Chapter 6 – Psychodynamic Psychotherapy Practice: An Introduction




Abstract




This chapter is designed as an introduction to psychodynamic psychotherapy practice for psychiatrists, training therapists, and for those who are interested in this work. This is an extensive area and this chapter is intended as a summary of its aim and process. The cases reported are composites of those presented in supervision by those in training, the majority of whom were seeing their patients once weekly for one year in NHS settings. The description is intended as a general guideline and is simplified from a broad heterogeneous theoretical area. Psychodynamic terms in italics are defined in the glossary.





Chapter 6 Psychodynamic Psychotherapy Practice: An Introduction



Rachel Gibbons



Introduction


This chapter is designed as an introduction to psychodynamic psychotherapy practice for psychiatrists, training therapists, and for those who are interested in this work. This is an extensive area and this chapter is intended as a summary of its aim and process. The cases reported are composites of those presented in supervision by those in training, the majority of whom were seeing their patients once weekly for one year in NHS settings. The description is intended as a general guideline and is simplified from a broad heterogeneous theoretical area. Psychodynamic terms in italics are defined in the glossary.



Aim of Therapy



Where Id was there Ego shall be


Freud [1]

Psychodynamic therapy aims to help the patient make conscious what is unconscious. This is achieved by providing a containing space where feelings, or affects, that have been unknowingly hidden, or repressed, because they would cause too much conflict with the conscious mind, can emerge and be gently confronted. These feelings then pass and through the process, patients gain ego strength and resilience.



Why Patients Seek Therapy


Patients tend to present with a range of psychological or psychiatric difficulties. They may have the feeling that ‘something is not right’ with some awareness that this is beyond rational or conscious explanation. They can be seeking a deeper exploration of themselves and wishing to resolve profound difficulty in securing or maintaining nurturing intimate relationships. They may be struggling with a stage of development, for example wanting a relationship or children, but fear commitment. In many cases there has been a painful loss that may not be fully recognised.



The Importance of Psychic Defences in Managing the Conflict between the Unconscious and Conscious Mind



… if life is going to exist in a Universe of this size, then the one thing it cannot afford to have is a sense of proportion.


Douglas Adams – Restaurant at the End of the Universe [2]

Psychic defences manage the permeability of the boundary between the unconscious and the conscious mind, keeping feelings and urges thought unacceptable out of awareness. Titration of the relationship with internal and external reality is necessary in normal functioning for many reasons some of which include:




  1. 1. To be aware on a daily basis of one’s global insignificance is likely to result in feelings of hopelessness and lack of motivation




    1. a. This is entertainingly illustrated by Douglas Adams in the Hitchhikers Guide to the Galaxy series quoted above. In this book a philosopher, Tin Tragula, built the Total Perspective Vortex to annoy his wife who kept telling him to get a ‘sense of proportion’ and ‘into one end he plugged the whole of reality as extrapolated from a piece of fairy cake, and into the other end he plugged his wife: so that when he turned it on she saw in one instant the whole infinity of creation and herself in relation to it. To Tin Tragula’s horror, the shock totally annihilated her brain.’




  2. 2. To maintain one’s sense of self




    1. a. For example, an individual may have a deeply held conviction that they are a ‘happy go lucky’ person and not an angry or jealous person. Angry or jealous feelings will therefore threaten self-identity and may cause a narcissistic injury




  3. 3. To resist or postpone change




    1. a. The acceptance of feelings of unhappiness in a job or relationship might trigger a major life change that would cause upheaval and pain that would better be postponed




Case: James



James came to therapy in his early fifties. His last child had just left home to go to University and he had become aware he wanted to leave his wife. He told his therapist that he had probably been unhappy in his marriage for the last 10 years but had not realised this until now. He thought he might have delayed acknowledging this because the thought of separation from his children was unbearable.




  1. 4. A loss can be too large or too painful to face




    1. a. Frequently patients will express concern that if they really faced their pain they might start crying and never stop




  2. 5. Habitual behaviour




    1. a. In early stages of life, it can be helpful for a child’s survival to hide feelings that could destabilise an unpredictable or easily hurt caregiver. This frequently becomes dysfunctional later in development. The following case example illustrate this




Case: Barbara



Barbara was in her fifties when she started psychotherapy. During her childhood her mother had been emotionally overwhelmed and angry a lot of the time. Barbara had learnt to hide her angry feelings, because they would trigger maternal violence. Barbara achieved well and became a nurse. In retrospect she thought that she began suffering with depression in her twenties. She did not manage to form any long-term relationships or have children. She put all her energy into work which she said became her ‘family’. When a new manager, an older woman, was appointed Barbara could not get on with her and six months after her arrival a patient died on the ward. The manager implied that Barbara was responsible for the death through poor supervision of a junior nurse. Barbara became depressed and stopped work for the first time in her life. She lost weight, her mood became very low, she became very self-critical, couldn’t sleep and had suicidal thoughts. At this point Barbara started psychotherapy and gradually recovered over the next two years. She told her therapist that one of the most helpful elements in her recovery was the realisation that she was full of anger and hatred for her mother. The new manager reminded Barbara of her mother. She felt angry at what she perceived as unfair treatment and this anger was turned back onto herself. This resulted in depression.


This case illustrates a number of key themes in psychodynamic psychotherapy. Through excessive use of repression Barbara’s own anger was turned inwards causing her intense self-hatred and self-criticism. There had been unconscious patterns of relating throughout her life that had been reactivated by her experiencing at work. This is an example of how feelings about our self and others are linked with key formative relationships and are powerfully active throughout our lives. For further discussion of defences see Chapter 1.



Process of Therapy


The therapist’s role is to tune into communications from the unconscious of the patient and gently, where appropriate, feed these messages back in a digestible form through interpretation. Over the passage of time the unconscious gradually becomes conscious, the patients develop a deeper understanding of themselves and their unconscious contributions to the difficulties they are experiencing. Sometimes patients can come to therapy wanting a large amount of change in a short space of time. They might not be aware that addressing long-standing beliefs about themselves and others requires commitment and their distress and anxiety might get worse before it gets better. The emotional challenge of the therapeutic process is often rewarded and by the end of therapy their symptoms of psychological distress have receded, and significant gains are made in the capacity for intimacy, work, creativity and pleasure.



Therapeutic Relationship


The relationship is the key tool in therapy. Both therapist and patient are involved in co-creating the therapeutic experience. The therapist’s role is to accompany the patient in emotional exploration that can, at times, be painful for both participants. Unconscious patterns can be explored in this confidential and containing setting.



Transference and Countertransference


The unconscious communication from the patient is received by the therapist through transference and countertransference. Transference is the name given to the emotional residue of the patient’s past attachments brought live into the therapeutic relationship. These patterns of relating affect the patient’s other relationships and when seen clearly in therapy, where dysfunctional, they can be worked with and gradually changed.


The therapist’s countertransference response is formed by their emotional reaction to the patient’s transference, and their own past history. Sometimes these two aspects of countertransference are difficult to identify and separate, this is one reason why therapists need their own therapy and supervision.


A very common example of transference in therapy is that a patient can treat their therapist as they would one of their parents. This then can elicit an emotional countertransference response in the therapist whereby they experience the patient as childlike. They can then be pulled into behaving in a maternal or paternal manner. Supervision is important in helping the therapist identify their countertransference response and work with it in a productive way.


Countertransference is a ‘whole body’ experience and affects the therapist physically, emotionally and psychically. It requires open, honest and compassionate self-attention to be used effectively. The therapist can have angry or disturbed countertransference feelings. They can, at times, feel physically sick, in pain or restless. The following example illustrates a somatic countertransference response.



Case: Nelly



Amina was becoming preoccupied. Every time she was in a session with her patient, Nelly, she found she was thirsty. She tried drinking before each session but that did not help. As soon as Nelly left the room at the end of the session, Amina would rush to the kitchen to have a drink. It gradually emerged in therapy that Nelly had an alcohol dependency earlier in her life and the emotions emerging in therapy were stimulating her ‘need for a drink’. Once this was recognised and discussed in the sessions, Amina’s feeling of thirst subsided. There then was the opportunity to address Nelly’s underlying feeling of deprivation and dependency.


These somatic experiences can be very powerful. The mind and body are interlinked, and the body is a potent tool that resonates with others.



Case: Zeynep



Pardeep’s patient Zeynep had been suffering with chronic pain for five years since her mother’s death from cancer whom she had nursed through the final years of her life. Zeynep had been struggling with increasing pain in her legs, back and head since her loss. Pardeep found that he too started to feel pain in his head during the sessions which would build until Zeynep began crying about her mother’s death. When she started active mourning Pradeep’s headache evaporated. Pradeep realised that Zeynep was projecting her pain at the loss of her mother into her body, so that her psychic pain became physical pain, which Pradeep then identified and resonated with.


During a session a therapist can find their mind going to their own early memories, creative internal images, or to an event or conversation they had the day before the session. They can have primitive phantasies related to sex or aggression. These experiences are helpful if the therapist recognises them as part of their countertransference pointing them in the direction of the unconscious of their patient.



Case: Annabel



Asim’s patient Annabel had been struggling with anorexia. While she was talking an image formed in Asim’s mind of a small girl holding a bunch of balloons. The girl was being lifted up off the ground and drifting off into the sky. Asim linked this to the dissociated state of his patient who was not in contact with the ground, or reality, about the seriousness of her condition. She also talked later of ‘drifting off’ somewhere where she would no longer feel pain.


Another example of a more challenging but frequent countertransference response follows.



Case: Desmond



Andy found that he was starting to feel bored with his patient Desmond. It was hard to concentrate, and he started making a shopping list for his dinner. He felt guilty about this and was concerned that he was not attending to Desmond. When this continued to happen, he wondered if this was a countertransference response. He asked Desmond how he was experiencing the therapy; he said that he dreaded it, feeling exposed and he tried to hide what he was feeling. Andy realised this feeling of boredom was related to the sense of dread that Desmond felt where he hid everything creative from Andy. Once acknowledged, Andy felt more connected to his patient and more alive as a therapist.


Therapists’ countertransference responses occur largely through identification with their patients’ projected feelings. Patients may or may not be aware of these feelings themselves.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 6 – Psychodynamic Psychotherapy Practice: An Introduction
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