychotherapeutic practices today, this is apparent in typically endless
searches for “residual organic brain lesions,” “mild manifestations
of endogenous mental disorders,” “genetic predisposition,” “hiding”
behind neurotic manifestations, and in overlooking the psychodynamic
mechanisms involved in causing these phenomena. This is likewise
reflected in Russian legislation prohibiting psychologists, who in
particular lack formal medical education, providing full-fledged
psychotherapeutic treatment of patients; they may provide only
counseling. This is also shown by the fact that the oversimplified
version of the psychodynamic model employed in Russia, namely,
Miasishchev pathogenetic therapy, is mostly applied to neurotic cases
where therapists can clearly, and patients much less so, observe the
connection between neurosis symptoms and patients’ controversial
attitudes towards people of special significance in their environment,
as well as correlation with the patients’ parents’ attitudes towards
them during childhood. Besides, these are cases in which patients can
accept their therapists’ interpretations clarifying those connections
(often in a rather straightforward and oversimplified manner) and use
them (interpretations) to facilitate their recovery process. Otherwise,
therapists habitually turn to searching for neurosis symptom triggers in
“implicit endogenous psychic disease,” “organic cerebral disorders,”
and so on, returning to the well-beaten psychiatric track. The influence
of this conjoint model based on psychiatry dominating over psychotherapy
is quite obvious in pathogenetic therapy practices.
Patient–psychotherapist relations in them are based on the same
principle as in psychiatry, that is, patient–doctor, where patients’
“wrong” beliefs are exposed to “correct” clarifying and convincing
influence of domineering flawless medical specialists guiding errant
patients in the right direction. In this context the dynamics of
transference–countertransference in patient–psychotherapist relations
is mostly overlooked, as well as the fact that the way these relations
develop is affected by both participants. Such attitude, caused by the
psychiatric paradigm taking precedence over psychotherapy, is also
manifested in the fact that in Russia, psychotherapy students are not
required to undergo a certain amount of personal psychotherapy as
patients during their education.
On considering another conjoint (unified) model, the American one, which
was greatly influenced in its establishment and development by
psychoanalysis, one can also find certain problems arising from
combining psychotherapy (psychoanalysis) and psychiatry paradigms into
one single system. For instance, the American classification of mental
disorders (and now the international classification based to a large
extent on the American model) DSM-5 does not distinguish between
psychogenic and endogenous types of depression, which largely results
from a number of specialists’ opinion that depression should be regarded
as a continuum ranging from mild to severe, without taking into account
qualitative differences in depression types. According to this point of
view, closely linked to psychoanalytical tradition, all types of
depression are caused by the same psychological mechanisms, and so there
is no need to qualitatively differentiate between them. As a result,
authors of a number of recent publications evaluating effectiveness of
antidepressants in depression treatment have reached a conclusion about
their effect being statistically insignificantly higher than that of
placebos, i.e. about their ineffectiveness (Fournier, J.C., DeRubeis,
R.J., Hollon, S.D., Dimidjian, S., Amsterdam, J.D., Shelton, R.C.,
Fawcett, J., 2010; Kirsch, I., 2009). Patients in the studies discussed
in these publications were selected according to DSM and ICD-10 criteria
without dividing the cases into endogenous and non-endogenous depression
types. However, the studies where those depression types were taken into
account repeatedly demonstrated that the effectiveness of
antidepressants on endogenous depression patients was much higher than
that of placebos (Winokur, G., 1986). Those studies also demonstrated
that in cases of endogenous depression, ECT produced a much better
result than in treating cases of psychogenic depression (Winokur, G.,
1986). Another example deals with introducing two new items into DSM-3:
“borderline personality disorder” and “schizotypal personality
disorder” instead of “latent schizophrenia” in DSM-2 (Stone, M.H.,
1986 b). While it is quite productive to place patients with
“borderline disorders” (a term, like that of “latent schizophrenia”,
describing people balancing on the edge of psychosis) whose state
dynamics resemble those of personality disorders rather than of
schizophrenia into the personality disorders group, and while it is also
useful to break that group into one subgroup of patients with prevailing
affective instability symptoms and one subgroup with ideational
disturbances similar to schizophrenic ones, certain considerations
should be kept in mind. R. Spitzer et al., working on diagnostic
criteria for the two above-mentioned disorders, justified replacing the
old “latent schizophrenia” item with the two new ones in the new
classification in the following way. He reasoned that two groups of
different researchers used one and the same “borderline disorder” term
to describe two different forms of pathology. Spitzer then suggested
defining those two pathologies as “borderline personality disorder”
and “schizotypal personality disorder” accordingly (Spitzer, R.,
Endicott, J., Gibbon, M., 1986). Spitzer, however, seems to overlook the
fact that one group of researchers he mentions, O. Kernberg in
particular (Kernberg, O., 1967), studied their patients from the point
of view of psychoanalysis. Meanwhile, the second group of researchers he
refers to, namely S. Kety and D. Rosenthal (Kety, S., Rosenthal, D.,
Wender, P., Schilsinger, F., 1986), regarded their patients from the
position of psychiatry clinicians employing a medical approach. R.
Spitzer tried to classify borderline patients from the whole sample
group into two separate groups, “borderline personality disorder” and
“schizotypal personality disorder,” with the help of questionnaires he
and his collaborators developed. The result was that 54% of the
patients met the criteria for both schizotypal and borderline unstable
personality disorder (Spitzer, R., Endicott, J., Gibbon, M., 1986). One
explanation for this could be that the two research groups discussed by
Spitzer were sometimes looking not so much at two different groups of
patients as they were describing the same group from two different
positions and using different terminology. Thus attempts to mix the
psychiatric (medical) approach with the psychotherapeutic
(psychoanalytical) one, each of them characterized by their own language
and terminology and their own concepts of norm and pathology, into a
single logical system often lead to distortion of their internal logic,
misunderstanding, and confusion.