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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
An updated and expanded new edition of a widely-used guide to the theory and practice of psychodynamic psychotherapy, Cabaniss' Psychodynamic Psychotherapy: A Clinical Manual, 2nd Edition provides material for readers to apply immediately in their treatment of patients.
This expanded and updated edition of a widely-used, practical guide to psychodynamic psychotherapy provides material that readers can apply immediately in their treatment of patients. It is built around a unique and proven approach that clearly teaches psychodynamic psychotherapy using three key steps - listening, reflecting, and intervening. These are applied to all aspects of treatment, and supported by core psychotherapeutic concepts such as evaluation, empathic listening, and setting the frame.
The Second Edition has been fully revised to reflect the latest developments in the field. While retaining the structure, clarity, and relevance that have made this one of the most popular texts in its field, the authors have added new research, a wealth of new exercises, and an educators' guide to help teachers and program directors make best use of the book in training programs. The result is an invaluable resource for those seeking to teach, understand, and practice psychodynamic psychotherapy.
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Seitenzahl: 881
Veröffentlichungsjahr: 2016
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Contents
Cover
Title Page
Copyright
Dedication
Preface
Acknowledgments
Use of This Manual
About the Companion Website
Introduction
Introduction: References
Part One: What Is Psychodynamic Psychotherapy?
Chapter 1: The Treatment for a Mind in Motion
What is Psychodynamic Psychotherapy?
The Unconscious
Psychodynamic Psychotherapy and the Unconscious
Uncovering and Supporting
The Importance of the Therapeutic Relationship
Chapter 1: References
Chapter 2: How Does Psychodynamic Psychotherapy Work?
Theories of Therapeutic Action
Chapter 2: References
Part Two: Assessment
Chapter 3: Creating a Safe Place and Conducting an Assessment
Creating a Safe Place for Talking
Making an Assessment
Chapter 3: References
Chapter 4: Assessing Domains of Function
Assessing Domains of Function
Self
Relationships
Adapting
Cognition
Capacity for Work and Play
Why is the Assessment of Functional Domains Important When We Assess People for Psychodynamic Psychotherapy?
Strengths and Difficulties
Ever-Changing Patterns of Function
Chapter 4: References
Chapter 5: The Initial Formulation
Describe
Review
Link
A Sample Initial Formulation
Formulating is Key to Goal Setting
Formulating Throughout the Treatment
Chapter 5: Reference
Chapter 6: Indications for Psychodynamic Psychotherapy
Choosing Psychodynamic Psychotherapy
Unconscious Factors
Acute or Persistent Functional Difficulties
Assessing Domains of Function Guides Therapeutic Strategy
Goals
Chapter 6: References
Part Three: Beginning the Treatment
Chapter 7: Informed Consent and Collaborative Goal Setting
Informed Consent in Psychodynamic Psychotherapy
Collaborative Goal Setting
Chapter 7: References
Chapter 8: Setting the Frame and Establishing Boundaries
Setting the Frame
Why do We Need a Frame?
The Elements of the Frame
Boundaries, Boundary Crossings, and Boundary Violations
Chapter 8: References
Chapter 9: Developing a Therapeutic Alliance
What is the Therapeutic Alliance?
Establishing a Therapeutic Alliance
Other Contributors to a Strong Alliance
When Trust is a Problem
How do You Know if You Have a Good Therapeutic Alliance?
Chapter 9: References
Chapter 10: Technical Neutrality
Technical Neutrality
Taking Sides
Therapeutic Abstinence
Neutrality, Abstinence, and “Woodenness”
Chapter 10: References
Chapter 11: Conducting a Psychotherapy Session
The Beginning – Opening
The Middle – Deepening
The End – Closing
Sessions – How Long, How Often, and How Many?
Chapter 11: References
Chapter 12: Our Patients' Feelings about Us and Our Feelings about Our Patients
Our Patients' Feelings about Us
Our Feelings about Our Patients
Preview – Transference and Countertransference
Chapter 13: Empathic Listening
Learning to be an Active Listener
Challenges to Empathic Listening
Oscillating between Our Perspective and the Patient's Perspective
Chapter 13: References
Chapter 14: Looking for Meaning
Looking for Meaning is Essential for Thinking like a Psychodynamic Psychotherapist
Beginning to Listen for Meaning
Should We Talk about Unconscious Meanings with Patients?
Chapter 15: Medication and Therapy
Using Psychodynamic and Phenomenological Models Simultaneously
Choosing an Approach
Becoming Comfortable with Uncertainty
The Meanings of Medication
Combined versus Split Treatment
Chapter 15: References
Part Four: Listen/Reflect/Intervene
Chapter 16: Learning to Listen
Listening is the First Step of the Three-Step Technique of Psychodynamic Psychotherapy
How do We Listen?
Types of Listening
What We Listen For
Important Content to Listen For
We all Listen in Different Ways
Chapter 16: References
Chapter 17: Learning to Reflect
Reflecting
Developing a Therapeutic Strategy
Chapter 17: References
Chapter 18: Learning to Intervene
Interventions can be Non-Verbal
Determining the Success of Our Interventions
Section 1: Basic Interventions
Key Concepts
Basic Interventions
Section 2: Supporting Interventions
Key Concepts
What is Support?
Supplying and Assisting
Supplying Interventions
Assisting Interventions
Supplying and Assisting – A Comparison
Section 3: Uncovering Interventions
Key Concepts
Uncovering Interventions
Chapter 18: References
Part Five: Conducting a Psychodynamic Psychotherapy: Technique
Chapter 19: Affect
Why is Affect Important in Psychodynamic Psychotherapy?
Technique
Chapter 19: References
Chapter 20: Free Association and Resistance
Free Association
What is Resistance?
Technique
Chapter 20: References
Chapter 21: Transference
What is Transference?
Why do We Care about Transference?
Is it Reality Or is it Transference?
Talking about the Transference is Important Since “You Were There”
Transference Related to the Current Therapeutic Relationship
Describing and Understanding Transference
Transference and Resistance
Technique
Chapter 21: References
Chapter 22: Countertransference
What is Countertransference?
Why do We Care about Countertransference?
Is it Bad to Have Countertransference?
Types of Countertransference
What Happens If I am Not Aware of My Countertransference?
Technique
Chapter 22: References
Chapter 23: Unconscious Conflict and Defense
What is Intra-Psychic Conflict?
Complexes
Technique
Comparing Supporting and Uncovering work with defenses
Chapter 23: References
Chapter 24: Dreams
Technique
Chapter 24: References
Review Activity for Part Five: The “Microprocess Moment” ‐ Understanding a Moment in Therapy
Reference
Part Six: Meeting Therapeutic Goals
Chapter 25: Improving Self-Perceptions and Self-Esteem Regulation
Self-Appraisal and Self-Esteem Management
The Goal
Recognizing the Problem
Therapeutic Strategies
Chapter 25: References
Chapter 26: Improving Relationships with Others
The Goal
Recognizing the Problem
Therapeutic Strategies
Chapter 26: References
Chapter 27: Improving Adapting to Stress
Conscious and Unconscious Coping Mechanisms
In What Ways can Defenses be Maladaptive?
The Goal
Recognizing the Problem
Therapeutic Strategies
Chapter 27: References
Chapter 28: Improving Cognitive Function
Can They or Can't They?
The Goal
Recognizing the Problem
Therapeutic Strategies
Chapter 28: References
Part Seven: Working Through and Ending
Chapter 29: Working Through
What is Working Through?
Technique
Chapter 29: References
Chapter 30: Ending
How do We Decide When to End a Psychodynamic Psychotherapy?
How Long should the Ending Phase Be?
Technique
Choreographing the Last Sessions
Communicating Your Thoughts about the Treatment
Chapter 30: References
Review Activity for Parts Six and Seven: “The Macroprocess Summary” – Understanding How Things Change in Treatment
Chapter 31: Continuing to Learn
Learning from Your Supervisors
Learning from Your Patients
Learning from Yourself
Ending
Appendix 1 How to Use Psychodynamic Psychotherapy: A Clinical Manual A Guide for Educators
Basic Principles for Teaching Psychodynamic Psychotherapy
Suggested Curriculum Materials
Suggested Additional Readings
Appendix 1: References
Appendix 2 Template for Assessment of the Microprocess Moment and Video Review
Appendix 3 The Post-Evaluation Psychodynamic Psychotherapy Educational Resource – The “PEPPER”
FAQs about Psychodynamic Psychotherapy
Recommended Reading
Recommended Reading: Part One
Recommended Reading: Part Two
Recommended Reading: Part Three
Recommended Reading: Part Four
Recommended Reading: Part Five
Recommended Reading: Part Six
Recommended Reading: Part Seven
Index
End User License Agreement
List of Tables
Table 1
Guide
Cover
Table of Contents
Preface
Part 1
Chapter 1
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Psychodynamic Psychotherapy
A Clinical Manual
Second Edition
By
Deborah L. Cabaniss
and
Sabrina Cherry
Carolyn J. Douglas
Anna Schwartz
Columbia University Department of Psychiatry, New York, USA
This second edition first published 2017 © 2017 John Wiley & Sons, Ltd.
Edition history: John Wiley & Sons Ltd. (1e, 2011)
Registered Office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Offices
350 Main Street, Malden, MA 02148-5020, USA
9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.
The right of Deborah L. Cabaniss, Sabrina Cherry, Carolyn J. Douglas, and Anna R. Schwartz to be identified as the authors of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
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Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Limit of Liability/Disclaimer of Warranty: While the publisher and authors have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. It is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
Library of Congress Cataloging-in-Publication Data
Names: Cabaniss, Deborah L., author. | Cherry, Sabrina, author. | Douglas, Carolyn J., author. | Schwartz, Anna R., author.
Title: Psychodynamic psychotherapy : a clinical manual / Deborah L. Cabaniss and Sabrina Cherry, Carolyn J. Douglas, Anna Schwartz.
Description: Second edition. | Chichester, West Sussex ; Malden, MA : John Wiley & Sons Inc., [2017] | Preceded by Psychodynamic psychotherapy : a clinical manual / by Deborah L. Cabaniss ... [et al.]. 2011. | Includes bibliographical references and index.
Identifiers: LCCN 2016018489| ISBN 9781119141983 (cloth) | ISBN 9781119141990 (epub)
Subjects: | MESH: Psychotherapy, Psychodynamic–methods
Classification: LCC RC480 | NLM WM420.5.P75 | DDC 616.89/14–dc23 LC record available at https://lccn.loc.gov/2016018489
A catalogue record for this book is available from the British Library.
Dedication
For our familiesThomas, William and DanielMarc, Rebecca and RuthJon, William and BenEric, Lena and Maia
Preface
In the four years since Psychodynamic Psychotherapy: A Clinical Manual was published, we have taken to heart the enormous amount we have learned about it from our students and readers. While the core of our “Listen/Reflect/Intervene” method is largely unchanged, we have worked hard in writing this second edition to produce a manual that truly brings this treatment into the 21st century. Here are the highlights of what's new:
Common factors
: Outcome studies indicate that common factors, such as rapport with the therapist and expecting positive results, account for at least some of the efficacy of all talk therapies. This is true of psychodynamic psychotherapy as well. In this edition, the role of common factors is featured as a major theory of therapeutic action, and common factors are highlighted throughout.
Modern language
: Using terms like “ego function” and “super-ego” suggested that ego psychology was still the dominant way to think about psychodynamics. In this edition, we introduce new language for a new era. The idea of “domains of function” – self, relationships, adapting, cognition, work/play – echoes current constructions such as the NIMH's Research Domain Criteria (RDoCs). Even the ominous word “termination” is gone.
Current research
: This manual includes up-to-date research from epigenetics to outcome studies that impacts the way we think about psychodynamic psychotherapy today.
Formulation
: We have brought our ideas about formulation from our 2013 book
Psychodynamic Formulation
(Wiley 2013) into this edition, including the “Describe/Review/Link” method for teaching and constructing formulations.
New concepts
: Important current concepts and techniques, from mentalization to transference-focused treatment, are included. We have also updated our approach to resistance, defenses, and dreams.
Use of this manual
: Today, it is critical for both students and educators to have a guide for how to use manuals in conducting and teaching psychotherapy. Our new “Use of this Manual” section is designed to do just that.
Educators' guide
: We have included an “Educators' Guide” in this edition, much like the one in
Psychodynamic Formulation
, to help educators use this manual to anchor a psychodynamic curriculum. There are also more “Suggested Activities” to use in class, as well as evaluation tools.
Psychoeducational material for patients
: Lastly, we have included the Post-Evaluation Psychodynamic Psychotherapy Educational Resource – the “PEPPER” – to help you help your patients learn about this important treatment.
We hope you'll agree that this new Psychodynamic Psychotherapy: A Clinical Manual is truly a psychotherapy manual for today and tomorrow.
Acknowledgments
That's Farsi for “Psychodynamic Psychotherapy.” Five years ago, I wouldn't have dreamed that I would know that. But since we published the first edition of this book, it has been translated into Mandarin, Korean, and Farsi, and has been adopted by training programs from Harvard to Stanford. We've been overwhelmed by the response, and delighted that it has helped students realize that psychodynamic psychotherapy can be taught in a clear way that makes sense to even the most junior learners. We've been particularly pleased that even people who are not in the field have said: “I wish I'd had that book when I was in therapy!” Our heartfelt thanks go to all of our readers, who have added “Listen/Reflect/Intervene” to the lexicon.
Once again, the dream team of Sabrina Cherry, Carolyn Douglas, and Anna Schwartz helped produced a book that no one of us could have done alone. Our “groupthink” propelled us out of ego psychology and into a psychodynamic psychotherapy manual for the 21st century. I'm sure they won't miss my late-night queries, but I will miss the incredible learning experience of working with a group like this day in and day out.
None of this could have happened without the Columbia University Department of Psychiatry Residency Program. Maria Oquendo and Melissa Arbuckle, our fearless leaders, have allowed us to experiment and innovate in order to produce something really new in psychodynamic training. And, as before, our terrific Columbia residents teach us every day what works and what doesn't.
Steven Roose provided wisdom that got us through many a conceptual sticky wicket. Darren Reed at Wiley gave us the opportunity to dive into this project again. Joshua Gordon and Richard Brockman shared their Columbia “Neuroscience of Psychodynamic Psychotherapy” curriculum. Yael Holoshitz, Lauren Havel, and Alison Lenet contributed with the “PEPPER.” William Cabaniss was there with technical support during crunch time. And a big shout-out to Maya Nair, who gave us a “pre-read” and was intrepid about offering feedback to her teachers.
Of course, our biggest thanks go to our families, who once again put up with us while we went down the drop-box rabbit hole. We're back, at least until we come up with a new three-step process to explore…
Deborah L. Cabaniss, m.d.
January 2016
Use of This Manual
Psychodynamic Psychotherapy: A Clinical Manual is a manual for conducting psychodynamic psychotherapy. It outlines the techniques used for
assessment
beginning the treatment
conducting psychodynamic psychotherapy using uncovering and supporting techniques
Like all psychotherapy manuals, it is designed to operationalize the techniques clearly so that this treatment can be taught, delivered, and studied in the most effective way. Psychotherapy manuals are not scripts or cookbooks. Rather, they are treatment guides. Here are some suggestions for optimal use of this manual:
For students:
Psychotherapy manuals are not meant to be read cover to cover like novels. Approach this manual chapter by chapter. Try to learn all of the terms and concepts, and then try to use them immediately, as appropriate, in your work with patients. Although you can initially use the exact language suggested in the examples, try to adapt the skills outlined in the manual to the patients with whom you are working. Return to chapters at various stages of your training in order to approach the skills in new, more advanced ways. Use the suggested activities to practice the skills you have learned individually, in supervision, or in a classroom setting.
For supervisors:
Even if you learned psychodynamic psychotherapy from other materials, read along with your supervisees to learn how to supervise from a manual. Use the Listen/Reflect/Intervene rubric to help your supervisees become aware of the specific skills they are using. Consider adapting the suggested activities to a supervisory setting.
For educators:
You can use this manual, as well as its companion book,
Psychodynamic Formulation
, as your primary texts for teaching psychodynamic psychotherapy to students of
Counseling
Nursing
Psychiatry
Psychoanalytic psychotherapy
Psychology
Social work
For more detailed suggestions about the use of this manual in didactics and supervision, see Appendix 1, “How to Use Psychodynamic Psychotherapy: A Clinical Manual – A Guide for Educators.”
About the Companion Website
This book includes a companion website:
www.wiley.com/go/cabaniss/psychotherapy
with the “Listening Exercise” for Chapter 16 (Learning to Listen).
This is a short recording that will help the reader to learn about different ways we listen. It is designed to accompany a listening exercise, which is found near the beginning of Chapter 16.
Introduction
“Why can't I find a good relationship?”
“Why do I keep bombing out at work?”
“Why can't I have more patience with my children?”
“Why can't I feel good about myself?”
Feeling good about ourselves, having loving relationships with others, and doing satisfying work – for most of us, those are our life goals. We all have certain patterns that guide the way we try to achieve these goals. By the time we are adults, our patterns are fairly fixed, and changing them is not so easy. The habitual nature of these patterns is akin to the way water runs down a hill – after a while, a certain groove gets carved out and the water always flows down that channel. If you want the water to flow another way, you're going to have to do some hard work to alter the path. It's the same with us – after a certain age, we're pretty consistent about the way we think and behave. But for many people, their characteristic ways of thinking about themselves and dealing with others are maladaptive and they need a way to change.
The problem is that although they know they want to change, they don't know what they want to change. That is because habitual patterns, more often than not, are motivated by wishes, thoughts, fears, and conflicts that are out of awareness. For example, take a person who never advocates for herself and doesn't know why – but who deep down feels that she deserves to be punished. Or a person who is lonely but is unaware that his fear of rejection is actually causing him to avoid others. For these people, learning about their deep-seated thoughts and fears can be unbelievably powerful. The insecure woman can understand that her self-sabotage has been a lifelong form of self-punishment, and the lonely man can begin to understand that he produces his own isolation by denying his need for others. They can start to develop new patterns of behavior. They can change their lives.
This is what psychodynamic psychotherapy is all about. It offers people a chance to create new ways of thinking and behaving in order to improve the quality of their lives. Since most of the ways we think about ourselves and deal with our environment evolved as we grew up, we can think of this process as reactivating development. One thing that is incredibly exciting about this view of psychodynamic psychotherapy is that it fits so well with advances in neural science [1–4]. For example, we now hypothesize that all learning comes with changes in our neural substrate – so adult brains change all the time. In the words of Eric Kandel, “Insofar as psychotherapy works, it works by acting on brain functions, not on single synapses, but on synapses nevertheless” [5]. New growth – new connections – new patterns.
In this model, not all environments foster new growth – you need a particular set of circumstances in which people feel safe enough to allow this to happen. If you've ever worked on changing anything that had become habitual, it's likely that the process involved another person, like a coach, teacher, or parent. In psychodynamic psychotherapy, that person is the therapist. Change happens not only because people learn new things about themselves, but also because they feel safe enough to try out new ways of thinking and behaving in the context of this new relationship.
This manual will teach you to conduct psychodynamic psychotherapy. Because it was first developed as a syllabus for teaching psychiatric residents, it has been classroom tested for many years. It will systematically take you from assessment to ending using straightforward language and carefully annotated examples. Psychodynamic psychotherapy is a specific type of therapy that requires the therapist to carefully and deliberately make a thorough assessment, establish a therapeutic framework, interact with patients in particular ways, and make choices about therapeutic strategies. As you journey through this book, you will learn all of these essential skills. Here's the basic roadmap: Part One (What Is Psychodynamic Psychotherapy?) will introduce you to psychodynamic psychotherapy and to some of the ways we hypothesize that it works. Part Two (Assessment) will teach you to assess patients for psychodynamic psychotherapy, including assessment of domains of function and defenses. In Part Three (Beginning the Treatment), you'll learn the essentials for beginning the treatment, including fostering the therapeutic alliance, setting the frame, and setting goals. Part Four (Listen/Reflect/Intervene) will teach you a systematic way of listening to patients, reflecting on what you've heard, and making choices about what to say and how. Part Five (Conducting a Psychodynamic Psychotherapy: Technique) will teach you to apply the Listen/Reflect/Intervene method to the essential elements of psychodynamic technique – affect, resistance, transference, countertransference, unconscious fantasy, conflict, and dreams. By then you'll be ready to use these methods to meet therapeutic goals, and in Part Six (Meeting Therapeutic Goals) you'll see how these techniques are used to address problems with self-esteem, relationships with others, characteristic ways of adapting, and cognitive functions. Finally, Part Seven (Working Through and Ending) will take you to the end of the treatment, addressing ways in which our technique shifts over time.
Learning is best when it's active – and thus we've included suggested activities at the end of most of the chapters. These are designed to allow you to try out the skills and techniques that you will learn in this book. They can be done alone, with a partner, or as part of a classroom activity. “Comments” are included to guide reflection and discussion; they are not meant to be definitive or “correct” answers.
We have made many deliberate choices about the use of jargon. For example, we do not extensively use terms like “transference” and “resistance” until we formally introduce them in Part Five, both because we want to define our terms carefully and because we want you to think as openly as possible as you begin learning this treatment. We all have preconceived ideas about these concepts and, as much as possible, we are trying to reduce the impact of previously held notions. We have also consciously decided to avoid discussion of particular theoretical schools of psychodynamic psychotherapy, such as object relations theory and self-psychology. Again, this decision reflects our intention to teach the technique of psychodynamic psychotherapy in the most ecumenical way possible.
So, let's begin at the beginning – on to Part One and “What Is Psychodynamic Psychotherapy?”
Introduction: References
1. Peterson B.S. (2005) Clinical neuroscience and imaging studies of core psychoanalytic concepts.
Clinical Neuroscience Research
,
4
(5), 349–365.
2. Rothman J.L., and Gerber A.J. (2009) Neural models of psychodynamic concepts and treatments: Implications for psychodynamic psychotherapy, in
Handbook of Evidence-Based Psychodynamic Psychotherapy
(eds R.A. Levy and J. S. Ablon), Humana Press, New York, p. 305–338.
3. Westen, D. (2002) Implications of developments in cognitive neuroscience for psychoanalytic psychotherapy.
Harvard Review of Psychiatry
,
10
(6), 369–373.
4. Westen, D., and Gabbard, G.O. (2002) Developments in cognitive neuroscience: I. Conflict, compromise, and connectionism.
Journal of the American Psychoanalytic Association
,
50
(1), 53–98.
5. Kandel, E.R. (1979) Psychotherapy and the single synapse: the impact of psychiatric thought on neurobiologic research.
New England Journal of Medicine
,
301
(19), 1028–10.
Part One:What Is Psychodynamic Psychotherapy?
1The Treatment for a Mind in Motion
Key Concepts
Psychodynamics means mind in motion.
A psychodynamic frame of reference postulates that dynamic (moving) elements in the unconscious affect conscious thoughts, feelings, and behavior.
A psychotherapy that is based on the psychodynamic frame of reference is a psychodynamic psychotherapy.
The basic goal of psychodynamic psychotherapy is to help people with problems and patterns that lead to unhappiness and dissatisfaction in life by uncovering unconscious thoughts and feelings and/or directly supporting function in the context of the relationship with the therapist.
Both uncovering and supporting techniques are used in almost every psychodynamic psychotherapy.
What is Psychodynamic Psychotherapy?
Literally, psychotherapy means treatment for the mind. Psychotherapy has its origins in psychoanalysis – the “talking cure” that was first developed by Sigmund Freud [1]. Consequently, the word psychotherapy has come to refer to a treatment that involves talking. But it's not just any talking – in order to be psychotherapy, the talking has to be:
a treatment
conducted by a trained professional
within a set framework
in order to improve the mental and emotional health of a patient
And what about psychodynamic? You've probably heard this word many times – but what does it mean? Psycho comes from the Greek word psyche, which meant soul but has come to mean mind, and dynamic comes from the Greek word dynamis, which meant power but has come to mean physical force in motion. Simply stated, the word psychodynamics refers to the forces of the mind that are in motion. Freud coined this word when he realized that, as opposed to earlier conceptualizations of a static psyche, the mind was an ever-changing system, rolling with perpetually moving energized elements. These unconscious elements could explode into consciousness and vice versa, while powerful wishes and prohibitions could barrel into one another, releasing the psychic equivalent of colliding subatomic particles [2].
Freud realized not only that elements of the mind were in motion, but also that most of this frenzied mental activity was going on outside of awareness. He described this mental activity as unconscious and hypothesized that it could affect conscious thoughts, feelings, and behavior. Thus, we arrive at the two definitions that provide the foundation for this manual:
A psychodynamic frame of reference is one that postulates that unconscious mental activity affects our conscious thoughts, feelings, and behavior.
A psychodynamic psychotherapy is any therapy based on a psychodynamic frame of reference.
The Unconscious
We often refer to our unconscious mental activity as the unconscious. Feelings, memories, conflicts, ways of relating to others, self-perceptions – all of these can be unconscious and can cause problems with thoughts and behavior. Unconscious thoughts and feelings develop in a person from childhood, and are a unique mix of early experiences and temperamental/genetic factors. We keep certain thoughts, feelings, and fantasies out of awareness because they threaten to overwhelm us if they become conscious. They might be too frightening or stimulating; they might fill us with shame or disgust. Because of this, we make them unconscious but they do not disappear – they remain full of energy and constantly push to reach awareness. Their energy affects us from their unconscious hiding places, and they exert their influence on the way we think, feel, and behave. A good analogy comes from Greek mythology:
Zeus, the young god, was tired of being ruled by the patriarchal Titans, so he buried them in a big pit called Tartarus. Deep beneath the earth, they no longer posed a threat to Zeus's dominance. Or did they? Though out of sight, they had not disappeared, and their rumblings were thought to cause earthquakes and tidal waves.
So too, unconscious thoughts and feelings are hidden from view but continue to rumble in their own way, causing unhappiness and suffering in the form of maladaptive thoughts and behaviors.
Psychodynamic Psychotherapy and the Unconscious
In many ways, the psychodynamic psychotherapist is like the plumber you call to fix your leaky ceiling. You see the dripping, but you can't see the source; you can catch the drops in a pail, but that doesn't stop the flow. The plumber knows that the rupture lies behind the plaster, somewhere in pipes that as yet can't be seen. Here, though, the plumber has an advantage over the psychodynamic psychotherapist – he can use a sledgehammer to break through the plaster, reveal the underlying pipes, find and fix the offending leak, and patch the ceiling. But the psychodynamic psychotherapist is working with a human psyche, not a plaster ceiling, and thus requires more subtle tools to seek and mend what's beneath the surface.
Uncovering and Supporting
Like the plumber, the psychodynamic psychotherapist's first goal is to understand what lies beneath the surface – that is, to understand what's going on in the patient's unconscious. Many of the techniques of psychodynamic psychotherapy are designed to do just that. Once we think that patients are motivated by thoughts and feelings that are out of their awareness, we then have to decide how to use what we have learned in order best to help them. Sometimes we decide that making patients aware of what's going on in their unconscious will help. We call this uncovering – Freud called it “making conscious what has so far been unconscious” [3]. We have many techniques for helping patients to uncover – or become aware of – unconscious material. What we're uncovering are inner thoughts and feelings that they keep hidden from themselves but that nevertheless affect their self-perceptions, relationships with others, ways of adapting, and behavior.
Sometimes, however, we decide that making patients aware of unconscious material will not be helpful. We generally make this decision when we judge that the unconscious material could be potentially overwhelming. Then we use what we have learned about the unconscious to support functioning without uncovering thoughts and feelings. (See Chapter 18 for discussion of uncovering and supporting techniques.)
Here are two examples – one in which we would choose to uncover and one in which we would choose to support:
Ms A is a 32-year-old woman who has a trusting relationship with her husband, many close friends, and a satisfying personal career. In the past, she has used journaling, cooking, and athletics to work through short periods of anxiety. She presents to you complaining of insomnia that she believes has been triggered by a fight she is having with her younger sister, B. Ms A says that she's “mystified” by B's hostile behavior, which began about a month ago in the context of B's impending graduation from medical school. Further exploration reveals that although B wanted to become a dermatologist, she was not offered a position in this field and will have to do an interim year of internal medicine and then reapply. Ms A says that she has been very sympathetic about this setback and does not know why B is so hostile toward her. When you ask about their earlier relationship, you discover that Ms A has cruised effortlessly from one Ivy League institution to another, while B has struggled academically. You hypothesize that B's hostility toward Ms A may be fueled by envy, and that Ms A has been unconsciously keeping herself from becoming aware of this out of guilt. You think that Ms A will benefit from learning about her unconscious guilt and decide to help heruncoverit. Once she grapples with her guilty feelings, she is able to recognize her sister's hostility and envy. This awareness helps her to understand their recent interpersonal difficulties and resolves the insomnia.
Ms C is a 32-year-old woman who is isolated, moves frequently from job to job, and often reacts to stress by binge eating and purging. She presents to you complaining of insomnia that she believes has been triggered by a fight with her younger sister, D. She says that she is shouldering the entire burden of caring for their chronically ill mother while D “just sits in her suburban home with the other soccer moms and sends checks.” Ms C, who is struggling to make ends meet, tells you that she thinks that her sister, who is married to a very wealthy man, is “shallow and materialistic” and that she “wouldn't switch lives with her if you paid me.” She says that she is “enraged” at D for not doing more to help their mother and that ruminations about this are causing her to stay awake at night. You hypothesize that Ms C's rage is fueled by envy of D, but you decide that learning about the way in which this might be contributing to the insomnia will not help her at this time. Instead, you decide tosupportMs C's functioning by empathizing with the amount of work she is doing to care for her ailing mother, and by suggesting that she use her mother's Medicare benefits to get some help with eldercare. Once she feels validated, Ms C relaxes, her insomnia resolves, and she is better able to understand many aspects of her current situation.
In both cases, the first thing that the psychodynamic psychotherapist needed to do was to understand the way in which unconscious thoughts and feelings were affecting the patient's conscious behavior. However, in one situation the therapist decided to uncover while in the other the therapist decided to support. Thus, we can say that the basic techniques of psychodynamic psychotherapy are to:
understand the ways in which the patient is affected by thoughts and feelings that are out of awareness
decide whether uncovering or supporting will help most at that moment
uncover unconscious material and/or support mental functioning in the way that best helps the patient
Making the decision in Step #2 depends on careful assessment of the patient, both at the beginning and throughout the treatment, to determine what will be most helpful at any given point in time (see Part Two). When psychodynamic psychotherapy primarily uses uncovering techniques, it is often called insight-oriented, expressive, interpretive, exploratory, or psychoanalytic psychotherapy, and when it primarily uses support, it is often called supportive therapy [4]. Unfortunately, these techniques are often seen as completely separate from one another. On the contrary, uncovering and supporting do not constitute separate therapies, but rather are both used in an oscillating manner inallpsychodynamic psychotherapy. One patient may benefit from therapy in which mostly uncovering techniques are used, while another may benefit from therapy in which supporting techniques predominate, but all treatments use some of each at different points.
The optimal mix of supporting and uncovering techniques will vary from patient to patient, and sometimes from moment to moment, depending on the individual person's strengths, problems, and needs. Some patients only require the implicit support conveyed in the therapist's attitude of empathy, understanding, and interest. Other patients need more explicit support throughout the treatment. Whatever the overarching goals we choose at the start of treatment, we are prepared to shift our approach flexibly depending on the patient's changing needs.
The Importance of the Therapeutic Relationship
Uncovering and supporting do not happen in a vacuum – they happen in the context of the relationship between therapist and patient. This relationship is central to what defines psychodynamic psychotherapy. It not only provides a safe environment in which patients can talk about their problems, it also allows them to learn about themselves and their relationships through their interaction with the therapist. The therapeutic relationship itself is likely to be an agent of change in psychodynamic psychotherapy, both as a “relationship laboratory” from which the patient can learn, and as a direct source of support that can foster growth and change. Talking about and learning from the therapeutic relationship is called discussion of the transference (see Chapters 12 and 21) and is often a major focus of psychodynamic psychotherapy.
With this addition, we can round out our definition of psychodynamic psychotherapy in this way:
Psychodynamic psychotherapy is a talk therapy based on the idea that people are affected and motivated by thoughts and feelings that are out of their awareness. Its goals are to help people to change habitual ways of thinking and behaving by helping them learn more about how their minds work, and/or directly supporting their functioning, in the context of the relationship with the therapist.
But how does this happen? Let's move on to Chapter 2 to explore some of the theories behind the technique.
Chapter 1: References
1. Vaughan, S.C. (1998)
The Talking Cure: The Science behind Psychotherapy
, Henry Holt, New York.
2. Moore, B.E., and Fine, B.D. (eds) (1990)
Psychoanalytic Terms and Concepts
, Yale University Press, New Haven, p. 152.
3. Freud, S. (1894) The neuro-psychoses of defense, in The Standard Edition of the Complete Psychological Works of Sigmund Freud (1893–1899): Early Psycho-Analytic Publications, Vol.
III
, Hogarth Press, London, p. 164.
4. Winston, A., Rosenthal, R.N., and Pinsker, H. (2004)
Introduction to Supportive Psychotherapy
, American Psychiatric Publishing, Washington, DC.
2How Does Psychodynamic Psychotherapy Work?
Key Concepts
A theory of therapeutic action is a theory that tries to explain how psychotherapy works. Basic theories of therapeutic action for psychodynamic psychotherapy include:
the role of common factors
making the unconscious conscious
supporting characteristic patterns of function
reactivating development
Psychodynamic psychotherapy can be thought of as a process in which development can be reactivated and new growth can occur in the context of the relationship with the therapist.
Explaining to patients how therapy works makes it more effective.
Theories of Therapeutic Action
In order to choose what to say to patients, we have to have some idea about why what we're saying will help them. This means that we have to have theories about how we think therapy works. A theory that tries to explain how psychotherapy works is called a theory of therapeutic action [1]. In psychodynamic psychotherapy, we have several theories of therapeutic action that help guide our work.
The Role of Common Factors
Research indicates that the most effective forms of psychotherapy – including psychodynamic psychotherapy – share similar elements that at least partially account for therapeutic outcome [2–10]. These are generally called common factors. They are closely related to the therapeutic alliance between patient and therapist – that is, the trust that is engendered when patients feel safe, heard, and understood in a non-judgmental atmosphere (see Chapter 9). Common factors include:
the rapport between therapist and patient
fostering positive expectations of the treatment
collaborative goal setting
role preparation for the treatment
offering a cogent rationale for the treatment
These elements convey to patients that the therapist is reliable and committed to helping them. They indicate that the therapist is listening and responding to the patient's needs and goals. And they offer hope that the treatment will address the patient's problems and lead to improvement.
We will return to a discussion of common factors in Part Three, “Beginning the Treatment.”
Making the Unconscious Conscious
In psychodynamic psychotherapy, one of the things that we think helps our patients is making the unconscious conscious. This idea was the basis for Freud's first theory of therapeutic action [11]. Drawing on his clinical work, Freud hypothesized that some patients developed symptoms because thoughts and feelings that were not accessible to consciousness nevertheless exerted a pathological effect on their conscious functioning. Freud's idea was that many of these thoughts were memories, and thus he famously said that these patients “suffer mainly from reminiscences” [12]. Although Freud first used hypnosis to bring sequestered memories into consciousness, he and his patients soon realized that simply talking freely brought unconscious thoughts and feelings to the surface. Since that time, ideas about therapeutic action have become more complex. However, the basic ideas that
thoughts and feelings that are out of awareness can affect and motivate people, often leading to habitual but maladaptive ways of thinking and behaving; and
becoming aware of these thoughts and feelings can be therapeutic
are still central tenets of psychodynamic psychotherapy.
Why Should Becoming Aware of Unconscious Thoughts and Feelings be Therapeutic?
There are many ways to think about this:
Lancing the abscess:
One idea is that cloistered-off thoughts and feelings can be harmful and releasing them can be cathartic. The analogy in physical medicine is the pus-filled abscess that causes pain even if it is hidden beneath the skin. This theory suggests that just as the abscess needs to be lanced and debrided, sequestered feelings need to be released. This is often called
abreaction
and remains an important idea in psychodynamic psychotherapy [13].
Preventing proliferation in the dark:
Freud said that an element from the unconscious “proliferates in the dark” if it is not brought into consciousness through speaking, meaning that it will grow to enormous, inappropriate dimensions [14]. Again, we have all had the experience of being less afraid of something once we've talked about it. In this model, talking about something is like turning on the light in your bedroom to find that the giant monster in the corner is really a hat on a chair.
Knowing ourselves better helps us make better decisions:
If the forces that govern our thoughts, feelings, and behavior are unconscious, we cannot control them. They guide our decision making, provoke anxiety, and produce feelings. It makes sense, then, that increasing awareness of these forces can help people by giving them more conscious control over how they make decisions, think about themselves, and have relationships with others. Explaining this concept to patients can be a very effective and powerful way to help them understand this treatment and its therapeutic potential.
How Do We Help People to Become Aware of Things That are Out of Awareness?
If we think that unconscious thoughts and feelings cause conscious suffering, we have to access them – but the question is how. It is like getting to uncharted territory without a map. Even with a map, we might not understand what we found there because the unconscious mind and the conscious mind use different types of thought processes. The unconscious mind is governed by what we call primary process, which is non-linear and non-verbal (like dreams), while the conscious mind is governed by secondary process, which is linear and verbal (like conscious thought) [15]. Thus, in order to understand unconscious thoughts and feelings, we have to translate them into a form that the conscious mind can understand. We do this with words. You can think of words as boats that ferry ideas between the unconscious and conscious parts of the mind. We've all had this experience – when we use a word to shape an inchoate thought, we often have an “a-ha” moment. This is enormously helpful, and can reduce anxiety. Once we have words for a thought or feeling, we can talk about it, subject it to conscious scrutiny, and use it to understand ourselves more fully.
You will learn specific techniques for helping patients to uncover unconscious thoughts and feelings in Parts Four and Five of this manual.
Supporting Function
A third theory of therapeutic action is that psychodynamic psychotherapy works by helping patients strengthen function in several domains. Formerly called ego functions (see Chapter 4), these domains of function include processes such as reality testing, impulse control, and self-esteem regulation that help us to manage our inner mental life and relationship to the world. They can be weakened globally or selectively, acutely or persistently.
As our understanding of the mind and neuroscience evolves, researchers in this area increasingly find that the best way to understand these functions is to cluster them into dimensions or domains [16,17]. As in our companion book, Psychodynamic Formulation, we follow this approach, using five domains of function (see Chapter 4 for more detail):
Self
Relationships
Adapting
Cognition
Work and Play
Psychodynamic psychotherapy helps patients by improving function in all of these domains. This theory of therapeutic action suggests that patients can not only derive temporary benefit by “borrowing” function from their therapists, but can also more permanently strengthen function by internalizing new ways of thinking and behaving. All of the supporting techniques described in this manual are designed to improve these functions (Chapter 18).
Reactivating Development
Another theory of therapeutic action in psychodynamic psychotherapy is that this treatment reactivates mental and emotional development in order to foster new, healthier growth. A good analogy for this model is what happens when a tennis player stops improving because she is hampered by a weak serve. A new coach diagnoses the problem, helps her to “unlearn” her old serve, teaches her new technique, and improves her game. Similarly, people may have difficulty moving forward as adults because of problematic function that resulted from abuse or neglect in combination with the person's unique temperamental and genetic milieu [18]. Like the coach, a therapist can offer people the opportunity to grow and develop healthier function in the context of the new relationship with the therapist. Areas in which new growth can occur include the development of
new ways of thinking about oneself and of regulating self-esteem
new ways of relating to others
more flexible, adaptive coping mechanisms
improved cognitive function
For example, if a person who believes that no one will take care of him realizes that his therapist does, we hypothesize that this reactivates the development of his self-esteem regulation and capacity for relationships with others, allowing for new, healthier growth. For some patients, putting this experience into words can help them become aware not only of the problem and the potential reasons for it, but also of the ways in which the therapeutic relationship is helping them to develop new patterns of thinking and feeling. With other patients, this process may be more experiential and less verbally explicit. Today, we are even beginning to have a sense of the neurobiological mechanisms through which psychotherapy might reactivate development. Advances in neuroscience suggest that early experiences can result in lasting neurobiological changes that may be reversible in certain circumstances [19]. For example, in animal models, variation in maternal care affects methylation of histones, the proteins around which a cell's DNA is wrapped. Methylation changes the structure of the histones, affecting which parts of the DNA are available for transcription. In this way, maternal care affects gene transcription without changing the genome itself. This is called an epigenetic change [20,21]. Although these changes can affect gene transcription for life, they have also been shown to be reversible in rodents when pups raised by neglectful mothers are cross-fostered by attentive ones [22].
Epigenetic changes in response to early parental loss or emotional deprivation may even cluster in particular areas of the brain, such as the amygdala [23]. Fortunately, the brain is a flexible organ that is continually built and rebuilt by our experiences throughout life. We have every reason to expect that this includes the experience of being in psychotherapy. Increasingly, the neuroimaging literature shows measurable changes in brain function after psychotherapeutic intervention [24–27]. Scientists have even suggested that psychotherapy may produce epigenetic changes in genes that affect the chemistry of the brain's neurocircuitry, leading to new synaptic connections [28–30]. In a very real sense, then, therapy may be successful to the degree that therapists create and foster the conditions that allow for neuroplasticity or changes in neural circuits to occur [31–34].
Explaining to Patients How Psychodynamic Psychotherapy Works
It is very important for therapists to understand how we think psychodynamic psychotherapy works. But our patients need to understand that, too. As we'll discuss further in Part Three, therapy is more effective when we offer our patients plausible rationales or “narratives” for their symptoms, as well as an explanation about how treatment actually works, early in the treatment [8]. In Appendix 3, we offer an example of the kind of basic information and FAQs (frequently asked questions) about psychodynamic psychotherapy that you can give to patients at the start of treatment. This two-page educational resource includes not only what patients can expect (“Will my therapist talk?”) and how they might best participate in therapy (e.g., by saying whatever comes to mind), but also how we think psychodynamic psychotherapy works. We recommend sharing this with your patients during the informed consent process (see Chapter 7). Of course, you may talk about how therapy works differently with different patients. Some of this may vary with the person's problem. For example, you might emphasize the importance of reactivating development with a person who has a history of severe childhood trauma, while you might emphasize the benefit of making the unconscious conscious with someone struggling with unconscious fears about expressing anger.
Now that you have an idea of what psychodynamic psychotherapy is, how we think it works, and how to share this with patients, let's move on to thinking about how we assess patients for this treatment and for whom it is most helpful.
Theories of Therapeutic Action
The role of common factors
Making the unconscious conscious
Supporting function
Reactivating development
Chapter 2: References
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