Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Although supportive psychotherapy and interpersonal psychotherapy share some similarities, these therapeutic approaches have many differences. When assessing clients and selecting therapies, it is important to recognize these differences and how they may impact your clients.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment. For this Assignment, as you compare supportive and interpersonal psychotherapy, consider which therapeutic approach you might use with your clients.

Learning Objectives

Students will:

  • Compare supportive psychotherapy and interpersonal psychotherapy
  • Recommend therapeutic approaches for clients presenting for psychotherapy

To prepare:

  • Review the media in this week’s Learning Resources.
  • Reflect on supportive and interpersonal psychotherapeutic approaches.

The Assignment

In a 1- to 2-page paper, address the following:

  • Briefly describe how supportive and interpersonal psychotherapies are similar.
  • Explain at least three differences between these therapies. Include how these differences might impact your practice as a mental health counselor.
  • Explain which therapeutic approach you might use with clients and why. Support your approach with evidence-based literature.

NOTE: THE CLIENTS SHOULD BE OLDER ADULTS FROM 52 YRS TO 99YRS.

Note: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

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ALL REFERENCES SHOULD BE 5 YEARS OR LESS. INCREASE THE TEXTBOOK REFERENCES BELOW AND NOT COUNTED AS YOUR TOTAL NUMBER OF REFERENCES Required Readings Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company. • Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242) • Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Dilemma of Psychotherapy Notes and HIPAA

by Ruby Nicholson, RHIT

For HIM professionals in behavioral health settings, the HIPAA privacy regulations pose a downright dilemma. Here’s why.

The privacy rule defines psychotherapy notes as:

Notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separate from the rest of the individual’s medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

The dilemma for many HIM professionals is determining what this means within the outpatient setting, particularly in free-standing outpatient behavioral health clinics.

Unlike an acute care hospital, where psychosocial documentation is maintained separately, records in behavioral health clinics are composed of screening assessments, psychosocial summaries, medication prescribing and monitoring, clinical tests, psychiatric evaluations, treatment planning, progress notes from multidisciplinary behavioral health teams, discharge summaries, and follow-up care. In a sense, the entire record could be considered a continuum of psychotherapy notes.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

However, the privacy regulations are clear that only those psychotherapy notes kept separate from the rest of the individual’s record are afforded additional protection. All psychotherapy notes maintained with other documentation lose any special protection for confidentiality and are not required to be treated differently. (Remember, however, that special provisions to some information apply in regulations such as those related to drug and alcohol abuse treatment and in state laws related to mental health disorders.) Because there was no further definition of psychotherapy notes in the guidance released in July 2001, organizations are left to further define how to handle psychotherapy notes on their own.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

The Law and Definition of Psychotherapy Notes

Clinical tests, assessments, treatment plans, case management notes, and other documentation found in a behavioral health record are just as confidential as counseling or therapy notes, and they often contain even more sensitive material. As a result, HIPAA task forces within many organizations are currently engaging in discussions around their definitions of psychotherapy notes. It may be possible to define some, if not all, of the documents in a behavioral health record as psychotherapy notes.

Included in these discussions is a review of individual state laws dealing with the release of information for mental health records. Some states have adequate language within existing state law that provides the protection not available through federal privacy regulations. In states where laws involving release of mental health records are ambiguous, HIM professionals need to initiate language with their state legislators now.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Because the privacy regulations do not preempt 42 CFR Part II (the federal law relating to the confidentiality of alcohol and drug abuse patient records) substance abuse providers will not lose the existing additional protection, but they will need to ensure that other components of the privacy regulations are implemented. Behavioral health organizations that are federally assisted substance abuse providers and also provide mental health services may decide to cover the entire organization under 42 CFR Part II. This has both advantages and disadvantages depending on the structure of service delivery within the organizations, so professionals will want to review this closely before making any final decisions.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Regardless of the type of behavioral health services an organization delivers, it is imperative for HIM professionals to prepare well in advance of the April 2003 implementation date. Internal discussions, agency decisions, and passage of state laws all take time. Individuals working in behavioral health must be proactive in planning privacy implementation strategies.

Ruby Nicholson is director of QI/health information at Kent County Mental Health Center, Warwick, RI.

Article citation:
Nicholson, Ruby. "The Dilemma of Psychotherapy Notes and HIPAA." Journal of AHIMA 73, no.2 (2002): 38-39.

 

Information Related to Mental and Behavioral Health, including Opioid Overdose

At times, health care providers need to share mental and behavioral health information to enhance patient treatment and to ensure the health and safety of the patient or others.  Parents, friends, and other caregivers of individuals with a mental health condition or substance use disorder play an important role in supporting the patient’s treatment, care coordination, and recovery. Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

The HIPAA Rules are designed to protect the privacy of all of an individuals’ identifiable health information and to ensure that health information is available when needed for treatment and other appropriate purposes.  Given the sensitive nature of mental health and substance use disorder treatment information, OCR is providing this guidance addressing HIPAA protections, the obligations of covered health care providers, and the circumstances in which covered providers can share information—as applied to this context.

This page is intended to be a one-stop resource for guidance and other materials on how HIPAA applies to mental health and substance use disorder information.  It will be periodically updated with additional information

Fact Sheets

HIPAA Helps Caregiving Connections NEW!

Information for patients with a mental health condition or substance use disorder, family and friends of these patients, and mental health professionals with a patient who may be a danger to themselves or others.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

When Your Child, Teenager, or Young Adult has Mental Illness: What Parents Need to Know about HIPAA - PDF NEW!

HIPAA Privacy Rule and Sharing Information Related to Mental Health - PDF Updated 12/19/17

This guidance addresses some of the more frequently asked questions about when the Privacy Rule permits a health care provider to share the protected health information of a patient who is being treated for a mental health condition.  The Rule is carefully balanced to allow uses and disclosures of information—including mental health information—for treatment and certain other purposes with appropriate protections.   The mental health guidance addresses three core areas: Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

  1. How information related to mental health is treated under HIPAA;
  2. When information related to mental health may be shared with family and friends of an individual with mental illness, including parents of minors; and
  3. The circumstances in which information related to mental health may be disclosed for health and safety purposes.

Guidance on Responding to an Opioid Overdose - PDF

HHS Office for Civil Rights has released guidance on when and how healthcare providers can share a patient’s health information with his or her family members, friends, and legal personal representatives when that patient may be in crisis and incapacitated, such as during an opioid overdose.

HIPAA and Personal Representatives for Adults and Minors

HIPAA recognizes that some patients (including those with a mental illness or substance use disorder) may be unable to make their own health care decisions, including decisions related to health information privacy.  HIPAA provides personal representatives of a patient with the same rights to request and obtain health information as the individual, including the right to obtain a complete medical record under the HIPAA right of access.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Parents of minor children (typically under age 18) are generally the personal representatives of their children.  State law addresses the age at which a minor child may consent to certain types of health care and may contain additional requirements related to disclosing a minor’s health information to parents (or withholding it).

HIPAA also allows a health care provider to determine, based on professional judgment, that treating someone as a patient’s personal representative for HIPAA purposes would endanger the patient, and to refuse to treat the person as a personal representative under those circumstances.  This applies whether the patient is an adult or a minor child.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Mental Health FAQ’s Updated 12/19/17

OCR has organized certain FAQ's related to handling mental health information under HIPAA in two easy-to-access PDFs.

Substance Use Disorder Treatment Records

The protected health information of individuals who receive drug and alcohol abuse treatment in federally-funded programs is subject to additional privacy protections under 42 USC § 290dd-2 and 42 CFR § 2.11 (Part 2). These federal rules are administered by HHS’s Substance Abuse and Mental Health Services Administration (SAMHSA).

Week 7: Supportive and Interpersonal Psychotherapy

Amelia, a 16-year-old high school sophomore, presents with symptoms of weight loss and a very obvious concern for her weight. She has made several references to being “fat” and “pudgy” when, in fact, she is noticeably underweight. Her mother reports that she is quite regimented in her eating and that she insists on preparing her own meals as her mother “puts too many fattening things in the food” that she cooks. After discovering that during the past 3 months Amelia has lost 15 pounds and is well under body weight for someone of similar age/sex/developmental trajectory, the psychiatric mental health nurse practitioner diagnosed Amelia with anorexia nervosa.

Evidence-based research shows that clients like Amelia may respond well to supportive psychotherapy and interpersonal psychotherapy. So which approach might you select? Are both equally effective for all clients? In practice, you will find that many clients may be candidates for both of these therapeutic approaches, but factors such as a client’s psychodynamics and your own skill set as a therapist may impact their effectiveness.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

This week, you continue exploring therapeutic approaches and their appropriateness for clients as you examine supportive psychotherapy and interpersonal psychotherapy. You also assess progress for a client receiving psychotherapy and develop progress and privileged psychotherapy notes for the client.

Photo Credit: Laureate Education

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

  • Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)
  • Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

Note: You will access this text from the Walden Library databases.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Note: You will access this resource from the Walden Library databases.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)

 

Note: You will access this article from the Walden Library databases.

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

 

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

 

Note: For this week, view Reality Therapy, Feminist Therapy, and Solution-Focused Therapy only. You will access this media from the Walden Library databases.

Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.

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Note: You will access this media from the Walden Library databases. The approximate length of this media piece is 110 minutes.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Supportive and Psychodynamic Psychotherapy

KATHLEEN WHEELER

This chapter begins with an overview of the underlying assumptions of psychodynamic psychotherapy, the history, and evidence-based research. Psychodynamic psychotherapy is discussed as on a continuum, with supportive, expressive, and psychoanalytic approaches considered. Rationale is provided for choice of approach based on developmental considerations for clinical decision making. How to develop a case formulation and the working through phase of treatment is examined, as is working with alliance ruptures and dreams. Guidelines for brief psychodynamic psychotherapy are provided with case studies illustrating concepts and techniques throughout the chapter. Those skilled in psychodynamic psychotherapy recognize the difficulties in suggesting specific standardized techniques, because technique is driven by the context of the interaction.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

In the current environment of managed care, in which a course of psychotherapy is often three to six sessions, practicing any meaningful relationship-based work is difficult, if not impossible. With these limitations in mind, an overview of relevant concepts and technical considerations is presented. The chapter ends with information about postmaster’s training and certification requirements for psychodynamic psychotherapy. Chapter 4 reviews the basic concepts of transference, countertransference, and resistance, which are foundational to understanding psychodynamic psychotherapy.

With the American Psychiatric Association’s (2008) mandate that all psychiatric residency training programs teach long-term psychodynamic psychotherapy to meet standards of accreditation, the relevance and importance of this type of therapy were affirmed by the psychiatric establishment (Gabbard, 2010). Knowledge about psychodynamic psychotherapy is essential for all advanced practice psychiatric nurses (APPNs) to deepen understanding about development and how the patient’s history is reenacted in the nurse–patient relationship in therapy and in life. Even if the APPN is using another approach, it is still important to understand the person’s dynamics to inform decisions about treatment. The patient does not necessarily need to achieve dynamic insights to experience symptom reduction and personal growth, but developmental considerations, anxiety, transference, countertransference, implicit memory (unconscious), defenses, motivation, and resistance are relevant in any therapeutic encounter. Knowledge about psychodynamic theory is also important for APPNs to communicate with other mental health disciplines. The literature in nursing reiterates the importance of psychodynamic theory for understanding the psychodynamics in the nurse–patient relationship and the inner world of both the nurse and the patient (Gallop & O’Brien, 2003). These authors stress that without knowledge of psychodynamic psychotherapy, nurses are at a tremendous disadvantage and at risk for acting inappropriately and not in the patient’s best interests.

Psychodynamic psychotherapy requires intensive teaching and experience to attain competency. This chapter lays the foundation for the APPN who wishes to understand the basics of this approach. Competencies in psychodynamic psychotherapy include using developmental models to understand personality and psychopathology, formulating a psychodynamic explanation and plan treatment, tracking the issue that is the focus of treatment, implementing the process of therapy, and managing the relationship (Binder, 2004).

UNDERLYING ASSUMPTIONS OF PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy is derived from psychoanalytic psychotherapy, which was developed by Sigmund Freud at the end of the 19th century. This type of therapy is also referred to as insight-oriented, intensive, exploratory, expressive, and depth psychotherapy. Underpinnings of psychodynamics are rooted in developmental theory, with the basic premise that what has happened in the past determines what we are doing today. It is thought that through understanding these factors, the person is empowered and then free to make more conscious decisions and consequently live a more satisfying and useful life.

Blagys and Hilsenroth (2000), in an extensive review of the literature, identify factors that distinguish psychodynamic from cognitive behavioral therapy (CBT). These include emphasis on the past; focus on expression of emotion; identification of patterns in actions, thoughts, feelings, experiences, and relationships; emphasis on past relationships; exploration of and working with resistances that impede treatment; exploration of intrapsychic issues through asking about wishes, dreams, and fantasies; and emphasis on the transference and the working alliance. Gabbard (2010) identifies seven key concepts of psychodynamic psychotherapy: the unconscious, a developmental perspective, transference, countertransference, resistance, psychic determinism, and unique subjectivity. Gabbard explains unique subjectivity as the therapist’s challenge to pursue the patient’s subjective truth and true self, which most likely has been thwarted by parents who cannot recognize, validate, and appreciate this self. This is based on the underlying premise that we do not really know ourselves and that much of what determines our behavior is governed by unconscious memories.

Most psychodynamic schools emphasize the centrality of conflict among powerful desires, wishes, and fears. Psychodynamic clinicians believe that to help the person, it is essential to understand how these conflicts are enacted in the present. Psychodynamic theorists agree that understanding unconscious psychological structures and patterns in daily life, as well as how they interact and maintain each other, are essential ingredients to understanding the person (McWilliams, 2011; Wachtel, 2011). Wachtel points out that a key characteristic of this pattern is irony; the person ends up in the very position that he or she was trying hard to avoid. For example, the person who is fearful of feelings of anger may act overly nice, unassertive, and maintain a passive stance toward others. This allows others to ignore his or her needs and, consequently, he or she begins to feel frustrated and devalued, which leads to more anger and more anxiety, and the pattern is repeated. Another example is a person who fears hostility from others and interprets every interaction as potentially hostile, preemptively acting in self-protective hostility toward others, which evokes hostility from others, which leads to more anxiety, and so on (Figure 5.1).

Anxiety is central to understanding these difficulties, and even if the person does not feel particularly anxious, defenses and characterological personality traits embedded in implicit memory systems bind the person to a life that is restrictive as compromises are made to keep anxiety at bay. Specific anxieties arise at every level of development, with various theorists positing different tasks based on various theoretical models (Tables 5.1 through 5.3). For each developmental stage, anxiety revolving around a specific issue is negotiated, and if successful, the fear surrounding that phase is assuaged so that the person is then able to proceed to the next stage without being preoccupied by that threat (McWilliams, 1999). For example, in early infancy, a major preoccupation is security, with annihilation the threat if the attachment to the mother is threatened or not present; for early childhood, the issue is autonomy, with the concomitant anxiety revolving around separation (i.e., how to be an independent agent and still maintain a relationship with the caregiver); for later childhood, issues of identity must be resolved, with fears of punishment, injury, and loss of control important to resolve. To regulate the anxiety associated with each stage and other painful affects, defense mechanisms develop in implicit memory networks through interaction with caregivers and interpersonal experiences.

FIGURE 5.1 Cyclical psychodynamics.

The job of the psychodynamic therapist is to help the person understand how fears and inhibitions in early life have led him or her to react to healthy feelings as if they were a threat and how this plays an active role in generating his or her difficulties in the present. The person inadvertently and consistently brings about consequences that are not consciously intended. The psychodynamic therapist uses interpretations to expose the person to previously avoided experiences combined with empathy in a safe therapeutic environment. Chapter 4 discusses interpretation. The focus of the interpretation depends on the school of psychodynamic thought the therapist subscribes to. This exposure is not just aimed toward intellectual understanding but emotional experiencing at a gradual pace. Re-experiencing painful affects allows adaptive processing so that dissociated or disconnected memory networks can be integrated with other, more adaptive neural networks (Cozolino, 2010).Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

HISTORY

The history and theory of psychodynamic psychotherapy since Freud’s time are complex, and his ideas have undergone numerous permutations and iterations. This evolution has paralleled paradigm shifts in science in the 20th century, which emphasize interconnections, mutual interactions, and subjectivity of phenomenon (Curtis & Hirsch, 2003). Each psychodynamic model evolved from the others before establishing a new perspective placing different emphases on human development and motivation for behavior. New perspectives addressed what was seen as the failure of Freud’s theory (Mitchell, 1988). These competing schools of thought—Freudian, ego, self, existential, Lacanian, analytic, object relations, interpersonal, relational, and intersubjective—are somewhat insular and fragmented in that each seems to take little notice of the others. Each school developed its own theoretical constructs and techniques. The following overview highlights selected theorists and does not do justice to the complexity, richness, and nuances of psychoanalytic theory.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

TABLE 5.1 Freud’s Psychosexual Stages

Adapted from Sadock, Sadock, and Ruiz (2009).

Sigmund Freud’s classic model of psychoanalytic psychotherapy is based on drive theory; that is, all behavior is determined by unconscious forces or instincts, either sexual or aggressive. Freud’s structural model of the id, ego, and superego explains the idea of psychic conflict. Symptoms are thought to develop through a conflict between an instinctual wish (id) and the defense against the wish (ego). The superego is part of the unconscious that is formed through internalization of moral standards of parents and society, and the superego acts to censor and restrain the ego. The concept of psychic determinism is embedded within this model and refers to the idea that nothing happens by chance and that everything on a person’s mind and all behavior, pathological and nonpathological, has a cause and is multiply determined. Freud delineated the psychosexual stages of development based on the idea that libidinal energy shifts from various erogenous zones in each stage. Freud posited that if a person had not successfully negotiated the previous stage, specific problematic character traits or psychopathology would continue throughout life (see Table 5.1).Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

In the 1960s, the scope of psychoanalysis was widened by interpersonal theorists such as Harry Stack Sullivan, Karen Horney, and Eric Fromm, who stressed the importance of relationship. Sullivan believed that the details of the patient’s interactions with others provided insight into what would help resolve intrapsychic difficulties. Using Sullivan’s framework, Hildegard Peplau developed the psychodynamic interpersonal model for psychiatric nursing. Sullivan’s perspective of the therapist as participant–observer expanded the prevailing paradigm. Sullivan believed that the therapist was not just a passive observer of what was going on in the patient but was a participant in the process of psychotherapy.

TABLE 5.2 Mahler’s Stages of Separation–Individuation

Adapted from Mahler, Pine, and Bergman (1975).

Ego psychology and object relation theorists such as Margaret Mahler followed with increased emphasis on relationship in producing change. Mahler’s object relation theory evolved from her observations of infants and children and analysis of this qualitative data (Mahler et al., 1975). Stages of development based on separation–individuation were described and explanations were offered about how children develop a sense of identity separate from their mothers (see Table 5.2). The infant is described as being totally dependent, with relatively little self–other differentiation, and the child develops through a relationship into a separate person with a high degree of differentiation.

Klein and Fairburn combined intrapsychic theory and drive theory with the idea that the primary motivation of the child is to seek objects (Curtis & Hirsch, 2003). Object means the internalization of experiences with other people. Object relation theorists posit that people are primarily motivated to seek other people and that this is the central motivating force in development rather than drive gratification (Winnicott, 1976). Winnicott (1976) speculated that for a child to develop a healthy, genuine self, as opposed to a false self, the mother must be a good enough mother, who relates to the child with primary maternal preoccupation. The child then can grow and explore without overwhelming anxiety feeling that the world is safe. The child develops a sense of me and those aspects that are not part of him or her create a potential space between himself or herself and the mother. This is the area of play and is an important dimension of the developing self. Winnicott (1976) said that the therapist’s chief task is to provide a holding environment for the patient so that the patient can have the opportunity to meet neglected ego needs and allow the true self to emerge. In contrast to the good enough mother, the not good enough mother is thought to create a dynamic in subsequent relationships in adult life, in which the person feels never good enough. Alice Miller (1981) in her widely recognized book, The Drama of the Gifted Child, describes eloquently the adverse effects of certain types of parenting on the development of the child’s true self.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Building on Freud’s ideas about intrapsychic conflict, Erik Erikson, a lay psychoanalyst, expanded the theory of development to encompass the entire life cycle. He conceptualized life as a struggle of conflicting needs in the quest toward self-actualization (Erikson, 1964). These conflicting needs revolved around the need for stability versus the need for growth at each stage of development. Table 5.3 shows Erikson’s stages of development. As we move from infancy to old age, Erikson posited that we face a stage-specific conflict that involves themes of inhibition versus desire. Although similar symptoms may be experienced in each stage, each of the eight stage-specific conflicts may have a different meaning, depending on unique issues and emotions for that particular stage, and success at resolution depends on how successfully the person has negotiated the previous stages.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

TABLE 5.3 Erikson’s Psychosocial Stages

Adapted from Erikson (1964, 1968).

For example, a 21-year-old woman came to therapy after being raped in college. She had become significantly depressed and attempted suicide shortly after the rape. Her depression reflected a loss of identity that was shattered beyond repair. She had previously functioned as her parents expected her to and was generally motivated to meet others’ expectations. Her depression precipitated an exploration of her own values and who she really was, a process that gradually allowed her to rebel against the need to conform. Finding her own voice was integral to the treatment, and she eventually was able to articulate the differences between her opinions and those of her parents. Her depressive symptoms represented the conflicting need for stability and conformity versus the need for self-awareness and growth.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Significantly departing from the idea of intrapsychic conflict, Heinz Kohut developed self psychology based on a deficit model of development. Kohut posited that the self was the central organizing frame of reference and that the self seeks out responses from others to maintain self-cohesion (Kohut & Wolf, 1978). Contrary to Freud’s conception of the individual as primarily being driven by the quest for pleasure, Kohut’s self strives for competence, self-esteem, and order, and these are the sine qua non motivators of behavior. Others serve self-object functions for the individual, and these include mirroring, idealizing, and alter-ego experiences. Individuals never lose the need for self-object experiences throughout life. However, if self-object experiences are less than adequate in early life, the person may later in life have difficulty with self-soothing, self-regulation, and maintenance of self-cohesion. Kohut based this idea on the clinical observation that a certain subgroup of patients developed an idiosyncratic transference in therapy, which he called the narcissistic transference. These patients, unlike the typical analytic patient, needed mirroring and idealized the analyst. Those with this type of self-pathology formed attachments based on these needs. Kohut posited that empathy played a central role in the psychotherapy of those with narcissistic psychopathology.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

The relational model evolved in the 1980s from object relations, self, interpersonal, existential, and feminist models. This significant shift in the psychoanalytic paradigm changed what was called a one-person psychology to a two-person psychology (Gabbard, 2010). This awareness of two separate minds interacting with one another is also referred to as intersubjectivity. The therapist is considered a coparticipant in the co-construction of the relationship, not an outside observer. It is only in the present moment as the process is unfolding that both participants’ understanding is deepened. The need for relationship derives from the physical closeness to the mother and is thought to be the prime motivator for behavior. The presence of the other is necessary and inescapable in human development and in the therapeutic relationship. Self-regulation results from mutually regulatory interactions with caretakers and evolves within the mother–infant dyad. Relational psychodynamic theory heightens our understanding about the need for attachments for psychophysiologic stability.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Schore’s (2012) neurobiologic research and theory on attachment provides a scientific basis for the importance of relationship to therapeutic action in psychotherapy. The growing capacity to self-regulate is contingent on transformations of underdeveloped functions that exist in the infant through early attachment experiences that assist the developing psychobiologic, homeostatic regulatory processes. Cumulative early attachment problems are thought to produce chronic dysregulation in central and autonomic arousal, with deficits in mind and body. Chapter 2 discusses the neurophysiology underlying this dysregulation. Problems in self-regulation include difficulties in tension regulation, such as in addictive disorders, eating disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder, and mood disorders.

A basic tenet of the contemporary relational model is that the therapist and patient are always participating in a relational configuration and that understanding this process is how change occurs. Before relational theory, much discussion ensued about the differences between the transference relationship and the real relationship between the therapist and patient. The transference and the patient’s feelings toward the therapist were artifacts of the past, whereas the real relationship was what was going on in the present. In the relational model, however, this is irrelevant because there are multiple truths and there is no real relationship, only a co-constructed interaction that is at best subjective (Gabbard, 2010). This interaction coupled with mindfulness is the agent of change, and developing and repairing problems in the therapeutic alliance are considered the work of relational psychodynamic psychotherapy.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Embedded in this idea of multiple truths is the concept of multiple selves; there is no unitary true self, but each person is constructed with many self-states. Different self-states are based on the various states of consciousness that we flicker in and out of throughout the day. Chapter 2 discusses the neurophysiology supporting this idea. These shifting, multiple self-states elicit complementary self-states in others through relationship. Dissociated self-states that are experienced as potentially dangerous are kept from the person’s awareness. By potentially dangerous, Safran and Muran (2000) explain that these states are associated with actual traumatic experiences or disruptions of relatedness to significant others. Assisting the patient to experience and accept the various dimensions of the self through enhanced awareness of these traumatic states is considered crucial to the relational psychodynamic therapy process.

A synthesis of the literature on the relational model reveals significant differences between Freudian psychodynamic psychotherapy and relational psychodynamic therapy. Table 5.4 compares and contrasts these models.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

EVIDENCE-BASED RESEARCH

Studies of the efficacy of psychodynamic psychotherapy began in earnest only within the past 10 years because this type of therapy developed outside of universities and the academic world (Shedler, 2010, 2011). Education and training in psychoanalysis took place in institutes that were open only to medical doctors and excluded psychologists who are trained in research methodology. However, several compendiums of psychoanalytic research published within the past 10 years have attempted to address this deficiency by presenting reviews of psychodynamic research (Fonagy 2002; Levy & Ablon, 2009). These volumes report positive results for psychoanalytic psychotherapy.

TABLE 5.4 Comparison of Classical Psychodynamic Therapy With Relational Psychodynamic Therapy

The late start for research on psychodynamic therapy does not demonstrate that this approach is not effective, but it may more accurately reflect the difficulties in experimental controlled design for this approach. Numerous methodological problems for research on psychodynamic psychotherapy have been identified, because psychodynamic techniques do not lend themselves to the precision required for a clinical trial (Curtis & Hirsch, 2003; Gabbard, 2010). The problems cited in the literature include the following:

  1. 1.  Manualized, structured protocols, such as CBT and interpersonal psychotherapy (IPT), are easier to systematically evaluate.
  2. 2.  There is great difficulty in randomizing subjects, which is the gold standard of experimental design. Patients who want to engage in psychodynamic psychotherapy must be motivated to engage in the self-reflected exploration needed and are self-selected.
  3. 3.  If the treatment is long term, which some psychodynamic therapies are, the costs would be too great to follow patients over time.
  4. 4.  Funding is lacking for studies in psychodynamic psychotherapy.
  5. 5.  The complexity and variety of psychodynamic approaches and technique make adherence to a specific model for intervention in an experimental design difficult.
  6. 6.  Because subjectivity and context are embedded in the psychodynamic process, it is not possible to study by traditional objective scientific inquiry.
  7. 7.  Most psychodynamic research consists of case studies, which limits the ability to generalize to other situations and populations.
  8. 8.  Outcomes involve internal change for psychodynamic psychotherapy, which is difficult to quantify.
  9. 9.  Randomized clinical trials focus on patients with one specific diagnosis and symptom measurement. Patients treated with psychodynamic therapy present with complex problems that usually are not limited to one disorder.

Despite the above limitations, many randomized clinical trials in the literature report positive results. The most compelling evidence includes meta-analytic studies of randomized clinical trials which are considered the most effective statistical method for synthesizing the findings of many studies through using effect size as a comparison. Effect size is the difference between the control and experimental groups with a 0.8 indicating a large effect size, 0.5 a moderate effect size, and 0.2 a small effect size. A review of meta-analytic studies of psychodynamic studies reveals overall large effect sizes for pretreatment to post-treatment outcomes. See Table 5.5 for selected meta-analytic studies. The large effect sizes for psychodynamic psychotherapy 0.69 to 1.46 are impressive but even more so when compared with studies of the U.S. Food and Drug Administration (FDA) research, which found effect sizes for fluoxetine (Prozac) of 0.26, for sertraline (Zoloft) of 0.26, citalopram (Celexa) at 0.24, and escitalopram (Lexapro) at 0.31 (Turner et al., 2008)Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment.

In addition, larger effect sizes are reported for follow-up outcomes than immediate post-tests after treatment for those studies that included this measure (Shedler, 2010). What this suggests is that the patient continues to change for the better after leaving therapy. This indicates that the changes are enduring and extend beyond symptom remission. As a result of this research, numerous practice guidelines include psychodynamic psychotherapy as a treatment for various psychiatric disorders (see Table 5.6).

PSYCHODYNAMIC CONTINUUM

Psychodynamic psychotherapy can be seen as a continuum from supportive psychotherapy to expressive to psychoanalysis using the practice treatment hierarchy from Chapter 1, Figure 1.6, as an overall framework for practice. The goals and focus of each type of psychodynamic psychotherapy differ, with the supportive end of the continuum aimed toward stabilization through restoring functioning, reducing anxiety, strengthening defenses, and more effective problem solving, whereas the psychoanalytic end of the continuum is aimed toward processing through interpreting unconscious conflict and gaining insight (Gabbard, 2010).

Expressive and psychoanalytic therapies involve more emotional processing than supportive psychotherapy with periods of stabilization alternating with processing, and therapy often shifts back and forth along this continuum. Chapter 1 (Figure 1.8) addresses the treatment process spiral that illustrates the process of psychotherapy. The degree to which the therapy is supportive versus psychoanalytic is based on the focus on transference issues and the frequency of sessions (Gabbard, 2010). In moving toward the psychoanalytic end of the continuum, the transference interpretations increase, as does the number of sessions per week. Through transference, unconscious conflicts are illuminated and then worked through. By increasing the number of sessions per week, it is thought that the transference intensifies, which is desired in psychoanalytic psychotherapy.

Along this continuum, some therapeutic communication techniques may be more appropriate for stabilization and others aid in processing. See Figure 5.2 on treatment hierarchy, psychodynamic continuum, and communication. Briere and Scott (2013) describe the therapeutic window of emotional processing and say that activation of emotion must accompany the narrative to process the trauma. The APPN helps the patient to modulate experience through questions that increase or decrease activation. As described in Chapter 4, the communication techniques considered to be more supportive are less emotionally laden and appropriate for stabilization, whereas those higher on the treatment triangle may trigger processing and implicit neural networks. Without the proper resources, this may be experienced as overwhelming accompanied by unmanageable feelings. The supportive techniques are considered to be resource building and less anxiety provoking. Thus, for patients who require primarily stabilization through supportive psychodynamic psychotherapy, the communication techniques toward the lower level of the treatment hierarchy are most often used. Supportive communication alternating with those communication techniques higher on the treatment hierarchy are appropriate for the emotional processing that occurs in expressive and psychoanalytic psychotherapies.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

TABLE 5.5 Selected Meta-Analytic Studies of Psychodynamic Psychotherapy

Adapted from Shedler (2010).

BT, behavior therapy; CBT, cognitive behavioral therapy; PT, psychodynamic psychotherapy; sx, symptoms; tx, treatment.

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TABLE 5.6 Practice Guidelines for Psychiatric Disorders

FIGURE 5.2 Psychodynamic case formulation.

Using communication techniques that are expressive to increase arousal may be needed for avoidant patients. These techniques may include immediacy, interpretation, observation, and focusing, depending on the psychotherapy approach being used. Another strategy to increase activation is to ask the person to go over the memory slowly in detail using the present tense. The amygdala is thought to hold memory in the present tense because it has not yet been processed. The narrative naturally shifts from what is happening to what did happen after processing has occurred. The greater the detail of the event narrated in the present tense, the greater the activation and the processing of traumatic material (Briere & Scott, 2013).

Processing involves exposure to the trauma and assisting the person in constructing a narrative through the exploration of the meaning of significant small and large traumas that impair functioning. The emotional dimension of the memory is essential for full processing to occur. Emotions are embedded in body sensations so that both in tandem are experienced during processing. Talking about the event without the attending emotions or body sensations may be an intellectual exercise only and preclude total processing. Briere and Scott (2013) emphasize that much of trauma activation and processing occurs at implicit, nonverbal, often relational levels.

Abreactions are intense emotional reactions to painful experiences that have been repressed. Chu (2011) delineates common phases that occur during abreactions: increased symptoms; intense internal conflict; acceptance and mourning; and mobilization and empowerment. Patients who do not have the capacity to withstand the intense feelings that occur during abreaction may instead use dissociation, substance abuse, distraction, and other avoidance responses (Chu, 2011). Avoidance responses may take the form of missing sessions, lateness to sessions, increased distress, or self-injurious or impulsive behaviors after sessions. Therapists not skilled in working with abreactions should heed these signs as indicators that the therapeutic window for processing has been exceeded.

When overactivation or abreaction occurs, suggestions include shifting the focus away from the trauma with breathing exercises or relaxation techniques; directing the person’s attention to less disturbing material; focusing on only one aspect or dimension of the experience such as the sounds or body sensations; distraction; using supportive communication techniques that are dearousing and supportive (see Figure 5.2) emphasizing intensity of emotion as doing good work; explaining activation before and after processing to normalize the person’s reactions; problem solving with the person to help mediate hyperarousal; using the safe place or container exercises (see Appendices 1.7 and 1.8); conveying optimism; and stabilizing with other affect management strategies (Briere & Scott, 2013). If the person is abreacting, do not touch the person or make any sudden moves, and allow for personal space.

Periods of processing are often followed by periods of destabilization. The APPN paces and structures treatment so that work on traumatic material alternates with resources, such as grounding and containment. “Trauma should not be the focus of session after session. Instead, as material is retrieved, it is much more important to process that material in a manner that allows the patient to remain stable than it is to move on to find and/or deal with more material” (Kluft, 1999, p. 15). As Kluft points out, slower is faster because the overall therapy time is reduced if treatment is relatively stable. Periods after processing may include feelings of increased sadness, anxiety, loss of control, or confusion. Sometimes, normal functioning is impaired, and the person may become suicidal or unable to function, especially if there are memories of childhood abuse. More sessions per week sometimes offer more support, and the person then can have the opportunity to move beyond crisis intervention to address deeper underlying difficulties (Kluft, 1999)Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment.

The APPN emphasizes the importance of maintaining supportive relationships and regular activities because these provide a positive sense of self and allow the work to continue. If the crisis is not averted quickly, this is an indication that the patient is not ready to continue with emotional processing. Hospitalizing the person to process trauma only furthers regression and is counterproductive unless needed to ensure patient safety. As illustrated in Figure 1.8 in Chapter 1, the treatment process often looks more like a spiral alternating interventions aimed at stabilization and then processing leading toward integration and future visioning. As life happens and job loss, serious illness, and other events may lead to destabilization, it may be necessary to stop processing and move to stabilizing again in the course of treatment.

Siegel (2012) posits that coherent narratives facilitate processing and interhemispheric integration. The left brain, which is language based, interprets the emotion-based autobiographical content of the right brain. Chapter 2 discusses right- and left-brain functions. The narrative in psychotherapy as told to an empathic other links self-states that have become dissociated due to trauma (Howell, 2005). This integration is considered the heart of mental health, with the successful resolution of trauma creating a deep sense of coherence (Siegel, 2012). The narrative helps the person to reconstruct a chronology to make sense of the experience by providing a context for time with a beginning, middle, and end. Research supports that through the reconstruction of the narrative, posttraumatic symptoms are reduced (Amir et al., 1998). Because the disturbing experience is disconnected from other dimensions of the person’s experience, it is important that the person integrate the event into his or her life and create meaning, allowing for closure. The literal recall is not as important as the meaning of the event to the person and how his or her sense of self or identity has been impacted.

As patients begin to accept what has happened, new perspectives about long held assumptions begin to shatter. Those who have suffered abuse typically have conflicts in many areas of life. For example, one young woman who had been sexually abused by her father as a child felt intense shame about not having been good enough to stop the abuse. She had both love and hate for her father and, consequently, for herself. Her ambivalence was reflected in many areas: “I was loved/I was hated; I was powerless/it was my fault.” These intense ambivalent feelings were extremely painful, repressed, and reflected entrenched neural networks of thought, emotion, and sensations. As she began to see her father more realistically, she was able to reformulate a more accurate view of herself. Over time, she began to see herself as a survivor instead of a victim. The reworking of traumatic material occurs over time in different ways. The person begins to understand the various elements of what happened and then understands the same event and sense of self in a different way at a later date.

Another patient, a man who suffered horrific physical abuse from his sadistic father, examined various aspects of this situation. First, he understood and experienced the betrayal and pain he felt because of his father and, subsequently, he also understood the event as betrayal and humiliation by his neglectful mother, who did not intercede and passively witnessed his abuse. He then examined how this reverberated into all areas of his life, such as his feelings about himself in relationships, difficulty setting boundaries, inability to make decisions, lost job opportunities, self-esteem issues, somatic symptoms, difficulty managing feelings and self-soothing, and poor coping skills. Changes in physical and emotional responses occurred as the fragments of the traumatic memory from the past were integrated with other more adaptive networks. The emotions elicited from the retelling are likely to be intense, and this expression is encouraged. Eventually, the events no longer increase emotional arousal after they are fully processed. Over time, memories are woven into a narrative reflecting the integration of neural networks as new information is learned.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Educating the person about relapse prevention is important. The patient may always be vulnerable to symptoms when re-exposed to stress because high states of arousal may promote retrieval of state-dependent memories, sensory information, or behaviors associated with prior disturbing experiences if the memories have not been fully processed. A plan for how to manage these times should be discussed, and this includes reviewing resource materials to enhance coping skills and booster sessions at vulnerable times. Explain to the patient that these high-risk periods may include developmental changes, periods of elevated stress, or reminders of partially processed traumas. Traumas that have not been previously identified may also be triggered at these vulnerable times. Resources should be increased prophylactically during these times.

Supportive Psychotherapy

Frequently, supportive psychotherapy is recommended, and it is assumed that the therapist knows what this entails without training. Supportive psychotherapy is psychodynamic in that it is based on a knowledge of the patient’s psychodynamics, which shapes the approach, but the goals of treatment differ considerably. Whereas psychoanalytic psychotherapy aims to restructure defenses and change personality organization through interpreting feelings, fantasies, and beliefs, supportive psychotherapy aims to strengthen defenses, promote problem solving, restore adaptive functioning, and provide symptom relief. Left-brain frontal cortex problem-solving abilities are greatly impaired in some patients because of personality organization structure or current life stressors that have precipitated regression to an earlier stage of functioning. Supportive psychotherapy is indicated to assist the person in stabilization, as illustrated by the treatment hierarchy in Figure 1.6 in Chapter 1. This involves increasing external and internal resources.

In A Primer of Supportive Psychotherapy, Pinkster (1997) says that the supportive model is the preferred model for most patients and that it is only when the goals of treatment cannot be met through this model that more expressive therapies should be employed. Although Figure 5.3 indicates that supportive therapy is for those who are on the psychotic end of the continuum, it is the treatment of choice for healthier patients too. Most clinicians believe that the decision about whether to use supportive psychodynamic psychotherapy should be based on the person’s ego strength and weaknesses, coping skills present, highest level of functioning previously achieved, recent losses, and other life stresses and circumstances (Hollender & Ford, 2000). In a seminal article, 16 basic strategies are identified as supportive (Misch, 2000) (see Table 5.7).Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

In assessing ego strength, it is important to identify the primary defenses the person uses to ward off anxiety. McWilliams (2011) lists the types of defenses most commonly associated with those in the psychotic level of personality organization and says these defenses are preverbal. These include denial, projection, splitting, primitive idealization and devaluation, withdrawal, omnipotent control, and dissociation. These defenses protect the person who is terrified of annihilation, lacks a basic security in the world, and is vulnerable to psychotic disorganization. Those in this end of the developmental continuum struggle with identity issues and confusion about who they are. Even if not overtly psychotic, the person is thought to be functioning at the symbiotic level of development, with little self–other differentiation. Some relational psychodynamic psychotherapists, such as Searles, Sullivan, and Fromm-Reichmann, advocate working with severe psychiatric disturbances such as schizophrenia using this model (Curtis & Hirsch, 2003).

Attachment research provides additional data for determining whether to use supportive or expressive interventions based on the person’s attachment style (Levy et al., 2011). See Table 2.1 in Chapter 2. Attachment style describes the person’s fear of rejection, yearning for intimacy, and preference of interpersonal distance in relationships. Determining the person’s attachment style assists the APPN in understanding about where to intervene on the psychodynamic continuum. The Adult Attachment Interview (AAI) is a semistructured interview that measures attachment style by analyzing how the patient describes childhood experiences (see Chapter 3). Those who are characterized as unresolved/disorganized are unable to form a coherent narrative about their life, due to lapses in memory or reasoning; those with preoccupied attachment styles seem overwhelmed with early relationship experiences and are unable to elaborate a coherent narrative without being flooded with emotion; while securely attached individuals are able to communicate with coherence and emotional genuineness about difficult childhood experiences.

An unresolved/disorganized attachment style may need more active interventions that facilitate emotional expression and connection, whereas a preoccupied style may need more supportive interventions that help the person contain overwhelming emotions; those with a secure attachment are able to work productively anywhere on the continuum without customizing psychotherapy interventions. Preoccupied attachment has been strongly correlated with borderline personality disorder (BPD; Fonagy et al., 1996). Not surprisingly, the patient’s attachment style predicts the nature of therapeutic alliance and the outcomes of treatment. The therapist’s attachment style also influences treatment. One study found that therapists who measured as insecure on attachment tools tended to worry more about rejection and were less empathic with patients (Rubino et al., 2000).

TABLE 5.7 Basic Strategies of Dynamic Supportive Therapy

Strategy #1: Formulate the case Serves as a roadmap for future interventions; why does this person have this problem now; evolves as more information becomes available; involves a developmental assessment
Strategy #2: Be a good parent “…to the extent that the patient is functioning at a childlike level in significant domains of life, the supportive therapist assumes a parental role” (p. 175)
Strategy #3: Foster and protect the therapeutic alliance First and primary goal throughout the therapy; respect the patient with compassion, empathy, and commitment; align with the healthy parts of the person; collaboratively set goals and strategies to attain these; interpersonally active treating the patient as the therapist would want to be treated
Strategy #4: Manage the transference Do need to explore the childhood experiences that underlie negative transference feelings but they must be corrected or the person may leave treatment; therapist acknowledges openly, explicitly, and nondefensively and/or apologizes
Strategy #5: Hold and contain the patient Provide empathy, understanding, soothing, helping the person to modulate affect, set limits when necessary, restrict acting out and impulsivity; may require medication and/or hospitalization; securing social services and so on while protecting the person’s autonomy
Strategy #6: Lend psychic structure Help as needed with reality testing, problem solving, impulse control, affect modulation, interpersonal awareness, social skills, and empathy
Strategy #7: Maximize adaptive coping mechanisms Support high level of defenses such as humor, altruism, sublimation, rationalization, and intellectualization and decrease use of denial, splitting, projection, and acting out; enhance coping skills such as mindfulness, dialectical behavior therapy and cognitive behavioral strategies to build distress tolerance skills and emotional regulation
Strategy #8: Provide a role model for identification Use judicious self-disclosure; be present, available, and real
Strategy #9: Decrease alexithymia Help the person to identify and name feelings; focus on somatic sensations associated with particular emotions; encourage use of metaphor to describe feelings Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment
Strategy # 10: Make connections Make associations between an event or situation and the person’s feelings such as how false negative beliefs about himself or herself have undermined self-esteem and prevented the person from setting and/or achieving goals, seeking out healthy relationships, and so on
Strategy #11: Raise self-esteem Foster competency in real skills; role play skills; correct cognitive distortions; unravel unconscious guilt; normalize thoughts, feelings, and behaviors; explain why counterproductive behavior in the present may have been adaptive attempts to deal with earlier adverse life situations
Strategy #12: Ameliorate hopelessness Use CBT, reframing, case management such as helping the person to obtain disability, housing, job, transportation, community resources
Strategy # 13: Focus on the here and now Address primary issues: (1) safety, (2) therapy interfering behaviors, (3) future-foreclosing events or plans, (4) treatment noncompliance, (5) negative transference
Strategy #14: Encourage patient activity Help the person to take action through setting concrete behavioral goals, devising a plan of action, behavioral rehearsal, role playing, relaxation, visualization, imagery, graded exposure, and serving as cheerleader for patient efforts
Strategy #15: Educate the patient and family Teach about medication(s) side effects and so on, diagnosis/illness, relapse symptoms, specific tasks or functions that the person cannot do on his or her own
Strategy #16: Manipulate the environment Intervene as appropriate with agencies or persons in order to advocate for the person; do for the person what he or she cannot do for himself or herself always with an aim toward maximum independence and growth

In supportive psychodynamic psychotherapy, the content of sessions most often focuses on feelings, life stresses, and problem solving, rather than on defenses. The therapeutic techniques most helpful in supportive psychotherapy are on the lower end of the continuum of therapeutic communication. Although giving advice is not on the continuum, it is sometimes prudent to offer a suggestion when the person cannot problem solve. Suggesting that someone see an attorney if it is apparent that there is an impending legal problem and suggesting that a patient see a medical specialist if those services are necessary are two examples of situations in which it is appropriate and necessary to offer a strong suggestion. It would be remiss in these situations to not offer this type of advice. In contrast, the therapist should not offer suggestions in some cases: suggesting that someone go to church, take a vacation, join a singles club, go back to school, or try online dating. These types of suggestions are imposing the APPN’s values on the patient, and shifting the responsibility away from the patient to the therapist, which also encourages dependency and regression. Another way to help the person problem solve without giving advice is to explore alternatives of action, expanding the possibility of choices with the person.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Often, supportive psychotherapy is most useful for people who need clarification and help in sorting out issues that they would be able to do under other circumstances. Patients may need to discuss situations, sort out the alternatives, and express feelings. Supportive psychotherapy focuses on safety, education, and assisting with enhancing coping skills. For example, Mrs. J came to therapy on the suggestion of her friend because of a crisis in her marriage. She recently found out her husband was having an affair and was quite despondent. She felt lonely, isolated, and useless. The therapist listened attentively as Mrs. J described her 30 years of marriage, the early years of their relationship, and her inability to forgive her husband. She felt stuck in her grief and anger and could not decide what course of action, if any, to take. The therapist suggested that it is sometimes better to wait to make decisions until feelings are clearer and that they would together explore the possible consequences of various courses of action. Through expressing her anger toward her husband in therapy, she felt somewhat better and was only then able to begin to examine other dimensions of disappointment that had been present in their relationship for a long time.

Sometimes, catharsis is all the person wants or needs from the therapy, without resolution of conflict. This is true especially in grief and the mourning process. Expression of feelings can be the first step in acknowledging other, more painful affects. For example, anger often masks underlying hurt, and anxiety often masks underlying anger. Through empathic exploring and open-ended questions, the person is gently guided to a full expression of the nuances of emotion. One caveat is warranted: With patients who are histrionic or overly emotional, emotion may need to be contained rather than freely expressed, and affect regulation strategies may be needed before encouraging emotional expression. Chapters 13 and 14 discuss specific affect management strategies. The objective for supportive psychotherapy is to restore emotional equilibrium as quickly as possible.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Expressive Psychotherapy

The psychodynamic treatment of choice for those with borderline character structure is expressive psychotherapy (McWilliams, 2011). The American Psychiatric Association (APA) guidelines for BPD state that psychodynamic psychotherapy is the psychotherapy of choice, along with dialectical behavior therapy (APA, 2010). Oldham (2005) reaffirms in a Guideline Watch that psychotherapy represents the core or primary treatment for BPD, with symptom-targeted psychopharmacology a secondary helpful adjunct. Those with borderline character structure as defined by McWilliams do not necessarily have a DSM-IV-TR diagnosis of BPD but may encompass BPD and a wider diversity of diagnostic categories that rely on primitive and immature defenses and include those with BPD. These individuals are not consistently in the mature spectrum of healthy defenses, and under stress, they may even appear psychotic; hence, the term borderline is used. Defenses predominately include projection, acting out, and splitting when under stress, but higher-level defenses may also be used.

Some theorists speculate that the genesis of difficulties occurs around 18 months of age in the rapprochement phase of separation–individuation (Masterson, 1976). It is thought that the child who still needs reassurance about his or her budding autonomy is thwarted developmentally by an unavailable caretaker or one who discourages separation. The child learns that independence equals loss of love (i.e., abandonment) and that closeness is associated with dependence and therefore fears of loss of control (i.e., engulfment). These early attachment issues can lead to a variety of adult relational problems and reflect unresolved attachment trauma. The ability to form and sustain reciprocal interpersonal relationships is notably disrupted in individuals who have experienced early traumatic attachment patterns (Schore, 2012). This essential dilemma gets played out in all subsequent relationships, including the psychotherapeutic relationship, creating chaos and unstable ego states.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Attachment trauma produces chronic problems in relationships, and processing relational trauma occurs largely through the therapeutic relationship. These individuals have difficulty in determining their own needs or sense of self and engaging in introspection. The relationally traumatized person has had to be hypervigilant, other directed, and accommodating to survive. This focus on other precludes the inner work needed to develop a coherent sense of self (Briere & Scott, 2013). The child who has been emotionally or physically abused or neglected in early life learns that he or she is not worth it and, due to cognitive immaturity, arrives at the conclusion that he or she must deserve such treatment. Consequently, the person views himself or herself as weak, helpless, and inadequate, existing at the whims of an inherently rejecting, unavailable, and hurtful other. These implicit schemas of worthlessness and helplessness become powerful organizing determinants of personality. Sometimes, an exaggerated façade of independence, willfulness, and self-sufficiency develops to counter these vulnerable feelings.

Most often, those with borderline personality structure are anxious, depressed, self-harm in crisis, and unable to tolerate ambivalence or defer gratification. These are individuals who are notoriously difficult to engage in treatment. Often, the precipitant for treatment is not because the person wants to change his or her personality, but because others have urged the person to seek help. These patients come to therapy with anxiety, depression, and dissatisfaction with their relationships. The challenge for the novice APPN is sorting out what to address first and what will be the focus of treatment. Because the person with borderline personality structure can appear to be high functioning and reality functioning seems intact, the nature of the underlying difficulties may not be readily apparent at intake.

As the transference evolves, it may take the form of idealizing or devaluing. The therapeutic relationship itself becomes a source of interpersonal triggers for implicit memories as the caring, empathic therapist often activates fears of abandonment. The growing feeling of emotional attachment to the therapist activates emotional responses from earlier childhood neglect or abuse experiences. These responses are often intense and may seem irrational and inappropriate. The therapist’s first clue of a rupture in the therapeutic alliance may be the person’s reaction to a comment that is intended to be helpful but the patient reacts as if attacked. For example, a man who is describing how angry he is that his boss is critical of him is asked by his therapist, “Does your boss remind you of anyone?” A higher functioning patient would most likely consider the question and answer, whereas the person with borderline personality structure may hear this as an accusation or criticism and feel angry at the therapist’s perceived lack of attunement and “judgmental” comment.

However, it is important to note that processing may be on an implicit level and may not always occur in words (Briere & Scott, 2013). Emotional processing can occur without higher processing systems of the brain that involve explicit memory. For example, conditioned responses of shame or anger associated with abandonment and/or self-hatred present in implicit memory as a consequence of relationship or attachment trauma are triggered through relationships in the present with the therapist as well as with significant others. Within the safety of the therapeutic relationship, counterconditioning occurs so that over time these schemas are not reinforced and the positive feelings of the therapeutic relationship allow new learning to occur.

Expressive psychodynamic therapy provides a vehicle for processing relational trauma through an ongoing therapeutic relationship over time. Briere and Scott (2013) identify healing components inherent in this approach:

  1. 1.  The therapist offers consistent support for introspection through exploration, which allows the patient to develop an articulated and accessible sense of self.
  2. 2.  The relationship itself provides a safe forum for activating and providing exposure to relational trauma.
  3. 3.  The disparity between the therapeutic relationship and the expectation of abuse or neglect is demonstrated and experienced.
  4. 4.  Counterconditioning occurs when the patient perceives safety, nurturance, and acceptance in the session and, consequently, fear is diminished.
  5. 5.  Desensitization occurs as relationships are no longer perceived as dangerous, and triggers of fear, anger, distrust, and avoidant behaviors are changed so that relationships are seen as a source of support rather than pain.

As the therapeutic relationship deepens over time, the inevitable dependency of the patient provides an opportunity to rework these implicit memories so that new learning can occur. The therapist does not encourage dependency but does provide support and caring in a nurturing environment so that the patient can safely re-experience childhood implicit relational memories.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

McWilliams (2011) says that the overall goal for expressive psychodynamic psychotherapy is the development of an integrated, complex, and positively valued self. This means that the person is able to tolerate ambivalent feelings and self-regulate emotions. Although there is no universal agreement about how to work with patients who have borderline character structure, several general principles of working in expressive psychodynamic psychotherapy with these individuals have been delineated: establishing consistent boundaries, using empathy before all interpretations, focusing on the here and now, asking the patient for help, rewarding assertiveness, discouraging regression and dependency, decreasing arousal levels so that communication can be heard, and understanding countertransference.

Countertransference is particularly challenging in working with those with borderline character organization. Even experienced therapists seek supervision when working with these individuals. It is thought that powerful unconscious communication occurs with these patients, even more so than with those psychotically or neurotically organized. The right-brain-to-right-brain communication often is more helpful in understanding the patient than what is actually said. Psychodynamic therapists call projective identification a specific type of countertransference that deepens the therapist’s understanding of the patient.

Projective identification is considered a defense mechanism and a countertransference constellation. It essentially involves behaving in such a way that subtle interpersonal pressure is placed on the therapist to take on dimensions of an experience or unconsciously identify with aspects of the patient (Gabbard, 2010). Projective identification is a type of concordant countertransference, as described in Chapter 4, in which the therapist identifies with an aspect of the patient’s experience (empathy). For example, a therapist may begin to feel afraid of the patient as the person is talking, which does not seem related to what the person is talking about. This out of the blue feeling may reflect the patient’s own fear being projected onto the therapist, and the patient does not have the feeling, but the therapist does. Not only fear can be projected, but also anger, boredom, intrusiveness, passivity, and other feelings.

Or the therapist may identify with an experience that has been projected, which is known as complementary countertransference. For example, the therapist begins to behave, think, and feel whatever the patient is projecting and as significant others felt when with the person. The therapist can identify whether this is occurring if the therapist begins to feel or act unlike herself. For example, the therapist begins to feel angry or is verbally abusive toward the patient. The challenge is for the APPN to identify the powerful feelings that occur during the session.

Although projective identification has been touted as a useful tool to deepen therapists’ understanding of patients, savvy therapists know that any feeling that may come up during a session may be from their own unconscious and not from a patient. Therapists should trust their own instincts but only after taking emotional inventory and responsibility for their own dynamics. Sometimes, projective identification is so powerful that the therapist may feel confused, and on reflection between sessions or with supervision, the therapist begins to sort out her contributions from that of the patient. Contemporary psychoanalysts feel that countertransference and transference are co-constructed, and as such, the therapist uses her own feelings as a barometer to understand the patient’s internal world only after considerable self-reflection. Relational psychodynamic psychotherapists believe that all transference–countertransference phenomena are forms of projective identification, in that the therapist unwittingly always lives out the reciprocal role of the significant other in the patient’s early life.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Psychoanalytic Psychotherapy

Patients who are considered ideal candidates for psychoanalytic psychotherapy are those with neurotic-to-healthy personality organization, who primarily rely on mature defenses. Some primitive defenses may be present, but along with these, mature defenses are also evident. These individuals have a sense of who they are, generally are in touch with reality, and have achieved object constancy. Object constancy refers to the capacity to be alone. When asked to describe others, they are able to give a fairly detailed account of the other person so that the APPN can get a clear picture of the person’s characteristics. The patient with a neurotic-level personality most likely has had some satisfying relationships and is experienced by the therapist as able to engage in a therapeutic alliance. These persons may come to treatment because of obstacles in love or work that they are uncomfortable about. Usually, they are the people who seek help without being forced. Problems for individuals with neurotic-level personality organization are often experienced as ego dystonic (i.e., alien to how they experience themselves). For example, patients may be troubled by disturbing thoughts about harm coming to them or loved ones. These experiences are felt as different from themselves, as ego alien. In contrast, persons with psychotically organized personality may be more likely to experience their problems as ego syntonic. This means that the problem is compatible with who they are, and these individuals often feel that it is others who have the problem, and they want reassurance, for example, that they have good reason to be paranoid or acting out.

If the person wants to understand himself or herself deeply and significantly change, psychoanalysis may be indicated. Psychoanalysis is more intense than psychoanalytic psychotherapy in that session frequency is increased and the transference is intensified. Sometimes, the person comes to treatment and has some initial psychotherapy and then decides to deepen the work and undergo psychoanalysis. Psychoanalysis generally takes three to five sessions each week and requires the amount of time for natural or normal maturational change (3–7 years). Many of the candidates for psychoanalysis are those in training programs to become psychoanalysts. Therapists who want to work in a deeper way with patients and understand that knowing themselves is a prerequisite to this work sometimes seek their own psychoanalysis without the structure of a formal training program. Traditionally, the basic methods of psychoanalysis involve free association by the patient lying on the couch, with the therapist sitting in back of the patient while listening and interpreting resistance and transference as these elements are manifested in dreams and considering what the patient says or does in and outside of sessions.

The development and facilitation of what is called the transference neurosis are integral to the process of Freudian psychoanalysis. The transference neurosis is a rerun of the developmental process through an intense relationship with the therapist. The patient feels toward the analyst feelings that were similarly expressed toward significant others in early development. This enactment and resolution of the transference are the work of psychoanalysis. The deep analysis of the relationship with the therapist distinguishes psychoanalytic therapy from other types of therapies. The transference is intensified with the increased frequency of sessions and the neutrality of the analyst. The analyst listens with evenly hovering attention, which means without preconceptions, absorbing what the person says with an attitude of nonjudgmental, empathic neutrality designed to create a safe environment. As the transference unfolds, the patient and analyst work together in understanding unconscious processes that are triggered in the therapeutic relationship.

CASE FORMULATION

In order for the APPN to decide on a relevant therapeutic focus, realistic expectations of treatment, and the appropriate type of psychodynamic psychotherapy to use, a dynamic case formulation is essential. In general, the shorter the length of the psychotherapy, the more intense the pressure to determine a therapeutic focus, and this is done through a psychodynamic formulation. Safran and Muran (2000) state: “It is the establishment of a dynamic focus and the consistent interpretation of that focus over time, as it emerges in a variety of different contexts that facilitates the working through process and allows the client to integrate treatment changes into his/her everyday life” (p. 178). As addressed in Chapter 1, Figure 1.6, the hierarchy of treatment aims is helpful in this regard, but a more sophisticated psychodynamic understanding of development and defenses further refines treatment choice and informs the work of psychodynamic psychotherapy. The case formulation identifies a central issue that underlies the person’s presenting problem that is related to the person’s early developmental history. This involves conceptualizing presenting issues developmentally and understanding intrapsychic conflict. Three personality organization levels have been identified—neurotic to healthy, borderline, and psychotic—based on a synthesis of major developmental theories (McWilliams, 2011) (Figure 5.3).Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

These developmental levels may be thought of as a continuum ranging from neurotic to psychotic and that cuts across all diagnostic categories, because virtually all diagnoses are represented at each level. Some diagnostic categories are more heavily represented on one end of the continuum or the other, depending on the primary category of the defense used: primitive, immature, neurotic, or mature. Chapter 2 lists defenses in each category. In general, the person who uses primarily primitive defenses is more likely in the psychotic range of the continuum, and the person who primarily relies more on mature, higher-level defenses more likely is in the neurotic-to-healthy range. However, given enough stress, anyone can veer toward the psychotic end of the continuum. For example, the person with narcissistic traits can be primarily in the neurotic-to-healthy range, but with enough stress, the individual can slip into the psychotic end of the continuum. Under stress, we revert to methods of coping from earlier levels of development that feel similar to the current situation. Implicit memory networks of defenses are triggered by biochemical states reflecting state-dependent learning.

FIGURE 5.3 Case formulation and psychodynamic therapy.

McWilliams (1994) says that dynamically oriented therapists make an assessment based on the following: “People with a vulnerability to psychosis may be understood as fixated on the issues of the early symbiotic phase; people with borderline personality organization are comprehensible in terms of their preoccupation with separation–individuation themes; and those with neurotic structure can be usefully construed in more oedipal terms” (p. 53). The importance of determining the primary defenses of the patient and assessing ego functions in light of these developmental levels is to determine a dynamic case formulation and what type of treatment can be most helpful for the person at this time. Chapter 3 explains how to assess ego development. The core conflicts of the patient inform how to proceed psychodynamically with treatment more than a formal Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis.

A summary of the dynamic formulation should be shared with the patient and should be tentative, with some idea about how the therapist sees the nature of the work to be accomplished. For example, Michele, a 27-year-old French woman, came to therapy because she felt “confused, depressed, and was losing control.” She had several recent panic attacks accompanied by paranoid ideation, fearing that she might be attacked and possibly raped. At the end of the first session after taking her history, the therapist said: “The recent loss of your boyfriend has contributed to you feeling increasingly sad and panicky. We need to work on shoring up your resources so you can feel more in control when bad things happen. How does that sound to you?” The APPN felt that relational psychodynamic psychotherapy would be helpful but was careful to not overwhelm Michele with too much information in the first session. Later in treatment, after an alliance was more firmly established, the APPN fleshed out the dynamic formulation to Michele by suggesting: “Most likely, the absence of your mother’s presence in your early life and your father’s anger made you feel unsafe and prevented you from learning and developing the coping skills you need to stay on an even keel. It would be helpful to deepen your understanding of how you seem to end up in relationships that are not good for you.”

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WORKING THROUGH

Working through is considered the heart of the therapeutic work. Freudian psychoanalysts see the working-through process as observing, clarifying, and interpreting defenses as manifested by the resistances and transferences again and again. However, relational psychodynamic psychotherapists emphasize working through as restructuring the person’s relational schemas through working with therapeutic impasses or ruptures in the therapeutic alliance. This “involves a recognition of how the relationship with the therapist reflects relationships from childhood and current extratransference relationships” (Gabbard, 2010, p. 170). Working through is the consistent interpretation of this dynamic focus over time. Rarely is there one insightful comment or interpretation that changes things dramatically. Rather, it is the repeated, consistent interpretation of the same themes and patterns as they are manifested in myriad situations and relationships. Both Freudian and relational psychodynamic therapists conceive that change occurs gradually and includes changing internal and external representations. Patterns of interactions are significantly changed with other people, and this is accompanied by changes in the patient’s internal representations or how the person perceives himself or herself and others. This change reflects adaptive information processing of memory networks that have been dysregulated or dissociated in implicit memory systems.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Emphasis in relational psychodynamic psychotherapy in the working-through process is on facilitating the development of the capacity for mindfulness (Safran & Muran, 2000). Mindfulness is the ability to observe internal processes and actions in relation to other people. This goal is conveyed to the patient at the outset of therapy. The APPN explains to the patient that how he or she feels with the therapist can also occur outside of therapy in other relationships. The patient is asked to monitor what dimensions of this situation are true or occur for him or her. The relational psychodynamic psychotherapist points out to the patient that with the therapist and with those outside of therapy, patterns of relating are similar and that these are fueled by the person’s early experiences. The therapist observes characteristic patterns of implicit relatedness and shares these observations with the patient, providing a new perspective that is different from the person’s own subjective impressions. Pointing out the person’s tendency to be controlling, demanding, dependent, or passive increases awareness of implicit modes of relatedness and the impact of these behaviors on others (Gabbard, 2010). This awareness often brings the patient a much greater sense of mastery, so that patterns of behavior can be reflected on before enacted in future relationships.

However, more than interpretations about relationships create change. The psychotherapeutic relationship itself provides a different relationship experience for the person so that new neural connections can be made. This inevitably leads to disillusionment as the person comes to accept his or her own separateness and that of the therapist, and it involves a mourning process in that the patient gives up an old way of being. Curtis and Hirsch (2003) state, “Salubrious new experience can only develop in a context in which old experience is first repeated, perhaps mourned, and let go of” (p. 81). Mourning the loss of possibilities and unhealthy relationships with significant others is considered curative because more energy is freed for current relationships. Unfulfilled desires are identified, tolerated, and then relinquished in a safe relationship.

The working-through process assists the person in recovering split off and dissociated aspects of the self that developed to maintain a relationship with parents. The person who has not been attuned to or who suffered trauma in early life has had to comply to survive, and a false self is thought to have developed. This false self lacks spontaneity and may result in a pervasive sense of unreality, futility, and lack of vitality (Safran & Muran, 2000). Relational theorists posit that there is not one false self, but multiple selves that need to be re-appropriated for the person to feel real and alive. These ways of being are embedded in important early relationships and templates of neural networks that at one time were adaptive. For example, the patient who was connected to her mother through chaos and unpredictability will experience sadness at giving up this state of consciousness, because this way of being is embedded in the fundamental attachment to the caretaker that ensured survival.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Various exploratory communication techniques assist in the working-through process. These include asking patients about their fantasies, daydreams, dreams, early memories, and ideas about what they perceive others are thinking, including what they imagine the therapist to be thinking. One way to help patients reflect on interactions outside of therapy involves helping them to experience situations fully by comments such as: “Imagine being there right now” (Curtis & Hirsch, 2003). Another exploratory technique is to observe and reflect what seems to be happening for the patient. For example: “You sound very angry today. I wonder what this is about?” Gabbard says this increases mentalization (i.e., mindfulness), which is the person’s ability to think about his or her own experiences and feelings, which invites further differentiation of emotions (2010). In a similar vein, if the patient reports an impulsive act, the therapist may ask what was going on just before that happened. Using open-ended, exploring communication allows patients to deepen their capacity for reflection. As a patient integrates emotional information that has been dissociated, a more robust sense of self develops that is grounded in the person’s own experience.

In contrast to cognitive therapy, in which there is a structured agenda for each session, psychodynamic psychotherapy is based on psychic determinism (Binder, 2004). This means that the patient’s spontaneous verbalizations will reveal affectively charged themes and that the person does not need to have a specific topic in mind but talks about whatever is on his or her mind that is relevant to the agreed problem focus. Those that are the most emotionally arousing and meaningful are current problematic relationships or past ones. This free association is thought to allow space so that the person’s own experience and ways of interacting can emerge. The therapist listens with the idea of discerning latent themes related to the person’s underlying conflicts and issues. The therapist asks herself: “What is the central issue here? What is going on now?” It is the therapist’s job to track salient themes and goals that were set at the outset of the treatment. Each session then is a continuation of the one before. What this means is that themes reverberate, threading throughout sessions, and what is talked about in the current session reflects issues that were salient at the end of the previous session. Taking good process notes at the end of each session helps in tracking these themes.

Integral to the working-through process is pointing out positive change and supporting the person’s strengths. The therapist points out positive changes to the patient and reframes experiences. For example, one patient who was struggling with rejection, neediness, and failed relationships was told by her therapist: “It is sad that things did not work out with Jim, but it seems that unlike past situations, you were able to see much sooner that your needs were not being met and to say what you wanted, rather than just hanging in there, hoping that things would change.” Encouraging risk taking and tolerating anxiety-producing situations through such comments provides the support needed and points toward positive change. Tempered comments without cheerleading are most effective; making the therapist happy is not the point of therapeutic gains. The idea that the patient changes to please the therapist is known as transference cure, and the therapist needs to be vigilant to ensure that the patient’s autonomy and self-actualization are the goal (Curtis & Hirsch, 2003).Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Structuring challenging situations through gradual tolerance of anxiety-provoking situations can be done through psychoeducation, role playing, imagery, rehearsal, and modeling. For example, a man who came to treatment for marital problems was extremely passive in his relationship with his wife and often expected her to know what he wanted without articulating his needs. He grew up the youngest of six children with an angry father and depressed mother, and he spent much time alone in his room, withdrawing passively from the chaos around him. This typical response to conflict, coupled with his fear of rejection and his wife’s anger, paralyzed him in addressing anything with her that he was unhappy about. The therapist role-played a typical scenario, with the patient playing the role of his wife and the therapist playing his role. This exercise provided a new way of responding that he eventually was able to try at home. The role playing helped to build his confidence, see new ways of relating, and enabled him to deepen his understanding about his anxiety in a safe context.

Because problems in relating to others are a core focus in relational psychodynamic psychotherapy, the therapist helps the person to understand his impact on others, deepening understanding of other people, too (Wachtel, 2011). Flexibility in relationships is considered a sign of health, with healing defined as the ability to assimilate new experiences and to transcend the unhealthy identifications with others and constraints of the past (Curtis & Hirsch, 2003). For example, in the previous situation, the therapist pointed out to the patient “Given what you have told me about your wife, she seems to strike out and get angry when she is feeling neglected, and she likely feels neglected when you withdraw and do not communicate.” This type of comment enables the patient to see the cyclical nature of the patterns of relating that perpetuate the difficulties that the person is experiencing. In this situation, the patient’s passivity created the very situation that he was trying to avoid: his wife’s rejection and anger.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

REPAIRING ALLIANCE RUPTURES

Many relational psychodynamic theorists believe that alliance ruptures are inevitable in therapy and that resolving these ruptures creates positive change (Binder, 2004; Safran et al., 2011). Any psychotherapy that goes too smoothly is thought to be an accommodation of the person’s false self to the therapist and is likely to remain superficial without really changing anything. In general, the therapeutic alliance may be stable from session to session, but there may be instances of strained interpersonal interactions between the therapist and patient. If the therapy is particularly brief, alliance ruptures may not develop because of the limitations of the treatment. The key to resolution lies in the experience for the patient of a collaborative conflict resolution with an emotionally significant other that is different from what the person expects (Binder, 2004). This is accomplished with the consistency and empathic attunement of the therapist.

Immediacy, a therapeutic communication technique described in Chapter 4, is useful in relational psychodynamic psychotherapy, especially in the throes of an alliance rupture. For example, one patient, a 46-year-old woman named Susan, came to therapy for depression because of a series of failed relationships. Her history revealed early deprivation with both parents, who were extremely self-involved and neglectful of their children. Her experience was one of chronically feeling devalued, which reinforced her schema that she was not lovable and not worth it. This theme played out in all her relationships in that no one could ever meet her needs or be there in the way she needed them to be. Chronic dissatisfaction and feelings of deprivation permeated every situation as she upped the ante, no matter what was offered to her. Whatever was given was not enough, providing proof of the person’s neglect or ill intentions. She presented an unpaid bill demanding to be paid in every interpersonal encounter. This was repeated in therapy, with Susan wanting more time, continuing to talk at the end of sessions, making frequent demands for changes of appointment times, and offering relentless criticisms of others. The therapist began to feel demoralized and tense up before each session, almost as if to shore up in order to withstand the barrage of negativity. The therapist felt hopeless and helpless, caught in the throes of a negative transference–countertransference enactment. After discussing the situation in supervision, the therapist understood that she was feeling as Susan must have felt, devalued in her family and hopeless, and the therapist offered this interpretation in the next session: “Perhaps you are feeling that I am not giving you what you need here.” This helped bring the process into the here and now, focusing on the therapeutic relationship, which allowed Susan to explore the reasonableness of her needs and her inevitable disappointment and hurt when she felt slighted. An interpretation is considered timely and relevant if it opens a productive avenue of therapeutic inquiry. The therapist encouraged and explored, listening empathically and nondefensively. She stated: “It is so hard to be here and feel so vulnerable and not get what you want or need.”Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Negative Therapeutic Reaction

A negative therapeutic reaction is a specific type of therapeutic impasse in which the patient gets worse and becomes entrenched in maintaining his or her problems despite the help of the therapist. Gabbard (2010) says that these reactions likely result from revenge fantasies, in that the therapist serving as parent in the transference is defeated by the patient by not getting better. This reaction is usually unconscious. The patient is often not aware of ill intentions, only that he or she is stuck or unhappy in treatment. In relational psychotherapy, this situation is not one-sided. The therapist may have too much invested in helping the person and begin to feel demoralized because nothing seems to be helpful. It is often necessary for the therapist engaged in the throes of a negative therapeutic reaction with a patient to seek supervision and consultation to sort out the situation. Evaluating the relational dynamics with a colleague can be helpful, but sometimes even then, the only solution is to refer the patient to someone else. The patient sometimes makes significant improvements only after treatment is terminated.

WORKING WITH DREAMS

Research on dreams has confirmed the importance and relevance of dreams for understanding the unconscious and implicit memory (Solms & Turnbull, 2002). Dreams are the brain’s attempt to process information and to integrate the day’s residue into the existing memory networks. Dreams represent current conflicts, and work on dreams focuses on the here and now, rather than the past, although current conflicts usually have roots in the past. Many psychodynamic psychotherapists consider dream work a useful tool to assist patients in deepening their understanding about themselves. A basic tenet of dream work is that dreams represent wishes, fears, and conflicts, as well as the person’s attempt to master unresolved issues and process traumatic experiences. Dreams are fertile ground for work in psychodynamic psychotherapy.

As in communication, there is the manifest content and the latent content. The manifest content is what the dreamer says the dream is about, and the latent content is the meaning of the dream. The latent content is disguised by defenses so that the person will not awaken. Although dream symbol books are interesting, they are not particularly useful in interpreting dreams, because all meaning and symbols in dreams are highly idiosyncratic and not universal. Dreams have multiple levels of meaning, and the symbols represented in the dream are unique for that person. Two people may have the same exact dream, and it may mean completely different things to each individual. However, dreaming about a house or type of house may symbolize the person and feeling about himself or herself. The other theme that seems to appear for many people is going someplace in a car or train, which sometimes heralds movement or change in therapy or in people’s lives. There are often transferential dimensions to the dream; the dream may reflect feelings the dreamer has about the therapist, albeit in disguised form. Dreams can reveal feelings that have arisen in the therapeutic relationship that have not been addressed (Curtis & Hirsch, 2003).

Dream interpretation is a little like trying to understand a poem or a work of art. It is undoubtedly a right-brain endeavor, and it is helpful to use right-brain functions when working with dreams. This can sometimes be accomplished through a mindful state, whereby the APPN attends by suspending usual left-brain problem-solving thinking by listening with empathic receptivity and resonance. Dreams are not linear in that time and space are suspended. To understand the patient’s dream, it is important to know the basic mechanisms associated with dreams. These include secondary revision, symbolic representation, condensation, and displacement (Gabbard, 2010). Secondary revision refers to the right-brain implicit message being translated into a coherent story. Symbolic representation refers to an image that represents a complex set of emotions that may be highly charged. Condensation is a mechanism that combines more than one wish, feeling, or impulse into one image. Displacement is similar to defense in that feelings for one person are displaced onto another person in the patient’s life.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Working with dreams can be introduced to the patient by asking in the assessment about recurring dreams, memorable childhood dreams, and recent dreams. It is helpful to suggest that the patient keep a dream log next to the bed so that he or she can jot down significant dreams on wakening. These dreams can be helpful in gaining insight. Even if patients do not usually remember their dreams, they can be trained to do so by beginning to keep track of their dreams in this way. After discussing the idea of working with dreams with patients, it is better to not bring up the subject again and to allow patients to report dreams when they are ready. Not all patients are able to remember their dreams. Alexithymic patients in particular have great difficulty in remembering their dreams because of their impoverished ability to symbolize (Hollender & Ford, 2000).

Bringing in the first dream often heralds a deepening of the therapeutic alliance and should be positively acknowledged by the APPN. The first dream often illustrates the dynamic focus for the work of treatment. For example, one woman, who came to treatment with significant long-term depression but who was fairly high functioning, had suffered significant attachment trauma from her early relationship with her mother, who had BPD. The patient reported her first dream in the sixth session: “My daughter and I are taking care of a baby, a baby girl, about 2 years old. She is dead and in parts, and we can’t seem to get her back together. I am trying to call the funeral home but can’t get through, and for some reason, I have only 45 minutes. That is not enough time. I wake up thinking that I won’t be able to put her together in such a short time.” Her thoughts about the dream were that the baby was her and the 45 minutes was the length of our session time. This was a graphic illustration of how the patient felt about herself and the work that needed to be accomplished in therapy.

Although dreams can advance the work of therapy, they can also serve as a resistance. If the patient comes in with several dreams and floods the session with dream material, it may not be possible to examine any dimension of the dream in the detail needed to be helpful. As with all therapy, the process or context should be dealt with first. What is going on in the process of psychotherapy that causes the person to overwhelm the therapist with so much material now? If a dream is reported in a session, the whole session’s latent content usually is about the dream, even if the dream content itself is not the topic of conversation. Asking the person: “What are your thoughts about the dream?” is often a good way to start getting the patient’s associations about the dream. Another way to work is to ask the person what stands out the most about the dream or what was the worst part of the dream. If the dream is readily understood and the manifest content is obvious, it is considered transparent, which may sound like a derogatory term, but it means that the content is not highly disguised or defended against. In contrast, the dream that is difficult to understand may reflect the strength of the defense against this implicit material coming to consciousness. Sometimes, novice therapists are hesitant to do dream work because they feel they must come up with a grand interpretation at the end. Often, however, the therapist gets only the person’s thoughts on the dream without much comment. It is thought that relating the dream is therapeutic because this translates right-brain material into left-brain information, which is integrative in and of itself. It is not incumbent on the therapist to make sense of the dream; after all, it is the patient’s dream, and it is his or her thoughts about it that count. The following example illustrates the concepts and how to work with dreams.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Sarah, a 22-year-old English woman from an orthodox Jewish family, was seen for depression and low self-esteem. She described her mother as depressed, sometimes staying in bed for weeks, and her father as hypersensitive, depressed, tense, and domineering. Sarah moved to the United States to go to school the previous year. Sarah began her 15th psychotherapy session by saying that she was too hard on herself and that she always feels she is going to be judged because she sees others as superior to her and wonders how they will perceive her. She wanted to be different but was anxious about changing. Her parents always implied that they knew the real Sarah and that she was too introspective. Her older sister was always down on everything and saw Sarah as emotional, selfish, and a troublemaker, and Sarah tended to agree with her. She then reported the following dream: “I was at home in my parents’ house in London. Dad died in the dream and was out in the front yard without his head. Blood was pouring out of his neck, but he was still talking. I was crying ‘no, no, no.’ I felt awful that he had died.”

When the therapist asked what she thought about this dream, Sarah said she thought that she was trying to kill off parts of herself that were like her dad. She thought that the dream was telling her that she loved her father and did not really hate him and that she could love him after she was in control of herself and did not feel as if he controlled her. The therapist responded: “You care a great deal about your father, but you have issues to work out about yourself before you can improve your relationship with him.” In understanding the session in light of the dream, Sarah had started the session being concerned about being judged and perhaps wondered what the therapist would think of such a murderous dream. This is the latent transferential part of the session. By listening nonjudgmentally and accepting her thoughts about the dream, the therapist provided a different experience for her from the one she had in her family. The therapist offered no new interpretation but agreed and reflected what Sarah said about the dream. The following illustrates the basic mechanisms in Sarah’s dream:

Secondary revision: Sarah recounts the dream in story form.

Symbolic representation: The house in London may represent her childhood experiences. Condensation: She sees her anger at her father and her own murderous impulses toward him on the one hand; his death brings freedom from his tyranny. On the other hand, he is still talking, and this may reflect the embedded wish that she can still maintain a relationship with him despite her anger or that his words would continue to influence her even though he is dead. Perhaps his talking head reflects her wish that her anger would not kill him and he would still be alive.

Displacement: Sarah is in part displacing her own anger about herself toward her father. She focuses on her father as the source of her unhappiness in the dream, but in her associations to the dream, she says that she wants to kill off parts of herself that are like her dad, which illustrates the utility of the dream in illuminating her displacement.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

In contrast to psychoanalysis, brief psychodynamic psychotherapy takes place in fewer days per week and lasts for a shorter duration. Although techniques are similar, less regression is encouraged, and the patient is not encouraged to use the couch but to sit facing the therapist. For those wishing to work on a particular issue or conflict, shorter-term psychodynamic psychotherapy may be indicated. This approach is sometimes called focal psychodynamic psychotherapy. Although psychodynamic psychotherapy is frequently thought of as long-term therapy, brief psychodynamic psychotherapy is probably most often practiced given the current climate of managed care.

How many sessions constitute brief therapy? It could be one session, although we might question what this one session would consist of and how helpful it would be. Most often, 20 to 30 sessions are considered brief therapy. Even if brief, psychodynamic assumptions and techniques are the same as if longer-term treatment was conducted. There is no qualitative difference between brief and long-term psychodynamic psychotherapy. “There are not specific techniques that hold the key to the practice of brief therapy. Instead, the most expeditious means to achieve efficient and effective therapeutic outcomes is to practice ‘good’ psychotherapy, regardless of the anticipated or planned length” (Binder, 2004, p. 22). Wolberg (1977) developed general guidelines for conducting brief psychodynamic psychotherapy. A slightly modified version is provided in Box 5.1.

Proponents of brief psychodynamic psychotherapy believe that setting a termination date at the beginning of treatment assists in the progress and resolution of the patient’s problems. Setting the termination date is thought to provide a focus that can link or thread unrelated experiences together for the therapist and the patient. A termination date is thought to be integral to the treatment in that the patient is helped to work through the meaning of termination. This central issue in the therapy parallels the separation–individuation developmental issue of life. Loss is a central theme for everyone, along with the tension of connecting through relationship while at the same time being a self-agent. Termination in psychotherapy can be a forum for addressing and exploring these central dilemmas in life. Specific issues related to termination that frequently arise in therapy are abandonment fears, disappointments, and anger about not getting what a person hoped for. The therapist listens empathically, and this noncritical acceptance of the patient’s needs and wants helps the patient to accept the limitations of others. This approach is thought to help the person access dissociated wishes and needs that have been split off due to early relationships. Through the process of acknowledging and relinquishing the pursuit of an idealized, unattainable goal, the limitations and realities of relationships are accepted. However, there may not be enough time for transference to develop sufficiently, so the therapist can use the relationship to work through as just described. The focus of therapy then is on interpersonal relationships outside of the therapeutic relationship.

BOX 5.1

GENERAL PRINCIPLES FOR CONDUCTING BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

Establish a therapeutic alliance

Set a termination date (within 30 sessions)

Deal with initial resistances

Gather historical and other data

What is the most important problem? Why now? What has been done so far?

What does the patient think caused the problem? What does the patient want from therapy?

Select the symptoms (focus) most amenable to treatment within the first three sessions

Define the precipitating event

Identify developmental issues and defenses to understand how to proceed

Share the case formulation with the patient

Enlist the patient as an active participant through a verbal contract

Use the most effective techniques to help the patient

Identify resistances or alliance ruptures, and address them with the patient

Be sensitive to how the past is influencing the present

Examine countertransference feelings

Give homework (optional)

Stress the need for continuing work

Adapted from Wolberg (1977).Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

CASE EXAMPLE

Ms. S is a 32-year-old, intelligent, attractive woman who is very successful in her career. Her reason for seeking treatment is related to her dissatisfaction with her chronic tendency to choose men who eventually abuse her emotionally. Ms. S stated that her father had abused her sexually as well as other female relatives in the family. When Ms. S got older and objected to his advances, her father accused her of being uptight and compared her unfavorably to her younger and more compliant sister, who obviously had no problem because she willingly accepted his behavior. Ms. S had a good early relationship with her mother. The sexual abuse left Ms. S with a profound mistrust of men. She was active and controlling in relationships with men (e.g., she was always the one who initiated sex). When her partner expressed an interest in sex, it felt analogous to her father’s sexually controlling, intrusive, and abusive behavior. In addition to initiating sex, she was giving in other ways (e.g., gifts, dinners, and arranging activities for her and her boyfriend to enjoy). The unfortunate side of this behavior was that it obscured the essentially narcissistic character structure of these men. In other words, they were fine as long as they were on the receiving end. Inevitably, the relationship would founder when she risked expressing needs of her own.

Developmentally, her anxiety and conflict seemed to lie in the area of identity and loss of control in that she experienced much anxiety in relationships with men if she did not control what happened. Ms. S had good object constancy and could be alone without much separation anxiety, could self-soothe, was self-directed, and was fairly autonomous even though controlling in relationships. In Erikson’s framework, issues of intimacy versus isolation were apparent in that the crux of her problems was in establishing an intimate relationship. Neurotic-level defenses of displacement and rationalization were evident, as well as denial, which is considered a primitive defense. Her displacement took the form of an inability to recognize her own deep feelings of worthlessness, and she became a compulsive giver and cared about the needs of others to avoid the fact that she was being exploited in her relationships with men. She rationalized whenever she was not treated well in a relationship that she was needed and that only she could help her boyfriend feel better about himself. She should care for men and was plagued with guilt if she did not give more. The should often indicates oedipal issues in that a harsh superego predisposes the person to be overly hard on himself or herself. This, coupled with her denial about the selfish, exploitive characteristics in the men she chose to date, corresponded to her denial on some level of her father’s motives. Her high level of functioning with use of the defenses of humor and sublimation led her male therapist to conclude that she was probably a candidate for psychoanalytically oriented psychotherapy. Twice-weekly psychotherapy was conducted over a 2-year period.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

Ms. S initially related to the therapist in a guarded, hypervigilant state, which sometimes made the therapist feel uneasy and constricted. At other times, she was quite seductive and incredulous that the therapist would not have sex with her. The following excerpt from a session illustrates the exploration of the importance of her sexual quest. She arrived characteristically late for her session and alluded to the previous session, which involved her declaring her sexual feelings for the therapist.

  Ms. S: I finally understand why you won’t have sex with me, and although it’s frustrating, at least I understand why you are doing this.
  Therapist: What is it that you understand?
  Ms. S: It’s your goddamn ethics, your code.
  Therapist: My code of ethics prevents me from having sex with you?
  Ms. S: Yes.
  Therapist: Anything else about me that may contribute to my not having sex with you?
  Ms. S: [after a long pause] Well maybe, just maybe you feel it would hurt me.
  Therapist: So, on the one hand, I want to have sex with you but don’t because of my ethical code, and on the other hand, I may care enough about you to not want to hurt you, as you have in the past been hurt.
  Ms. S: Perhaps I’m trying here to create a situation that is familiar to me.
  Therapist: Perhaps, but you also consider that I may have different, more caring motives, and that is very new for you.

This session highlights the use of the relational model of psychodynamic psychotherapy. Relational psychodynamic psychotherapy is based on the idea that problems are caused by disturbances in relationships with early caretakers that pattern subsequent relationships. The therapist’s understanding emerged over time as the relationship unfolded. The therapist initially explained to Ms. S the importance of mindfulness and observing her own thoughts and feelings in the therapy relationship as it is taking place in the present moment. In exploring other aspects of a relationship in the here and now with the therapist, Ms. S was able to consider that the therapist cared about her, which introduced a new hypothesis about what ingredients there are in relationships. She spent numerous sessions struggling with a shift in her thinking that someone would care about her and not want to exploit her. As she mourned the loss of the illusion of a loving father and saw her father more realistically, she was able to see men in her life more realistically, too. Over time, she developed better object choices in that she looked for indicators that the men who she dated overtly cared about her, and she was able to make a better assessment of their intentions. Her defenses were modified, and she no longer had to compulsively control and give in intimate relationships. New, more adaptive information in implicit memory networks was learned through the processing that took place in her relationship with the therapist.

POSTMASTER’S PSYCHODYNAMIC PSYCHOTHERAPY TRAINING AND CERTIFICATION REQUIREMENTS

Although there is no one certifying body or national certification in psychodynamic psychotherapy, there are many psychodynamic training programs in most major cities in the United States that offer certification. Psychodynamic training is most often offered at an analytic institute and requires the therapist’s own analysis, coursework, and supervised psychoanalytic treatment of a requisite number of patients, culminating in a written case presentation and an oral defense, much like an oral dissertation defense. There are a number of 2-year programs with a focus on psychodynamic psychotherapy and 4-year programs in traditional psychoanalysis. In the past, programs affiliated with the American Psychoanalytic Association limited training to doctors of medicine (MDs), but most of these programs now allow APPNs, social workers, and psychologists to matriculate into their programs.

The American Psychoanalytic Association (2008) sets standards for candidates eligible for admission and includes: doctors of osteopathic medicine, medical doctors, mental health professionals with a doctorate as well as those with a clinical master’s degree. The many institutes of psychodynamic psychotherapy represent the various schools of psychodynamic thought and their respective curricula reflect their orientation. These include ego psychology, self psychology, traditional Freudian psychoanalysis, intersubjectivity approaches, interpersonal therapy, and relational therapy. APPNs who wish to pursue this type of training are advised to obtain information about the institute’s orientation before matriculation, because the theoretical foundation and practice approach may differ greatly.Supportive Psychotherapy Versus Interpersonal Psychotherapy Assignment

CONCLUDING COMMENTS

Psychodynamic psychotherapy is forging new connections with neurobiology to validate existing clinical practice as new knowledge about implicit unconscious processes continues to be generated. It is this meeting of psychology with physiology that Freud envisioned more than 100 years ago. The contemporary model of relational psychodynamic psychotherapy builds on the important contributions of interpersonal psychodynamic theory and is consistent with the centrality of relationship that nursing espouses. The interpersonal psychodynamic model of psychotherapy has been the dominant paradigm for psychiatric nursing for the past 3 decades, since Hildegard Peplau based her framework of psychiatric nursing on the work of Harry Stack Sullivan. The contemporary psychoanalytic theory discussed here for APPN psychotherapy practice is moored in the one-to-one relationship, which builds on that model. The evolving, expanding knowledge of psychodynamic psychotherapy is based on a developmental, neurophysiologic model that deepens the understanding of others and offers the APPN relevant principles important for clinical practice.

DISCUSSION EXERCISES

  1. Diagram (as in Figure 5.1) and discuss the cyclical dynamics of a patient you are currently working with or have worked with in the past.
  2. Identify at least five reasons why evidence-based research is difficult to conduct in psychodynamic psychotherapy.
  3. Compare and contrast the developmental models (i.e., Freud, Mahler, and Erikson) presented in this chapter.
  4. Discuss the evolution of psychoanalytic thought.
  5. What is the relational psychodynamic model of psychotherapy, and how can you integrate the concepts and techniques described in this chapter in your work with patients?
  6. Using the diagram in Figure 5.3, present a case formulation for a specific patient, covering all the dimensions (e.g., anxiety, developmental issue, attachment schema, defenses, and developmental level), and then discuss what type of psychodynamic therapy you think would be appropriate and why.
  7. Describe supportive psychodynamic psychotherapy, and discuss the various techniques for this type of therapy.
  8. Discuss the dynamics of borderline personality organization, and describe general principles for how to work with patients with this character structure.
  9. A patient comes to you for brief psychotherapy, and you believe that psychodynamic psychotherapy would be helpful. Discuss the beginning steps of treatment, and elaborate on how you would go about establishing a therapeutic alliance.

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(Wheeler)

Wheeler, Kathleen, PhD, APRN-BC, FAAN. Psychotherapy for the Advanced Practice Psychiatric Nurse, Second Edition, 2nd Edition. Springer Publishing Company, 20131211. VitalBook file.

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