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Psychoanalysis, Psychoanalytic/ Psychodynamic Therapy
UNIT 1 PSYCHOANALYSIS,
PYCHOANALYTIC/
PSYCHODYNAMIC THERAPY
Structure
1.0 Introduction
1.1 Objectives
1.2 Psychoanalysis
1.2.1 Theoretical Models
1.3 Freudian Psychoanalytical Theory 1.3.1 Basic Human Drives 1.3.2 Structural and Topographical Models of Personality 1.3.3 Stages of Psychosexual Development 1.3.4 Ego Defense Mechanisms 1.3.5 Limitations
1.4 Object Relations Theory 1.4.1 Symbiosis and Separation/ Individuation 1.4.2 Self Identity and Gender Identity 1.4.3 Reproduction of Social Patterns
1.5 Self Psychology
1.6 Attachment Theory
1.7 Lacanian Psychoanalysis
1.8 Postmodern Schools
1.9 Psychoanalytic/ Psychodynamic Therapy
1.9.1 Basic Tenets and Concepts of Psychoanalytic Therapy 1.9.2 Components of Psychoanalytic and Psychodynamic Psychotherapy 1.9.3 Distinctive Features of Psychodynamic Technique
1.10 Let Us Sum Up
1.11 Unit End Questions
1.12 Suggested Readings
1.13 Answers to Self Assessment Questions
1.0 INTRODUCTION
To the majority of people, psychotherapy is synonymous with psychoanalysis. This may be because psychoanalysis is the most well known psychotherapy method practiced. In addition, the popular media such as television and movies continue to depict most psychiatrists and psychologists solely as practitioners of psychoanalysis. Most people are surprised to learn that psychoanalysis is only one of many therapeutic techniques currently used by clinicians. Also surprisingly, Sigmund Freud was not the first individual to apply principles of psychotherapy.
Historically psychoanalysis (of course developed by Freud) is one of the most influential methods of psychotherapy. The contributions of psychoanalysis to psychotherapeutic and counselling theories and practices are enormous. The main
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ideas of psychoanalysis have been instrumental in the development of many therapeutic methods that followed. Concepts such as unconscious, transference, and dream analysis continue to play a very prominent role with many clinicians who do not consider themselves psychoanalysts.
1.1 OBJECTIVES
After completing this unit, you will be able to:
- Elucidate the theoretical principles of classical psychoanalytic or Freudian theory;
- Describe the different theoretical orientations under the broad umbrella of ‘psychoanalysis’; and
- Explain the treatment principles, standard methods, techniques, concepts and features of psychoanalytic/ psychodynamic therapy.
1.2 PSYCHOANALYSIS
Psychoanalysis (or Freudian psychology) is a body of ideas developed by Austrian neurologist Sigmund Freud and continued by others. It is primarily devoted to the study of human psychological functioning and behaviour, although it can also be applied to societies. Psychoanalysis has three main components:
- a method of investigation of the mind and the way one thinks;
- a systematised set of theories about human behaviour;
- a method of treatment of psychological or emotional illness.
Under the broad umbrella of psychoanalysis, there are at least 22 theoretical orientations regarding human mentation and development. The various approaches in treatment called “psychoanalysis” vary as much as the theories do. The term also refers to a method of studying child development.
1.2.1 Theoretical Models
The predominant psychoanalytic theories can be grouped into several theoretical “schools.” Although these theoretical “schools” differ, most of them continue to stress the strong influence of unconscious elements affecting people’s mental lives. There has also been considerable work done on consolidating elements of conflicting theory. As in all fields of healthcare, there are some persistent conflicts regarding specific causes of some syndromes, and disputes regarding the best treatment techniques. Some of the most influential theories are described below.
1.3 FREUDIAN PSYCHOANALYTICAL THEORY
Sigmund Freud is important as the first major theorist to write exclusively about non biological approaches to both understanding and treating some of mental illnesses. These illnesses, specifically what was then called hysteria, were considered medical in his time, but were reshaped through his theories.
Freud was awarded Hypnosis grant and after completing his hypnosis grant, he published his first book The Interpretation of Dreams , and although it originally sold only 600 copies, it has become one of the most respected and most
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hot, too cold, or just wants attention, the Id speaks up until his or her needs are met. The Id does not care about reality, about the needs of anyone else, only its own satisfaction. If you think about it, babies are not real considerate of their parents’ wishes. They have no care for time, whether their parents are sleeping, relaxing, eating dinner, or bathing. When the Id wants something, nothing else is important.
Within the next three years, as the child interacts more and more with the world, the second part of the personality begins to develop. Freud called this part as the Ego. The Ego is based on the reality principle. The ego understands that other people have needs and desires and that sometimes being impulsive or selfish can hurt us in the long run. It’s the Ego’s job to meet the needs of the id, while taking into consideration the reality of the situation.
By the age of five, or the end of the phallic stage of development, the Superego develops. The Superego is the moral part of the personality and develops in response to the moral and ethical restraints placed on the individual by the caregivers. Many equate the Superego with the conscience as it dictates our belief of right and wrong.
In a healthy person, according to Freud, the Ego is the strongest so that it can satisfy the needs of the id, not upset the Superego, and still take into consideration the reality of every situation. If the Id gets too strong, the impulses and self gratification take over the person’s life. If the Superego becomes too strong, the person would be driven by rigid morals, would be judgmental and unbending in his or her interactions with the world.
Topographical Model Freud believed that the majority of what individuals we experience in their lives, the underlying emotions, beliefs, feelings, and impulses are not available to them at a conscious level. He believed that most of what drives them is buried in their unconscious. For instance, in the case of Oedipus and Electra complex, the feelings and thoughts associated with the same sex parents were pushed into the unconscious, out of the awareness of the individual due to the extreme anxiety these thoughts and feelings caused. While buried there, however, they continue to impact us dramatically according to Freud.
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The role of the unconscious is only one part of the model. Freud also believed that everything we are aware of is stored in our conscious. Our conscious makes up a very small part of who we are. In other words, at any given time, we are only aware of a very small part of what makes up our personality; most of what we are is buried and inaccessible.
The final part is the preconscious or subconscious. This is the part of us that we can access if prompted, but is not in our active conscious. It’s right below the surface, but still buried somewhat unless we search for it. Information such as our telephone number, some childhood memories, or the name of your best childhood friend is stored in the preconscious. Because the unconscious is so large, and because we are only aware of the very small conscious at any given time, this theory has been likened to an iceberg, where the vast majority is buried beneath the water’s surface. The water, by the way, would represent everything that we are not aware of, have not experienced, and that has not been integrated into our personalities, referred to as the nonconscious.
1.3.3 Stages of Psychosexual Development
Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to the development of personality. Freud’s Stages of Psychosexual Development are, like other stage theories, completed in a predetermined sequence and can result in either successful completion or a healthy personality or can result in failure, leading to an unhealthy personality. This theory is probably the most well known as well as the most controversial, as Freud believed that we develop through stages based upon a particular erogenous zone.
During each stage, an unsuccessful completion means that a child becomes fixated on that particular erogenous zone and either over– or under-indulges once he or she becomes an adult.
Oral Stage (Birth to 18 months): During the oral stage, the child is focused on oral pleasures (sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality which is evidenced by a preoccupation with oral activities. This type of personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise, these individuals may become overly dependent upon others, gullible, and perpetual followers. On the other hand, they may also fight these urges and develop pessimism and aggression toward others.
Anal Stage (18 months to three years): The child’s focus of pleasure in this stage is on eliminating and retaining faeces. Through society’s pressure, mainly via parents, the child has to learn to control anal stimulation. In terms of personality, after effects of an anal fixation during this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On the opposite end of the spectrum, they may become messy and disorganised (anal expulsive).
Phallic Stage (ages three to six): The pleasure zone switches to the genitals. Freud believed that during this stage boys develop unconscious sexual desires for their mother. Because of this, he becomes rivals with his father and sees him as competition for the mother’s affection. During this time, boys also develop a fear that their father will punish them for these feelings, such as by castrating them. This group of feelings is known as Oedipus complex (after the Greek Mythology figure, who accidentally killed his father and married his mother).
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Ego defenses are not necessarily unhealthy as you can see by the examples above. In face, the lack of these defenses or the inability to use them effectively can often lead to problems in life. However, we sometimes employ the defenses at the wrong time or overuse them, which can be equally destructive.
1.3.5 Limitations
Some of the limitations typically raised in response to Freudian theory are:
Freud’s hypotheses are neither verifiable nor falsifiable. It is not clear what would count as evidence sufficient to confirm or refute theoretical claims.
The theory is based on an inadequate conceptualisation of the experience of women.
The theory overemphasises the role of sexuality in human psychological development and experience.
1.4 OBJECT RELATIONS THEORY
1.4.1 Symbiosis and Separation/Individuation
Another adaptation of psychoanalytic theory known as “object relations theory” starts from the assumption that the psychological life of the human being is created in and through relations with other human beings. Thus, the object
Intellectual- isation
Projection
Rational- isation
Reaction Formation
Regression
Repression
Sublimation
Suppression
avoiding unacceptable emotions by focusing on the intellectual aspects placing unacceptable impulses in yourself onto someone else supplying a logical or rational reason as opposed to the real reason
taking the opposite belief because the true belief causes anxiety returning to a previous stage of development
pulling into the unconscious
acting out unacceptable impulses in a socially acceptable way
pushing into the unconscious
focusing on the details of a funeral as opposed to the sadness and grief
when losing an argument, you state “You’re just Stupid;” homophobia stating that you were fired because you didn’t kiss up the the boss, when the real reason was your poor performance having a bias against a particular race or culture and then embracing that race or culture to the extreme sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don’t get your way forgetting sexual abuse from your childhood due to the trauma and anxiety sublimating your aggressive impulses toward a career as a boxer; becoming a surgeon because of your desire to cut; lifting weights to release ‘pent up’ energy trying to forget something that causes you anxiety
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relations theorist distinguishes between the physical and the psychological birth of the individual. While the physical birth is a process that occurs over a specific and easily observable period of time, the psychological birth is typically extended over the first three years of life and can occur only in and through social relations. During this time, certain “innate potentials and character traits” (the ability to walk and talk) are allowed to develop in the presence of “good object relations”. The quality of these relations affects the quality of one’s linguistic and motor skills.
The first three years of life are characterised by a) the establishment of a close (symbiotic) relationship to the primary caretaker (which is generally the mother), and b) the subsequent dissolution of that relationship through separation (differentiating oneself from the caretaker) and individuation (establishing one’s own skills and personality traits).
A central element in this emerging “core identity” is one’s gender, which tends to be determined within the first one and a half to two years. Unlike Freudian theory, in object relations theory this gendering of the subject has little to do with the child’s own awareness of sexuality and reproduction. It does, however, involve the internalisation of any inequities in the value assigned to one’s gender, as well as the associated imbalance in power.
This psychological development of the child is part of a reciprocal process of adjustment between child and caretaker — both must learn to be responsive to the needs and interests of the other. During the symbiotic stage (one to six or seven months) the infant has little if any sense of distinction between self and other, and is extremely sensitive to the moods and feelings of the caretaker. In order for this phase to be adequate (i.e. “good enough”), the mother must be emotionally available to the child in a consistent, reasonably conflict-free way. She should be able to enjoy the sensual and emotional closeness of the relationship without losing her own sense of separateness. She should be concerned for the child’s well being without developing a narcissistic overinvestment in the child as a mere extension of her own self. Her infantile wishes for a symbiotic relationship should have been adequately gratified in childhood. If this was not the case, resentment and hostility may be aroused in her by the infant’s needs. The mother requires adequate support, both emotional and material, during this period from adults who are able both to nurture her and reinforce her own sense of autonomy.
The process of separation begins at around the sixth month and continues through the second year. During this time, the child experiences both pleasure and frustration as motor skills develop along with the corresponding awareness of one’s limitations. The child explores and continually develops its separateness, then returns to the mother for ‘emotional refueling’. The potential presence of the relationship between child and mother allows the child to leave it.
Gradually the relationship is internalised and becomes part of the child’s internal psychic reality. Both members of the dyad must learn to let go of the early bond without rejecting the other. The ambivalence present throughout this process gradually intensifies. The child both wants to return to the symbiotic state and
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1.5 SELF PSYCHOLOGY
Self psychology emphasises the development of a stable and integrated sense of self through empathic contacts with other humans, primary significant others conceived of as “self objects”. Self objects meet the developing self’s needs for mirroring, idealisation, and twinship, and thereby strengthen the developing self.
The process of treatment proceeds through “transmuting internalisations” in which the patient gradually internalises the self object functions provided by the therapist. Self psychology was proposed originally by Heinz Kohut, and has been further developed by Arnold Goldberg, Frank Lachmann, Paul and Anna Ornstein, Marian Tolpin, and others.
1.6 ATTACHMENT THEORY
John Bowlby was responsible for the development of attachment theory, largely in opposition to the existing psychoanalytic theories of his day. Nevertheless, in recent years attachment theory has started to become integrated with the pluralistic edifice of psychoanalysis.
Bowlby (1988) repeatedly emphasised the child’s real experience and the importance of the external world in the child’s healthy development. Borrowing from ethology, attachment behaviours were viewed by Bowlby as not reducible to another drive. In contrast to object relations thinking, the motivation of the child is not object seeking. Rather, the goal of the child is to achieve a psycho physiological state related to being in close proximity with the mother or caretaker.
Holmes (2001) suggested that the same is true of adults, who, when stressed or threatened, may, if insecurely attached, resort to ‘pathological secure base phenomena’, such as substance abuse, deliberate self-harm, or binge eating. These behaviours may re-create a shortcut to the physiological state of the secure base without its relational or psychological components.
The work of Ainsworth et al. (1978) was critically important in refining the attachment concept by studying the infant’s response to what was called the Strange Situation. In this 20 minute laboratory test, a child is exposed to brief separations from the child’s mother. The reaction to these separations led to a classification of children as securely attached, anxious-avoidantly attached, anxious-ambivalent or resistant in the attachment style, or disorganised/ disoriented.
Although there is not a one-to-one correlation necessarily between the categories of child attachment and those of adults, attachment theorists have found it clinically useful to think of adult individuals in four somewhat analogous categories of attachment:
- secure/autonomous individuals who value attachment relationships;
- insecure/dismissing individuals who deny, devalue, idealise, or denigrate both current and past attachments;
- Preoccupied adults who are overwhelmed or confused by current and past attachment relationships; and
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- Disorganised or unresolved individuals who have often suffered neglect or trauma.
Compared with other psychoanalytic schools of thought, there is much more rigorous empirical research behind attachment theory. Some of this research demonstrates that expectant parents’ mental models of attachment predict subsequent patterns of attachment between mother and infant.
A key concept in attachment theory is mentalisation, the capacity to understand that one’s own behaviour and that of others is motivated by internal states, such as thoughts and feelings.
In addition, part of mentalisation is an understanding that one’s perceptions of others are representations rather than the way reality actually is. The mother’s or caregiver’s capacity to observe the infant’s intentional state and internal world appears to influence the development of secure attachment in the child. The child’s secure attachment to the caregiver is highly influential in the child’s development of the capacity to mentalise.
1.7 LACANIAN PSYCHOANALYSIS
Lacanian psychoanalysis, which integrates psychoanalysis with semiotics and Hegelian philosophy, is especially popular in France and parts of Latin America. Lacanian psychoanalysis is a departure from the traditional British and American psychoanalysis, which is predominantly Ego psychology. Jacques Lacan frequently used the phrase “retourner à Freud” (“return to Freud”) in his seminars and writings, as he claimed that his theories were an extension of Freud’s own, contrary to those of Anna Freud, the Ego Psychology, Object relations and “self” theories and also claims the necessity of reading Freud’s complete works, not only a part of them. Lacan’s concepts concern the “mirror image”, the “Real”, the “Imaginary” and the “Symbolic”, and the claim that “the unconscious is structured as a language”.
Though a major influence on psychoanalysis in France and parts of Latin America, Lacan and his ideas have had little to no impact on psychoanalysis or psychotherapy in the English speaking world, where his ideas are most widely used to analyse texts in literary theory. Due to his unorthodox methods and theories, Lacan was expelled by the International Psychoanalytic Association, and many of Lacan’s psychoanalytic concepts have been described as nonsensical, inconsistent or pseudoscientific.
1.8 POSTMODERN SCHOOLS
In recent years a number of theoretical models that emphasise the two person nature of psychoanalytic treatment have emerged. These various approaches, with labels such as intersubjectivity, relational theory, constructivism, or interpersonal psychoanalysis, all endorse scepticism about any fundamental truth residing in the patient or in the analyst. The truth is co-constructed in the interaction between therapist and patient. They are all postmodernists in outlook in that they doubt the existence of an objective reality.
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1.9 PSYCHOANALYTIC/PSYCHODYNAMIC
THERAPY
The terms psychodynamic and psychoanalytic are often used interchangeably. However, within the psychodynamic and psychoanalytic terms , psychoanalysis is the term used when referring to a psychological treatment where the therapist, called a psychoanalyst or analyst, adheres to standard techniques focused on interpretation leading to insight in the context of the transference. In psychoanalysis the patient usually attends treatment three to five times weekly for 45- to 50-minute sessions. Treatment usually involves the patient lying on a couch and the analyst sitting behind the patient while the patient free associates i.e., says whatever comes to mind. Psychodynamic psychotherapy is characterised by the same basic techniques as psychoanalysis but tends to be briefer and less intensive than psychoanalysis.
Although any given session of psychodynamic psychotherapy may be indistinguishable from a psychoanalytic session, in psychodynamic psychotherapy the therapist is more likely to be actively engaged with the patient, to resonate emotionally with the patient’s affect states, and rely more on the interpersonal relationship between client and therapist than in psychoanalysis.
1.9.1 Basic Tenets and Concepts of Psychoanalytic Therapy
A number of basic tenets and concepts are central to psychodynamic psychotherapy. These include the following:
The Unconscious
Freud’s premise that much of mental life is unconscious has been extensively validated by research in the field of experimental psychology. However, psychoanalytic psychotherapists are more likely to refer to unconscious representations or unconscious mental functioning rather than the unconscious. The notion of ‘the unconscious’ as a storage place or reservoir is no longer in keeping with contemporary neuroscience research.
We now recognise that memories are stored differently, depending on the type of knowledge being stored. Declarative memory involves facts and episodes of one’s life, while procedural memory involves skills or procedures. Defense mechanisms, for example, are automatic unconscious procedures that regulate affect states. Memories of difficult times in one’s life are aspects of declarative knowledge that may be conscious and easily recalled or may be repressed and therefore unconscious. Declarative knowledge is knowledge ‘of’, whereas procedural knowledge is knowledge ‘how’. The table below presents the type of knowledge and mode of expression
Type of knowledge versus mode of expression Type of knowledge Mode of expression or retrieval (with or without conscious awareness)
Declarative Procedural Explicit Implicit
(Reprinted from Gabbard, G. O. (2000). Psychodynamic psychiatry in clinical practice, 3rd edn, p. 8. Washington, DC: American Psychiatric Press.)
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In current thinking that integrates psychodynamic and neuroscience data, both procedural and declarative memories can be viewed as either conscious or unconscious. A distinction between explicit and implicit memory relates to whether knowledge is expressed and/or retrieved with or without conscious awareness. Hence the explicit versus implicit distinction can be understood as equivalent to conscious versus unconscious.
Within this model defense mechanisms are primarily in the domain of implicit procedural memory. Suppression, though, one of the few conscious defense mechanisms, lies in the realm of explicit procedural memory because it involves the conscious banishment of certain thoughts and/or feelings from one’s mind.
Implicit declarative knowledge involves repressed ideas and repressed memories of events in one’s life and knowledge that involves various kinds of expectations about how others will react in response to what one does. This latter category may be retrievable if one shifts one’s attention to it, a category Freud called preconscious. Explicit declarative knowledge consists of facts and events that are fully conscious.
Unconscious aspects of mental functioning may reveal themselves as slips of the tongue, forgetting, or substituting names or words. Nonverbal behaviour is also a reflection of unconscious and internalised modes of relating to others. In other words, how the patient relates to the therapist may say a great deal about unconscious representations of self and other within the patient.
The Developmental Perspective All psychoanalytic thinking is based on a developmental model of behaviour. A fundamental assumption is that childhood events shape the adult person. The repetitive patterns of problematic interactions with others stem from intrapsychic issues that are internalised during childhood. In contemporary thinking about the interface between genetics and environment, we know that the genetically based temperament of the child shapes much of the interaction with the parents. In other words, characteristics that are genetically determined evoke specific parental responses, which in turn shape the child’s personality. Psychoanalytic therapists do not blame parents for their patient’s difficulties. They see the patient’s difficulties as a complex interaction between the child’s characteristics, the parents’ characteristics, and the ‘fit’ between them.
Subjectivity Subjectivity is a psychodynamic perspective that emphasises the importance of individual or personal meaning of events. Psychodynamic clinicians are interested in the patient’s phenomenological experience, that is how the patient experiences himself, important others, the world in general, etc.
In this way, psychodynamic clinicians are focused on what those from the cognitive-behavioural therapy tradition call schemas or schemata. The difference, however, is that in a psychodynamic model, these schemas are seen as having explicit, conscious, and implicit unconscious aspects, and the implicit parts can be simply out of awareness or kept out of awareness for defensive purposes. The psychoanalytic model posits that individuals may use one set of representations to defend against other intolerable representations. There is greater attention to the emotional aspects of these schemas or representations and to the structural
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hobbies are shaped by unconscious forces that are beyond our awareness. The psychodynamic therapist approaches a patient with the understanding that any symptom or problem may serve multiple functions. A variety of conflicts from different developmental levels all may converge to form the end result of a behaviour or symptom. A psychoanalytic therapist recognises that many of the reasons for the patient’s difficulties lie outside the patient’s awareness, and both therapist and patient must be willing to explore a variety of converging causes.
Although other concepts have been stressed within psychoanalysis at various times, such as the Oedipus complex or psychosexual stages, it should be noted that these concepts are not as central or crucial to the psychoanalytic and psychodynamic models as the other tenets we have identified.
1.9.2 Components of Psychoanalytic and Psychodynamic
Psychotherapy
The aim of psychodynamic psychotherapy is to make what is unconscious conscious in an effort to better understand a person’s motivations and thus respond to them in reality more honestly. Three essential features of the psychoanalytic method are interpretation, including
i) clarification and confrontation, ii) analysis of the transference, and iii) technical neutrality. These three aspects are dealt with in detail below:
i) Clarification, Confrontation and Interpretation: The three main techniques used in psychodynamic psychotherapy are clarification, confrontation, and interpretation.
Clarifications simply are requests for more information or further elaborations in order to better understand the patient’s subjective experience. Beginning therapists and those with only a cursory understanding of psychodynamic psychotherapy, often neglect this technique and move prematurely to interpretation. Even if a therapist could determine the appropriate interpretation without clarifying, it would be difficult for the patient to integrate it without first properly clarifying.
Clarifying and confronting a patient’s experience are preparatory steps for interpretation. The therapist should clarify thoroughly until both the therapist and the patient have a clear understanding of any areas of vagueness. It is important to recognise vague communications, which is not easily done, because therapists prematurely foreclose clarification by inserting their own preconceptions when patients are vague or unclear.
For example, if a patient says he feels depressed, the therapist should clarify what the patient means by the term. A standard technique is to start with short open ended questions and become more specific as needed. For example, a therapist might simply respond by saying “Can you say more about that?”
A recommended device for determining if clarification is required is to ask oneself whether a patient’s presentation could be veridically described to a
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supervisor or consulting colleague. Frequently, a patient will become puzzled by contradictions in his or her thinking or experience during the clarification process.
Confrontations sound harsher than they are because they actually involve tactfully pointing out discrepancies or incongruities in the patient’s narrative or the patient’s verbal and nonverbal behaviour (affect or actual behaviour). It is difficult to successfully confront a patient without thoroughly clarifying because the patient may not be aware of what the therapist is observing. (Conversely, without clarifying, the therapist may incorrectly confront the patient regarding material that would otherwise be clear.)
The therapist uses the clarified material or information that is contradictory for further exploration and understanding. This is done in an effort to better understand conflicting mental states or representation of experience that implicitly address the patient’s defensive operations.
Interpretations focus on the unconscious meaning of what has been clarified and confronted.
Interpretations can be made regarding experience in the therapy or about the relationship between the patient and the therapist (interpretations of the “here and now”) or about relationships outside the therapy, either with important others or other people in the patient’s life.
Interpretations about relationships outside of therapy are referred to as extra transferential interpretations. Interpretations made about early experiences with caregivers are called genetic interpretations. In any regard, it is important that interpretations be timely, clear, and tactful and made in a collaborative manner only after clarifying the patient’s experience and pointing out gaps and inconsistencies. The interpretation is not offered until the patient is just about ready to discover it by him or herself. Interpretation is offered as a hypothesis in the context of a collaborative endeavour and not as a pronouncement from an all knowing authority as is frequently portrayed in movies, the media, and poorly trained individuals.
ii) Technical neutrality: The psychodynamic psychotherapist uses the techniques of clarification, confrontation, and interpretation in the context of technical neutrality. Technical neutrality, or therapeutic neutrality, is an often misinterpreted construct whereby the psychodynamic therapist mistakenly believes that he or she needs to adopt a stone-face or blank screen, say very little, refuse to self-disclose, or provide advice, support, or reassurance. The therapist is seen as nonactive, passive, maybe even bland, monotonous, or indifferent and at worst cold and lacking in concern. This is not what technical neutrality is supposed to be.
Technical neutrality is a therapeutic strategy in which the therapist avoids communicating any judgment about the patient’s conflicts while they are being discussed (i.e., remains equidistant from all sides of the patient’s conflicts). Typically, therapists refrain from providing advice, praise, or reproof of the patient, and they restrain their own needs for a particular type of relationship (to be liked, valued, idealised, or the centre of attention).
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of affect, focusing on external circumstances rather than one’s own role in shaping events, and so on. Psychodynamic therapists actively focus on and explore avoidances.
iii) Identification of recurring themes and patterns: Psychodynamic therapists work to identify and explore recurring themes and patterns in patients’ thoughts, feelings, self-concept, relationships, and life experiences. In some cases, a patient may be acutely aware of recurring patterns that are painful or self-defeating but feel unable to escape them (e.g., a man who repeatedly finds himself drawn to romantic partners who are emotionally unavailable; a woman who regularly sabotages herself when success is at hand). In other cases, the patient may be unaware of the patterns until the therapist helps him or her recognise and understand them.
iv) Discussion of past experience (developmental focus): Related to the identification of recurring themes and patterns is the recognition that past experience, especially early experiences of attachment figures, affects our relation to, and experience of, the present. Psychodynamic therapists explore early experiences, the relation between past and present, and the ways in which the past tends to “live on” in the present. The focus is not on the past for its own sake, but rather on how the past sheds light on current psychological difficulties. The goal is to help patients free themselves from the bonds of past experience in order to live more fully in the present.
v) Focus on interpersonal relations: Psychodynamic therapy places heavy emphasis on patients’ relationships and interpersonal experience (in theoretical terms, object relations and attachment). Both adaptive and nonadaptive aspects of personality and self-concept are forged in the context of attachment relationships, and psychological difficulties often arise when problematic interpersonal patterns interfere with a person’s ability to meet emotional needs.
vi) Focus on the therapy relationship : The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged. To the extent that there are repetitive themes in a person’s relationships and manner of interacting, these themes tend to emerge in some form in the therapy relationship. For example, a person prone to distrust others may view the therapist with suspicion; a person who fears disapproval, rejection, or abandonment may fear rejection by the therapist, whether knowingly or unknowingly; a person who struggles with anger and hostility may struggle with anger toward the therapist; and so on (these are relatively crude examples; the repetition of interpersonal themes in the therapy relationship is often more complex and subtle than these examples suggest). The recurrence of interpersonal themes in the therapy relationship (in theoretical terms, transference and countertransference) provides a unique opportunity to explore and rework them in vivo. The goal is greater flexibility in interpersonal relationships and an enhanced capacity to meet interpersonal needs.
vii) Exploration of fantasy life: In contrast to other therapies in which the therapist may actively structure sessions or follow a predetermined agenda, psychodynamic therapy encourages patients to speak freely about whatever
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is on their minds. When patients do this (and most patients require considerable help from the therapist before they can truly speak freely), their thoughts naturally range over many areas of mental life, including desires, fears, fantasies, dreams, and daydreams (which in many cases the patient has not previously attempted to put into words). All of this material is a rich source of information about how the person views self and others, interprets and makes sense of experience, avoids aspects of experience, or interferes with a potential capacity to find greater enjoyment and meaning in life.
The last sentence hints at a larger goal that is implicit in all of the others: The goals of psychodynamic therapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something) but also foster the positive presence of psychological capacities and resources. Depending on the person and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a realistically based sense of self-esteem, tolerate a wider range of affect, have more satisfying sexual experiences, understand self and others in more nuanced and sophisticated ways, and face life’s challenges with greater freedom and flexibility. Such ends are pursued through a process of self- reflection, self-exploration, and self-discovery that takes place in the context of a safe and deeply authentic relationship between therapist and patient.
Self Assessment Questions 2
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