CONTEMPORARY PSYCHOANALYTIC/PSYCHODYNAMIC PSYCHOTHERAPY: A FRAMEWORK AND CASE EXAMPLE Lydia Khuri, Psy.D. 2/1/11 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 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 What comprises psychodynamic psychotherapy? (Shedler, 2010) 1. 2. 3. 4. 5. 6. 7. 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 Contemporary (Lichtenberg, 1989) 1. 2. 3. 4. 5. Psychic regulation of physiological requirements Attachment and affiliation Exploration and assertion Aversive reaction through antagonism or withdrawal Sensual enjoyment and sexual excitement Psychoanalytic Sensibility Curiosity and awe Identification and empathy Subjectivity and attunement to affect Attachment Faith 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 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* Psychoanalytic psychotherapy as effective as other empirically-supported treatments (effect sizes similar) 2. Core processes and techniques as defined by psychoanalytic theory are facilitative of change, regardless of theoretical orientation 3. Effects extend beyond symptom reduction and after therapy has ended 4. Factors of culturally sensitive therapies have not been teased apart from “traditional” variables (Sue et al., 2008) 1. Shedler (2010) Preparing the Therapist New therapists make lots of mistakes Being yourself in role of therapist Supervision Own therapy Broad education 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 Listening Talking Facilitation Power Therapeutic power Empowering the client Love 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 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 Chance encounters Social invitations Gifts Request for other therapy Disclosure Touch Sex 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 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 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 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 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 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 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 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 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 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 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 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 Initiated by James We agreed on a date (three months hence) Tolerated some exploration of meaning & feelings Consolidation and On-going issues 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 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 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 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 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 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): 265272. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.