Contemporary Psychoanalytic/Psychodynamic Psychotherapy: A Framework and Case Example

1. Lydia Khuri, Psy.D. 2/1/11 Contemporary Psychoanalytic/Psychodynamic Psychotherapy: A Framework and Case Example

2. Outline • Framework* • Theoretical assumptions • Psychoanalytic sensibility • Multicultural/feminist critiques • Empirical research • Preparing the therapist • Preparing the client • Therapy process • Boundaries • Case Material *based on Nancy McWilliams (2004) and Jonathon Shedler (2010)

3. Learning Objectives • You will be able to identify components of the psychoanalytic psychotherapy framework • You will be able to identify components of the framework as applied to a case study

4. Contemporary Psychoanalytic • What comprises psychodynamic psychotherapy? (Shedler, 2010) • Focus on affect and expression of emotion • Exploration of attempts to avoid distressing thoughts and feelings • Identification of recurring themes and patterns • Discussion of past experiences (developmental focus) • Focus on interpersonal relations • Focus on therapy relationship • Exploration of fantasy life

5. Basic Motivational Systems • Contemporary (Lichtenberg, 1989) • Psychic regulation of physiological requirements • Attachment and affiliation • Exploration and assertion • Aversive reaction through antagonism or withdrawal • Sensual enjoyment and sexual excitement

6. Psychoanalytic Sensibility • Curiosity and awe • Identification and empathy • Subjectivity and attunement to affect • Attachment • Faith

7. Multicultural/feminist Critiques • Feminist critique of inherent androcentrism • Biologically-based gender differences • Reification of power relations between men & women • Normative gender and sexual development • Deterministic (personality patterns established in early development) • Feminist principles • Personal is political • Commitment to change on social level • Female subjectivity • Egalitarian therapeutic relationship • Focus on strengths • Recognition of interlinking of oppression

8. Multicultural/feminist Critiques • Multicultural critique of Western worldview • Role of the past • Blaming parents • Concept of trauma • Family structures • Autonomous self • Multicultural principles • Focus on cultural identity in relation to psychological well-being • Understand power in therapy and larger social contexts • Understand worldviews • View of human nature • Orientation toward time • Definition of proper human activity • Definition of social relations • Understanding of relationship of people and nature

9. Empirical Research* • Psychoanalytic psychotherapy as effective as other empirically-supported treatments (effect sizes similar) • Core processes and techniques as defined by psychoanalytic theory are facilitative of change, regardless of theoretical orientation • Effects extend beyond symptom reduction and after therapy has ended • Factors of culturally sensitive therapies have not been teased apart from “traditional” variables (Sue et al., 2008) Shedler (2010)

10. Preparing the Therapist • New therapists make lots of mistakes • Being yourself in role of therapist • Supervision • Own therapy • Broad education

11. Preparing the Client/patient • Psychotherapy as peculiar relationship • Physical safety • Emotional safety • Informed consent • Encourage spontaneous, candid, emotionally expressive speech • Introduce work of transference • Boundaries

12. Therapy Process • Listening • Talking • Facilitation • Power • Therapeutic power • Empowering the client • Love

13. Major Concepts • Unconscious • As adjective: mental contents not available to conscious awareness • As noun: component of mental system known as id, yet some aspects of ego (defenses) and superego (moral standards) part of Ucs. • The adjective form is generally accepted in contemporary psychoanalysis whereas there are several models of the mental system besides Freud’s model known as structural. • Defense • The ego’s attempt to protect self against danger, overwhelming, or unacceptable affect and ideas • Repression: exclusion from awareness thoughts and feelings once felt consciously or never felt consciously; ex., hatred directed at a sibling. • Reaction formation: changing unacceptable thoughts and feelings to acceptable; ex., longing for loving experience changed into hatefulness (Moore, B E. & Fine, B. D. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press.)

14. Major Concepts • Transference • Displacement of feelings, thoughts, patterns of behavior, originally experienced in relation to significant figures during childhood, onto a current relationship. • More intensified in psychoanalysis; reveals early patterns (Moore, B E. & Fine, B. D. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press.)

15. Boundaries • Chance encounters • Social invitations • Gifts • Request for other therapy • Disclosure • Touch • Sex

16. Case Material: “James” • James’s reasons for seeking therapy • My early clinical impressions • James’s personal history • Phases of therapy • Beginning • Middle • End (“Termination”) • Post termination

17. Reasons for Seeking Therapy • Referred by a university mental health center for longer term psychotherapy • Crisis about major • Symptoms of depression • Sense of feeling lost • Feeling effects of parents’ divorce two years ago

18. James’s Initial Presentation • Monotone & restricted expression of affect • Image of wave (overwhelming feelings) • Anxiety • “Waiting” expression • Subtly vigilant • Pleased others & took on feelings of others • Didn’t want to make waves

19. My Early Impressions • Earnest • General vagueness in contrast to moments of precise insight • Strengths • Attentive • Thoughtful, intelligent • Sense of humor • Willing to try • Types of defenses • Reversal • Exhaustion/keeping extremely busy • “Fogginess”/not noticing things • Lack of “dialogue” • How would I need to be with him?

20. James’s Personal History • 19 y/o, single heterosexual, college student • Father 1st generation Chinese American, not religious, converted to Catholicism • Sacrificing, wants things to be “normal,” i.e., no conflict • Mother European American, raised Catholic • Alcoholic; affectionate when inebriated but otherwise enraged and explosive • Parents divorced when James 17 y/o • Younger brother by 4 years • Explosive like mother • Top student in high school • Premed but struggled • Switched to another major with some success • Paying for college himself

21. Treatment Goals • Not in crisis when he came to me • Exploratory psychodynamic psychotherapy • Feel better • Find his niche, who he was • Therapy lasted 3 yrs, 8 mo’s

22. How I worked with James • What I did • Listened • Communicated interest and warmth • Explained how therapy works • Provided structure by asking open-ended questions while remaining attentive to his cues • “What’s your inside life like?” • Reflected back • Did not let silence lapse too long • What I did not do • Interpret too much • Give advise

23. Initial Phase: Themes • Sadness persisting beyond subsiding of depression symptoms • Sensitivity to emotional intrusion • Distancing from affect (speaking in second person, e.g., “Being alone let’s you think too much.”) • “Squashing” affect (“I don’t like to get too excited about things.’) • Trouble with initiating conversation • Ambivalence about attachment • Foreshadow process: “I’m afraid to attach b/c it will go away.” • Foreshadow ending: “I don’t know how to do endings.”)

24. Initial Phase: Progress • Within 4 mo’s • Symptoms of major depression remitted but paradoxically began to experience persistent, puzzling melancholy • Met a girl he really liked • Doing better in school but questioning purpose • Insight into emotional pattern: turn anger into sadness • Insight into family dynamics: mother doesn’t “see” him; father didn’t intervene • By 6th Month • Could tolerate my having separate mind to mirror him

25. Second Phase • Long phase of exploration • Talked more openly but still trouble initiating conversation • Sadness more accessible if not sources • Focus on current life • Weathered ups and downs with girlfriend • Left school to work full time • Attempted to integrate painful truths about his family he learned while in therapy • Parents marrying b/c mother was pregnant

26. Second Phase: Themes • Anger • Self-assertion • Ambivalence about cultural identity • Loss of closeness to father • Ambivalence about growing up • Fear of dependency and separation (felt less of it in relation to me)

27. Second Phase: Progress • Seeking others to express dependency needs and allowing attachments (girlfriend; friends) • Explore own power and authority (trusting own feelings; role as manager) • Able to talk about therapy itself; what needed from me • Able to take in my mirroring about positive aspects of self • “You’re sadness isn’t just buried. There’s also aliveness and spontaneity.”

28. Termination • Initiated by James • We agreed on a date (three months hence) • Tolerated some exploration of meaning & feelings • Consolidation and On-going issues

29. Consolidated Changes • Behavior • Initiated separation from me • Tolerated exploration of motivation • Better social network of friends • Long lasting romantic relationship & commitment to future • Stand up to girl friend • Promotion at work • Able to set some limits/say “no” at work • Initiated separation from family w/out “cutting them off” • Intrapsychic • Greater range of expressed affect • Moments of experiencing grief for past • Tolerate ambivalence better • Consider own needs and feelings • Saw parents in more realistic light • Acknowledge ambition

30. Remaining Issues • Effects of mother’s issues & alcoholism • Caretaker • Substitute husband • Persistent hope for more closeness with both parents based on infant/childhood needs • Unresolved issues about surpassing parents’ academically, especially father • Fear of dependency and rage

31. Transference • In behavioral terms “stimulus generalization” • Old relational paradigm • Took care of me by not burdening me with his needs, feelings, or hopes • I would be indifferent or hostile if he expressed needs • He waited for me to take lead • New relational paradigm • I was a calming, understanding presence (but kept at a distance) • My subjectivity did not overwhelm his • I gave him time to think (literally) • He could explore his need for me to take lead • He could initiate separation from me and not be undermined by guilt

32. Countertransference • Strong personality • Fleeting moments of boredom and rage • Different defenses to deal with dependency issues • Me: action/ambition/grandiosity • James: passivity/floating/shrinking • Distanced from his helplessness and “inner deadness” to avoid confronting my own • Own on-going therapy and paid consultation

33. Post-therapy Contact • Able to explore with my support • Able to acknowledge limitations of therapy relationship • Relieved that he could come back (“safety net”) • Called several months later • Engaged • Doing well • Therapist recommendation for fiancée

34. End “If change were easy, psychotherapists would be out of a job.” Nancy McWilliams, Psychoanalytic Psychotherapy: A Practitioner's Guide • Suggested Reading • Lowder, G., Hansell, J., McWilliams, N. (n.d.) The enduring significance of psychoanalytic theory and practice. Retrieved February 9, 2008 from http://www.division39.org/sec_com_pdfs/PsychoaResearchPP.pdf • McWilliams, N. (2003). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guildford press. • Milrod, et al (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164(2): 265-272. • Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.