Objetivos específicos

Cinematic stereotypes of psychoanalysis and psychodynamic therapy often portray the therapist as an aloof, silent, and cold figure whose facial expressions never change. The contemporary dynamic therapist is warm, empathic, and spontaneous; the "blank screen" therapist belongs to an earlier era. We now know from studies in nonverbal

communication that it is impossible to entirely conceal one's feelings, and probably not helpful even if one could do so. A psychodynamic therapist focuses on the patient, so self-disclosure is kept to a minimum unless saying

something about here-and-now feelings or an area of common interest is likely to enhance the therapy. In any case, the therapeutic atmosphere should be one of a spontaneous conversation in which the patient feels understood and helped. Terms such as neutrality in describing the therapist's attitude are often misunderstood as cold aloofness. A better understanding of the term would be conveyed by saying that the therapist assumes a nonjudgmental attitude of listening to the patient's concerns.

Although the therapeutic dialogue should have a spontaneous quality to it, it is useful to have in mind a continuum of interventions that are designed to promote therapeutic change. These categories will not encompass all of the therapist's comments, but they serve as useful guideposts to help the therapist tailor the technique to the patient. As noted previously, dynamic psychotherapy usually takes place along an expressive-supportive continuum.

Interventions can be conceptualized as residing on that continuum, as shown in Figure 2–1.

Interpretation

The term expressive is used synonymously with exploratory or interpretive. Hence, at the left end of the continuum is interpretation, the most expressive or insight-producing comment in the therapeutic armamentarium. The intent is to make patients aware of things that are currently outside of their awareness. Interpretations may bring to

consciousness something that was previously unconscious, or they may explain a linkage that was outside of the patient's awareness in a way that produces insight. An example of an interpretation is the following:

Therapist: You seem to hold yourself back from succeeding because you worry that your mother will be envious and retaliate against you.

As this example illustrates, interpretation usually involves explaining something to the patient. An interpretation is more likely to be received with an open mind if presented to the patient in a tentative way, as a possibility rather than as a definitive statement from an oracular source of knowledge.

Observation

Interpretation, by definition, explains a link between one thing and another. Observation stops short of making a linkage or explaining an underlying motivation. Hence it calls the patient's attention to something that is outside of his or her awareness. An example might be a simple comment such as, "Have you noticed that you almost always yawn as you enter the office and greet me?" Observations frequently focus on nonverbal communications or unconscious enactments that are visible to the therapist but for which the patient has blind spots.

Confrontation

Whereas observations target behavior that is outside of the patient's conscious awareness, confrontation generally points out something that is being avoided but that is within the conscious awareness of the patient. A narcissistic patient came to a psychotherapy session on September 11, 2001, and made no reference to the terrorist attacks on the World Trade Center and the Pentagon that had occurred several hours earlier. As the patient went on and on about how his girlfriend had mistreated him, the therapist said, "I notice that you have not mentioned the terrorist attacks today." The avoidance of that topic led to a productive exploration of how the patient wished to deny the

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impact of the event on him because it terrified him. Confrontation may also involve the placing of limits for patients who are pushing the limits of the treatment setting.

Clarification

Much of the therapist's activity involves clarifying what the patient is getting at. Patients may be vague or uncertain about what they are feeling or thinking, and therapists often try to summarize or repackage what the patient is saying in a way that clarifies it for both patient and therapist: "It sounds like what you're really saying is that you can't decide whether you really want to stay in this relationship or leave it." Often the therapist's voice has a questioning tone: "Do I understand correctly that you really didn't see your father from the age of 6 to 8?"

Encouragement to Elaborate

In the middle of the continuum is the intervention known as encouragement to elaborate. Perhaps the most common form of communication from the therapist, this intervention is designed to elicit further commentary from the patient.

The principle of free association stemming from psychoanalysis is applied to dynamic therapy as well. Therapists do whatever they can to stimulate the patient's uncensored, open reporting of whatever comes to mind. Hence, a frequent intervention is, "I'd like to hear more about that." Sometimes the patient is stopped at a moment when the therapist feels more needs to be said: "I'm sure you must have other feelings about it than those you have told me so far. Could you say a little more?" Generally, this kind of intervention is open-ended, but it may also be directed at something specific: "I'd like to hear more about your mother's father. I don't know much about him."

Empathic Validation

While self psychology regards empathy as central to technique, therapists of all persuasions must be alert to patients' need for empathic validation. Often patients have had their internal experiences invalidated or denied by parents as they grew up, leading to a need to present a façade or a false self to the family. Therapists can be particularly helpful when they validate that the patient has a right to certain feelings and that the patient's response is legitimate in light of what has happened to the patient. An empathically validating comment could be, "It is completely understandable to me that you would be angry at your father after he said that to you." Such interventions can also be applied to the here-and-now situation: "You have every reason to be mistrustful of me, given what you've experienced from authority figures in the past."

Psychoeducational Intervention

Near the supportive end of the continuum, psychotherapy becomes more akin to teaching. Dynamic psychotherapy always has an educational aspect because patients learn about themselves in the process of trying to express the nature of their problems. Sometimes patients require specific forms of education about the nature of their illness, the goals of psychotherapy, or the limits of psychotherapy. One patient needed to be told, "I really can't accept your donation to my research because it would be unethical for me to take advantage of our therapeutic relationship by soliciting donations from you." Another dynamic therapist said to a patient with anxiety, "Most of the research on anxiety indicates that there are probably both a genetic component and contributions based on adverse

environmental experiences."

Advice and Praise

The most supportive interventions in dynamic psychotherapy are those that directly praise the patient for specific behaviors or comments, or offer advice to the patient on a particular course of action. Patients who are in a state of crisis may need specific advice such as, "You must go to a women's shelter rather than risk your life by staying with your husband." This intervention was needed after a woman who was beaten by her husband had a gun pointed at her. Praise can facilitate the therapeutic alliance and can help the patient feel that he or she is participating in

therapy effectively. A typical comment involving praise is, "I think you've come up with a very important insight there that I hadn't thought about before." Praise often involves a therapist's statement of positive regard for the patient:

"I'm proud of you for having the courage to speak directly to your mother about this problem instead of concealing it."

TRANSFERENCE

As the definition at the beginning of this chapter reveals, the focus on transference is a hallmark of psychodynamic psychotherapy. A simple definition of transference is the displacement of feelings and thoughts associated with a figure in the patient's past onto the therapist. Transference is often unconscious, at least initially, and the patient is bewildered by behavior toward the therapist because it does not make sense, based on who the therapist really is. A patient may say, "I have no idea why I forgot to come today. I'm not aware of any negative feelings about you."

Hence the enactment of missing a session or of coming late to a session may reveal unconscious transference.

Whereas the original definition assumed that a kind of template in the unconscious was taken from the patient's mind and superimposed on the therapist without much alteration, today the prevailing view is that the therapist's actual behavior is always influencing the patient's experience of the therapist (Hoffman 1998). Hence the transference to the therapist is partly based on real characteristics and partly on figures from the patient's past—a combination of old and new relationships.

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Beginning therapists can err on the side of calling too much attention to the transference too soon. As a general principle, one should postpone the interpretation of transference until it becomes a resistance and until it is close to the patient's awareness (Gabbard 2004). In other words, if things are going reasonably well, it makes no sense to interpret transference. If the patient develops, for example, erotized or highly negative feelings, which impede the process of the therapy, interpretation may be essential. Many therapists regard treatment that focuses on

transference as more exploratory than therapy geared to extratransference relationships. In supportive therapy, interpretation of the transference may be minimized, although the therapist may silently interpret the transference as a way of increasing his or her understanding of the patient.

The following vignette illustrates the evolution of transference in one therapy session, and its management by the therapist:

Patient: I need to tell you what happened in my conversation with Mom last night. She tries to control everything I do. You've heard of the book My Mother/My Self? Well, with her, it's My Daughter/My Self. She wants me to be a clone of her, and I can't stand her control.

Therapist (also female): What exactly happened last night?

Patient: She said she wanted to take me to dinner, so I went. Then, when I tried to order, I just about lost it. She insisted that I get the special, which was what she was ordering. She told me that she specifically took me to the restaurant so I would try a particular dish. I've told her a hundred times that I'm trying to get red meat out of my diet, and the special was some kind of beef bourguignonne that I simply did not want to eat. So we had an argument right there in front of the people at the next table, who were listening in.

Therapist: I know that you are exasperated right now but, as I've told you before, part of you unconsciously sets up that situation because you get something out of the conflict with your mother. I think you could have written last night's scenario before you went to the restaurant.

Patient: Why would I want to interact with my mother in such an annoying and argumentative way?

Therapist: I don't think we fully understand that yet.

Patient: We don't understand it because it's not true. There's nothing whatsoever appealing about that type of interaction.

Therapist: I think we go through the same type of "dance" here. It's very hard for you to accept what I say because you imagine I'm like your mother, believing that I insist that you think just like I do.

In this vignette, the patient begins to recreate the relationship with her mother in the therapeutic setting. Dynamic therapists assume that patients will reestablish their family situation in therapy, just as they do in intimate

relationships outside of therapy. One way that the therapist helps is by interpreting transference, a process designed to illustrate to the patient that what happens in the therapeutic relationship is similar to what happens outside of therapy. Many patients feel shamed or "caught" when the therapist interprets this type of repetition, so the therapist must be judicious in using transference interpretations.

Transference has many manifestations. Dreams may reveal feelings toward the therapist that otherwise do not enter into the process. Patients may talk about another doctor or professional in highly emotional terms as a way of displacing transference feelings elsewhere. Patients who have concealed erotic feelings toward their therapist may engage in an intense erotic relationship with someone who resembles the therapist.

Transferences also may vary in the course of psychotherapy. In contemporary psychoanalytic and psychodynamic discourse, it is generally recognized that there are multiple transferences—stemming from parents, siblings, and other figures—and not simply one specific transference. Moreover, some patients do not work well within the

transference and do not feel intense feelings toward the therapist—a situation known as resistance to the awareness of transference—so the therapist will need to work interpretively on outside relationships until the patient feels comfortable enough to bring material into the therapeutic relationship. Other patients go through an entire psychotherapy and benefit greatly without a focus on the transference. Hence one must adapt the types of interventions and the degree of transference work to the specific patient.

COUNTERTRANSFERENCE

The original use of countertransference, as described by Freud (1910), was the analyst's transference to the patient.

In other words, the patient might remind the therapist of someone from the therapist's past, so that the therapist starts to treat the patient as though he or she were that figure. Over time, this view of countertransference was broadened to include the total emotional reaction of the therapist to the patient. Today it is recognized that

countertransference is jointly created—it partly involves the therapist's past relationships, but it also involves feelings induced in the therapist by the patient's behavior. The part of the countertransference induced by the patient is generally referred to as projective identification. This process involves two steps: 1) a self or object representation within the patient is projectively disavowed by its unconsciously being placed onto someone else, and 2) the

projector exerts internal pressure that nudges the other person to experience or unconsciously identify with whatever

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has been projected. One could say that step 1 is a type of transference, whereas step 2 is a countertransference reaction. In a psychotherapeutic context, a third step occurs: 3) the recipient of the projection, the therapist, contains and tolerates the affective state and the projection of the self or object representation associated with the affect until the patient can take them back and "own" what has been projected. In this manner, projective identification can be regarded as both an interpersonal communication and an intrapsychic defensive operation.

Projective identification often feels obligatory. Therapists may feel that an alien force is taking them over, and feel that they cannot avoid enacting the role that the patient has thrust on them. This state of affairs can be

therapeutically useful, however, because the therapist is experiencing something that others in the patient's life experience.

Some therapists may use the countertransference as a step on the road to interpreting something useful to the patient. For example, the therapist might say, "I notice myself feeling a bit frustrated because I keep asking you questions to try to find out what you are thinking or feeling, but you tell me very little. This sounds like what goes on with your husband at home quite frequently." Pointing out the interpersonal process, the therapist can help the patient reflect on how he or she takes an active role in creating a situation that may be unpleasant or difficult in relationships outside of therapy.

The therapist is using self-disclosure of countertransference to promote therapeutic gains in the patient. This type of self-disclosure must be used judiciously, because disclosure of some countertransference feelings may be harmful to the process. For example, it is rarely useful to say, "I hate you," to the patient or "I feel bored by what you are telling me." The patient has no obligation to entertain the therapist, and the revelation of such feelings to the patient may inflict a severe wound that leaves the patient unable to trust the therapist. The revealing of sexual feelings toward the patient is rarely useful. The patient may feel that the therapeutic setting is no longer a safe place if the therapist begins to express sexual desire toward him or her.

Positive countertransference feelings can be present without the therapist knowing it. Positive regard toward the patient may be seen as simply a caring posture that facilitates the therapy. However, countertransference blind spots can grow out of positive feelings. Therapists may be reluctant to confront the patient about aggression or other problems if they do not want to "rock the boat" and cause the patient to have negative feelings toward them.

Similarly, a need to rescue the patient may keep the patient from developing his or her own resources for problem solving.

RESISTANCE

The identification and management of resistance is also fundamental to the technique of psychodynamic psychotherapy. Dynamic therapists recognize that patients are ambivalent about changing. They unconsciously oppose the therapist's efforts to offer insight and therapeutic change. Defense mechanisms that defend against uncomfortable feelings are activated by the therapy as resistances.

Resistance is not necessarily spoken. It may take the form of a conscious admission of not wishing to go where the therapist wants the patient to go, but it may also appear as a failure to show up on time, a tendency to forget sessions, lapses into silence for no apparent reason, or a preference for discussing matters that appear to be quite irrelevant to the therapeutic goals. However, dynamic therapists know that the way the patient resists is a revelation of something important about the patient—often a highly significant internal object relationship from the patient's past, transported into the present moment with the therapist (Friedman 1991).

In this regard, many resistances are transference resistances. The patient may be opposing the therapist's efforts because of unconscious feelings or thoughts about the therapist, based on figures from the patient's past. Patients may feel that the therapist may shame them if they open up, or criticize them for their shortcomings. A good

In this regard, many resistances are transference resistances. The patient may be opposing the therapist's efforts because of unconscious feelings or thoughts about the therapist, based on figures from the patient's past. Patients may feel that the therapist may shame them if they open up, or criticize them for their shortcomings. A good