Contemporary Psychodynamic Psychotherapy

Evolving Clinical Practice

David Kealy,John S. Ogrodniczuk

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128134009
• Topic: Psychologie
• Subtopic: Psychotherapeutische Beratung

Contemporary Psychodynamic Psychotherapy: Evolving Clinical Practice covers the latest applications of psychodynamic therapy for a range of clinical issues, including depression, anxiety, psychosis, borderline personality and trauma. It discusses psychodynamic practice as an evidence-based therapy, providing reviews of outcome and process research. Covering a wide array of treatments tailored for specific disorders and populations, this book is designed to appeal to clinicians and researchers who are looking to broaden their knowledge of the latest treatment strategies, novel applications, and current developments in psychodynamic practice.

• Outlines innovative delivery strategies and techniques
• Features therapies for children, refugees, the LGBT community, and more
• Covers the psychodynamic treatment of eating, psychosomatic and anxiety disorders
• Includes psychotherapy strategies for substance misuse and personality disorders

Section 1

Conceptual advances

Outline

• 1 Theoretical evolution in psychodynamic psychotherapy
• 2 Working with cyclical relational patterns in contemporary psychodynamic psychotherapy
• 3 Attachment and mentalization in contemporary psychodynamic psychotherapy

1

Theoretical evolution in psychodynamic psychotherapy

David Kealy and John S. Ogrodniczuk, Department of Psychiatry, University of British Columbia, Vancouver, Canada

Abstract

Theory serves as an essential framework to the practice of psychodynamic psychotherapy. Considerable evolution of theory has occurred with regard to the understanding of the mind, psychopathology, and treatment in the field of psychodynamic psychotherapy. This chapter provides an overview and discussion of some of the key developments in psychoanalytic theory that have contributed to contemporary psychodynamic psychotherapy. A concise introduction to classical, object relations, self psychology, and relational models is provided in order to illustrate major theoretical developments. The chapter highlights several points of convergence and debate that are salient to psychotherapy practice, and that contribute to the complexity of contemporary psychodynamic psychotherapy.

Keywords

Psychoanalytic theory; psychodynamic psychotherapy; object relations theory; self psychology; relational psychotherapy; attachment theory

Theory is essential to the practice of psychotherapy. It helps therapists to organize information about their patients and to understand their patients’ difficulties, and it provides a framework for mechanisms of therapeutic action. As Wampold (2010) notes, “there is no therapy without theory” (p. 43). Psychodynamic psychotherapy is founded upon psychoanalytic theory, the elucidation, refinement, and revision of which has arguably preoccupied the field to a greater extent than empirical research or dissemination of formal psychodynamic treatment guidelines. Psychoanalytic theory has changed a lot since its inception more than a century ago; thorough documentation of this would require a book unto itself, if not several volumes. We believe, however, that a basic grasp of the evolution of psychoanalytic theory—at least some major points along the way—can help clinicians in their understanding and practice of contemporary psychodynamic psychotherapy.

In this chapter we will discuss some of the key developments in psychoanalytic theory that have contributed to contemporary psychodynamic psychotherapy. Given the breadth and depth of the psychoanalytic theoretical literature, we will paint with broad strokes and focus on theoretical developments that we perceive to be particularly salient to practitioners of psychotherapy therapy today. Our aim is to provide a concise introduction to readers who may be less familiar with psychodynamic psychotherapy and its theoretical foundations while at the same time highlighting some points of convergence and debate that may resonate with more experienced clinicians. In doing so, we will chart a crash course through the evolution of psychoanalytic theory and into its application in the contemporary practice of psychodynamic therapy.

What makes a theory—and therapy—psychodynamic?

While technical distinctions can be made between psychoanalysis and various psychodynamic psychotherapies, a shared emphasis on unconscious mental processes forms the bedrock of a uniting theoretical foundation. Beyond this foundation, however, the precise nature of core psychodynamic theory has been rather difficult to pin down, partly owing to a proliferation of ideas and schools of thought within psychoanalysis and throughout the numerous psychotherapies informed by psychodynamic concepts. This makes for some difficulty in precisely defining a core psychodynamic theory. Indeed, contemporary psychodynamic practice is more fittingly characterized by a plurality of approaches under a broad psychoanalytic umbrella. Nevertheless, all psychodynamic models conceive of unconscious psychological processes as playing an important role in shaping the ways in which people experience (i.e., make sense of) and act in their world (Gabbard, 2017). Thus psychodynamic theories emphasize a motivated unconscious or, in other words, unconscious motivation. Moreover, the nature of unconscious experience is regarded as highly unique for each individual, knowable largely through inference or introspection or partially glimpsed through dreams and fantasies. Psychodynamic theories also pay careful attention to childhood experiences as influences on the development of unconscious motivational tendencies, representations of self and other, and conflicts between motivational or affective states. Similarly, psychopathology is typically conceptualized as involving unconscious causes—such as excessive conflict or problematic relational representations—playing a significant role in consciously perceived distress or dysfunction.

In addition to conceptualizations of the mind and psychopathology, theories of therapeutic technique and change mechanisms distinguish psychodynamic approaches from other psychotherapies. In general, psychodynamic therapies emphasize change occurring by way of increased access to emotional experience and through the development of insight into unconscious motivations, defenses, and interpersonal patterns (Gabbard, 2017). Psychodynamic therapy also emphasizes the therapeutic relationship itself as a vehicle of change, both for highlighting the patient’s emotional and interpersonal patterns and for providing interactional experiences that serve corrective developmental purposes for the patient. Various technical stances and interventions support and facilitate these mechanisms, including the patient’s free association—expressing whatever comes to mind—or at least the patient’s leading the dialogue, the therapist’s observation and clarification of difficult or contradictory thoughts and feelings, and a joint exploration of unconscious meanings and motivations. Exploration, guided by empathic inquiry, is applied not only to the various concerns and issues in the patient’s world, but also to the relational dynamics occurring between therapist and patient. Indeed, perhaps more so than other therapy models, psychodynamic approaches pay close attention to the emotional responses of the patient regarding the therapist—known as transference—and of the therapist regarding the patient—referred to as countertransference.

Despite the centrality of such interventions to dynamic psychotherapy, it must be noted that aspects of these elements are increasingly being absorbed by other, nondynamic approaches—often referred to using different jargon—and combined with other techniques by therapists who take an integrative stance toward treatment. Moreover, as a close reading of this book’s chapters will reveal, psychodynamic approaches often differ in their emphasis on particular mechanisms and technical strategies. Indeed, the considerable breadth and depth in the revisions of psychoanalytic theory provide numerous opportunities for divergence in its application to treatment. Our coverage of these developments will be focused on their application to psychotherapy rather than on psychoanalysis per se and will by necessity be exceedingly brief and beyond incomplete. Our succinct account of Freudian theory, for instance, does little justice to the revisions Freud made during his lifetime. Several excellent volumes offer comprehensive treatment of the evolution toward contemporary psychoanalytic theory, including those by Mitchell and Greenberg (1983), Bacal and Newman (1990), Fonagy (2001), and Eagle (2011). Discussion of some of the finer points of convergence and divergence in contemporary theory is also offered by Gabbard and Westen (2003) and Kernberg (2011).

From classical theory to ego psychology

Freud’s model of the mind—regarded as “classical” psychoanalytic theory—considered the nervous system as a mediator of the buildup and discharge of affect, serving regulatory functions aimed toward the seeking of pleasure and reduction of unpleasure (Freud, 1920/1966). Survival-oriented biological drives (reflecting survival of both the individual and the species), such as hunger or sexual urges, press for discharge and register in the mind as desires or wishes. The constant pressure on the mind for the gratification of these wishes—the discharge of drives—manifests in their expression across various aspects of cognition and behavior. Sexual wishes, for example, may find expression in how one interprets a painting or in the content of an erotic dream (Freud, 1920/1966). These expressions reflect the conflict between internal, instinct-based wishes (emanating from a mental structure labeled the “id”) and the demands and limits imposed by external reality. Freud evolved his theory to suggest that a specific structure of the mind, the ego, serves to inhibit immediate drive gratification in response to reality considerations and to facilitate eventual, appropriate gratification (Freud, 1923). Partial gratification, represented by the various expressions of these wishes in the individual’s mental life, is allowed by the ego in order to prevent excessive buildup of excitation. The ego also attenuates awareness of the instinctual origins of such wishes in order to spare the individual from excessive anxiety associated with their forbidden nature and with the anticipated consequences of their gratification.

Freudian theory emphasizes the implications of drive derivatives—particularly sexual and aggressive wishes—being directed toward childhood “objects” (the child’s parents) for gratification. The need to manage potential anxiety associated with childhood instinctual wishes peaks during the so-called oedipal period (roughly 3–5 years old). During this phase, the child’s libidinal wishes directed toward one parent—and aggressive wishes toward the “rival” parent—raise the fear of several detrimental consequences, including the risk of retribution (including bodily damage) from the “rival” parent or the loss of the parental object or that parent’s love. The ego must find a way to discharge the persistent drive derivatives while avoiding a calamitous outcome—as well as to reduce the anxiety that accompanies cognizance of these forbidden desires. Thus the ego seeks to obtain some measure of compromise in which attenuated fulfillment of a wish is achieved as its instinctual basis remains hidden, lest the child become fully aware of its forbidden nature and dangerous consequences. While Freud (1936) focused on repression as a principal mechanism by which the ego renders forbidden wishes unconscious, various ego defenses were subsequently identified as accomplishing the function of repression via an array of means. Thus, defense mechanisms—projection, displacement, reaction formation, and so on—reduce tension by responding to signal anxiety with the relegation of threatening drive derivatives to an unconscious portion of the mind. This dynamic unconscious is a distinctly psychoanalytic notion of unconscious mental activity, in that the latter comprises not only nonconscious mental automaticity, but also affects and thoughts that are banished from awareness for regulatory purposes. The end result of the pressing of instinctual wishes and their modulation by the ego is a compromise between wish and defense that may manifest either adaptively or maladaptively, with the potential to emerge as a symptom or character trait.

Evolving from Freud’s classical theory, ego psychology represents the contributions of analysts who paid closer attention to the functions of the ego, arguing that the ego exerted a substantial influence on behavior and personality beyond its role as mediator of instinct and reality. While ego psychologists expanded the conceptualization of defenses (Freud, 1966), they highlighted additional ways in which the ego regulates the individual’s mental life. Heinz Hartmann, a key figure in ego psychology, suggested that the ego possesses several capacities that are largely independent from drive regulation (Hartmann, 1958). These ego functions—including capacities for reality testing and judgment—serve to perceive, organize, and synthesize aspects of the environment in order to allow the individual to adapt to his or her reality. The expansion of the role of the ego introduced by Hartmann (1958) and others included motivational interests, such as desires for personal and social achievements, that were mainly autonomous from, and sometimes competing with, pressure from drive derivatives (Eagle, 2011). Indeed, Erikson (1959) situated the development of personal identity, facilitated through cultural and environmental experience, within the ego and elaborated a model of psychosocial development throughout the life span that transcended drive theory. The conceptual extensions of ego psychology helped psychoanalytic theory transition from what has been referred to as a one-person psychology, in which endogenous drives are directed at objects (i.e., people as targets whose individual psychologies were deemphasized), toward a two-person psychology whereby the qualities and behaviors of other people are seen as playing a significant role in shaping the individual’s psychic life. To regard thi...