Lydia Khuri, Psy.D.2/1/11

Outline Framework*

Theoretical assumptions Psychoanalytic sensibility Multicultural/feminist critiques Empirical research Preparing the therapist Preparing the client Therapy process Boundaries

Case Material

*based on Nancy McWilliams (2004) and Jonathon Shedler (2010)

Learning Objectives

You will be able to identify components of the psychoanalytic psychotherapy framework

You will be able to identify components of the framework as applied to a case study

Contemporary Psychoanalytic What comprises psychodynamic

psychotherapy? (Shedler, 2010)

1. Focus on affect and expression of emotion2. Exploration of attempts to avoid distressing thoughts

and feelings3. Identification of recurring themes and patterns4. Discussion of past experiences (developmental focus)5. Focus on interpersonal relations6. Focus on therapy relationship7. Exploration of fantasy life

Basic Motivational Systems Contemporary (Lichtenberg, 1989)

1. Psychic regulation of physiological requirements2. Attachment and affiliation3. Exploration and assertion4. Aversive reaction through antagonism or withdrawal5. Sensual enjoyment and sexual excitement

Psychoanalytic Sensibility Curiosity and awe Identification and empathy Subjectivity and attunement to affect Attachment Faith

Multicultural/feminist Critiques Feminist critique of inherent

androcentrism Biologically-based gender differences Reification of power relations between men &

women Normative gender and sexual development Deterministic (personality patterns

established in early development) Feminist principles

Personal is political Commitment to change on social level Female subjectivity Egalitarian therapeutic relationship Focus on strengths Recognition of interlinking of oppression

Multicultural/feminist Critiques Multicultural critique of Western worldview

Role of the past Blaming parents Concept of trauma Family structures Autonomous self

Multicultural principles Focus on cultural identity in relation to

psychological well-being Understand power in therapy and larger social

contexts Understand worldviews

View of human nature Orientation toward time Definition of proper human activity Definition of social relations Understanding of relationship of people and nature

Empirical Research*

1. Psychoanalytic psychotherapy as effective as other empirically-supported treatments (effect sizes similar)

2. Core processes and techniques as defined by psychoanalytic theory are facilitative of change, regardless of theoretical orientation

3. Effects extend beyond symptom reduction and after therapy has ended

4. Factors of culturally sensitive therapies have not been teased apart from “traditional” variables (Sue et al., 2008)

Shedler (2010)

Preparing the Therapist

New therapists make lots of mistakes Being yourself in role of therapist Supervision Own therapy Broad education

Preparing the Client/patient Psychotherapy as peculiar

relationship Physical safety Emotional safety Informed consent Encourage spontaneous, candid,

emotionally expressive speech Introduce work of transference Boundaries

Therapy Process

Listening Talking Facilitation Power Therapeutic power Empowering the client Love

Major Concepts Unconscious

As adjective: mental contents not available to conscious awareness As noun: component of mental system known as id, yet some aspects

of ego (defenses) and superego (moral standards) part of Ucs. The adjective form is generally accepted in contemporary

psychoanalysis whereas there are several models of the mental system besides Freud’s model known as structural.

Defense The ego’s attempt to protect self against danger, overwhelming, or

unacceptable affect and ideas Repression: exclusion from awareness thoughts and feelings once

felt consciously or never felt consciously; ex., hatred directed at a sibling.

Reaction formation: changing unacceptable thoughts and feelings to acceptable; ex., longing for loving experience changed into hatefulness

(Moore, B E. & Fine, B. D. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press.)

Major Concepts

Transference Displacement of feelings, thoughts, patterns of behavior, originally

experienced in relation to significant figures during childhood, onto a current relationship.

More intensified in psychoanalysis; reveals early patterns

(Moore, B E. & Fine, B. D. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press.)

Boundaries

Chance encounters Social invitations Gifts Request for other therapy Disclosure Touch Sex

Case Material: “James”

James’s reasons for seeking therapy My early clinical impressions James’s personal history Phases of therapy

Beginning Middle End (“Termination”) Post termination

Reasons for Seeking Therapy Referred by a university mental

health center for longer term psychotherapy

Crisis about major Symptoms of depression Sense of feeling lost Feeling effects of parents’ divorce

two years ago

James’s Initial Presentation Monotone & restricted expression of

affect Image of wave (overwhelming

feelings) Anxiety “Waiting” expression Subtly vigilant Pleased others & took on feelings of

others Didn’t want to make waves

My Early Impressions

Earnest General vagueness in contrast to moments of precise

insight Strengths

Attentive Thoughtful, intelligent Sense of humor Willing to try

Types of defenses Reversal Exhaustion/keeping extremely busy “Fogginess”/not noticing things

Lack of “dialogue” How would I need to be with him?

James’s Personal History

19 y/o, single heterosexual, college student Father 1st generation Chinese American, not religious,

converted to Catholicism Sacrificing, wants things to be “normal,” i.e., no conflict

Mother European American, raised Catholic Alcoholic; affectionate when inebriated but otherwise

enraged and explosive Parents divorced when James 17 y/o Younger brother by 4 years

Explosive like mother Top student in high school Premed but struggled Switched to another major with some success Paying for college himself

Treatment Goals

Not in crisis when he came to me Exploratory psychodynamic

psychotherapy Feel better Find his niche, who he was Therapy lasted 3 yrs, 8 mo’s

How I worked with James

What I did Listened Communicated interest and warmth Explained how therapy works Provided structure by asking open-ended

questions while remaining attentive to his cues “What’s your inside life like?”

Reflected back Did not let silence lapse too long

What I did not do Interpret too much Give advise

Initial Phase: Themes

Sadness persisting beyond subsiding of depression symptoms

Sensitivity to emotional intrusion Distancing from affect (speaking in second

person, e.g., “Being alone let’s you think too much.”)

“Squashing” affect (“I don’t like to get too excited about things.’)

Trouble with initiating conversation Ambivalence about attachment

Foreshadow process: “I’m afraid to attach b/c it will go away.”

Foreshadow ending: “I don’t know how to do endings.”)

Initial Phase: Progress

Within 4 mo’s Symptoms of major depression remitted but

paradoxically began to experience persistent, puzzling melancholy

Met a girl he really liked Doing better in school but questioning purpose Insight into emotional pattern: turn anger into

sadness Insight into family dynamics: mother doesn’t

“see” him; father didn’t intervene By 6th Month

Could tolerate my having separate mind to mirror him

Second Phase

Long phase of exploration Talked more openly but still trouble

initiating conversation Sadness more accessible if not sources Focus on current life Weathered ups and downs with girlfriend Left school to work full time Attempted to integrate painful truths

about his family he learned while in therapy Parents marrying b/c mother was pregnant

Second Phase: Themes

Anger Self-assertion Ambivalence about cultural identity Loss of closeness to father Ambivalence about growing up Fear of dependency and separation

(felt less of it in relation to me)

Second Phase: Progress

Seeking others to express dependency needs and allowing attachments (girlfriend; friends)

Explore own power and authority (trusting own feelings; role as manager)

Able to talk about therapy itself; what needed from me

Able to take in my mirroring about positive aspects of self “You’re sadness isn’t just buried. There’s also

aliveness and spontaneity.”

Termination

Initiated by James We agreed on a date (three months

hence) Tolerated some exploration of

meaning & feelings Consolidation and On-going issues

Consolidated Changes

Behavior Initiated separation from me Tolerated exploration of motivation Better social network of friends Long lasting romantic relationship & commitment to future Stand up to girl friend Promotion at work Able to set some limits/say “no” at work Initiated separation from family w/out “cutting them off”

Intrapsychic Greater range of expressed affect Moments of experiencing grief for past Tolerate ambivalence better Consider own needs and feelings Saw parents in more realistic light Acknowledge ambition

Remaining Issues

Effects of mother’s issues & alcoholism Caretaker Substitute husband

Persistent hope for more closeness with both parents based on infant/childhood needs

Unresolved issues about surpassing parents’ academically, especially father

Fear of dependency and rage

Transference

In behavioral terms “stimulus generalization” Old relational paradigm

Took care of me by not burdening me with his needs, feelings, or hopes

I would be indifferent or hostile if he expressed needs He waited for me to take lead

New relational paradigm I was a calming, understanding presence (but kept at a

distance) My subjectivity did not overwhelm his I gave him time to think (literally) He could explore his need for me to take lead He could initiate separation from me and not be

undermined by guilt

Countertransference

Strong personality Fleeting moments of boredom and rage Different defenses to deal with

dependency issues Me: action/ambition/grandiosity James: passivity/floating/shrinking

Distanced from his helplessness and “inner deadness” to avoid confronting my own

Own on-going therapy and paid consultation

Post-therapy Contact

Able to explore with my support Able to acknowledge limitations of

therapy relationship Relieved that he could come back

(“safety net”) Called several months later

Engaged Doing well Therapist recommendation for fiancée

End“If change were easy, psychotherapists would be out of a job.”

Nancy McWilliams, Psychoanalytic Psychotherapy: A Practitioner's Guide

Suggested Reading Lowder, G., Hansell, J., McWilliams, N. (n.d.) The enduring

significance of psychoanalytic theory and practice. Retrieved February 9, 2008 from http://www.division39.org/sec_com_pdfs/PsychoaResearchPP.pdf

McWilliams, N. (2003). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guildford press.

Milrod, et al (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164(2): 265-272.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.