Psychodynamic Therapy

Conceptual and Empirical Foundations

Steven K. Huprich

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781135591519
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Psychodynamic Therapy reintroduces psychoanalytic and psychodynamic theory to the practice of clinical psychology in ways that are easily understandable, practical, and immediate in their application. Huprich readily demonstrates that, contrary to what is misconstrued and taught as relic and historical artifact, Sigmund Freud's ideas and their evolution offer a comprehensive, useful framework from which clinical psychology and psychiatry can benefit.

There are more theories and approaches to psychotherapy today than ever before. Psychodynamic Therapy attests to the fact that psychoanalytic and psychodynamic theory has more to offer clinicians and patients than any other theory. Through this book, readers will gain a greater appreciation for what psychodynamic theory offers and how they may apply these ideas toward effective clinical practice.

1
Introduction

Patients enter psychotherapy for a host of reasons, and, with few exceptions, almost all who seek treatment do so because they c annot find a way to solve their psychological problems. In other words, they are blocked from knowing or understanding something about themselves in a different way from that which they currently do. They come to treatment believing that such knowledge or insight would allow them to be more satisfied or to live in a more gratifying or satisfying way.

It also is not uncommon to hear many patients say, “I know that I should not feel this way,” or “This obviously is bad for me,” yet they are unable to make the kinds of changes that ultimately would reduce their suffering and increase their sense of well-being. Other individuals may not be aware that what they are thinking, feeling, or experiencing or what is motivating them is problematic. For instance, the man who is successful yet is despised by his coworkers may refuse to consider the possibility that his needs for control and his perfectionism are what alienate him from them. He may well believe that his lifelong work ethic, attention to detail, and “Midwestern values” that were instilled in him and his siblings account for his success and that it is others who need to adapt to him, not vice versa. But, as he becomes more depressed over the lack of friends in his life, he may attempt to ingratiate himself to others by taking them out to lunch or buying them a drink aft er work, which only increases their sense that he is trying to control or manipulate how they feel. He may have the same attitude in his social life, which he may find dissatisfying for much of the same reasons.

In virtually all patients, it also is the case that there is an element of interpersonal relatedness that becomes part of the focus of treatment. Ask any therapist, and she or he will likely state that it is diffi cult, if not impossible, to separate how a person’s reasons for being in psychotherapy are not related in some way to the person’s interpersonal relationships. Interpersonal relatedness evokes emotional states, ideas, wishes, fantasies, desires, and impulses to act (or not act) toward another person or group of people. Psychological difficulties do not occur in isolation, although the suffering that many patients experience makes it seem as if they are alone, as if they cannot be understood, or that their unhappiness may be representative of a more severe problem. Additionally, if their problems are brought more to the surface, many patients fear that they would be disliked, disapproved of, shunned, humiliated, or rejected rather than helped with their pain. For instance, if a married man’s fantasies of being sexually involved with another man were to be made known, they may lead to feelings of disgust and a possible separation or divorce from his wife. Thus, even in those problems that seem most private or hard to experience, how the problem interfaces with other people in the patient’s life takes on salience and meaning.

Good therapists know that effective therapy is based on a theory of personality and psychopathology that has substantial explanatory power and applicability to people’s lives. Without theory driving the applied action of therapy, treatment oft en proceeds in a haphazard way. In this situation, therapy can be ineffective and potentially harmful to the patient. Now over 100 years old, psychoanalytic and psychodynamic theories have stood the test of time. They have considerable explanatory power and applicability, even in a climate in which brief and (empirically supported) treatments are preferred. It is the focus of this text to review psychoanalytic and psychodynamic theories and their application to various kinds of psychotherapy.

So, to begin to understand psychoanalytic and psychodynamic therapy and the theory it is based on, it might be helpful to examine some case studies and to review the major tenets of psychoanalytic theory to see their therapeutic applications, aft er which I discuss them in the context of psychodynamic theory, hoping to draw attention to what has become a very effective and highly relevant approach to clinical work.

The Case of Mr. Shelby

Mr. Shelby was a 19-year-old high school dropout who worked for his family’s restaurant. He was referred by his parents, with whom he lived, because they believed he needed help with the severe bouts of panic that had come upon him about 8 months earlier for no apparent reason. Though he was legally an adult and responsible for his own treatment, he came to see the psychologist only with his parents and at their insistence. In the first session, the therapist learned from his parents that Mr. Shelby was rather quiet as a child, one who seemed to keep to himself oft en. His interactions with his family were generally good, and even as he entered into his teenage years he tended to favor playing with cousins who were in preschool or just entering the primary grades. Mr. Shelby had few friends in school, though as he aged, the friends he made had interests in computer games. These games had aggressive and violent themes, in which characters were killed; however, they could be “resurrected” through a spell cast upon them by another character in the game. As a child, Mr. Shelby was not particularly violent, although on one occasion when he was 12 he became so angry with his parents that he broke a lamp. Neither his parents nor he could recall why he became so upset, yet he was punished, which all remembered as having a strong effect on curtailing his behavior. At the time therapy began, Mr. Shelby showed very little affect, except for some disdain toward his parents, particularly his loquacious and domineering mother, who had made him come to see a psychologist.

Mr. Shelby stated that he dropped out of high school when he was 17 because he did not like it. Later, it was learned that Mr. Shelby was becoming very anxious at school and did not want to be there for fear of how he might behave (e.g., getting anxious, red in the face). His parents conceded to his wish, and shortly thereaft er Mr. Shelby began working at the restaurant, initially clearing tables but then starting to work as a waiter. His parents stated that he did well with customers, despite some initial anxiety.

About 1 year before, Mr. Shelby’s favorite uncle had died suddenly. He attended the funeral but said he did not cry. Two months aft er the uncle’s death, Mr. Shelby was leaving his home to go to work when he became very anxious. He felt faint and had many symptoms of panic disorder. Upon getting into his car, he felt nauseated, vomited, and felt unable to go to work. These symptoms happened several times and generalized once to when he was going to a movie with a friend. Over the past few months, the symptoms had subsided somewhat, but Mr. Shelby continued to have anxious feelings and was highly concerned about leaving the house.

The Case of Ms. Murdock

Ms. Murdock was a highly successful 43-year-old businesswoman who came to therapy aft er suddenly breaking up with her longterm male partner (David) of 6 years. Ms. Murdock was rather sad, lacked energy, and could not seem to get over David’s sudden departure from their home. Several years prior, she had been married to another man, Nathan, for about 3 years. The marriage ended aft er they seemed to “grow apart.” Again, this relationship was hard for her to get over. She described Nathan as needing much support and reassurance, particularly when others did not appreciate his hard work. David was unlike Nathan in that he was outgoing and freespirited and liked to be the “life of the party.” Particularly upsetting in her relationship with David was his capricious spending and gambling. Ms. Murdock reported that David spent thousands of dollars on goods and products that he wanted and had lost about $2500 in gambling over the past 6 years.

Ms. Murdock had a hard time identifying what went wrong with David. She did not appreciate his spending habits but did not think it affected how she felt toward him. More oft en, she speculated that she must have done something to annoy him and worried what this might be. At times, her ruminations about the separation woke her up in the middle of the night, leading to notable sleep deprivation.

Ms. Murdock had a strong network of friends and a mother who was generally supportive and understanding. Her father, however, had grown increasingly negative and bitter toward her, which stood in contrast to the almost idealized role that he had toward her as a child. Their relationship had changed at the time Ms. Murdock entered high school when her father had lost his job due to a layoff. He was unable to find meaningful employment aft er that and had become sullen, isolated, and negative toward his family.

Basic Psychodynamic Ideas

Psychoanalytic and psychodynamic theory has been and is primed to address the very issues that lead patients to seek treatment. In one of the most comprehensive and well-researched review papers on the legacy of Sigmund Freud, Westen (1998, pp. 334–335) highlighted five major postulates that define contemporary psychodynamic theory, which are easy to see in the cases presented herein:

1. Much of mental life—including thoughts, feelings, and motives— is unconscious, which means that people can behave in ways or can develop symptoms that are inexplicable to themselves.

2. Mental processes, including affective and motivational processes, operate in parallel so that, toward the same person or situation, individuals can have conflicting feelings that motivate them in opposing ways and oft en lead to compromise solutions.

3. Stable personality patterns begin to form in childhood, and childhood experiences play an important role in personality development, particularly in shaping the ways people form later social relationships.

4. Mental representations of the self, others, and relationships guide people’s interactions with others and influence the way they become psychologically symptomatic.

5. Personality development involves not only learning to regulate sexual and aggressive feelings but also moving from an immature, socially dependent state to a mature, interdependent state.

Mr. Shelby and Ms. Murdock each experienced distress, for which they had little realization of why it occurred and how to manage it (point 1). The origin of their symptoms resided in that part of their minds that was not accessible to them, namely, the unconscious mind. Not only were the symptoms unconscious, but so were many other aspects of each patient’s life. Mr. Shelby could not account for why he enjoyed playing violent video games so much. Yet it seemed to be associated with ways he managed his angry and aggressive feelings. In Ms. Murdock’s case, she was not aware of the extent to which she had become involved with partners who were highly self-focused and for whom their own self-interests were essentially supported at her expense. She also was not aware of the way her frustration with them ultimately was directed toward herself, leading to feelings of guilt and consequential depression.

Both patients had adopted a compromise solution (or compromise formation as it is called in psychoanalytic terminology) for managing their distress (point 2). Mr. Shelby developed severe panic symptoms, which were associated with two opposing feelings: (1) frustration toward his parents for pushing him to become more independent; and (2) fear of losing them someday. His conflicted feelings of hate and fear of loss led him to experience anxiety and panic that led him to physically expel the conflict from his body. In this way, he was able to avoid facing the conflict directly. Ms. Murdock had been successful at blocking out of awareness her angry feelings toward her selfish partners by acting as if things were all right. When angry feelings began to surface, she asked herself what she might have been doing that led to problems in the relationship. And when each partner eventually left because of their own self-focused needs that could not be met by Ms. Murdock’s patient and kind support, Ms. Murdock became very depressed and self-critical.

Both cases also show how personality patterns developed in early life continued to exist in adulthood (point 3). Mr. Shelby was a rather quiet and introverted child. Except for the time he broke a lamp, he caused very few problems for his parents. As he grew older, he continued to identify mostly with younger children, who were dependent on adult figures to care for them and to protect them from the troubles and challenges of life’s experiences. This was a safer world, which in early childhood is characterized by naiveté about the dangers that exist and in which magical solutions still seem possible. Indeed, as Mr. Shelby became a young man, he continued to return to the electronic world, where dangers lurk but protection and care are available. It came as no surprise that he had no interest in leaving his parents’ home and had few, if any, ideas about what his future would look like.

Ms. Murdock shared a mutually strong attachment with her father as a child. She was idealized and received much love and support from an attentive and adoring father. Like Mr. Shelby, she appeared to have a normal development and reasonable success in school, yet when her father experienced a traumatic job loss and an inability to be a good caregiver his attention to her waned. She was puzzled by his evolving distance but seemed to have few negative feelings toward him, instead feeling occasional guilt and bewilderment at his absence. Thus, when men to whom she was close as an adult left her, she responded with similar disbelief and confusion.

Closely related to these longstanding personality patterns is point 4, which describes the mental representations and templates individuals develop of others. Such templates, or object relations as they are described in psychodynamic theory, involve thoughts, feelings, and desires that are developed about oneself, others, and relationships. Mr. Shelby had very little to say about himself; he identified no strengths or weaknesses, could not describe many long-term goals, and only desired more time on the computer to play video games and (somewhat parenthetically) to be free of disabling panic. Others had greater definition or representation in his mental life, although such definitions were not always realistic. His mother, in particular, was represented as a powerful and oppressive woman, who forced therapy on him, as well as the idea of finishing high school, moving out someday, and becoming more independent. His father was seen as less oppressive and at times almost treated him as a peer. Yet when his father introduced the idea of becoming more independent Mr. Shelby became quite hostile. In his interactions with both parents, Mr. Shelby had a very poorly developed sense of himself as a capable, distinctive individual who had a lifetime in front of him to make it what he pleased. With little there to draw upon, Mr. Shelby’s reactions to his parents’ reasonable concerns took on a sense of danger and fear, and his parents were viewed as much more forceful and less compassionate than they really were.

As already described, Ms. Murdock’s representations of herself were that of a dutiful, responsible woman who could please a man to whom she was attached. She felt special and important to men in her life, and when they disappointed her she was devastated and self- critical. As she had formed an early, idealized relationship of her father and his love toward her, Ms. Murdock could not analyze the faults or weaknesses in her father, who was a real person devastated by a job loss and permanent disability who had inexplicably disappointed her. Consequently, the same was true of her partners, whom she held in high regard despite their frustrating qualities. Her experience of them and herself was held prisoner to her childhood representations of each.

Point 5 describes the important developmental tasks of mastering sexual and aggressive impulses, as well as learning how to move from dependence to interdependence. In the case examples, it is clear that Mr. Shelby was at a much earlier (in analytic terms, primitive) level of development. He did not seem like a typical 19-year-old. He had very little interest in sexual relationships, mentioning only one woman in whom he had some interest. He did not date, nor was he at all c omfortable talking about sexual feelings or desires. His aggressive feelings and impulses were contained in the fantasy world of an electronic medium. This was well documented one day when he described having a stressful day at work with some of the employees. When he came home, he went to the computer for several hours and “blew up” many characters. When his therapist made the connection between these two events, his response was that he “felt better.” Mr. Shelby showed little awareness of the connection between these events, only indicating (when asked) that he very strongly disliked these coworkers. In terms of his dependency needs, it already has been noted that Mr. Shelby was highly dependent on his parents for having his basic physical and safety needs met. He came to recognize his parents’ frustrations with their business and identified with them without analyzing a situation from his own perspective. So if his father was angry at an employee, Mr. Shelby became angry at the employee. However, Mr. Shelby’s only solution to how his father (and he) might feel better was to fire the individual immediately. In no way did Mr. Shelby see that his shared experiences of the employee, which might well differ from his father’s view or add to his father’s understanding of the problem employee, might be helpful to his father in deciding what his next step should be. For instance, might further training help resolve the problem?

Ms. Murdock, being more developmentally advanced, had less severe problems than Mr. Shelby. While being able to seek out and maintain sexual relationships for an extended period, she experienced some difficulties in recognizing her aggressive feelings toward the men in her life, instead directing them toward herself. Consequently, this led her to experience relationships in a more dependent way, in that her sense of satisfaction in the relationship was dependent upon her partner’s reactions to her. Instead of viewing the relationship as that of two adults who shared a mutual interdependence on each other for love, support, and care, Ms. Murdock unconsciously took on more responsibility in maintaining the stability of the relationship, putting her in more of a dependent relationship to her partner, and enabling her partner to be less responsibl...

Table of contents

• Contents
• Preface
• 1 Introduction
• Section I Theoretical Underpinnings
• Section II Treatment Principles and Empirical Support
• Section III Therapeutic Process
• References
• Index