Introduction to Psychodynamic Psychotherapy Technique

Sarah Fels Usher

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135956813
• Edition: 2
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Introduction to Psychodynamic Psychotherapy Technique is a revised edition of the popular technical guide to the conduct of psychodynamic psychotherapy written by Sarah Fels Usher, published in 1993. In her thoroughly updated book, the author takes the student from the very beginning through to the end of the processes involved in using psychodynamic psychotherapy as a method of understanding and treating patients.

Introduction to Psychodynamic Psychotherapy Technique offers explanations of how psychoanalytic/psychodynamic theory underwrites the technique, and demonstrates how the technique follows from the theory in a clear and accessible style. Each chapter is organized around the psychoanalytic concepts of transference and counter-transference, demonstrating how these concepts bring the work together. New material includes a chapter devoted to working with patients' defenses, an in-depth look at the emotions on both sides during termination, and a chapter on the experience of supervision, all accompanied by lively clinical examples.

The book is unique in that it is written from the point of view of the student, highlighting the difficulties they may encounter in practice and offering concrete suggestions for technique. Introduction to Psychodynamic Psychotherapy Technique will be of interest to psychoanalysts, psychotherapists, psychiatric residents, graduate psychotherapy students and social work students.

Chapter 1
Understanding the language of psychodynamic psychotherapy

This chapter offers definitions for some of the most frequently used concepts in psychodynamic psychotherapy. Although they may not all be meaningful to you at this point, they are offered at the beginning in an attempt to make the rest of the book more accessible. They can easily be referred back to as needed.

Interwoven into some of the definitions are beginning suggestions for technique; that is, examples of working with the concept in the therapy situation. Sometimes definitions and technique are hard to separate when one tries to explain them. This is particularly true here in the sections on transference and defence.

Psychodynamic

The psychodynamic approach is based on the psychoanalytic thought and theory that began with the writings of Sigmund Freud. Freud got his data from listening to his patients, and used this clinical data to describe the study of neurosis, which was originally believed to be the study of neurotic conflict (Greenson, 1967). In essence, behaviour was viewed as a product of hypothetical mental forces, motives, or impulses and the psychological pro-cesses that regulate, inhibit, and channel them. The word dynamic implies movement; in psychodynamic therapy, it is taken as a given that there is a fluid movement of these forces—which are often in conflict with each other— and an ebbing and flowing of the strength of the defences that arise to modify them in relation to the outside world.

A summary of the characteristics of psychodynamic therapy is given in the Preface.

As the therapist listens, he or she begins to make connections between the patient’s current thoughts and feelings and their past experiences—sometimes very early ones. Some of these experiences have been “forgotten” or repressed, and can only be seen in their current—often disguised or distorted— manifestations, for example, a phobia, or an unusual mannerism, or indeed, the patient’s transference reactions, to be discussed later. It is from these thoughts and feelings that we infer the underlying inner psychological processes.

In both the psychoanalytic and the psychodynamic approaches, the meaning of the patient’s symptomatology (e.g., anxiety) is thought about in the context of an overall picture of the person as a dynamic, growing, feeling human being, with conflicts, fears, anxieties, and psychological defences. The patient’s ability to form close relationships—both within the family and outside it— his or her character/ego strengths and weaknesses, preference for certain styles of coping, and how these factors shape character, are all part of, and useful in, a psychodynamic approach.

Psychologists who administer and interpret projective tests (e.g., the Rorschach) are accustomed to the detective work of discovering what makes a person tick. It may be helpful for therapists to read psychological reports that focus on unconscious dynamics, and then to watch for them in the therapy situation. Psychodynamic treatment is always informed by an understanding of the relationship the patient develops with the therapist (see the sections on Transference and Working Alliance). To greater or lesser degrees, this relationship becomes the fulcrum for the treatment; in this type of therapy, it should never be ignored.

History

The psychodynamic approach is essentially an historical approach to treatment, meaning that the therapist’s comments—observations and interpretations— which help the patient understand their behaviour will, at least in part, be based on the therapist’s knowledge of the patient’s history (i.e., their early upbringing and family life). As Basch (1980) puts it:

Throughout our lives we signal implicitly by behaviour, appearance, and attitudes, the hopes, the wishes, and the fears of childhood which we try explicitly to hide from ourselves and from others by assuming so-called adult roles. Our happiness depends to a great extent on how successfully we manage to blend those early needs with the expectations we and others have of us, as adults. A person who becomes a patient in psychotherapy is saying in effect that in some significant way he or she has failed to achieve this goal.

(Basch, 1980, p. 30)

A thorough understanding of the patient’s childhood, then, will help the therapist identify important themes in terms of relationships with significant others, attitudes towards school and work, philosophy of life, and so on. Having some knowledge of this is also invaluable in predicting what will happen in the therapy, in terms of the patient’s motivation for the work, the resistances that may emerge, and of course in predicting some of the ways the relationship with the therapist will be played out. Therefore, a more or less structured history (the newer you are at this, the more structured it should probably be) should be obtained as close as possible to the beginning of treatment. A suggested outline for the history taking is given in Chapter 3.

Empathy

Two words, sympathy and empathy, are commonly used to describe three distinguishable things. These are: 1) an elementary, involuntary capacity which puts us in touch with the emotional state of another; 2) the use of “trial identification” to discover, consciously or unconsciously, the emotional state of another; 3) the affect of compassion.

(Black, 2004, p. 579)

Black states that because these three usages have not been sorted out, and because the word sympathy has been disparaged in psychoanalysis and psycho-dynamic therapy, the term empathy has been overused. If a psychoanalyst uses the word sympathy inadvertently, he or she often corrects it and says “empathy” instead. Empathy is a word we use with pride. We feel that by empathy we make a trial identification with our patient, without losing our secure stance in ourselves, and as a result of this, we may make the assumption that our interpretations relate to our patient’s internal state.

At the conclusion of his article, Black defines sympathy as: “the elemental and involuntary capacity that makes affect [emotional] attunement possible” (p. 592). It also makes possible “the more sophisticated operation of empathy, and the more developed and specific affect of compassion that is often, confusingly, also called sympathy” (p. 593).

The use of empathy is inherent to the conduct of all effective psychotherapy (including therapies that are not psychodynamically oriented). As stated above, it involves feeling the world from the patient’s point of view, and not according to how the therapist thinks the patient should, or must, be feeling. The definition of empathy from the Oxford English Dictionary is: “the power of entering into the experience of or understanding objects or emotions outside ourselves.” Freud (1921) considered empathy an essential part of treatment.

Carl Rogers (1951), in his landmark book, Client-Centered Therapy, talked about putting oneself in the client’s shoes, and outlined ways of learning empathy—including paraphrasing what the client has said. This method can sometimes be carried too far by beginning therapists, as the patient perceives the greater emphasis to be on reflection and not enough on forward movement. More recently, the psychoanalyst Heinz Kohut (1977), in working with borderline and narcissistic personalities, formalized the concept, refocusing therapists’ attention on the central importance of empathy:

In psychoanalytic therapy empathy is used to describe an intrapsychic process in the therapist by which an understanding of the patient, particularly an emotional understanding, a capacity to feel what the other is feeling, is enhanced. Situated somewhere between listening and interpreting, empathy serves as a precondition for both.

(Berger, 1987, p. 8)

The therapist, then, has to be able somehow to accurately attune to the affect of the patient’s experience—to know what it must feel like for the patient— by just taking a sample of it. If a patient is sobbing, it doesn’t help if the therapist is sobbing, too. But it would help if the therapist can feel the sadness enough to say: “This is a very sad moment/event/memory for you.” Having said that, of course there are times when we are genuinely moved and that is fine, as long as it is infrequent; otherwise, the patient begins to feel that they must protect us from sad/scary/angry feelings, or take care of us when they do occur. As an example, I was seeing a 20-year-old woman whose family had to put down a beloved dog. I have heard about many deaths of loved ones over the years, but the death of George, a golden cockapoo, whose antics I had heard a lot about, and whose picture I had seen in various poses, made me incredibly sad. My patient’s raw, undefended emotions around her dog’s death really got to me and I teared up.

The ability to empathize depends partly on the capacity to identify with others. It is not necessarily a natural talent, although some people do seem to find it easier to accomplish than others. With practice it can be learned, and our capacity for empathy improves with the experience of seeing patients. Not only do patients teach us how to empathize with them, but also they show us the skill of putting ourselves in the background while still remaining exquisitely present.

If you are one of those therapists for whom empathy seems to come relatively easily, it is important to know the limits of your empathic ability and to be able to learn to use it as a therapeutic tool. This means being conscious enough of the process so that you can move in to what the patient is feeling and move out to your more objective knowledge and experience, as is most helpful. It also means being as aware as possible of your own emotional (counter-transference) reactions to your patient, particularly when you may be having difficulty in being empathic, or when you may be getting “too involved.” More will be said about counter-transference later in this chapter and throughout the book.

If you are a therapist who has considerable difficulty empathizing, then it is important to search out the categories of patients you have difficulty with, either in your personal therapy or in supervision. For most therapists, or people who want to become therapists, this usually occurs in relation to specific types of patients, for example, narcissistic patients, or patients who do something that is against your values.

Sometimes a beginning therapist can go overboard in trying to reflect a feeling back to a patient in an effort to be really empathic. A new intern I was supervising was exploring her young patient’s dilemmas about which courses to take for her new career, as she had decided to change plans rather late. The therapist said, in a pained tone of voice: “That must have torn you apart.” Her patient said: “No, it actually didn’t feel that bad.” This attempt at empathy was really an empathic failure—because the therapist was not in tune with her patient. Usually people aren’t “torn apart” by course decisions as they might be, say, by the break-up of a relationship or the death of a loved one. This therapist needed to learn how to use her own sense of what it might be like for the patient, and also whatever cues she was picking up from the patient, to make a more accurate empathic comment.

Empathic failure is the term used to describe a “miss,” when the patient’s feelings are not captured accurately. There can be degrees of empathic failure, from very slight to gross, and most therapists—no matter how experienced— have failures from time to time. When this happens, it may be noticeable from your patient’s verbal reaction, from a facial expression, or from body language (e.g., the patient may shift away from you). Depending on the patient and the point that has been reached in the therapy, I find it is best to “admit” to these types of failures as soon as you notice them, and to ask the patient for a further clarification of what they meant. It is also important to ask about the patient’s reaction to not being understood. Self psychology has taught us that acknowledging and repairing these kinds of failures usually makes the therapy relationship stronger, once it is back on track.

When a therapist has been able to give an accurate, empathic response, the patient will not only agree heartily, but will continue with the theme, sometimes using the therapist’s words, giving more examples, and taking the exploration of the material deeper.

Transference

This term has been misused so often, in an almost clichéd manner, that it is important to try to get an understanding of it as early as possible. The concept was first introduced by Freud to describe a phenomenon that develops when a neurotic patient is undergoing psychoanalysis. When he first wrote about transference in the Studies on Hysteria (Breuer and Freud, 1893–1895), he referred to it as that part of the therapist–patient relationship where the patient makes a “false connection” onto the analyst. His (1905) broad definition, which is still useful today, reads:

What are transferences? They are new editions or facsimiles of the impulses and phantasies which are aroused and made conscious during the progress of the analysis; but they have this peculiarity, which is characteristic for their species, that they replace some earlier person by the person of the physician… Some of these transferences have a content which differs from that of their model in no respect whatever except for the substitution.

(Freud, 1905, p. 116)

Freud’s advice about how to handle the transference was taken as gospel: 1) Make the transference conscious; 2) demonstrate to the patient that it is an obstacle to the treatment; and 3) attempt, with the patient’s help, to trace its origin in the patient’s history (Greenson, 1967).

Although Freud describes patients “falling in love” (in Freud’s time, this always referred to a female patient with a male therapist), and although some patients do feel as though they are falling in love with their therapist or analyst, the concept of transference is usually used in a much broader sense. The term refers to both conscious and unconscious repetitions of early important relationships and can, and does, occur in any type of psychotherapy— regardless of whether it is recognized or labelled as such. In fact, transference is ubiquitous, and occurs in all of our relationships to some extent: in work, friendships, and most certainly in our choices in romantic relationships (Usher, 2008).

The technique of psychodynamically oriented psychotherapy, or psychoanalytic psychotherapy, then, puts the transference under a magnifying glass, where it can be more clearly seen, analyzed, and explained. In the therapy situation, the transference is understood as the displacement (or misplacement) onto the therapist of the patient’s at least partly unconscious perceptions of important figures in their past, such as father or mother.

One of the tip-offs that your patient is in the throes of a transference reaction is that the reaction is usually inappropriate. It may be an overreaction to the situation or to you, an under-reaction, a bizarre reaction, or even a total lack of reaction when one would naturally expect one. Ambivalence is also a characteristic of transference reactions, where one aspect or dimension of the feeling (often the negative part) is unconscious (Greenson, 1967). A patient may experience in a therapy session only loving feelings and not angry ones, or vice versa, in an intense and unidimensional manner, even though both feelings are present intrapsychically. Tenacity is, perhaps unfortunately, another characteristic of a transference reaction; it many take many interventions by the therapist—and several observations by the patient—for the reaction to ease up.

For several years I saw in analysis a professional woman, Alice, in her thirties, who was very aggressive and argumentative, and who had difficulty forming relationships both socially and at work. Her main affect was hostility, both with me and in her life outside the analysis. After some time—and some interpretation of the hostility—Alice decided to try getting a cat, hoping she would be able to be kind to it and look after it. All at once, in one session, she turned around to me and asked: “Do you have a cat?” Perhaps because of my surprise at the direct question, or maybe because I was trying to function as a model for identification, I answered: “Yes.” Her next words were: “Really? I thought you were too nasty to have a cat.” So, there you go: a mixture of transference (I hope)—her mother was mean and teased her a lot—and also an example of projective identification—where she put into me the bad feelings she had about herself.

A less primitive example can be seen in the case of Betty, a 42-year-old woman, who always came early for our appointments. She was annoyed if I did not come to call her in exactly on time—although she never acknowledged this. Then we changed our morning meeting, by mutual agreement, to a much earlier time and I arrived for our first session five minutes late. She spoke to me in an overly sweet, and definitely condescending, tone: “Would you prefer to meet at our former time instead?” Of course, I commented that she must be quite angry at me, which turned out to be the tip of a very productive iceberg. (I grant here that a therapist’s being five minutes late is, in reality, something to be angry about; however, in this case, the feelings seemed unusually intense.) During the session, Betty recalled waiting in the family car as a young child, with her mother and sisters, excited about going out together, while her father—a tyrant who controlled the women and girls of the family with threats of physical violence—stormed around inside the house deciding whether and when to leave. She had spent a lot of time sitting in that car, in the driveway, waiting: frustrated but also frightened. In this way, then, Betty’s intense anger at my lateness was fuelled by a displacement from past feelings about her father. In the session Betty, who had been her father’s favourite, was finally able t...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgements
• 1 Understanding the language of psychodynamic psychotherapy
• 2 Starting out
• 3 History taking and formulation
• 4 Selecting appropriate patients
• 5 The ongoing therapy
• 6 Stick-handling defensive patients
• 7 Ending
• 8 Using supervision
• Bibliography
• Index