CFPS: Work of Therapy

Psychoanalytic Perspective

Gabbard (2010), Chatper 1

McWilliams (2004), Chapter 2

Preparation of the Therapist

McWilliams (2004), Chapter 2

Horney (Chapter 5) breaks the work of the analyst into five main divisions. (1) Observation. The analyst, like everyone else, observes “general qualities in the patient’s behavior, such as aloofness, warmth, rigidity, spontaneity,” etc. Additionally, the analyst, by paying attention to the patient’s free associations, observes actions deriving from his unconscious. (2) Understanding. The analyst can be likened to the detective in a mystery story. (3) Interpretation. “Interpretations are suggestions as to possible meanings. They are by nature more or less tentative, and the patient’s reactions to them vary.” (4) Help in Resistance. Resistance halts the work, and the analyst must respond by helping the patient to see that he is using resistance and to understand what the resistance is “warding off.” (5) General Human Help. The analyst does this in different ways. For example, “by his very presence, he gives the patient a unique opportunity to become aware of his behavior toward people.”

Preparing the Patient

McWilliams (2004), Chapter 5

Horney (Chapter 4) writes that the patient has three main tasks: (1) “to express himself as freely and frankly as possible,” (2) “to become aware of his unconscious driving forces and their influences on his life,” and (3) “to develop the capacity to change those attitudes that are disturbing his relations with himself and the world around him.” Regarding (2), she writes that this is “not only an intellectual process” but also an emotional experience, “gaining information about ourselves which we feel in our ‘guts.’”

Basic Psychodynamic Therapy Processes

Gabbard (2010), Chatper 4

McWilliams (2004), Chapter 6

Ogden (1992) writes that transference begins before the first session: “In addition to viewing the analyst as a person trained to understand and (through some as yet unknown process) help the patient find relief from psychic pain, the analyst is also experienced as the healing mother, the childhood transitional object, the wished-for oedipal mother and father, and so on.”

Ogden tells the patient that the first session is a “consultation” “in order to make it clear that this meeting will not necessarily be the beginning of ongoing work together” since he cannot know on the basis of a phone call whether he will want to work with the individual. If he doesn’t initially feel like he likes the patient, he will not work with them. “It is sometimes said that the analyst ought to be able to analyze his negative countertransference and therefore should be able to work with any patient who is otherwise suitable for analytic work. In theory this may be true; in practice, however, I believe that the analytic task is difficult enough without attempting to build the analytic edifice upon a foundation of a powerful negative countertransference (or an intense negative transference).”

Nonetheless, Ogden intends for the first session “to facilitate the creation of an interaction that will constitute an analytic experience that will be of some value to the patient in providing him with a sense of what it means to be in analysis.” Recognizing that the new patient’s anxiety is extremely high, he nonetheless does not try to “put the patient at ease.” Rather, he believes it is his job “to help the patient not miss an important opportunity to recognize and understand something about the transference thoughts, feelings, and sensations with which he has been struggling.”

It might be tempting to “put the patient at ease” while walking from the waiting room to the consulting room — e.g., by saying, “I hope you didn't have trouble finding a parking space. Parking is awful around here.” — such comments are actually unkind. First, “he has communicated to the patient his unconscious feeling that the patient is an infant who has trouble making his way in a hostile world and that the therapist feels guiltily responsible for not making the patient's life less difficult.” Second, there is “a hint in the therapist's comment that he is not confident that the therapy he will offer the patient is worth the trouble to which the patient is going.” Third, this “misleads the patient about the nature of the analytic experience,” giving the impression that the analysis will alleviate the patient’s anxiety when in fact we ask patients to endure “psychological strain.” “Whether the incident is ever spoken of again, the analysand unconsciously registers the fact that the analyst has granted himself license to handle his own anxiety by means of countertransference acting in.”

Although the patient might have many questions about analysis, Ogden prefers that the analyst’s explanations will generally be ineffective, and he believes that “the analyst's most eloquent explanation of what it means to be “in analysis” is to conduct himself as an analyst.”

In the first session, he is listening for the patient’s transference anxiety, i.e., “the patient's unconscious explanations of why he feels the analysis is a dangerous undertaking and his reasons for feeling the analysis is certain to fail.” “Whatever the nature of the analysand’s disturbances, his anxieties will be given form in terms of the danger of entering into a relationship with the analyst. The patient unconsciously holds a fierce conviction (which he has no way of articulating) that his infantile and early childhood experience has taught him about the specific ways in which each of his object relationships will inevitably become painful, disappointing, overstimulating, annihilating, unreliable, suffocating, overly sexualized, etc. There is no reason for him to believe that the relationship into which he is about to enter will be any different.”

Frame and Resistance

Gabbard (2010), Chatper 6

McWilliams (2004), Chapter 5

Assessment and Formulation

Gabbard (2010), Chatper 2

McWilliams (2004), Chapter 1

Transference

Basch (1980), Chapter 4

Cabaniss (2011), Chapter 21

Countertransference

Gabbard (2010), Chatper 8

McWilliams (2004), Chapter 7

Sandler (1976) Freud rightly came to understand that transference was not a hindrance but “an indispensable vehicle” for therapeutic work; however, he failed to see the value in countertransference. We now know that countertransference came help us “understand the hidden meaning of material brought by the patient,” the main idea being “that the analyst has elements of understanding and appreciation of the processes occurring in his patient, that these elements are not immediately conscious and that they can be discovered by the analyst if he monitors his own mental associations while listening to the patient.”

Transference can involve, not just seeing one person in another, but also unconscious attempts “to manipulate or to provoke situations with others which are a concealed repetition of earlier experiences and relationships.” The patient does this to resist “becoming aware of any infantile relationship which he might be attempting to impose.”

We might often think that we’re acting differently with a particular patient because of our own problems or blind spots and might “resort to self-­analysis in order to discover the pathology behind [our] particular response or attitude to the patient.” However, it is often the case that our attitude or behavior can be “regarded as a compromise-­formation between [our] own tendencies and [our] reflexive acceptance of the role which the patient is forcing on [us].”

One way we’re able to tap into our countertransference is through “free-­floating attention,” which is not “the ‘clearing of the mind’ of thoughts or memories, but the capacity to allow all sorts of thoughts, daydreams and associations to enter the analyst’s consciousness while he is at the same time listening to and observing the patient.”

* * * * * 

Michael Basch, 1980, Doing Psychotherapy.

Deborah Cabaniss, 2011, Psychodynamic Psychotherapy: A Clinical Manual. 

Glen Gabbard, 2010, Long Term Psychodynamic Psychotherapy: A Basic Text, 2nd Edition.

Karen Horney, 1942, Self-Analysis.

Nancy McWilliams, 2004, Psychoanalytic Psychotherapy. 

Thomas Ogden, 1992, Comments on Transference and Countertransference in the Initial Analytic Meeting.

Joseph Sandler, 1976, Countertransference and Role-Responsiveness.