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Lydia Khuri, Psy.D. 2/1/11. Contemporary Psychoanalytic/Psychodynamic Psychotherapy: A Framework and Case Example. Outline. Framework* Theoretical assumptions Psychoanalytic sensibility Multicultural/feminist critiques Empirical research Preparing the therapist Preparing the client

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outline
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)

learning objectives
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
contemporary psychoanalytic
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
basic motivational systems
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
psychoanalytic sensibility
Psychoanalytic Sensibility
  • Curiosity and awe
  • Identification and empathy
  • Subjectivity and attunement to affect
  • Attachment
  • Faith
multicultural feminist critiques
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
multicultural feminist critiques1
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
empirical research
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)

preparing the therapist
Preparing the Therapist
  • New therapists make lots of mistakes
  • Being yourself in role of therapist
  • Supervision
  • Own therapy
  • Broad education
preparing the client patient
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
therapy process
Therapy Process
  • Listening
  • Talking
  • Facilitation
  • Power
  • Therapeutic power
  • Empowering the client
  • Love
major concepts
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.)

major concepts1
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.)

boundaries
Boundaries
  • Chance encounters
  • Social invitations
  • Gifts
  • Request for other therapy
  • Disclosure
  • Touch
  • Sex
case material james
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
reasons for seeking therapy
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
james s initial presentation
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
my early impressions
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?
james s personal history
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
treatment goals
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
how i worked with james
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
initial phase themes
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.”)
initial phase progress
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
second phase
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
second phase themes
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)
second phase progress
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.”
termination
Termination
  • Initiated by James
  • We agreed on a date (three months hence)
  • Tolerated some exploration of meaning & feelings
  • Consolidation and On-going issues
consolidated changes
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
remaining issues
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
transference
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
countertransference
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
post therapy contact
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
slide34
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.