Contemporary Psychoanalytic/Psychodynamic Psychotherapy: A Framework and Case Example

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Contemporary Psychoanalytic/Psychodynamic
Psychotherapy A Framework and Case Example

• Lydia Khuri, Psy.D.
• 2/1/11

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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)

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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

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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

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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

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Psychoanalytic Sensibility

• Curiosity and awe
• Identification and empathy
• Subjectivity and attunement to affect
• Attachment
• Faith

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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

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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

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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)

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Preparing the Therapist

• New therapists make lots of mistakes
• Being yourself in role of therapist
• Supervision
• Own therapy
• Broad education

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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

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Therapy Process

• Listening
• Talking
• Facilitation
• Power
• Therapeutic power
• Empowering the client
• Love

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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
  Freuds model known as structural.
• Defense
• The egos 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.)

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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.)

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Boundaries

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

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Case Material James

• Jamess reasons for seeking therapy
• My early clinical impressions
• Jamess personal history
• Phases of therapy
• Beginning
• Middle
• End (Termination)
• Post termination

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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

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Jamess Initial Presentation

• Monotone restricted expression of affect
• Image of wave (overwhelming feelings)
• Anxiety
• Waiting expression
• Subtly vigilant
• Pleased others took on feelings of others
• Didnt want to make waves

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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?

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Jamess 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

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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 mos

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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
• Whats your inside life like?
• Reflected back
• Did not let silence lapse too long
• What I did not do
• Interpret too much
• Give advise

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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 lets you think too
  much.)
• Squashing affect (I dont like to get too
  excited about things.)
• Trouble with initiating conversation
• Ambivalence about attachment
• Foreshadow process Im afraid to attach b/c it
  will go away.
• Foreshadow ending I dont know how to do
  endings.)

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Initial Phase Progress

• Within 4 mos
• 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 doesnt
  see him father didnt intervene
• By 6th Month
• Could tolerate my having separate mind to mirror
  him

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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

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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)

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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
• Youre sadness isnt just buried. Theres also
  aliveness and spontaneity.

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Termination

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

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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

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Remaining Issues

• Effects of mothers 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

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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

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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

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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

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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/Psycho
  aResearchPP.pdf
• McWilliams, N. (2003). Psychoanalytic
  psychotherapy A practitioners 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.