Psychodynamic Psychotherapy

A Clinical Manual

Deborah L. Cabaniss

• Publisher: Wiley
• Year: 2016
• ISBN:
  9781119141990
• Edition: 2
• Topic: Medicina
• Subtopic: Psichiatria e salute mentale

An updated and expanded new edition of a widely-used guide to the theory and practice of psychodynamic psychotherapy, Cabaniss' Psychodynamic Psychotherapy: A Clinical Manual, 2nd Edition provides material for readers to apply immediately in their treatment of patients.

Part One:
What Is Psychodynamic Psychotherapy?

1
The Treatment for a Mind in Motion

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Key Concepts

Psychodynamics means mind in motion.

A psychodynamic frame of reference postulates that dynamic (moving) elements in the unconscious affect conscious thoughts, feelings, and behavior.

A psychotherapy that is based on the psychodynamic frame of reference is a psychodynamic psychotherapy.

The basic goal of psychodynamic psychotherapy is to help people with problems and patterns that lead to unhappiness and dissatisfaction in life by uncovering unconscious thoughts and feelings and/or directly supporting function in the context of the relationship with the therapist.

Both uncovering and supporting techniques are used in almost every psychodynamic psychotherapy.

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What is Psychodynamic Psychotherapy?

Literally, psychotherapy means treatment for the mind. Psychotherapy has its origins in psychoanalysis – the “talking cure” that was first developed by Sigmund Freud [1]. Consequently, the word psychotherapy has come to refer to a treatment that involves talking. But it's not just any talking – in order to be psychotherapy, the talking has to be:

• a treatment
• conducted by a trained professional
• within a set framework
• in order to improve the mental and emotional health of a patient

And what about psychodynamic? You've probably heard this word many times – but what does it mean? Psycho comes from the Greek word psyche, which meant soul but has come to mean mind, and dynamic comes from the Greek word dynamis, which meant power but has come to mean physical force in motion. Simply stated, the word psychodynamics refers to the forces of the mind that are in motion. Freud coined this word when he realized that, as opposed to earlier conceptualizations of a static psyche, the mind was an ever-changing system, rolling with perpetually moving energized elements. These unconscious elements could explode into consciousness and vice versa, while powerful wishes and prohibitions could barrel into one another, releasing the psychic equivalent of colliding subatomic particles [2].

Freud realized not only that elements of the mind were in motion, but also that most of this frenzied mental activity was going on outside of awareness. He described this mental activity as unconscious and hypothesized that it could affect conscious thoughts, feelings, and behavior. Thus, we arrive at the two definitions that provide the foundation for this manual:

1. A psychodynamic frame of reference is one that postulates that unconscious mental activity affects our conscious thoughts, feelings, and behavior.
2. A psychodynamic psychotherapy is any therapy based on a psychodynamic frame of reference.

The Unconscious

We often refer to our unconscious mental activity as the unconscious. Feelings, memories, conflicts, ways of relating to others, self-perceptions – all of these can be unconscious and can cause problems with thoughts and behavior. Unconscious thoughts and feelings develop in a person from childhood, and are a unique mix of early experiences and temperamental/genetic factors. We keep certain thoughts, feelings, and fantasies out of awareness because they threaten to overwhelm us if they become conscious. They might be too frightening or stimulating; they might fill us with shame or disgust. Because of this, we make them unconscious but they do not disappear – they remain full of energy and constantly push to reach awareness. Their energy affects us from their unconscious hiding places, and they exert their influence on the way we think, feel, and behave. A good analogy comes from Greek mythology:

Zeus, the young god, was tired of being ruled by the patriarchal Titans, so he buried them in a big pit called Tartarus. Deep beneath the earth, they no longer posed a threat to Zeus's dominance. Or did they? Though out of sight, they had not disappeared, and their rumblings were thought to cause earthquakes and tidal waves.

So too, unconscious thoughts and feelings are hidden from view but continue to rumble in their own way, causing unhappiness and suffering in the form of maladaptive thoughts and behaviors.

Psychodynamic Psychotherapy and the Unconscious

In many ways, the psychodynamic psychotherapist is like the plumber you call to fix your leaky ceiling. You see the dripping, but you can't see the source; you can catch the drops in a pail, but that doesn't stop the flow. The plumber knows that the rupture lies behind the plaster, somewhere in pipes that as yet can't be seen. Here, though, the plumber has an advantage over the psychodynamic psychotherapist – he can use a sledgehammer to break through the plaster, reveal the underlying pipes, find and fix the offending leak, and patch the ceiling. But the psychodynamic psychotherapist is working with a human psyche, not a plaster ceiling, and thus requires more subtle tools to seek and mend what's beneath the surface.

Uncovering and Supporting

Like the plumber, the psychodynamic psychotherapist's first goal is to understand what lies beneath the surface – that is, to understand what's going on in the patient's unconscious. Many of the techniques of psychodynamic psychotherapy are designed to do just that. Once we think that patients are motivated by thoughts and feelings that are out of their awareness, we then have to decide how to use what we have learned in order best to help them. Sometimes we decide that making patients aware of what's going on in their unconscious will help. We call this uncovering – Freud called it “making conscious what has so far been unconscious” [3]. We have many techniques for helping patients to uncover – or become aware of – unconscious material. What we're uncovering are inner thoughts and feelings that they keep hidden from themselves but that nevertheless affect their self-perceptions, relationships with others, ways of adapting, and behavior.

Sometimes, however, we decide that making patients aware of unconscious material will not be helpful. We generally make this decision when we judge that the unconscious material could be potentially overwhelming. Then we use what we have learned about the unconscious to support functioning without uncovering thoughts and feelings. (See Chapter 18 for discussion of uncovering and supporting techniques.)

Here are two examples – one in which we would choose to uncover and one in which we would choose to support:

Ms A is a 32-year-old woman who has a trusting relationship with her husband, many close friends, and a satisfying personal career. In the past, she has used journaling, cooking, and athletics to work through short periods of anxiety. She presents to you complaining of insomnia that she believes has been triggered by a fight she is having with her younger sister, B. Ms A says that she's “mystified” by B's hostile behavior, which began about a month ago in the context of B's impending graduation from medical school. Further exploration reveals that although B wanted to become a dermatologist, she was not offered a position in this field and will have to do an interim year of internal medicine and then reapply. Ms A says that she has been very sympathetic about this setback and does not know why B is so hostile toward her. When you ask about their earlier relationship, you discover that Ms A has cruised effortlessly from one Ivy League institution to another, while B has struggled academically. You hypothesize that B's hostility toward Ms A may be fueled by envy, and that Ms A has been unconsciously keeping herself from becoming aware of this out of guilt. You think that Ms A will benefit from learning about her unconscious guilt and decide to help her uncover ...