Object Relations Therapy

Object Relations is a theory of the human personality developed from the study of the therapist-patient relationship as it reflects the mother-infant dyad. The theory holds that the infant’s experience in relationship with the mother, or primary caregiver, is the primary determinant of personality formation and that the infant’s need for attachment is the motivating factor in the development of the infantile self. It is an amalgam of the work of British analysts Ronald Fairbairn, Donald Winnicott, and others of the British Independent group, augmented by that of Melanie Klein and the Kleinian group. Both the Independent and the Kleinian groups have developed theories of personality formation and psychic structure different from Freud’s, and different from each other. The Independent group, for example, disagreed with Freud’s views about the nature and power of the instincts, while the Kleinian group stayed true to Freud’s view of instincts but disagreed about the role of unconscious fantasy in the infant’s regulation of instinctual tension. Nevertheless, they can be integrated because of their commonality in focus on the first three years of life and their emphasis on the experience of the mother-infant relationship as a major component of psychic structure formation.

The Internal Object
Object Relations theory and therapy focus on internal objects. An internal object is a piece of psychic structure that formed from the person’s experiences with the important caretakers in earlier life. It is captured in the personality through the process of internalization, so that the personality thereafter bears the trace of that earlier relationship. The internal object is neither a memory nor a representation, but is rather an integral part of the self’s being. Internal objects become expressed in the individual’s choice of, and interactions with, other people (i.e., external objects) in their present life. Internal objects may also be modified through relationships with present external objects (such as the therapist).

The Self
Internal objects are just one component of the self. In brief, the self comprises: (1) the old-fashioned concept of the ego as an executive mechanism that modulates self-control through its control of motility, sphincters, and affect states, and that mediates relations with the outside world, (2) the internal objects, and (3) objects and parts of the ego bound together by the affects (feelings) appropriate to the child’s experiences of those object relationships. The self, then, refers to the combination of ego and internal objects in a unique, dynamic relation that comprises the character and gives a sense of personal identity that endures and remains relatively constant over time.

The Self in Relation with Others
Object Relations is an inclusive technical term that spans the intrapsychic and interpersonal dimensions. It refers to the system of interactions and inter-relationships between the various elements of the self, which are then expressed in the arena of current relationships with other people. Internal objects and other parts of the self are reciprocal with outer objects so that, in any relationship, the personalities are mutually influenced by each other. That is, external relationships are in constant interaction with internal psychic structures.

Object Relations Psychotherapy
John Sutherland liked to say that object relations is not so much a theory as a way of working. Object relations theory puts the relationship between the therapist and the patient at the center of the way of working. While the therapist and patient join together in the task of examining the patient’s internal world and its effect on the patient’s relationships, at the same time the patient and therapist are in a relationship themselves. This therapeutic relationship forms the laboratory in which the therapist learns most centrally about the patient’s ways of relating and the difficulties they include. As the therapist processes the experience of this current relationship, he or she is able to inform the patient about this experience. In this way, patient and therapist have a current shared relationship that both can study and learn from.

The patient (or couple, family or group) establishes a current relationship with the therapist that reflects the internal object relations set that is brought to all of their relationships. The therapist’s task is to experience these current expressions of object relationships by making himself or herself available to the fantasies, feelings, etc. that arise within them specifically in response to the patient. This way of working is characterized by the use of what Freud termed transference and countertransference. Object relations theory views the patient’s transference as the expression of their internal object relationships within the therapeutic relationship itself. Countertransference, on the other hand, is seen as the basis for the therapist’s ability to understand and fully interpret the patient. The set of countertransference feelings and attitudes that are stirred up in the therapist during a course of therapy form a model of what happens inside the people with whom the patient is in relationship. Providing that therapists have been well trained and have had personal therapy so that their own personal issues do not interfere prominently, they are then in the position to use their internal experience with their patient to make sense of the patient’s ways of relating. Object relations therapists, therefore, monitor their internal states of feeling and the ideas, associations, and fantasies that occur to them during treatment in order to make sense of the relationship with the patient. While the therapist does not report these experiences in raw and unmetabolized forms to the patient, they will examine them thoughtfully as the best set of clues as to the patient’s problems in relating in depth, and will then use the countertransference to inform the ensuing interpretation of the transference.

Adapted from Scharff, J.S. & Scharff, D.E. (1992). Scharff Notes: A Primer of Object Relations Therapy. Northvale, NJ: Jason Aronson.

Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge

Patients Continue to Improve After Treatment Ends, New Study Finds

WASHINGTON—Psychodynamic psychotherapy is effective for a wide range of mental health symptoms, including depression, anxiety, panic and stress-related physical ailments, and the benefits of the therapy grow after treatment has ended, according to new research published by the American Psychological Association.

Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient’s life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.

“The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support,” said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. “The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last.”

To reach these conclusions, Shedler reviewed eight meta-analyses comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. Shedler focused on effect size, which measures the amount of change produced by each treatment. An effect size of 0.80 is considered a large effect in psychological and medical research. One major meta-analysis of psychodynamic therapy included 1,431 patients with a range of mental health problems and found an effect size of 0.97 for overall symptom improvement (the therapy was typically once per week and lasted less than a year). The effect size increased by 50 percent, to 1.51, when patients were re-evaluated nine or more months after therapy ended. The effect size for the most widely used antidepressant medications is a more modest 0.31. The findings are published in the February issue of American Psychologist, the flagship journal of the American Psychological Association.

The eight meta-analyses, representing the best available scientific evidence on psychodynamic therapy, all showed substantial treatment benefits, according to Shedler. Effect sizes were impressive even for personality disorders—deeply ingrained maladaptive traits that are notoriously difficult to treat, he said. “The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended,” Shedler said. “In contrast, the benefits of other ‘empirically supported’ therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety.”

“Pharmaceutical companies and health insurance companies have a financial incentive to promote the view that mental suffering can be reduced to lists of symptoms, and that treatment means managing those symptoms and little else. For some specific psychiatric conditions, this makes sense,” he added. “But more often, emotional suffering is woven into the fabric of the person’s life and rooted in relationship patterns, inner contradictions and emotional blind spots. This is what psychodynamic therapy is designed to address.”

Shedler acknowledged that there are many more studies of other psychological treatments (other than psychodynamic), and that the developers of other therapies took the lead in recognizing the importance of rigorous scientific evaluation. “Accountability is crucial,” said Shedler. “But now that research is putting psychodynamic therapy to the test, we are not seeing evidence that the newer therapies are more effective.”

Shedler also noted that existing research does not adequately capture the benefits that psychodynamic therapy aims to achieve. “It is easy to measure change in acute symptoms, harder to measure deeper personality changes. But it can be done.”

The research also suggests that when other psychotherapies are effective, it may be because they include unacknowledged psychodynamic elements. “When you look past therapy ‘brand names’ and look at what the effective therapists are actually doing, it turns out they are doing what psychodynamic therapists have always done—facilitating self-exploration, examining emotional blind spots, understanding relationship patterns.” Four studies of therapy for depression used actual recordings of therapy sessions to study what therapists said and did that was effective or ineffective. The more the therapists acted like psychodynamic therapists, the better the outcome, Shedler said. “This was true regardless of the kind of therapy the therapists believed they were providing.”

Article: “The Efficacy of Psychodynamic Psychotherapy,” Jonathan K. Shedler, PhD, University of Colorado Denver School of Medicine; American Psychologist, Vol. 65. No.2.

Contact Jonathan Shedler, PhD, by email.

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.