Essential Psychodynamic Psychotherapy

An Acquired Art

Teri Quatman

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317611110
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicoanalisi

Essential Psychodynamic Psychotherapy: An Acquired Art provides an essential, accessible grounding in current psychodynamic theory and practice for a wide range of readers. For trainees, it offers a very useful toolset to help them make the transition from purely theoretical training to the uncharted territory of clinical practice. For more seasoned therapists and those seeking to deepen their understanding of psychodynamic therapy, it provides conceptual clarity, and may also serve as a stepping stone to more complex and denser psychoanalytic works written for advanced clinicians.

Essential Psychodynamic Psychotherapy: An Acquired Art is an introduction to how to think and work psychodynamically. It is written primarily for those training at a postgraduate level in psychoanalysis and psychodynamic psychotherapy, but reaches well beyond that audience. It is grounded in contemporary psychoanalytic theory, drawing on the work of Winnicott, Bion, and Ogden, all of whom are pivotal in current psychodynamic thought and practice. It also integrates attachment theory and research, and includes fresh contributions from neuropsychological research.

The voice of the book is honest and intimate. The tone is practical. It is written with a clear-minded understanding of contemporary psychodynamic theory that allows the new therapist to access the deepest and richest parts of the therapy itself. It translates many of the key theoretical tenets of psychodynamic psychotherapy, giving the reader a clear (but non-formulaic) guide as to how handle the contours of any analytic session; how to open one's perceptual and emotional apertures as clinician; how to work in and understand "the relationship"; and how to work with the most common intra- and interpersonal problems patients present. This publication will be a valuable guide for new analysts and therapists, and also for those seeking to understand what the world of psychodynamic therapy may hold for them, no matter where they are in their clinical careers.

Dr. Teri Quatman is an Associate Professor of Counseling Psychology in the Graduate Department of Counseling Psychology at Santa Clara University. She earned her Ph.D. from Stanford University in 1990, and has studied, practiced, and taught psychodynamic psychotherapy to graduate students for the past 25 years.

1

AN ACQUIRED ART

When I was assigned my first client in graduate school—my first adult client who had made an appointment and was going to meet with me for an hour of psychotherapy—I was excited. This would be real therapy; not the ad hoc school counseling kind I had done along the way as a high school teacher or middle school/high school counselor, not the kind I had done in graduate school classes when I’d paired up and practiced a counseling skill with a classmate. This was the real deal. I was indeed excited.

But as the idea of it crept inexorably toward the reality of it, I began to have uncertain feelings in my gut. By the time I had one more hour before our therapy meeting, I was beside myself with anxiety. I remember I was sitting in a graduate Career Development seminar and shot a note to my friend Pat, who was sitting next to me. Pat had been an experienced clinical social worker before he joined our doctoral program. “What do I do?” was my anxious question. In that moment I really had no idea, despite having sat with scores of students one-on-one as a counselor-in-training, and having conducted dozens of structured interviews for those seeking to qualify for an anxiety disorders study across campus. My program had somehow certified me at this point as being ready to see this real client for just plain therapy—the 50-minute kind. Pat leaned in and whispered, “You listen to him … Just listen to him. And at the end tell him, ‘I think I can help you.’ He’ll be more nervous than you are.” Not possible, I thought privately.

Of course, I did meet with that first client. I did listen to his story about a failed marriage in the distant past and its impact on his current relationship. I did tell him I thought I could help him. I do even think I remember meeting with him for a second appointment. Beyond that, my memory fades, or was it that he did not return? The anxious feelings return as I write the story.

Acquiring the art of psychodynamic therapy is a long, arduous process fraught with scary moments: first times, indecipherable concepts, people who can’t seem to change, the gap between how we interact with a client or patient and the way we imagine a more mature therapist would, the wish to steer it down a more meaningful track, the wondering where that would be and how we might get there.

We are certified as ready to start practicing at some point, and most of us hope we’ll be good at it because we thought we would be, or we hoped we would—that’s why we went through all the trouble and training in the first place. But then, we get in the room with the patient and it seems at times that everything we think we have studied or known exits out the door.

In this book I will be attempting to speak about an acquired art. Acquired, because it’s something more than studied or even practiced. It comes upon you gradually as you position yourself to take it in and practice what you know to practice. And then there is the inexorable element of time. An acquired art takes a long time, because the various complexities of it require a readiness within us even to identify them as desired elements.

Rather than a practiced art, an acquired art is more like an internalized state. We are taught, we read, we think, we hear our colleagues present, we identify supervisors who do the thing we want to be able to do, we try to copy them. But until a certain readiness is born within us, all the copying in the world does not seem to budge us forward one bit. It truly takes an act of faith to keep going in the pursuit of an acquired art.

This book addresses itself to the very elusive and hard-to-acquire art called psychodynamic psychotherapy. It especially attempts to address the front end of this acquisition process, because this is the time when we feel most lost, most fraudulent, most discouraged, and most seemingly unable to benefit from anything we hear or read about along the way. We keep going, but if we’re honest with ourselves, for most of us, it is with a deep sense of doubt that we will ever become the kind of therapist we see (or can’t even imagine) in our mind’s eye.

I suppose it is not unlike acquiring a truly fine touch as a musician. The beauty will ultimately reside in the nuance, but one has to live for a long time with garish approximations of that nuance, and keep pressing with what one author called “a long obedience in the same direction” (Peterson, 1980). Our mentors, our fellow students, and ultimately our patients give us just enough encouragement along the way for us to bear with our own not-knowings, and to keep on keeping on. For my part, I have only ever observed my own growth as a therapist in retrospect, and that, probably in five-year chunks. Furthermore, I didn’t start to make sense to myself as a therapist for the first ten years. It’s a long time to stay at something (and even to be paid for doing something) that one doesn’t truly understand. But that is our path.

So I will start as close to the beginning as I possibly can, and move forward only when I feel I’ve said something clearly. This may mean that I give you some of the dryer stuff first, but do try to stay with it. Foundations are never sexy, but the whole rest of the house depends on them. So let’s start at the beginning.

The Art of What?

The art of what? What are we supposed to be attempting to do or have happen when we “sit with” or “listen to” a client or patient? In this moment, with this person, in this room, what? What is the goal? What is the process? And most importantly, what is the point?

The answer is: it depends. That’s a really unsatisfying answer, but it actually does depend. It depends on where we’re headed. While it may be true that as psychotherapists our main tool is to listen to the other, absent some orienting compass to tell us where we’re going and what our listening might be accomplishing, it can feel like bobbing in an inner tube in the middle of the ocean: too cold, too directionless, ultimately not getting us anywhere, and most certainly not worth being paid to do!

So for a few minutes, let’s stand back and consider what is, or might be, the intended goal of our listening, then we can talk about the process of it (and the point of it).

What’s the Goal?

The goal of psychotherapy can be thought about in its broadest terms as being oriented toward one of two outcomes: either toward alleviating human suffering or toward promoting human growth (although most therapies do some of both). In general, it is the first—the suffering part—that brings people to a therapist to begin with. And this—suffering part—comes as a surprise and a shock to many new therapists. It’s different from what we may have envisioned when we came to the field.

Perhaps we were the confidants of our friends or mothers or fathers as younger people. People came to us with their problems, with their secrets. We learned that we were good listeners, and that they felt safe with us. They opened up to us. That felt good. We found ourselves giving what we thought was wise advice. That felt good. We were valued for our skill, and enjoyed doing it. We decided we wanted to be paid for this thing we did with such success. Good plan.

But when we begin the professional practice of psychotherapy, most of us encounter human suffering well beyond the scope or severity of our experience with friends and relatives. The range of suffering that presents in a therapist’s office is enormous; to a new therapist (and sometimes to an old therapist) it is overwhelming. The suffering has many stripes. It can be circumscribed, such as the inability to finish a school degree or the desire to lose weight. It can be global (“I just feel lost in my life”). It can focus on emotions like sadness, guilt, anger, disgust, fear, shame, grief, etc.; or even positive ones (“I get so full of joy and excitement that I spend piles of money all at once”), or dysregulated ones (“I get set off, and then I have to cut myself in order to feel better”). The suffering can focus on behaviors (“I have to check the locks on my house seven times before I can leave” or “I find myself raging at my second child”). It can be intrapersonal (“I’m depressed,” “I’m anxious”) or interpersonal (“I’ve never really trusted anyone” or “I feel hated at work”). It can focus on the past (for example, having lived through traumatizing events) or the present (“My marriage is falling apart”) or the future (“I have no hope for my life”). The list is endless.

And the examples I’ve given here, as you may well know by now, are quite sanitized. Some of what we see and listen to is beyond heartbreaking—young adolescents beginning to devolve into psychoticism—hearing voices and sealing off their bedrooms with layers of tin foil; children whose parent has punished them by killing their beloved pet. If we stop to think about it, the suffering that people bring into our counseling room is far more than we bargained for, and is often deeply traumatizing to us. The expectation that we might be able to help in many moments exceeds our bandwidth entirely.

Some therapies focus exclusively on the alleviation of such suffering. This would certainly seem to be a big enough task! But other therapies (i.e., the psychodynamic spectrum) go a step beyond that goal and focus on the life potential inherent in people beyond and underlying their points of suffering. This focus tends to be shifted slightly toward the person carrying the symptom rather than the symptom itself. This is not to say that the point of suffering is ignored, but it is contextualized within the personality and history of the person expressing this hurt in this particular way.

Let me give you an example of how this might look. A young man came to me some years back because of his wife’s concern that he was “losing it” with his children. While he did not feel that he was “suffering” from this, the rest of the family was. And he was at risk of experiencing the loss of his marriage and family over this issue. My task as therapist was to help alleviate the suffering in the system.

But as I listened to this young man for several sessions, what struck me about him was his lostness in general. He not only “lost it” in particular moments with his children, he seemed to have “lost it” in his life in general. He seemed mechanized with me—dutiful, pasty, routinized, monotonic, depressed—missing the warm glow of interpersonal spontaneity and vitality that makes us most human.

As I experienced this man’s absence, the focus of the therapy shifted from the circumscribed symptom of his “losing it” with his children to the more general goal of his more fully inhabiting his own life as a human being. The work included the effort to understand his absence: how and why it came to be, what it felt like (physically and emotionally) to be absent with his children, with his wife, with himself, and in his time with me; what it stirred in him to talk about these things with me, and so on.

Over time, the “losing it” with his children subsided. But, as important as this was, the therapy was about much more than this “presenting” symptom. By the end of it, this young man had became much more able to be present in all these contexts, and to understand the forces that had driven him so far from himself that he had gone missing from his own life. (We will get to the hows and whats of such a therapy in the upcoming chapters.)

Different Goals: Different Looks

To be clear, the range of therapies we learn about in school—behavioral through psychodynamic—do share one theme common to all: the effort to change something about a person. And it’s worth noting at this point that whatever your theoretical orientation, changing something about a human is, in and of itself, a rather lofty aspiration. We humans are junkies for the emotionally familiar. While in a constant change trajectory related to our own physical growth and aging process, we are profoundly wedded to and soothed by the power of the familiar. So without our willing it, we often resist change (even for the better) with a resoluteness that borders on fanaticism (and wanders into the unconscious).

But beyond what the various therapies share in common, they differ substantially in their look and feel. Some are more oriented toward the symptom, are time-limited and focused, and usually feature a rather active stance on the part of the therapist (think behavioral and cognitive behavioral therapies here). Some therapies are more oriented toward the patient or client’s more global personal growth, tend to be longer-term and more multi-focal, and usually feature a more non-directive style from the therapist (think psychodynamic psychotherapies here, as well as Rogerian, Gestalt, Jungian, and Existential, among others).

The process of therapy, at least theoretically, should follow from the goal. This is precisely why we study different “schools” of therapy—because there are legitimately different ways to a) define the problem and b) go about its solution in psychotherapy. (This, of course, presents a problem to the naïve seeker of psychotherapy who just wants to see a therapist. These various theoretical nuances make no difference to and indeed are invisible to someone who is seeking a therapist because they have lost a loved one or find themselves overwhelmed with anxiety or have decided they need help with their obesity or are alarmed with how they find themselves treating their children, or…). But that very obvious flaw in the user-end of clinical practice aside, how we as practitioners orient ourselves theoretically will determine where we swim in our inner tube, at what pace, and toward what shore.

Ultimately, since this is a book about psychodynamic process and technique, we will focus there in the remaining chapters. But understanding the legitimacy of other therapeutic approaches helps us to respect rather than to dismiss other therapies, and to know what might be appropriate for a particular client or patient. So let me talk for just a few minutes about several main points along the spectrum of psychotherapies, because where we position on this spectrum determines what we’ll be aiming at and doing as a psychotherapist.

Symptom-Focused Therapies

On one end of the spectrum of therapies are the behavioral therapies. If you’ve potty trained an infant or rewarded a puppy for the “right” behavior, you’ve no doubt employed the techniques of behavioral therapy—perhaps unawares. Behavioral therapies aim to change a targeted behavior, such as stopping smoking or increasing behavioral compliance in some way. Virtually anything visible about a human—or mammals in general (animal lovers do this intuitively)—can be subdivided into discrete behavioral entities. So the art and genius of the behavioral therapies lies in this subdividing and conquering analysis. Necessarily, the more amorphous the complaint, the more a behavioral therapist must use a contraction of the target as a proxy for the larger or more amorphous target.

Behavioral therapies are powerful for what they aim at: discrete behavior change. We experienced their power in a group program we set up in the schools for bullying and picked-on middle-schoolers in Southern California. We gathered the teacher-identified twenty-five “worst” kids in the school for one hour per week. We sat them in a large circle and used a curriculum to teach them about assertive, aggressive (bullying), and passive (doormat) behaviors, with much student participation. We observed the kids during the group time, and circulated among them dispensing white (appropriate), red (aggressive), and blue (passive) poker chips, in response to their identifiable behaviors in the group. The chips had positive and negative values, respectively. We also gave teachers a limited number of white chips (only) with instructions on their use. The chips would be reconciled at each session’s end, and could be “cashed in” during the school week for certain valued targets, like being able to cut to the front of the food line at lunch (“butt passes”), or being able to be exchanged for ice creams at the cafeteria. Pretty soon, the teens caught onto the game and began to adopt appropriately assertive behaviors inside and outside the group. By the end of the year, the “Social Behavior Group” had become quite high-status among students, and teachers were blown away at the positive changes wrought in members of the group.

Let me offer a quick digression here on a common misapprehension of behaviorism. It is not about punishment. There was a reason we only gave white (reward) chips to teachers. Parents and teachers often naïvely orient themselves toward meting out punishments for the crimes of children. Time outs, grounding, loss of internet privileges, loss of dessert, change in curfew, canceling the field trip. It’s endless, and all well intentioned. What gets lost in the shuffle is the relative power of positive reinforcement (think white chips and butt passes) versus the relative impotence of narrow and stimulus-dependent punishment.

Example: when did you last speed on the freeway? When there was no policeman visible, right? So the threat of getting a ticket didn’t really extinguish your speeding behavior. The threat of punishment (police car on the side of the road) had to be present and proximate to get its desired effect. Absent constant monitoring, we all game the system. Even when we are ticketed, we go back to our former-surveillance-driven speeding behaviors quite soon. Why? Because punishment requires that the punisher catch the behavior. So get this! All the moments of not being caught function to reinforce positively (with the feeling of freedom, our need for speed, and our getting away with it) our entrenched speeding behaviors. That’s why we all—well, most of us—speed. The system has taught us to.

Now, consider the power of a positive reinforcer. Suppose your insurance company were to devise a (not yet invented) GPS speed monitor in your car, and to rebate a direct percentage of your car insurance per month based upon the percentage of time you drove at or below the speed limit. Different motivational system entirely. Staying at the speed limit would earn something valuable to you. The research is robust and unequivocal on this point. Rewards change behavior; punishments create surveillance behavior. End of digression.

CBT

OK. One step over from the purely behavioral therapies are the cognitive-behavioral approaches (CBT). These have become the genre of choice in the current managed-care environment. The CBT schools differ from the purely behavioral therapies in that its practitioners marshal the substantial role of the thinking proce...