A Clinical Guide to Psychodynamic Psychotherapy

Deborah Abrahams, Poul Rohleder

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781351138567
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología aplicada

A Clinical Guide to Psychodynamic Psychotherapy serves as an accessible and applied introduction to psychodynamic psychotherapy.

The book is a resource for psychodynamic psychotherapy that gives helpful and practical guidelines around a range of patient presentations and clinical dilemmas. It focuses on contemporary issues facing psychodynamic psychotherapy practice, including issues around research, neuroscience, mentalising, working with diversity and difference, brief psychotherapy adaptations and the use of social media and technology. The book is underpinned by the psychodynamic competence framework that is implicit in best psychodynamic practice. The book includes a foreword by Prof. Peter Fonagy that outlines the unique features of psychodynamic psychotherapy that make it still so relevant to clinical practice today.

The book will be beneficial for students, trainees and qualified clinicians in psychotherapy, psychology, counselling, psychiatry and other allied professions.

1 Introduction

When Sigmund Freud first began and developed psychoanalysis, it was referred to as ‘the talking cure’, a radical new approach to the treatment of mental health problems which were at that time treated through medicine and surgery. This new ‘talking cure’ formed the basis of much of the psychological therapies that we see today, which emphasise particular ways of talking, thinking, and listening as a means for understanding and working through traumatic or distressing experiences. Freud not only revolutionised ideas about the treatment of mental health problems, but he also developed a metapsychology of human development and behaviour. Thus, psychoanalysis is both a method of treatment as well as a theory of human development. We know a great deal about human development from biological disciplines about the body’s growth over time while neuroscience focuses on the development and functioning of the brain. By contrast, psychoanalysis is a theory of human subjectivity, perhaps the most elaborate and developed theory of human subjectivity there is.

Freud’s influence and legacy cannot be disputed. However, psychoanalysis has seen much criticism over the decades where short-term, evidence-based and solution-focused therapies have increasingly dominated public mental health service provision, most notably cognitive-behavioural therapy (CBT). In the United Kingdom, the National Health Service (NHS) predominantly provides CBT as the preferred treatment for many mental health problems. There are numerous reasons for this, including the greater availability of research evidence claiming CBT to be effective. This compares to psychoanalytic approaches which have thus far lagged considerably behind in accumulating research evidence into their efficacy. Thankfully there are recent changes in this regard, with important efficacy research published establishing psychoanalytic therapies to be as effective as CBT, and in some cases more enduring in effect. We will review this research evidence in the third chapter of this book.

Readers will note that the title of this book refers to ‘psychodynamic psychotherapy’, rather than psychoanalysis. Usually, ‘psychoanalysis’ refers to the theoretical corpus as well as the intensive form of treatment that involves being seen three to five times a week over a long-term period. The term ‘psychodynamic’ refers to therapy that draws on the theoretical framework of psychoanalysis and applies it to less intensive or short-term therapy. We use the term ‘psychodynamic psychotherapy’ to refer to a variety of ways of working psychoanalytically.

We may be witnessing a resurgence in recognising the important contribution of psychodynamic psychotherapy for mental health care. Fonagy and Lemma (Fonagy et al., 2012) in a debate about the relevance of psychoanalytic or psychodynamic therapies in the NHS, argue that psychodynamic therapies make three “valuable and unique contributions to a modern healthcare economy” (p. 19). They argue that psychoanalysis has a well-established model for understanding the developmental nature of mental health problems, stemming from childhood experiences, which few other models provide. Psychoanalysis also provides the theoretical foundation for a number of other applied interventions, including CBT. Furthermore, psychoanalysis, with its focus on interpersonal dynamics, helps healthcare staff better understand and manage their stressful, and at times distressing, reactions to the care work that they are involved in. They conclude that public mental health care cannot operate on a ‘one size fits all’ basis, dominated by CBT, and that other therapeutic modalities are needed. Recent critics have argued that CBT has not delivered the successful outcomes it has claimed to provide, and that mental health care requires a rethink to incorporate other approaches, including psychodynamic psychotherapy (e.g., Dalal, 2018; Jackson and Rizq, 2019). We the authors, Deborah Abrahams and Poul Rohleder, each trained firstly as clinical psychologists and then as psychoanalytic psychotherapists; we have both used a range of approaches in our clinical work. We are not here to advocate for psychodynamic psychotherapy over CBT or other approaches, recognising, as Fonagy and Lemma put it, that different therapies are needed for different difficulties and that people respond differently to different treatments. After all, as Fonagy put it in the 44^th Maudsley debate (see Box 1.1), why would you throw out all your spanners and only keep the one you used most of the time in your proverbial therapy tool box?

What is psychodynamic psychotherapy?

All forms of counselling and psychotherapy involve the patient (please refer to our note below about our use of the term ‘patient’) talking with the therapist about their problems and life experiences and the therapist facilitating some form of understanding and insight into why things may feel so distressing for the patient at that moment; through this exchange of perspectives and understanding, the hope and possibility for change emerges. Individual therapies, such as CBT, tend to focus on psychological factors that contribute to distress in the present, such as problematic ways of thinking about issues (e.g. a tendency to perceive problems as bigger than they are or seeing problems in black-and-white terms) or problematic behaviours (e.g. avoidance behaviour, security seeking), or unreasonable perceptions about oneself and others (e.g. faulty cognitions or core beliefs). Psychodynamic psychotherapy is distinguished from other models in that it focuses primarily on unconscious aspects of our behaviour that lead to internal conflict, as well as how we experience, regulate and express our emotions in an interpersonal context, including in the therapeutic relationship (the transference, discussed in Chapter 9). The focus includes identifying repeated patterns of behaving or relating to others that we adopt from childhood and are then re-experienced in adulthood. We will elaborate on these and other distinctive features of psychodynamic psychotherapy in Chapter 3.

Many forms of treatment in mental health care attempt to rid patients of their symptoms. In psychiatry this is typically achieved through the use of medication. In CBT, this is achieved by recognising cognitive and behavioural factors that maintain symptoms, and focusing on ways of changing our thoughts and behaviours that help alleviate negative or fearful thoughts and experiences. In psychodynamic psychotherapy, we are not aiming for a cure or to rid patients of their symptoms, but rather to help patients understand how past experiences may have contributed to the distress they feel, and develop a more flexible and expansive way of relating to themselves and others. This is facilitated by attempting to bring together ambivalent and complex feelings of love and hate towards self and other. We help patients recognise dysfunctional or defensive patterns of relating that have developed over time, and to recognise their unconscious desires and impulses, in order to find a freedom, energy and playful creativity that would be otherwise diverted into defensive manoeuvres. Thus, we might say that the goal of psychodynamic psychotherapy is not so much symptom alleviation, but more personal growth, emotional maturity and increased affect regulation. Interestingly, research suggests that therapists, including CBT therapists, who seek personal therapy, usually select psychoanalytic or psychodynamic psychotherapy as the theoretical orientation of choice (Norcross, 2005). This may reflect the centrality of the ‘personal growth’ aspects of psychodynamic psychotherapy and our inherent preference to be treated as a whole person without being reduced to a constellation of symptoms.

Although all patients ostensibly enter therapy with the wish to improve their mental health, this is always easier said than done. If change were so easy, psychotherapists would be out of a job. Psychodynamic psychotherapy is not didactic or problem-solving. Indeed, most of our patients probably know what would be best for them to do – it is not about the advice per se but our inevitable resistance to following that advice. Alongside the conscious goals for help and the recognition of the need for change, there is also a strong, unconscious wish for homeostasis, to keep things as they are. It is this resistance that the therapist and patient will come up against repeatedly.

These aspects of psychodynamic psychotherapy make it difficult to develop a ‘how-to-do-it’ manual. In our experience of training clinical psychologists and counsellors, there is an expressed wish and anxiety about knowing precisely what to do and how to do it. This applies to all trainees, whatever the modality. However, while there are well-developed, circumscribed manuals for treating depression with CBT, for example, we do not have the same type of manuals for psychodynamic psychotherapy. There is no session-by-session psychodynamic psychotherapy protocol for treating a depressed patient. Furthermore, as we shall see in Chapter 2, there are many different theoretical schools of psychoanalysis, each with differing models for understanding psychic life, the ontogenesis of an individual, the development of mental health problems and therapeutic ways of working. While there are particular therapeutic techniques and skills that are shared across different modalities, practising psychodynamic psychotherapy cannot be reduced to defined techniques and exercises; rather, it entails holding a particular analytic attitude or relational stance that remains open to the patient’s unfolding communications, both conscious and unconscious. A prescriptive approach will inevitably compromise the emergent quality of psychotherapy and inhibit unconscious communication. Yet there is a need to establish the common elements and skills across different schools of psychodynamic psychotherapy. In recent years, a team from University College London (Lemma et al., 2008) developed a set of core competences for psychodynamic psychotherapy, and we have drawn on these as a framework to underpin this book.

The core competences of psychodynamic psychotherapy

The core competences (see Figure 1.1) for psychodynamic psychotherapy were derived from existing manualised psychotherapy approaches that were then checked and validated by a peer review process. A number of manuals for time-limited psychodynamic psychotherapy were identified that were associated with positive outcomes in research trials. A set of shared competences was extracted from those manuals and then validated by a peer review that included psychotherapists and psychoanalysts from a diverse range of theoretical orientations. The derived set of competences can be considered implicit to good practice of psychodynamic psychotherapy and despite divergence at the level of theory, there is great convergence when it comes to the application, i.e. the practice of psychotherapy. As such, these core competences offer a way of bridging differences across competing schools of thought in the area of psychotherapy in order to facilitate research, training and skills transfer. The competence set has been used consistently since it was developed.

Figure 1.1 The core competences for psychodynamic psychotherapy

Source: Adapted from: www.ucl.ac.uk/clinical-psychology/competency-maps/psychodynamic-map.html. Reproduced here with permission.

When we focus on competences, we are trying to evaluate the level of the therapist’s judgement and skill when delivering and implementing psychotherapy as it was intended; it forms part of an assessment of treatment fidelity that allows us to identify the key ingredients of a treatment approach and draw accurate conclusions about the efficacy of a treatment. Interestingly, it has been shown that an intermediate level of adherence, representing a balance between manual adherence and clinically flexible deviation, predicted better outcomes than did overly rigid adherence on the one hand, or loose treatment adherence on the other (Henry et al., 1993; Frank et al., 1991; Barber et al., 1996). This relates to the generic meta-competences in Lemma et al.’s (2008) framework for flexibility and adaptation. The therapist requires the ability to judge when to intervene and when to abstain by weighing up the appropriateness and timing of interventions in a dynamic way based on transference and countertransference moment to moment in the session. The concept of adaptive flexibility is a fundamental component of competence as it entails the ability of the therapist to intuitively adjust, improvise and reshape the understandings and therapeutic strategies in agreement with the continuous changes of the therapy (Binder, 1999; Schön, 1983, 1987) Assessing competence should also take into account knowledge of the patient and the therapeutic context. As you can see, it is a complicated process to identify these elements, which probably explains why psychoanalytic psychotherapy did not readily engage in this type of research. More recently, there have been attempts to pinpoint the critical ingredients for a psychoanalytic/dynamic approach such as David Tuckett’s European Psychoanalytic Federation (EPF) Working Party on Comparative Clinical Methods in order to identify the essential ingredients of psychoanalysis and Tamara Ventura’s (2019) doctoral work that develops a competence framework underpinning Dynamic Interpersonal Therapy.

Competences are a useful way of articulating the required standards for profession accreditation. Focusing on a competence-based approach represents a way of demystifying the acquiring of psychotherapy skills and allows training courses to be more transparent about the expectations and evaluation of their students. Notwithstanding the challenges, it is important that we are able to identify the key ingredients associated with therapeutic impact in psychotherapy. This will aid in evaluation and delivery of psychotherapy trainings as well as therapeutic outcomes and future research. The competence in the green box in Figure 1.1 is the overarching psychodynamic competence, namely maintaining an analytic attitude. Permeating the psychodynamic stance is an emphasis on unconscious processes and being able to listen on different levels to the latent as well as the manifest content of what our patients bring.

Aim and outline of the book

This book aims to provide an accessible, hands-on introduction to psychodynamic psychotherapy for students and trainees from psychology, counselling, psychotherapy, psychiatry and other allied professional backgrounds. From our experience in teaching and supervising clinical and counselling psychology trainees among others, we were often asked for accessible resources on psychodynamic psychotherapy that give helpful and practical guidelines for responding to the plethora of situations, clinical choices and dilemmas that arise in this line of work. Existing textbooks tend to focus on the intensive end of treatment, namely psychoanalytic psychotherapy and psychoanalysis, and tend to require an in-depth knowledge of psychoanalytic theory in order to grasp the concepts. At the other extreme, there are textbooks directed at entry level skills in psychodynamic counselling. Our hope in writing this book is to bridge this gap for an applied text on psychodynamic psychotherapy and to bring attention to contemporary issues facing psychodynamic psychotherapy practice in the 21^st century, such as the role of the technology in our practice and an analytic view of diversity. By taking a practical approach to this topic with minimal use of jargon, we aim to introduce these psychodynamic concepts to a wider audience, including undergraduate students. Each topic discussed in this book could be the subject of a book in its own right, and so the various chapters serve as an introduction to thinking about how these aspects may be...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Acknowledgements
• Foreword
• 1. Introduction
• PART 1: Theory and research
• PART 2: Competences
• PART 3: Adaptations and practicalities
• Appendix 1: Specimen terms and conditions
• Appendix 2: Specimen referral/pre-assessment questionnaire
• Appendix 3: Specimen end of therapy report
• Appendix 4: Specimen social media contract
• Appendix 5: Specimen privacy notice for website
• References
• Index