Long-Term Psychodynamic Psychotherapy, Gabbard (2010)
Chapter 1
Patient: “[W]hat I thought was 'everything' was only the beginning. When I thought I'd reached the ground floor of my psyche, you helped me see that there were basements, caves, and dark recesses below the ground floor that I never knew existed. Our psychotherapy took me to places I didn't want to go.”
Chapter 4
Neutrality, Anonymity, and Abstinence
Neutrality should mean that the therapist tries to remain nonjudgmental about the patient’s wishes, longings, and even barriers to some degree, in the service of understanding them. Patients are much more likely to open up to a therapist if they feel understood rather than judged. However, at times we will have strong reactions to what the patient shares, and at times we should be open about this: Therapists who don’t react to reports of egregious crimes or instances of cruelty may be seen as tacitly endorsing the patient’s behavior and colluding with the patient’s rationalize that it is somehow acceptable.
Anonymity. Therapists are self-disclosing in a variety of ways all the time. The choice of art and photographs in the therapist’s office, the way the therapist changes facial expressions in response to various comments by the patient, and even the therapist’s choice of when to comment within a session all say a great deal about the therapist. Therapists do not talk about their private lives, their families, or their personal problems, however, because the inherent asymmetry of the relationship makes it imperative that the major focus be on the patient’s issues. Sharing personal problems with patients can burden them so that they feel responsible to take care of the therapist… [I]t is now widely understood that whatever the therapist does has a continuing impact on the patient’s perceptions of the therapist, so it is virtually impossible to avoid influencing the patient’s transference.
Abstinence as a principle is an admonition to avoid excessive gratification of the patient’s transference wishes. A total absence of gratification, however, would result in losing the patient. Unless the patient gets something from the therapist, the therapy is unlikely to continue. Even worse, the patient may masochistically submit to a cold therapist, thinking there will ultimately be some reward for submission. Therapists provide a good deal of gratification in simply listening in a humane and warm way to the patient’s concerns… They certainly do maintain abstinence regarding the gratification of sexual wishes and any other form of potential exploration of the patient for their own personal needs.
Interventions
(1) Interpretation. The intent is to make the patient aware of things outside their awareness. While this sometimes means that one is making conscious something that was previously unconscious, at other times it involves pointing out connections between phenomena when the patient does not see the linkage. There is also an explanatory aspect to an interpretation. Therapists try to help their patients gain insight by explaining motives and meanings. Example: “You know, I have the impression that you actually create a nagging situation with both your mom and me by taking an oppositional stance regarding trying a new job. I wonder if being nagged makes you feel like someone cares about you.”
Deliver the interpretation as a possibility (“I wonder…”) to avoid an authoritarian stance and to allow for the possibility that the patient has a different view. Unconscious wishes, fantasies, and beliefs may often be the focus of interpretive work, because they appear in childhood relationships, in current relationships outside the therapy, and the transference.
A therapy that is more expressive places greater emphasis on the transference and will occur 2-3 times weekly, whereas supportive therapy can be once weekly or less. When you increase the frequency of sessions, the transference intensifies, so it can be a central target of interventions by the therapist… A useful guideline is that the transference needs to be interpreted when it becomes a resistance to the process (e.g., you need to address the transference when the patient is coming late to sessions)... We use transference to help the patient understand significant relationships outside the therapy.
(2) Observation. Observation stops short of interpretation in that it doesn’t include attempts to explain or link. The therapist merely notes a behavior, comment, flash of affect, or pattern within the therapy. The motive or explanation is left untouched, with the hope that the patient will reflect on the meaning of the therapist’s observation. Example: “You teared up when I asked about your sister” or “I notice that you always avoid eye contact with me when you leave” or “I don’t know if you’re aware of it, but you always change the subject when I make connections to your father’s abandonment of you.”
(3) Confrontation. Confrontation generally involves an attempt to draw a patient’s attention to something that is being avoided. Unlike observation, which usually targets something outside the patient’s conscious awareness, confrontation usually points out the avoidance of conscious material. Example: “I noticed that you haven’t paid your bill in 3 months. What are your plans for doing something about that.” Example of a patient who had recently lost her mother and came to therapy after Mother’s Day and seemed down: “I noticed you haven’t told me how you felt on your first Mother’s Day since your mother passed away.”
(4) Clarification. Clarification is a way of bringing clarity to issues that are vague, diffuse, or disconnected. Iit can be a way of helping the patient recognize a pattern or of checking the correctness of a therapist’s understanding with a patient. Example: “If I understand you correctly, every time you are involved with a man, you start to have the feeling of being used and want to break off the relationship before it gets any worse. Is that right?” Clarification can also be a way of summarizing key points of information that the patient is making by repacking what the patient has said; example: “So what I hear you saying ist that when you went to the party, each time you tried to strike up a conversation with a woman, you felt that you were seen as undesirable and the women were more interested in other men.”
(5) Encouragement to Elaborate. Encouragement to Elaborate can involve simple comments like, “Can you tell me more about that?” and “I noticed you stopped in the middle of your sentence. I’m curious about what made you stop. Can you elaborate?” Empathic Validation comes from a perspective in which the therapist tries to immerse herself in the patient’s internal state. An effort is made to see the patient’s internal world from the patient’s perspective. This allows for the patient to feel understood and validated with comments such as, “I can appreciate why you would feel so horrible when your mother refused to comment on such an outstanding report card” or “You have every right to feel hurt when someone treats you that way.”
(6) Psychoeducation and Advice and Praise. Psychoeducation and Advice and Praise are much more common in supportive psychotherapy, but some patients require these interventions from time to time in expressive forms of psychotherapy. An example of psychoeducation: a clinician explaining to a patient that depression tends to be a disorder characterized by recurring episodes. Praise is designed to reinforce constructive and positive behaviors or attitudes. Advice involves the offering of the therapist’s opinion about a matter of concern to the patient or therapist.
Many patients require long periods of supportive interventions in the course of therapy. Narcissistically vulnerable patients may feel understood only with empathically validating comments, and the effort to provide a view of their internal world from the outside would be seen as wounding and insensitive.
Chapter 6: Resistance
Freud came to discover that, instead of moving past the patient’s resistance “so that memories could surface,” the analyst “must enter more deeply into the resistance” and invite “the patient to be curious about the resistance because a detailed exploration of what impedes the therapy illuminates wishes, fantasies, conflicts, and desires.”
Acting out “serves a resistance function because the patient is taking something into action rather than verbalizing it and understanding it with his therapist.”
Chapter 8: Countertransference
“[C]ountertransference feelings involve a joint creation with contributions from both patient and therapist,” the patient inducing feelings in the therapist and the therapist also bringing “her own past into the dyad.” Our own life circumstances can influence our countertransference; e.g., a patient who resembles the therapist’s mother will evoke a different reaction than a patient who does not.
Projective identification involves two steps. (1) Transference: the patient disavows a self or object representation by placing it into someone else. (2) Countertransference: the patient nudges the therapist “to experience or unconsciously identify with that which has been projected.” Ideally, the therapist will implement a third step. (3) The therapist “contains and tolerates” the self or object representation and “processes the projected contents, allowing them to be taken back (in a somewhat altered form) or reintrojected by the patient who projected them.” When the patient takes back “the self or object representation, it is “modified to some extent so that over time there is an alteration in the patient's internal object relationships.”
We can realize that projective identification is happening when we realize we’re not acting like ourselves. We might become “abnormally angry, unusually forgiving, atypically bored, or excessively voyeuristic.”
Two types of projective identification. (1) Concordant countertransference: we identify with a self representation that the patient has projected. (2) Complementary countertransference: we identify with an object representation that the patient has projected. Example: an adult patient that was abused as a child. “Within this patient is an object representation of an abuser and a self representation of a victim.” At times, the therapist might “feel like the object” and “become angry or verbally abusive with the patient. At other times, the patient may be angry and demanding, and the therapist may feel like a victim, identifying with the patient's self representation, while the patient is identified with her own internal object representation of an abuser.”
Containment is the process in which we metabolize projective identification; that is, we go “from thinking the patient's thoughts to thinking [our] own thoughts.” To be more specific, we “sort out [our] own contributions versus the patient's and contemplate how [we] are recreating the patient's internal object relations.”
There are different ways we can manage the countertransference. (1) Tolerate the countertransference. “Winnicott (1971 ) once noted that the patient must destroy the therapist, and the therapist must survive the patient's attacks, before the patient can truly make use of the therapist.” He believed that “the therapist's durability may be a significant factor in producing therapeutic change. Thus at times the therapist need not do anything but simply sit with the feelings, contain them, and finally understand them to have a powerful impact on the patient. When patients observe their therapist tolerating feelings formerly regarded as intolerable, a mutative process may occur.”
(2) Use the transference to inform our understanding. “If something is being externalized and recreated with the therapist, it reflects a self-other constellation within the patient's inner world.” Example: "I've noticed that often you don't quite make room for me to engage with you by sharing my in the sessions here. is it possible that your daughters and your mother appear not to be listening to you because you don't make an effort to listen to them?"
(3) Use judicious self-disclosure. This would involve disclosing feelings in the here-and-now. Example: “I sometimes feel like I am just a sounding board for you, and that you really don't want to hear what I have to say.”
Patient: “[W]hat I thought was 'everything' was only the beginning. When I thought I'd reached the ground floor of my psyche, you helped me see that there were basements, caves, and dark recesses below the ground floor that I never knew existed. Our psychotherapy took me to places I didn't want to go.”
Chapter 4
Neutrality, Anonymity, and Abstinence
Neutrality should mean that the therapist tries to remain nonjudgmental about the patient’s wishes, longings, and even barriers to some degree, in the service of understanding them. Patients are much more likely to open up to a therapist if they feel understood rather than judged. However, at times we will have strong reactions to what the patient shares, and at times we should be open about this: Therapists who don’t react to reports of egregious crimes or instances of cruelty may be seen as tacitly endorsing the patient’s behavior and colluding with the patient’s rationalize that it is somehow acceptable.
Anonymity. Therapists are self-disclosing in a variety of ways all the time. The choice of art and photographs in the therapist’s office, the way the therapist changes facial expressions in response to various comments by the patient, and even the therapist’s choice of when to comment within a session all say a great deal about the therapist. Therapists do not talk about their private lives, their families, or their personal problems, however, because the inherent asymmetry of the relationship makes it imperative that the major focus be on the patient’s issues. Sharing personal problems with patients can burden them so that they feel responsible to take care of the therapist… [I]t is now widely understood that whatever the therapist does has a continuing impact on the patient’s perceptions of the therapist, so it is virtually impossible to avoid influencing the patient’s transference.
Abstinence as a principle is an admonition to avoid excessive gratification of the patient’s transference wishes. A total absence of gratification, however, would result in losing the patient. Unless the patient gets something from the therapist, the therapy is unlikely to continue. Even worse, the patient may masochistically submit to a cold therapist, thinking there will ultimately be some reward for submission. Therapists provide a good deal of gratification in simply listening in a humane and warm way to the patient’s concerns… They certainly do maintain abstinence regarding the gratification of sexual wishes and any other form of potential exploration of the patient for their own personal needs.
Interventions
(1) Interpretation. The intent is to make the patient aware of things outside their awareness. While this sometimes means that one is making conscious something that was previously unconscious, at other times it involves pointing out connections between phenomena when the patient does not see the linkage. There is also an explanatory aspect to an interpretation. Therapists try to help their patients gain insight by explaining motives and meanings. Example: “You know, I have the impression that you actually create a nagging situation with both your mom and me by taking an oppositional stance regarding trying a new job. I wonder if being nagged makes you feel like someone cares about you.”
Deliver the interpretation as a possibility (“I wonder…”) to avoid an authoritarian stance and to allow for the possibility that the patient has a different view. Unconscious wishes, fantasies, and beliefs may often be the focus of interpretive work, because they appear in childhood relationships, in current relationships outside the therapy, and the transference.
A therapy that is more expressive places greater emphasis on the transference and will occur 2-3 times weekly, whereas supportive therapy can be once weekly or less. When you increase the frequency of sessions, the transference intensifies, so it can be a central target of interventions by the therapist… A useful guideline is that the transference needs to be interpreted when it becomes a resistance to the process (e.g., you need to address the transference when the patient is coming late to sessions)... We use transference to help the patient understand significant relationships outside the therapy.
(2) Observation. Observation stops short of interpretation in that it doesn’t include attempts to explain or link. The therapist merely notes a behavior, comment, flash of affect, or pattern within the therapy. The motive or explanation is left untouched, with the hope that the patient will reflect on the meaning of the therapist’s observation. Example: “You teared up when I asked about your sister” or “I notice that you always avoid eye contact with me when you leave” or “I don’t know if you’re aware of it, but you always change the subject when I make connections to your father’s abandonment of you.”
(3) Confrontation. Confrontation generally involves an attempt to draw a patient’s attention to something that is being avoided. Unlike observation, which usually targets something outside the patient’s conscious awareness, confrontation usually points out the avoidance of conscious material. Example: “I noticed that you haven’t paid your bill in 3 months. What are your plans for doing something about that.” Example of a patient who had recently lost her mother and came to therapy after Mother’s Day and seemed down: “I noticed you haven’t told me how you felt on your first Mother’s Day since your mother passed away.”
(4) Clarification. Clarification is a way of bringing clarity to issues that are vague, diffuse, or disconnected. Iit can be a way of helping the patient recognize a pattern or of checking the correctness of a therapist’s understanding with a patient. Example: “If I understand you correctly, every time you are involved with a man, you start to have the feeling of being used and want to break off the relationship before it gets any worse. Is that right?” Clarification can also be a way of summarizing key points of information that the patient is making by repacking what the patient has said; example: “So what I hear you saying ist that when you went to the party, each time you tried to strike up a conversation with a woman, you felt that you were seen as undesirable and the women were more interested in other men.”
(5) Encouragement to Elaborate. Encouragement to Elaborate can involve simple comments like, “Can you tell me more about that?” and “I noticed you stopped in the middle of your sentence. I’m curious about what made you stop. Can you elaborate?” Empathic Validation comes from a perspective in which the therapist tries to immerse herself in the patient’s internal state. An effort is made to see the patient’s internal world from the patient’s perspective. This allows for the patient to feel understood and validated with comments such as, “I can appreciate why you would feel so horrible when your mother refused to comment on such an outstanding report card” or “You have every right to feel hurt when someone treats you that way.”
(6) Psychoeducation and Advice and Praise. Psychoeducation and Advice and Praise are much more common in supportive psychotherapy, but some patients require these interventions from time to time in expressive forms of psychotherapy. An example of psychoeducation: a clinician explaining to a patient that depression tends to be a disorder characterized by recurring episodes. Praise is designed to reinforce constructive and positive behaviors or attitudes. Advice involves the offering of the therapist’s opinion about a matter of concern to the patient or therapist.
Many patients require long periods of supportive interventions in the course of therapy. Narcissistically vulnerable patients may feel understood only with empathically validating comments, and the effort to provide a view of their internal world from the outside would be seen as wounding and insensitive.
Chapter 6: Resistance
Freud came to discover that, instead of moving past the patient’s resistance “so that memories could surface,” the analyst “must enter more deeply into the resistance” and invite “the patient to be curious about the resistance because a detailed exploration of what impedes the therapy illuminates wishes, fantasies, conflicts, and desires.”
Acting out “serves a resistance function because the patient is taking something into action rather than verbalizing it and understanding it with his therapist.”
Chapter 8: Countertransference
“[C]ountertransference feelings involve a joint creation with contributions from both patient and therapist,” the patient inducing feelings in the therapist and the therapist also bringing “her own past into the dyad.” Our own life circumstances can influence our countertransference; e.g., a patient who resembles the therapist’s mother will evoke a different reaction than a patient who does not.
Projective identification involves two steps. (1) Transference: the patient disavows a self or object representation by placing it into someone else. (2) Countertransference: the patient nudges the therapist “to experience or unconsciously identify with that which has been projected.” Ideally, the therapist will implement a third step. (3) The therapist “contains and tolerates” the self or object representation and “processes the projected contents, allowing them to be taken back (in a somewhat altered form) or reintrojected by the patient who projected them.” When the patient takes back “the self or object representation, it is “modified to some extent so that over time there is an alteration in the patient's internal object relationships.”
We can realize that projective identification is happening when we realize we’re not acting like ourselves. We might become “abnormally angry, unusually forgiving, atypically bored, or excessively voyeuristic.”
Two types of projective identification. (1) Concordant countertransference: we identify with a self representation that the patient has projected. (2) Complementary countertransference: we identify with an object representation that the patient has projected. Example: an adult patient that was abused as a child. “Within this patient is an object representation of an abuser and a self representation of a victim.” At times, the therapist might “feel like the object” and “become angry or verbally abusive with the patient. At other times, the patient may be angry and demanding, and the therapist may feel like a victim, identifying with the patient's self representation, while the patient is identified with her own internal object representation of an abuser.”
Containment is the process in which we metabolize projective identification; that is, we go “from thinking the patient's thoughts to thinking [our] own thoughts.” To be more specific, we “sort out [our] own contributions versus the patient's and contemplate how [we] are recreating the patient's internal object relations.”
There are different ways we can manage the countertransference. (1) Tolerate the countertransference. “Winnicott (1971 ) once noted that the patient must destroy the therapist, and the therapist must survive the patient's attacks, before the patient can truly make use of the therapist.” He believed that “the therapist's durability may be a significant factor in producing therapeutic change. Thus at times the therapist need not do anything but simply sit with the feelings, contain them, and finally understand them to have a powerful impact on the patient. When patients observe their therapist tolerating feelings formerly regarded as intolerable, a mutative process may occur.”
(2) Use the transference to inform our understanding. “If something is being externalized and recreated with the therapist, it reflects a self-other constellation within the patient's inner world.” Example: "I've noticed that often you don't quite make room for me to engage with you by sharing my in the sessions here. is it possible that your daughters and your mother appear not to be listening to you because you don't make an effort to listen to them?"
(3) Use judicious self-disclosure. This would involve disclosing feelings in the here-and-now. Example: “I sometimes feel like I am just a sounding board for you, and that you really don't want to hear what I have to say.”
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