Symptom-Focused Dynamic Psychotherapy

Mary E. Connors

• Editorial: Routledge
• Año: 2013
• ISBN:
  9781134915255
• Edición: 1
• Categoría: Psicologia
• Categoría: Psicologia applicata

Traditionally, psychoanalytically oriented clinicians have eschewed a direct focus on symptoms, viewing it as superficial turning away from underlying psychopathology.But this assumption is an artifact of a dated classical approach; it should be reexamined in the light of contemporary relational thinking.So argues Mary Connors in Symptom-Focused Dynamic Psychotherapy, an integrative project that describes cognitive-behavioral techniques that have been demonstrated to be empirically effective and may be productively assimilated into dynamic psychotherapy.What is the warrant for symptom-focused interventions in psychodynamic treatment?Connors argues that the deleterious impact of symptoms on the patient's physical and emotional well being often impedes psychodynamic engagement. Symptoms associated with addictive disorders, eating disorders, OCD, and posttraumatic stress receive special attention.With patients suffering from these and other symptoms, Connors finds, specific cognitive-behavior techniques may relieve symptomatic distress and facilitate a psychodynamic treatment process, with its attentiveness to the therapeutic relationship and the analysis of transference-countertransference. Connors' model of integrative psychotherapy, which makes cognitive-behavioral techniques responsive to a comprehensive understanding of symptom etiology, offers a balanced perspective that attends to the relational embeddedness of symptoms without skirting the therapeutic obligation to alleviate symptomatic distress.In fact, Connors shows, active techniques of symptom management are frequently facilitative of treatment goals formulated in terms of relational psychoanalysis, self psychology, intersubjectivity theory, and attachment research.A discerning effort to enrich psychodynamic treatment without subverting its conceptual ground, Symptom-Focused Dynamic Psychotherapy is a bracing antidote to the timeworn mindset that makes a virtue of symptomatic suffering.

CHAPTER ONE

Rationale for a Symptom-Focused Dynamic Treatment

THE QUESTION OF WHAT CONSTITUTES an appropriate goal of psychotherapeutic treatment has been debated since Freud's time. Freud (1917b) emphasized making the unconscious conscious and enlarging the realm dominated by the ego while constricting that of the id. He stated (1917c) that an analysis was ready to end when the patient no longer suffered from his symptoms, had surmounted his anxieties and inhibitions, and possessed the capacity for enjoyment and for efficiency in functioning. Repressions should be lifted and any gaps in memory filled in. Moreover, these changes ought to be stable and enduring: “Through the overcoming of these resistances the patient's mental life is permanently changed, is raised to a high level of development and remains protected against fresh possibilities of falling ill” (p. 451).

As psychoanalytic thinking evolved in ways less dominated by drive theory, some analytic authors focused on the state of the self and on object relations. For instance, Kohut (1971) emphasized the development of a cohesive self that is capable of achieving its goals and using its talents. Summers (1994, 1999) describes the goal of treatment as enabling the self to function more effectively by changing the ways in which a patient's object relationships are internally structured, and he noted the importance of realizing the self's potential through authentic being and relating. Mitchell (2000) stressed helping the patient find ways of interacting that are genuine and rich, thus expanding a limited relational repertoire characterized by repetition, stasis, and loyalty to the familiar. Stolorow and his colleagues (1987) have described the goal of treatment as the progressive exploration, clarification, and transformation of the patient's subjective world.

In contrast, treatment goals discussed in cognitive behavioral writings tend to be much less lofty, smaller in scope, and more specific. These authors emphasize the correction of problematic behavioral excesses and deficits and cognitive distortions. For cognitive behaviorists, targeting a patient's anxiety disorder symptoms, rather than global change in the self, is the appropriate focus of a helpful treatment. Amelioration or removal of a symptom is viewed as the hallmark of a successful psychotherapy. London (1986), lucidly discussing the conflict between therapies of insight and therapies of action, stated that, whereas insight therapists want to undermine symptoms, action therapists are more interested in directly alleviating them so that patients can feel better: “The technical dispute is thus a function of the importance assigned to symptoms relative to the conditions that sponsor them” (p. 30). He notes that accusations are common on both sides; insight therapists view those more action oriented as superficial and mechanical, while action therapists consider insight treatment ineffectual and pseudoscientific.

The controversy surrounding the proper aims of treatment continues today, with the opinions of managed care reviewers and insurers added to those of mental health professionals. Psychoanalytic clinicians, who already feel beleaguered by diminished cultural and financial support for long-term treatment, may be inclined to dismiss the cognitive behavioral orientation as just another irritating but ultimately irrelevant manifestation of the current wrongheaded Zeitgeist. However, at the same time analytic thinkers are not unconcerned about their patients’ symptomatic difficulties. It may seem that these divergent perspectives on treatment goals are irreconcilable; I believe, however, that some degree of integration is possible and useful. Throughout this book I develop a model of psychoanalytically informed psychotherapy that includes specific interventions to address particular symptoms. In developing this thesis, I first discuss the distress engendered by symptoms, their formation and function, and then introduce an integrative approach.

People do not tend to seek treatment unless they are suffering. As Freud (1940) noted, “On the patient's side a few rational factors work in our favor, such as the need for recovery which has its motive in his sufferings” (p. 181). The DSM-IV (American Psychiatric Association, 1994) defines mental disorder as a syndrome or pattern that is associated with present distress, such as a painful symptom, or a significant impairment in functioning. Persons may experience intense disturbance when they suffer from Axis I disorders with symptoms that can be debilitating, such as some anxiety disorders and mood disorders. These symptoms might appear alone or in conjunction with characterological difficulties. Some individuals with Axis II disorders may cause more distress to those around them than they experience themselves, but others with personality pathology are disturbed by their repetitive patterns and wish to change. In my experience, many persons are troubled by conditions that do not conform to a specific diagnostic category but, rather, relate to the state of the self or to attachment difficulties that impair relations with others. Such patients may enter treatment complaining that they have “low self-esteem” or that they cannot maintain intimate relationships.

Clinicians who have been trained from behavioral perspectives would view all these problems as appropriate targets of intervention. Psychoanalytic therapists, however, are likely to be far more cautious in their approach to symptoms. The classical psychoanalytic stance toward symptoms has been to conceptualize them as compromise formations resulting from the interplay of reprehended drives, ego defenses, and superego prohibitions (e.g., Freud, 1917a). Traditional theory has thus viewed symptoms as manifestations of underlying conflicts and has proposed that they will resolve only when the dynamic unconscious forces propelling them are brought to awareness in analysis or psychotherapy. Furthermore, the symptom was thought to occupy such an integral position in the psychic economy that attempting to remove a symptom prematurely was believed to result only in the substitution of another symptom. Although numerous current psychoanalytic theorists do not accept many aspects of Freudian metapsychology, few have turned their attention to specific symptomatic disorders.

RATIONALE FOR A SYMPTOM FOCUS

I have proposed that there are several reasons that interventions designed to affect specific symptoms may be indicated (Connors, 2001a). Some symptomatic disorders place patients in actual physical jeopardy. Anorexia nervosa has been estimated to have a mortality rate close to 10% (Sibley and Blinder, 1988). Bulimia nervosa can also be life threatening, with such consequences as cardiac arrest resulting from electrolyte imbalances (Johnson and Connors, 1987). Major depressive disorder often has fatal consequences, with up to 15% of those afflicted committing suicide and many more dying prematurely because of the confluence of depression and other medical conditions (American Psychiatric Association, 1994). Alcohol abuse is involved in at least 100,000 premature deaths annually (McGinnis and Foege, 1993). Drug abuse can be quite dangerous as well, particularly when toxic drugs such as inhalants are used or needle sharing takes place; approximately one-third of AIDS cases in the United States are related to intravenous drug use (Center for Disease Control and Prevention, 1994). Compulsive unsafe sexual activity may have fatal consequences. Violent behavior, including domestic violence and child abuse, constitutes a major public health issue.

The impairment caused by some symptoms may be such that psychotherapy is not a real possibility until the symptoms abate. Here I am referring particularly to symptoms that are so debilitating, frightening, or preoccupying that they interfere greatly with a patient's ability to engage in psychological exploration. A certain measure of physiological well-being, moderate levels of arousal, and a degree of psychological safety and freedom are optimal to promote reflective dialogue between patient and therapist. Obviously patients differ greatly in their capacity for psychological exploration, but conditions outside a certain range will hinder even the most emotionally aware person. If we reflect on our own experience of suffering physical pain, such as from a muscle spasm or a toothache, we may be aware that this severe pain makes it difficult to focus on anything except how much it hurts. Our usual ability to deploy attention to a range of topics and exchange ideas with others is restricted.

I believe that many patients who come to therapy are experiencing the psychological equivalent of a severe pain that dominates their consciousness and precludes conversation about topics other than their suffering. A malnourished anorexic whose cognitive functions are impaired by starvation is in no position to achieve insight into her unconscious motivation. Neither is the alcoholic who is always either inebriated or beginning to experience withdrawal, or the bulimic who is binge eating and purging many times a day. Patients who are feeling terrorized by panic attacks or flashbacks related to traumatic experiences likewise cannot be very present in a therapeutic relationship. Persons with symptoms that affect their arousal levels, such as manic states, anxiety disorders, or severe depressive episodes, may require help in moderating their over- or underarousal before mutual dialogue is possible.

A patient's level of distress about a symptom might also warrant a specific symptom focus. Some symptoms are so ego dystonic, anxiety provoking, or deleterious to self-esteem that their rapid amelioration is desperately sought. Many patients experience great shame concerning their symptoms. Others feel panicked about the potentially disastrous relational consequences of their continuing to engage in substance abuse or compulsive sexual behavior. Many symptomatic conditions affect patients’ performance in the workplace, and continued employment may be predicated on improvement in such problems as depression or anxious avoidance that interfere with attendance and task performance.

The classical analytic tradition, with its emphasis on abstinence rather than gratification, renunciation of infantile wishes, and removal of resistances to uncovering unconscious conflicts, may lead clinicians to adopt an unnecessarily harsh stance toward symptom relief (Connors, 2001a). We may believe that nonintervention is appropriate because we think that these symptoms would diminish only over a prolonged period of time as internal conflict resolves, that people in treatment must feel worse before they can feel better, and that in general symptomatic suffering is somehow beneficial and necessary for the therapeutic process or, at any rate, that it is unavoidable. We might also expect that symptom substitution would occur should the original symptom diminish prematurely, rendering intervention fruitless.

My view is that distress resulting from troublesome symptoms is generally not useful, and that many times it can be harmful, promoting rigid and risk-avoidant behavior. I invite clinicians to question their own attitudes about patients’ suffering. Should symptoms be alleviated if it means patients will opt for a briefer treatment or fail to explore themselves fully? Is assisting patients with symptoms a “quick fix” that we should eschew, and, if so, is it because of some Nietzcheian ideal that suffering will make our patients stronger? Or, in an era in which psychiatric drugs are advertised on television, are we reacting against the increasing conceptualization of complex human situations as remediable with a prescription for a pill or a technique rather than with self-understanding? As a culture we tend to hold conflicting attitudes toward the relief of suffering; advertisements tout the “fast results” promised by various nostrums, but terminally ill patients are undermedicated because physicians are not taught to prioritize pain management relative to other concerns. Obviously we do not wish to collude with some of the messages promulgated in our consumer culture that the optimal response to distress is its eradication. Yet it might be worthwhile to examine whether we hold views concerning the virtue of suffering that constrain our ability to consider direct techniques of symptom alleviation.

In Buddhist teachings there is a story concerning a follower of the Buddha who expressed his dissatisfaction with his path because the Buddha had not declared his views on such matters as whether or not the world is eternal and what happens after death. The monk determined to abandon his training unless he received answers. The Buddha responded with a tale about a man who had been wounded by a poisoned arrow. Although a surgeon was brought to treat the man, he stated that he would not permit the surgeon to remove the arrow until he knew the name of the man who had wounded him, where the man lived and what his occupation was, what type of bow shot the arrow, what kind of feathers were on the shaft, and so on. “All this would still not be known to the man and meanwhile he would die” (Nanamoli and Bodhi, 1995, p. 535). The Buddha emphasized the need to remove the poisoned arrow of ignorance without wasting precious time on fruitless speculation.

I consider the exploratory process of psychoanalytic psychotherapy to be powerful and transformative, and my use of the Buddha analogy here is not intended to suggest otherwise. But what about that arrow? I suggest that the most empathic and attuned therapist response to a patient in great symptomatic distress is to try to do something about the symptom as quickly as possible, even if it means that understanding is not yet perfect (Connors, 2001a). Clinicians from different perspectives agree that active crisis intervention is necessary when a patient is suicidal. In such a case, it is obvious that severe consequences could ensue unless the therapist manages the situation and secures the patient's safety—this being the priority in treatment until the crisis has passed. Distressing symptoms are not necessarily life threatening, but they may be so pressing that a patient will not remain in psychotherapy or be able to engage in a therapeutic relationship unless the symptoms are attended to relatively early in the treatment. The immediacy with which a clinician intervenes when a patient is suicidal, regardless of the clinician's views concerning underlying causality, might be appropriate in less extreme situations as well.

Patients with problematic symptoms, particularly those involving substance abuse, eating disorders, or mood disorders, have often been relegated to inpatient treatment. The former availability of inpatient hospitalization meant that some clinicians who felt insufficiently trained in symptom-focused work, or who had theoretical objections to doing it, were able to employ a “split treatment” model, in which patients with disabling symptoms worked on them with an inpatient team. In an era of great concern about health care costs, however, such formerly ubiquitous practices as a four-week hospital stay for alcoholism are exceedingly rare unless a patient has considerable personal means. Because outpatient treatment is far less costly than hospitalization, clinicians will have to manage many situations involving symptomatic disorders without the assistance provided by inpatient care. Hospitalization increasingly is reserved for brief crisis situations such as a medically supervised detoxification from substances or stabilization of an acutely suicidal patient.

SYMPTOM FORMATION AND FUNCTION

A proposal for active intervention with symptomatic behavior raises issues about the origin and function of symptoms. Traditional psychoanalytic theory has focused on the role of internal conflict in the genesis of a symptom and its function in effecting a compromise between adversarial elements of the mind. However, Freud (1937) presciently recognized the complex origin of pathology: “The aetiology of every neurotic disturbance is, after all, a mixed one. . . . As a rule there is a combination of both factors, the constitutional and the accidental” (p. 220). More recent theoretical developments advocate a biopsychosocial approach to understanding symptomatology (e.g., Adams and Sutker, 2001). This multidimensional approach eschews a single-factor theory of pathology and instead suggests that a complete explanation must include such biological variables as genetic vulnerabilities; such psychological factors as attachment security and traumatic history; and the sociocultural milieu, including the impact of gender, race, ethnicity, religion, sexual orientation, and prevailing cultural norms (Connors, 1994). For example, bulimia nervosa has been found to have a considerable genetic component (Bulik, Sullivan, and Kendler, 1998). It has also been linked to particular types of family constellations and to such risk factors as sexual abuse (Connors and Morse, 1993; Connors, 2001b). This symptom is associated with a cultural emphasis on thinness, which is more prominent in certain groups than in others and places Caucasian heterosexual young women of higher socioeconomic status at especially high risk for developing this disorder (Connors, 1996). The expression of a symptom depends on complex interactions of such risk factors as these.

I believe that effective treatment of symptomatic disorders is related to a comprehensive understanding of their etiology. As useful as a biopsychosocial perspective on the development of psychopathology is, however, it does not tell us very much about the role that a particular symptom comes to play in the psyche of an individual. In an earlier work (Connors, 1994), I suggested four particular pathways to symptom formation, although I suspect quite a few more could be enumerated. Common to all is the idea of a vulnerable self in a relational matrix that is or was somehow inadequate. It should be noted, however, that in addition to limitations in the caregiving environment of the child due to such issues as parental psychopathology, intergenerational transmission of trauma, and lack of resources, some children with extreme difficulties due to biological vulnerabilities might present insuperable challenges to the most competent parents.

One pathway to symptom formation represents a reworking of Freud's (1917b) understanding of a symptom as a compromise between conflicting impulses (Connors, 1994). Some patients who have experienced trauma manifest a reduction in functioning to protect the self from overwhelming and unacceptable affects and knowledge. The nature of these affects may be sexual or aggressive, often reflecting what has been done to the person in abusive experiences rather than the wishes for sexual and aggressive expression emphasized by classical theory. Herman (1992) noted that trauma survivors always face a conflict between forgetting and keeping secrets about the trauma, or remembering and telling about it. Symptoms in traumatized patients may represent a compromise between the two. For example, a number of female Cambodian refugees who witnessed atrocities later suffered loss of vision that was found to have no organic basis (Rozee and Van Boemel, 1989). Group treatment was effective in restoring some vision to these trauma survivors who could not bear to see any more horror. Some authors have suggested the term somatoform dissociation (e.g., Nijenhuis and Van der Hart, 1999) for physical complaints subsequent to trauma that may include disorders of movement and sensation. Patients suffering from somatoform dissociation, once considered to be “hysterics,” might manifest sensory losses and problems with motor control that they experience as unconnected to the original trauma.

Traumatized patients must find a symptomatic compromise that achieves multiple purposes. First, the self must be protected from knowledge of unbearable events (often perpetrated by family members) and the accompanying rage, pain, sense of betrayal, and hopelessness. Second, ties with caregivers must be preserved to ensure physical and psychological survival. Affects such as rage may be far too dangerous to permit in an abusive interpersonal environment, so that relational bonds are maintained by disavowing and denying large sectors of self-experience, including affects and memories. Finally, a part of the self might retain hope that someday one's story may safely be told and finds a way to hint at it through disguised representations of actual experiences. This compromise could result in such symptoms as amnesia for large portions of one's personal history, self-mutilation, dissociative phenomena, and somatoform disorders.

Another pathway to symptom formation is seen in addictive disorders and some compulsive behaviors. Problems such as alcoholism, substance abuse, bulimia nervosa, and compulsive gambling all involve reliance on an inanimate object or an activity for self-regulation (Connors, 1994). Strong evidence exists that addictive disorders have relatively high genetic heritability (e.g., Goodwin, 1984), and individual differences in such areas as physiological tolerance of alcohol have been cited as significant risk factors (e.g., Schuckit, 1989). Other research has shown that addicted behavior tends to be associated with negative emotional states; persons are more likely to abuse substances or engage in addictive activities such as gambling when they are angry, anxious, sad, lonely, and so on (Donegan et al., 1983; Peele, 1985). Such emotional states are also more strongly associated with relapse into addictive behavior after a period of abstinence than is any other factor (Marlatt and Gordon, 1985).

Thus, people who are b...