Contemporary Psychodynamic Psychotherapy: Evolving Clinical Practice 9780128133736

Citation preview

Contemporary Psychodynamic Psychotherapy

Contemporary Psychodynamic Psychotherapy Evolving Clinical Practice

Edited by

David Kealy Department of Psychiatry, University of British Columbia, Vancouver, Canada

John S. Ogrodniczuk Department of Psychiatry, University of British Columbia, Vancouver, Canada

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2019 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN: 978-0-12-813373-6 For Information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Nikki Levy Acquisition Editor: Nikki Levy Editorial Project Manager: Ruby Smith Production Project Manager: Bharatwaj Varatharajan Cover Designer: Mark Rogers Typeset by MPS Limited, Chennai, India

List of contributors

Dana Atzil-Slonim Psychology Department, Bar-Ilan University, Ramat Gan, Israel Louise Balfour The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada Jacques P. Barber Derner Institute of Advanced Psychological Study, Adelphi University, New York, NY, United States Anthony Bateman University College London, London, United Kingdom Fredric N. Busch Weill Cornell Medical College, New York, NY, United States Eve Caligor Columbia University College of Physicians and Surgeons, New York, NY, United States Richard A. Chefetz Washington Baltimore Center for Psychoanalysis, Washington, DC, United States; Institute of Contemporary Psychotherapy & Psychoanalysis, Washington, DC, United States John F. Clarkin Weill Cornell Medical College, New York, NY, United States; New York Presbyterian Hospital Cornell Medical Center, White Plains, NY, United States Katherine Crits-Christoph Department of Psychiatry, University of Pennsylvania, PA, United States Paul Crits-Christoph Department of Psychiatry, University of Pennsylvania, PA, United States Celine De Meulemeester Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium Martin Debbane´ Developmental Clinical Psychology Research Unit, Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland; Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom

x

List of contributors

Guy Diamond Center for Family Intervention Science, College of Nursing and Health Professions, Drexel University, Philadelphia, PA, United States Nel Draijer Private practice Johannes C. Ehrenthal Heidelberg University, Heidelberg, Germany Peter Fonagy Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom Mary Beth Connolly Gibbons Department of Psychiatry, University of Pennsylvania, PA, United States Geoff Goodman Clinical Psychology Doctoral Program, Long Island University, Brookville, NY, United States; Institute for Psychoanalytic Training and Research, NY, United States Charles A. Granoff, MSW Community Services Institute, Springfield and Dorchester, MA, United States Robert J. Gregory Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY, United States James Higginbotham Community Services Institute, Springfield and Dorchester, MA, United States Mark J. Hilsenroth Derner School of Psychology, Adelphi University, New York, NY, United States Robert Johansson Department of Psychology, Stockholm University, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linko¨ping University, Linko¨ping, Sweden David Kealy Department of Psychiatry, University of British Columbia, Vancouver, Canada John R. Keefe Weill Cornell Medical College, University of Pennsylvania, University Park, PA, United States Johannes Kruse Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany; Department of Psychosomatics and Psychotherapy, University of Marburg, Marburg, Germany

List of contributors

xi

Falk Leichsenring Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany; Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany Kenneth N. Levy Department of Psychology, Weill Cornell Medical College, Pennsylvania State University, University Park, PA, United States Suzanne Levy Center for Family Intervention Science, College of Nursing and Health Professions, Drexel University, Philadelphia, PA, United States Vittorio Lingiardi Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy Patrick Luyten Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium; Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom Norka T. Malberg, Psy.D Western New England Psychoanalytic Society, CT, United States; Yale Child Study Center, CT, United States Syreeta Mason Center for Family Intervention Science, College of Nursing and Health Professions, Drexel University, Philadelphia, PA, United States Helga Mattheß University of Worcester, Worcester, United Kingdom Kevin S. McCarthy Chestnut Hill College, Philadelphia, PA, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States Nick Midgley Anna Freud National Centre for Children and Families, University College London, London, United Kingdom Barbara L. Milrod Weill Cornell Medical College, New York, NY, United States; New York Psychoanalytic Institute, New York, NY, United States; Columbia University Center for Psychoanalytic Training and Research, New York, NY, United States Nicola Nardelli Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy Pamela Nathan CASSE Aboriginal Australian Relations Program

xii

List of contributors

John S. Ogrodniczuk Department of Psychiatry, University of British Columbia, Vancouver, Canada Seth R. Pitman Austen Riggs Center, Stockbridge, MA, United States Bent Rosenbaum Institute of Psychology, University of Copenhagen, Denmark; Head of Psychotherapy Research, Psychiatric Center Copenhagen, Clinic of Psychotherapy Frank Sacco Jr, Psy.D. Community Services Institute, Springfield and Dorchester, MA, United States Frank C. Sacco, PhD Community Services Institute, Springfield and Dorchester, MA, United States Bjo¨rn Salomonsson Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden Daniel Smyth Private practice, London, United Kingdom; Sport and Thought, Football as Therapy, London, United Kingdom Christiane Steinert Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany; Department of Psychology, MSB Medical School Berlin, Berlin, Germany; Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany Giorgio A. Tasca School of Psychology, University of Ottawa, Ottawa, ON, Canada Pratyusha Tummala-Narra Department of Counseling, Developmental and Educational Psychology, Boston College, Chestnut Hill, MA, United States Pauline Van Zon Private practice Wolfgang Wo¨ller Rhein-Klinik, Hospital for Psychosomatic Medicine and Psychotherapy, Bad Honnef, Germany Frank E. Yeomans Weill Cornell Medical College, New York, NY, United States Sigal Zilcha-Mano University of Haifa, Haifa, Israel

Introduction

Psychodynamic psychotherapy is one of the most widely practiced forms of psychotherapy today, applied in a variety of settings and contexts, across a wide range of patient or client problems, and by members of several mental health disciplines. A great many psychotherapists expressly identify themselves as “psychodynamically oriented,” and countless others incorporate psychodynamic principles and strategies in their work, often blending or integrating psychodynamic understanding and technique with other therapy models. Similarly, many consumers of psychotherapy benefit from psychodynamic approaches without having explicitly sought them out in their quest to obtain help. Seeking relief from suffering, they may happen upon a psychodynamic process through consulting with a therapist at a local outpatient clinic or in an integrative therapy group that blends psychoeducation with examination of interpersonal processes. Many individuals seeking psychotherapy, however, are intent upon engaging in a therapeutic process that allows for a thorough exploration of one’s mind, interpersonal relationships, and broader sociocultural influences in the process of understanding and addressing complex life problems. These consumers have little difficulty regarding an extended, even meandering, exploratory therapy as a legitimate and effective means to alleviate suffering and expand personal capacities. Psychodynamic psychotherapy offers this possibility for those who seek it. Indeed, many psychotherapists themselves choose to obtain psychodynamic therapy for their own personal therapy, whether to address personal challenges or simply for better self-understanding, regardless of the therapeutic approach they offer their clients. Other prospective therapy consumers, however, seek a more direct route to problem resolution. These individuals may want a time-limited, structured approach that can zero in on conflicted motivations, constricted affects, or unsatisfactory attachment patterns underlying their troublesome symptoms. Here again, psychodynamic therapy can deliver, with well-defined, structured models available for a range of mental health problems. These various permutations, among others, add up to a lot of psychodynamic psychotherapy being sought by clients, practiced by clinicians, and—we would argue—delivered to good effect. Despite this widespread proliferation, misconceptions abound regarding psychodynamic psychotherapy as a contemporary treatment. One common misconception is the notion that a psychodynamic approach is old-fashioned, a dusty relic of a bygone era. According to this perception, the theory underlying psychodynamic therapy was long ago supplanted by more modern, scientific understandings of the mind and mental disorder, rendering psychodynamic therapy an antiquated and irrelevant endeavor. Related to this misconception is the claim that psychodynamic psychotherapy has been eclipsed by “evidence-based” treatments that have been

xiv

Introduction

validated by rigorous empirical research, implying that psychodynamic therapy has not been or, worse, that it has been found to be an inferior approach compared to other mental health treatments. Another misconception may even be unwittingly perpetuated by some practitioners within the psychodynamic community: that there is one particular way—steeped in tradition—of doing psychodynamic psychotherapy. This myth is most likely to be transmitted implicitly, through the training and supervision of new clinicians, and may be compounded by new therapists’ anxieties about practicing “the right way.” From our perspective, these various misconceptions could hardly be further from the truth. Psychodynamic psychotherapy today is a diverse and vibrant field. The scientific basis for psychodynamic approaches has become more robust and expansive, with an ongoing accrual of research evidence regarding treatment outcomes and processes—shedding light on how therapy works —across different conditions and populations. Meanwhile, theoretical and practice innovations continue, contributing further conceptual refinements and novel applications. Rather than ossifying, psychodynamic psychotherapy is enjoying a quiet renaissance. When we were considering the development of this volume, our objective was to share some of the evolution and vitality evident in the field of contemporary psychodynamic psychotherapy. We felt that it was about time for a book to bring together a number of recent developments, including research contributions, conceptual developments, research-to-practice translation, and innovations in clinical delivery. This book is thus intended to celebrate the leading edge of psychodynamic psychotherapy today. In one sense, we view the book as a compendium of current knowledge regarding psychodynamic psychotherapy: a snapshot of where the field is today and some of the directions in which it is moving. At the same time, we also hope that this compilation overall conveys a sense of the organic, everdeveloping nature of contemporary psychodynamic science and practice. For the reader who is new to psychodynamic psychotherapy, we hope that the chapters within will reveal how versatile this approach can be. While the chapters are not exhaustive in scope, we have tried to include a variety of problem areas for psychodynamic applications, with different points of technical emphasis conveyed across the chapters. Similarly, for readers who identify with other theoretical traditions but seek to incorporate psychodynamic interventions in their clinical toolkit, the different approaches described in the book offer opportunities for comparison, integration, and further exploration. Our hope for the seasoned psychodynamically oriented reader is a volume that provides an update on research-based models, contemporary practice considerations, and innovative treatment formats. To meet the objectives we had in mind for this book, we sought contributions from people who are actively moving psychodynamic therapy forward and who are communicating their work through academically oriented writings. This work doesn’t always get into the hands of practitioners in a timely manner and often not in one volume. Here, we wanted such contributions to be addressed to clinicians— therapists in real-world practice—in a way that distills key insights, allows for ready translation to clinical work, and stimulates interest in further learning. We asked leading psychodynamic therapy researchers to present key implications of

Introduction

xv

their work, focusing on various mental health problems that often bring people to psychotherapy. To complement this problem-based focus, we invited scholars to discuss psychodynamically informed perspectives regarding clinical work with particular client populations as well as special clinical considerations that reflect the diversity and complexity of contemporary practice. Recognizing that leading edge practices are often not well established in the literature, we also invited contributions from authors whose academic work is nascent, though highly innovative in applying and integrating psychodynamic principles and interventions in novel ways. Thus to further reflect the vitality of contemporary psychodynamic psychotherapy, we sought to bring under one roof the work of scholars and clinicians across a variety of areas and stages of development. Some readers may observe that psychoanalysis is conspicuously underrepresented throughout this book. The relationship between psychodynamic psychotherapy and psychoanalysis is a complicated one, discussion of which would take us too far afield from the objectives of this book. Suffice it to say that psychodynamic psychotherapy and psychoanalysis are not one and the same. Psychoanalysis has left an indelible impression on psychodynamic psychotherapy, and there remains an ongoing exchange between these disciplines that, in our view, strengthens both. Yet psychodynamic psychotherapy has evolved in its own right, and our intention is to showcase the current state of this evolution. While echoes of psychoanalysis may be heard throughout these chapters, psychodynamic psychotherapy is playing the lead role here. The chapters have been loosely organized into five sections. We begin with a section on prominent theoretical developments in contemporary psychodynamic psychotherapy, followed by a section devoted to an overview of the empirical support for psychodynamic constructs, treatments, and therapeutic processes. The third section comprises chapters that describe psychodynamic therapy approaches for various mental health problems. These chapters draw upon the authors’ and others’ empirical research and clinical expertise, often including illustrative case material, to convey a sense of how these disorders can be addressed using psychodynamic therapy. Since the differences and concerns among clients transcend their presenting problem or diagnosis, the fourth section is focused on special populations and critical considerations. These chapters draw attention to some of the nuances that emerge through clients’ diverse needs and experiences and highlight psychodynamic perspectives that can assist the clinician in working effectively with these complexities. The final part of the book contains chapters that outline several novel means of delivering psychodynamic intervention. These contributions provide compelling examples of the ways in which psychodynamic therapy is extending its reach, often through integration with other modes of service.

Section 1: conceptual advances Our first chapter gives an overview of prominent theoretical developments, aimed at introducing key features of psychodynamic theory to the novice reader and

xvi

Introduction

providing a sense of conceptual evolution to readers grounded in psychodynamic practice. In the second chapter, Mark Hilsenroth and Seth Pitman focus on the specific issue of understanding and working with patients’ cyclical relational patterns, a hallmark of psychodynamic therapy. This contribution takes the reader through the traditional meta-psychological construct of transference and moves toward a more descriptive and experience-near conceptualization of the processing of insession, here-and-now relational dynamics. Next, Martin Debbane´ provides an overview of contemporary attachment and mentalization theories. This chapter introduces a mentalization-based conceptualization of psychopathology along with a discussion of the nature of therapeutic change from the perspective of mentalization theory.

Section 2: psychodynamic psychotherapy as evidence-based treatment The second section is intended to give the reader a sense of the scientific work being done to support the efficacy of psychodynamic psychotherapy and to further our understanding of how it works and for whom. Owing to the volume of work in these areas, these chapters are necessarily concise, providing summaries and overviews of the current evidence base rather than a detailed examination of each individual study. This section begins with a chapter by Falk Leichsenring and Christiane Steinert that reviews the efficacy of psychodynamic therapy, revealing substantial evidence for the efficacy of psychodynamic therapy in depressive, anxiety, somatoform, eating, substance-related, and personality disorders. This is followed by a review by Kevin McCarthy, Sigal Zilcha-Mano, and Jacques Barber of some of the sophisticated and novel studies regarding interventions in psychodynamic psychotherapy, the therapeutic relationship, and their relation to other phenomena in psychodynamic psychotherapy and its outcomes. The section closes with a chapter by Kenneth Levy, John Keefe, and Johannes Ehrenthal that provides an overview of empirical evidence that supports basic psychodynamic tenets, with consideration of the implications of these concepts for the process of psychotherapy treatment.

Section 3: contemporary psychodynamic treatment for specific conditions Major advances in the application of psychodynamic therapy regarding specific clinical disorders are presented in this section. These chapters provide informative overviews of empirically supported psychodynamic models, many with illustrative case examples, for several mental health challenges. The section begins with a chapter in which Mary Beth Connolly Gibbons, Katherine Crits-Christoph, and Paul

Introduction

xvii

Crits-Christoph outline an adaptation of short-term supportive-expressive psychotherapy for the treatment of depression, specifically designed for implementation in community mental health settings. The treatment of anxiety is taken up by Fredric Busch and Barbara Milrod, with a description of Panic-Focused Psychodynamic Psychotherapy. This chapter outlines an extension of the panic-focused psychodynamic psychotherapy model to address a range of DSM-V anxiety disorders, cluster C personality disorders, and posttraumatic stress disorder. In their chapter on mentalization-based treatment, Anthony Bateman and Peter Fonagy expand on a conceptualization of personality disorder that emphasizes the vulnerability to losing the capacity to mentalize. The chapter outlines the use of mentalization-based therapy for patients suffering from borderline and antisocial personality disorders, conditions that are commonly regarded as challenging to treat. Another prominent evidence-based treatment for personality disorder is featured in the chapter by Eve Caligor, John Clarkin, and Frank Yeomans. These authors articulate the use of transference-focused psychotherapy for patients with both borderline and narcissistic personality disorder, the latter of which is often neglected in structured approaches to treating personality disorders. Focusing on the immense challenges of working with patients who suffer from cooccurring substance use and personality disorder, the chapter by Robert Gregory presents a comprehensive treatment model called dynamic deconstructive psychotherapy for use with this patient population. Although there is a rich history of its use with patients who suffer from psychoses, psychodynamic treatment has often been overlooked as an appropriate therapy for such patients. Bent Rosenbaum provides a chapter that challenges this omission by describing the contemporary use and empirical grounding of psychodynamically informed supportive therapy for patients with psychosis. Next, Patrick Luyten, Celine De Meulemeester, and Peter Fonagy describe dynamic interpersonal therapy, a contemporary psychodynamic approach to the understanding and treatment of patients with somatic symptom disorder or functional somatic disorder. Their work is founded on three related biobehavioral systems that are central in current psychodynamic approaches to helping patients with these conditions. The section closes with a contribution from Giorgio Tasca and Louise Balfour describing an approach to psychotherapy for patients with eating disorders that is informed by attachment theory and an interpersonally based psychodynamic model. This chapter invites readers to consider psychodynamic conceptualizations and approaches to treating eating disorders that take into account social and relational contexts and attachment-related states of mind.

Section 4: special populations and critical considerations This section extends the practical focus of the preceding section to the application of psychodynamic approaches for client populations with specialized needs as well as critical considerations for generalist clinicians to bear in mind, better equipping them to consider the unique experiences and needs of diverse clients. A trio of chapters

xviii

Introduction

focus on the use of psychodynamic therapies for younger populations (infants, children, and adolescents). Bjorn Salomonsson considers the development of psychodynamic therapy for infants and parents, comparing models on the basis of their conceptual and technical emphases regarding the psychologies of and interactions between infant, parent, and therapist. Geoff Goodman and Nick Midgley provide a review of five different manualized child psychodynamic therapies, presenting the aims and methods of each approach, summarizing their treatment course, and offering empirical evidence in support of their effectiveness. Following along the age trajectory set forth by these two chapters, Dana Atzil-Slonim contributes an overview of adolescent psychodynamic psychotherapy, discussing psychodynamic theories of adolescence and describing psychodynamic practice with adolescent clients. Psychotherapy that ignores issues related to clients’ sexual orientation and/or gender identity is, in addition to lacking effectiveness, likely to perpetuate marginalization of sexual and gender minorities. Many such issues and their implications for psychodynamic therapy are discussed in a chapter by Vittorio Lingiardi and Nicola Nardelli. This contribution offers the clinician a framework for contemplating critical issues in psychodynamic practice with clients who identify as members of sexual and gender minorities. Immigrants and refugees represent another broad group whose social challenges, including trauma and marginalization, need special consideration in psychotherapy. Pratyusha Tummala-Narra provides an overview of key sociocultural factors that may shape the clinical picture in work with immigrant and/or refugee clients. The chapter invites the reader to consider premigration and postmigration contexts, acculturation and related stress, and trauma as well as the implications of these factors for the client’s negotiation of separation and loss and for the dynamics of the therapeutic relationship. The next set of chapters in this section present potential considerations and approaches in psychodynamic work with people who have encountered profoundly traumatic experiences. Richard Chefetz addresses the issue of dissociative processes, often highly salient in the experience of individuals who have suffered severe trauma. This chapter demonstrates the dissociative concealment of the underlying meanings of experience, behavior, and motivation that ultimately shapes the client’s subjective sense of self and organization of mind. Next, Nel Draijer and Pauline Van Zon describe the application of transference-focused psychotherapy to the treatment of former child soldiers suffering from dissociative identity disorder. These authors discuss how this approach can address overwhelming, dissociated negative affects, including their role in controlling and alienating others, in order to help sufferers of severe trauma to find release from internal oppression. The final chapter in this section, contributed by Christiane Steinert, Johannes Kruse, Falk Leichsenring, Helga Mattheß, and Wolfgang Wo¨ller, considers the immense gap between the need for mental health services and the availability of such services in postconflict and refugee crisis settings. The chapter describes a brief, culturally adaptable, manualized intervention that puts special emphasis on the therapeutic relationship, stabilization and emotion regulation, and the strengthening of resources while addressing dissociative states and transference and countertransference reactions in the context of trauma.

Introduction

xix

Section 5: innovative modes of delivery The final section of the book highlights several novel ways of delivering psychodynamically informed intervention beyond the typical configuration of therapist and client meeting in the consulting room. Chapters in this section describe applications that extend the reach of psychodynamic work, offering benefit to clients who otherwise might not access psychodynamically informed intervention as traditionally offered. While the applications profiled in this section are diverse, a common thread of innovation runs through these contributions. While some of these efforts have been well researched, several represent the work of leading clinicians who—fortunately for the contemporary psychodynamic field—have recently begun writing about their work. We hope that the sharing of these accomplishments might inspire clinicians to implement such novel approaches or to consider other ways in which they might develop innovative psychodynamic applications in their own practice. Robert Johansson begins the section with a chapter that describes psychodynamic intervention in the form of guided self-help through the internet. This mode of delivery holds promise for the potential to reach individuals who may not otherwise have access to sophisticated psychological treatment. For others, online delivery may be ideally suited to their preferences and life demands. The next chapter, by Guy Diamond, Syreeta Mason, and Suzanne Levy, provides an overview of a psychodynamically informed, attachment-based family therapy. Aimed at helping distressed adolescents and young adults, this approach seeks to identify and resolve, through direct family-level therapeutic work, family conflicts that contribute to damaged trust between parents and adolescents. Psychodynamic principles are also being applied at the broader community level. The chapter by Pamela Nathan describes such an effort, profiling the work of a notfor-profit, psychoanalytic organization known as Creating A Safe Supportive Environment (CASSE) in central Australia. Guided by key principles of psychodynamic practice and modified for broader application to the community, CASSE forms partnerships and collaborations with Aboriginal organizations and other stakeholders to work toward ameliorating the psychological impact of colonialism and cultural dispossession experienced by Aboriginal communities. Another community-based effort, known as Sport and Thought, is described in the chapter by Daniel Smyth. This chapter outlines an innovative approach to help adolescent boys with behavioral and emotional difficulties through the fusing of psychodynamic principles with football. The Sport and Thought program offers an accessible prevention and early intervention approach for youth who would not engage via traditional therapeutic routes. The next chapter, by Frank Sacco, Jr., James Higginbotham, Charles Granoff, and Frank C. Sacco, also profiles an approach targeting high-risk youth. This contribution describes therapeutic mentoring, a community-based program that extends mentalizing work into community settings with young people who are receiving more traditional psychodynamic therapy. Therapeutic mentoring is delivered as part of a team-based approach whereby the mentor reinforces mentalizing and social adaptation through engagement in

xx

Introduction

community-based activities. Young people are also featured in the final chapter in this section, although the insights shared by Norka Malberg in this contribution extend to various populations receiving intensive medical treatment. This chapter describes psychodynamic group intervention in inpatient medical settings, indicating the benefits—both for patients’ emotional well-being and for their ongoing medical care—of helping patients work through the psychodynamic concerns that often accompany compromised physical health and the need for intensive medical treatment.

A final note The field of psychodynamic psychotherapy is continually evolving. While traditionally focused on unconscious elements that underlie various psychological maladies, psychodynamic psychotherapy in contemporary practice has a broad scope that merges attention to complex mental states with consideration of biological, interpersonal, social, and cultural factors. Drawing upon a rich heritage of theorizing about the complexities of human development, interaction, and psychopathology, contemporary psychodynamic psychotherapy represents a viable means of addressing emotional suffering and mental disorder. Moreover, the principles and interventions gathered under the psychodynamic umbrella are aimed not only at the amelioration of particular symptoms, but also toward the encouragement of growth in essential human capacities to love, work, play, and laugh—to live with creativity and meaning. To support these aims, psychodynamic theorists, clinicians, and researchers eschew complacency by contemplating new questions and challenges that further advance the perspectives, applications, and empirical bases of psychodynamic psychotherapy. It is our hope that this book, through consolidating some of the foremost advances in the psychodynamic field, will inform and inspire readers to consider how such developments might help to shape their own contemporary psychodynamic practice. David Kealy and John S. Ogrodniczuk

Theoretical evolution in psychodynamic psychotherapy

1

David Kealy and John S. Ogrodniczuk Department of Psychiatry, University of British Columbia, Vancouver, Canada

Theory is essential to the practice of psychotherapy. It helps therapists to organize information about their patients and to understand their patients’ difficulties, and it provides a framework for mechanisms of therapeutic action. As Wampold (2010) notes, “there is no therapy without theory” (p. 43). Psychodynamic psychotherapy is founded upon psychoanalytic theory, the elucidation, refinement, and revision of which has arguably preoccupied the field to a greater extent than empirical research or dissemination of formal psychodynamic treatment guidelines. Psychoanalytic theory has changed a lot since its inception more than a century ago; thorough documentation of this would require a book unto itself, if not several volumes. We believe, however, that a basic grasp of the evolution of psychoanalytic theory—at least some major points along the way—can help clinicians in their understanding and practice of contemporary psychodynamic psychotherapy. In this chapter we will discuss some of the key developments in psychoanalytic theory that have contributed to contemporary psychodynamic psychotherapy. Given the breadth and depth of the psychoanalytic theoretical literature, we will paint with broad strokes and focus on theoretical developments that we perceive to be particularly salient to practitioners of psychotherapy therapy today. Our aim is to provide a concise introduction to readers who may be less familiar with psychodynamic psychotherapy and its theoretical foundations while at the same time highlighting some points of convergence and debate that may resonate with more experienced clinicians. In doing so, we will chart a crash course through the evolution of psychoanalytic theory and into its application in the contemporary practice of psychodynamic therapy.

What makes a theory—and therapy—psychodynamic? While technical distinctions can be made between psychoanalysis and various psychodynamic psychotherapies, a shared emphasis on unconscious mental processes forms the bedrock of a uniting theoretical foundation. Beyond this foundation, however, the precise nature of core psychodynamic theory has been rather difficult to pin down, partly owing to a proliferation of ideas and schools of thought within psychoanalysis and throughout the numerous psychotherapies informed by psychodynamic concepts. This makes for some difficulty in precisely defining a core psychodynamic theory. Indeed, contemporary psychodynamic practice is more fittingly Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00001-5 © 2019 Elsevier Inc. All rights reserved.

4

Contemporary Psychodynamic Psychotherapy

characterized by a plurality of approaches under a broad psychoanalytic umbrella. Nevertheless, all psychodynamic models conceive of unconscious psychological processes as playing an important role in shaping the ways in which people experience (i.e., make sense of) and act in their world (Gabbard, 2017). Thus psychodynamic theories emphasize a motivated unconscious or, in other words, unconscious motivation. Moreover, the nature of unconscious experience is regarded as highly unique for each individual, knowable largely through inference or introspection or partially glimpsed through dreams and fantasies. Psychodynamic theories also pay careful attention to childhood experiences as influences on the development of unconscious motivational tendencies, representations of self and other, and conflicts between motivational or affective states. Similarly, psychopathology is typically conceptualized as involving unconscious causes—such as excessive conflict or problematic relational representations—playing a significant role in consciously perceived distress or dysfunction. In addition to conceptualizations of the mind and psychopathology, theories of therapeutic technique and change mechanisms distinguish psychodynamic approaches from other psychotherapies. In general, psychodynamic therapies emphasize change occurring by way of increased access to emotional experience and through the development of insight into unconscious motivations, defenses, and interpersonal patterns (Gabbard, 2017). Psychodynamic therapy also emphasizes the therapeutic relationship itself as a vehicle of change, both for highlighting the patient’s emotional and interpersonal patterns and for providing interactional experiences that serve corrective developmental purposes for the patient. Various technical stances and interventions support and facilitate these mechanisms, including the patient’s free association—expressing whatever comes to mind—or at least the patient’s leading the dialogue, the therapist’s observation and clarification of difficult or contradictory thoughts and feelings, and a joint exploration of unconscious meanings and motivations. Exploration, guided by empathic inquiry, is applied not only to the various concerns and issues in the patient’s world, but also to the relational dynamics occurring between therapist and patient. Indeed, perhaps more so than other therapy models, psychodynamic approaches pay close attention to the emotional responses of the patient regarding the therapist—known as transference— and of the therapist regarding the patient—referred to as countertransference. Despite the centrality of such interventions to dynamic psychotherapy, it must be noted that aspects of these elements are increasingly being absorbed by other, nondynamic approaches—often referred to using different jargon—and combined with other techniques by therapists who take an integrative stance toward treatment. Moreover, as a close reading of this book’s chapters will reveal, psychodynamic approaches often differ in their emphasis on particular mechanisms and technical strategies. Indeed, the considerable breadth and depth in the revisions of psychoanalytic theory provide numerous opportunities for divergence in its application to treatment. Our coverage of these developments will be focused on their application to psychotherapy rather than on psychoanalysis per se and will by necessity be exceedingly brief and beyond incomplete. Our succinct account of Freudian theory, for instance, does little justice to the revisions Freud made during his lifetime. Several excellent volumes offer comprehensive treatment of the evolution toward

Theoretical evolution in psychodynamic psychotherapy

5

contemporary psychoanalytic theory, including those by Mitchell and Greenberg (1983), Bacal and Newman (1990), Fonagy (2001), and Eagle (2011). Discussion of some of the finer points of convergence and divergence in contemporary theory is also offered by Gabbard and Westen (2003) and Kernberg (2011).

From classical theory to ego psychology Freud’s model of the mind—regarded as “classical” psychoanalytic theory—considered the nervous system as a mediator of the buildup and discharge of affect, serving regulatory functions aimed toward the seeking of pleasure and reduction of unpleasure (Freud, 1920/1966). Survival-oriented biological drives (reflecting survival of both the individual and the species), such as hunger or sexual urges, press for discharge and register in the mind as desires or wishes. The constant pressure on the mind for the gratification of these wishes—the discharge of drives—manifests in their expression across various aspects of cognition and behavior. Sexual wishes, for example, may find expression in how one interprets a painting or in the content of an erotic dream (Freud, 1920/1966). These expressions reflect the conflict between internal, instinct-based wishes (emanating from a mental structure labeled the “id”) and the demands and limits imposed by external reality. Freud evolved his theory to suggest that a specific structure of the mind, the ego, serves to inhibit immediate drive gratification in response to reality considerations and to facilitate eventual, appropriate gratification (Freud, 1923). Partial gratification, represented by the various expressions of these wishes in the individual’s mental life, is allowed by the ego in order to prevent excessive buildup of excitation. The ego also attenuates awareness of the instinctual origins of such wishes in order to spare the individual from excessive anxiety associated with their forbidden nature and with the anticipated consequences of their gratification. Freudian theory emphasizes the implications of drive derivatives—particularly sexual and aggressive wishes—being directed toward childhood “objects” (the child’s parents) for gratification. The need to manage potential anxiety associated with childhood instinctual wishes peaks during the so-called oedipal period (roughly 3 5 years old). During this phase, the child’s libidinal wishes directed toward one parent—and aggressive wishes toward the “rival” parent—raise the fear of several detrimental consequences, including the risk of retribution (including bodily damage) from the “rival” parent or the loss of the parental object or that parent’s love. The ego must find a way to discharge the persistent drive derivatives while avoiding a calamitous outcome—as well as to reduce the anxiety that accompanies cognizance of these forbidden desires. Thus the ego seeks to obtain some measure of compromise in which attenuated fulfillment of a wish is achieved as its instinctual basis remains hidden, lest the child become fully aware of its forbidden nature and dangerous consequences. While Freud (1936) focused on repression as a principal mechanism by which the ego renders forbidden wishes unconscious, various ego defenses were subsequently identified as accomplishing the function of repression via an array of means. Thus, defense mechanisms—projection, displacement, reaction formation,

6

Contemporary Psychodynamic Psychotherapy

and so on—reduce tension by responding to signal anxiety with the relegation of threatening drive derivatives to an unconscious portion of the mind. This dynamic unconscious is a distinctly psychoanalytic notion of unconscious mental activity, in that the latter comprises not only nonconscious mental automaticity, but also affects and thoughts that are banished from awareness for regulatory purposes. The end result of the pressing of instinctual wishes and their modulation by the ego is a compromise between wish and defense that may manifest either adaptively or maladaptively, with the potential to emerge as a symptom or character trait. Evolving from Freud’s classical theory, ego psychology represents the contributions of analysts who paid closer attention to the functions of the ego, arguing that the ego exerted a substantial influence on behavior and personality beyond its role as mediator of instinct and reality. While ego psychologists expanded the conceptualization of defenses (Freud, 1966), they highlighted additional ways in which the ego regulates the individual’s mental life. Heinz Hartmann, a key figure in ego psychology, suggested that the ego possesses several capacities that are largely independent from drive regulation (Hartmann, 1958). These ego functions—including capacities for reality testing and judgment—serve to perceive, organize, and synthesize aspects of the environment in order to allow the individual to adapt to his or her reality. The expansion of the role of the ego introduced by Hartmann (1958) and others included motivational interests, such as desires for personal and social achievements, that were mainly autonomous from, and sometimes competing with, pressure from drive derivatives (Eagle, 2011). Indeed, Erikson (1959) situated the development of personal identity, facilitated through cultural and environmental experience, within the ego and elaborated a model of psychosocial development throughout the life span that transcended drive theory. The conceptual extensions of ego psychology helped psychoanalytic theory transition from what has been referred to as a one-person psychology, in which endogenous drives are directed at objects (i.e., people as targets whose individual psychologies were deemphasized), toward a two-person psychology whereby the qualities and behaviors of other people are seen as playing a significant role in shaping the individual’s psychic life. To regard this transition as a sharp departure would be misleading; Freud’s own concept of the superego as the structure containing morals and ideals—internalized through relations with parental objects—was itself a step toward a psychology grounded in interpersonal relationships (Ogden, 2002). With regard to psychopathology, classical and ego psychological theory emphasize symptom- and character-based neuroses rooted in repressed conflicts, typically connected to sexual and aggressive wishes from the oedipal period. Such conflicts—more precisely, pathological compromise formations—take the form of phobias, compulsions, inhibitions, and character traits that contribute to suffering, though their origins remain obscured by defenses. A primary goal of treatment is thus to promote insight into the wish-defense compromises underlying the patient’s symptoms and to explicate their origins in the patient’s particular oedipal struggles. Since drive derivatives continue to press for discharge and given the unresolved nature of the patient’s oedipal conflicts, the wishes and the defenses mobilized to contain them will invariably find expression in the patient’s relationship with the

Theoretical evolution in psychodynamic psychotherapy

7

therapist. Known as the transference neurosis, this “transference” of the patient’s earlier oedipal situation to the therapy relationship provides an in vivo demonstration of the patient’s unresolved childhood wishes and conflicts. Further evidence obtained through the patient’s free associations and recounting of dreams and memories informs the therapist in gradually making interpretations regarding the patient’s unconscious mental life. Thus the mechanism of therapeutic action rests largely upon the interpretation of wish-defense conflicts and compromises and the resolution of the transference neurosis. To facilitate this, the therapist remains relatively neutral and abstinent so that the intrapsychic origins of the transference are rendered more vivid and so that the patient can—without undue suggestion from the therapist—employ newly acquired insight to relinquish oedipal wishes and strengthen the capacity of the ego to tolerate anxiety and seek adaptive discharge of affect (Eagle, 2011).

Interpersonal and object relations theories Although the theoretical extensions of ego psychology paved the way for a twoperson psychoanalysis, other, more radical departures from Freudian classical theory shifted the field toward its contemporary appreciation for real-world interactions between people and their implications for unconscious and conscious mental life. Such developments brought renewed attention to the pathogenic influence of actual traumatic experience—particularly in early parent-child relations—rather than instinct- and fantasy-related conflicts (Freud renounced his original theory of sexual abuse as the origin of hysteria) and introduced a broader and more pluralistic conceptualization of therapeutic action (Greenberg & Mitchell, 1983). Several analysts were inspired to modify or reject aspects of Freudian theory through their observations of more troubled patients, for whom traditional interpretation of oedipal transferences seemed ineffective. Melanie Klein was particularly influential in contributing to what became known as British object relations theory (the term object unfortunately was retained to refer to people toward whom wishes are directed). Klein (1946) retained the classical focus on endogenous drives, emphasizing aggressive wishes and the anxieties they evoke. However, she positioned the oedipal situation much earlier in the infant’s development, portraying infants as seething with oscillations of contentment/deprivation and love/hate. The infant projects these affects onto—fantasying them to reside within—parental objects (whose actual qualities Klein minimized) and thus experiences the mother as either a “good breast” or a “bad breast.” In this way, defense is used very early on by the infant to deal with primitive anxieties related to wishes to possess or destroy the parental object. This primitive cauldron of affect developmentally resolves into an easing of extreme wishes, the capacity for guilt over aggressive urges, and tolerance of coexisting positive and negative affects; psychopathology reflects relative deficiency in such development. While Klein’s theory itself did not radically move psychoanalysis toward relational models, her elaboration of the infant’s defensive

8

Contemporary Psychodynamic Psychotherapy

splitting of the psyche to reflect internal objects—aspects of the mind identified with caregivers—influenced subsequent theorists’ work and drew attention to early infancy, and her concept of projective identification was later reformulated as an interactive process that contributes to mental development (Bion, 1962). Fairbairn (1952) presented a more comprehensive object relations theory that rejected the primacy of instinctual drives and founded the development of the personality upon the establishment of loving and responsive relationships with real figures. Fairbairn suggested that ties with caregivers form the basis of the child’s primary motivation, to be preserved at all costs. Rather than seeing ego splitting as a consequence of the fantasized return of endogenous wishes projected onto objects (as in Klein’s theory), Fairbairn regarded the actual behavior of parents as contributing to the child’s need to manage inevitable—and sometimes extreme and overwhelming—frustrations through introjection and splitting. He developed a complex model, the scope of which we are unable to reproduce here, detailing the splitting of the ego into components representing experiences with early caregivers; these internal object relations shape one’s personality throughout life at a level beyond conscious awareness. Fairbairn suggested that when early relationships are fraught with turmoil or trauma, the child maintains a psychological tie with parental objects by “cleansing” them through the internalization of their overstimulating and rejecting aspects (Grotstein, 1993). One mechanism in this process consists of feeling responsible for frustration or maltreatment; the child can then maintain a relationship with a “good” parent by defensively obscuring frustrating aspects of the relationship—at an extreme, feeling convinced that it is the child who is bad and thus undeserving of love. The “bad objects” that reflect dissatisfying early relations continue to haunt the individual with feelings of shame and badness and are brought to bear on subsequent interpersonal relationships. Indeed, while Fairbairn paid particular attention to patients who managed this bleak situation by withdrawal into fantasy, he regarded restriction of intimate relatedness more generally as a hallmark feature of psychopathology rooted in internalized early experience. Winnicott (1965) also highlighted the crucial role of caregivers’ actual qualities and behaviors in the development of personality and psychopathology. Winnicott’s (1965) concept of the holding environment refers to the quality of environmental provision required for the emergence of the child’s sense of being a person. The caregiver’s adequate “holding” of the infant—metaphorically encompassing sensitivity and responsiveness to the child’s needs—is considered the cornerstone element in helping the infant to feel secure, alive, and integrated. A vital aspect of holding is the mother’s or father’s sense of the infant as a subjective self, involving the parents’ prioritization of the infant’s nascent experience of being a person. This process requires the parents’ tolerance of negative features of infant care and “good-enough” management of the inevitable ruptures in the caregiver-infant relationship (Winnicott, 1965). Otherwise, a deficient holding environment composed of repeated faulty parent-child responsiveness impinges on the child’s natural development. Under these conditions the child’s “true self” retreats, and a compliant “false self” evolves to manage the impinging environment (Winnicott, 1956). This false self protects the more authentic core of the personality, though at the expense

Theoretical evolution in psychodynamic psychotherapy

9

of feeling fully alive and capable of creativity and intimacy. Moreover, as in Fairbairn’s theory, the origins of early relational frustrations—the foundation of psychopathology—remain defensively obscured from awareness. Thus object relations theories retain the notion of the dynamic unconscious while positing alternative unconscious content and motivation, at least with regard to psychopathology. Rather than forbidden sexual and aggressive wishes, what are regarded as most threatening—and therefore relegated to the unconscious—are the inimical experiences with early caregivers that thwart the optimal growth of one’s personality. In other words, conflict and compromise represent repressed wishes for contact and responsiveness, kept at bay to reduce anxiety over the danger of losing all object ties and to avoid anticipated further rejections. Sullivan’s (1953) interpersonal theory similarly situated personality development within an interactional field. Sullivan observed fundamental “integrating tendencies” that bring people together throughout the life span. An infant’s cry, for example, yields in the mother a corresponding responsiveness tendency (including biophysical changes). Successful coming together in such scenarios produces positive feelings and, over time, integration of one’s sense of personhood in relation to others’ responses. Imbalanced integrating tendencies (i.e., failed responsiveness) lead to disintegrating experiences, a preponderance of which will flood the self with anxiety. Sullivan (1953) regarded anxiety as a universal threat to interpersonal relations, potentially upending integrating tendencies and contagiously suffusing one or both participants with intolerable dysphoria. Repeated anxiety-ridden interactions throughout development leave lasting negative self-concepts known as “bad me” or “not me” experiences. Thus Sullivan’s interpersonal theory is concerned not only with interactions among people, but also with the internal psychological structures that arise from—and are subsequently reinforced or modified by—interpersonal relations. Sullivan observed the use of “security operations” to manage anxiety. These psychological safety features are functionally similar to defense mechanisms, though protective against perceived interactional and self-representational endangerment rather than against drive derivatives. Security operations may become pathological if entrenched as “illusionary me you patterns” (Bacal & Newman, 1990, p. 34) that reflect characterological distortions of the interpersonal field. These departures from classical theory held profound implications for treatment, in that therapeutic action could be seen to arise from a “corrective emotional experience” (Alexander, 1950) provided through the analyst’s direct action or a “new beginning” (Balint, 1968) in the therapeutic relationship that counters previous traumatic experience. Rather than resolving the transference of oedipal wishes, psychotherapy from Fairbairn’s perspective involves the therapist’s acceptance and interpretation of the patient’s imposed object representations onto the therapist. At the same time, the therapist’s provision of actual concern and interest, as a new good object, helps the patient to reduce the perniciousness of internal bad objects and the restriction of real relatedness (Fairbairn, 1952). Winnicott also suggested that the therapist treating a patient with a “false self-disorder” must expect to provide a holding environment that withstands the transference of earlier frustrations, gradually allowing for the patient’s vulnerable, “true self” to emerge in accordance

10

Contemporary Psychodynamic Psychotherapy

with the therapist’s steadfast responsiveness to the patient’s sensitivities and needs. The implications for therapeutic action—involving both transferential and real relatedness with the therapist—afforded by object relations and interpersonal theories is highlighted in Harry Guntrip’s succinct synopsis: To find a good parent at the start is the basis of psychic health. In its lack, to find a genuine ‘good object’ in one’s analyst is both a transference experience and a real life experience. In analysis as in real life, all relationships have a subtly dual nature. All through life we take into ourselves both good and bad figures who either strengthen or disturb us, and it is the same in psychoanalytic therapy: it is the meeting and interacting of two real people in all its complex possibilities (Guntrip, 1975, p. 156).

Psychologies of the self and the patient’s subjectivity Interestingly, the evolution of psychoanalytic theories toward a focus on faulty early relationships in pathogenesis corresponded with a greater emphasis on conceptualizing the self. Interpersonal and object relations theories placed the seeking of connectedness with others and the experience of being recognized and responded to at the center of motivation and the development of a subjective self. Heinz Kohut, initially formulating a conceptualization of narcissistic personality disorder, articulated a psychoanalytic psychology of the self in which the cohesiveness and strivings of the self—the central organization of subjective experience—are themselves principal sources of motivation. According to Kohut’s self psychology, a healthy and cohesive self is developed through repeated experiences of empathic responses from caregivers (Kohut & Wolf, 1978; Kohut, 1971). Empathic responses from others contribute to a greater sense of cohesion and vitality of the self; such responses are referred to as selfobject experiences. An individual functions as a selfobject to the extent to which his or her “presence or activity evoke and maintain the self and the experience of selfhood” (Wolf, 1988, p. 184). Early childhood (or “archaic”) responses to selfobject needs, such as the need to be mirrored and prized by a parent or the need to merge with an admired parent, are thought to be experienced subjectively as aspects of the self. When such responses on the whole are appropriate, selfobject needs become less urgent and more differentiated as development advances, and their expression changes according to maturational themes. Moreover, while selfobject responses are required throughout the life span, their internalization into the structure of the self reduces the urgency with which other people’s responses are required for self-cohesion. Because selfobject experiences are essential for the self’s robustness and vitality, their absence or chronic frustration pave the way for dysfunction and disorder of the self. Kohut (1971, 1984) wrote extensively on the fragmentation of the self as a painful subjective experience of deficiency, shame, and weakness. Individuals with a fragmentation-prone self may develop maladaptive strategies such as

Theoretical evolution in psychodynamic psychotherapy

11

self-aggrandizement, impulsive behavior, and superficial admiration seeking to bolster a fragile self, forestall fragmentation, and compensate for unmet selfobject needs. Indeed, unmet archaic selfobject needs do not merely evaporate and may be vigorously pursued in maladaptive ways that represent significant psychopathology (Kohut & Wolf, 1978). At the same time, such needs—and the sense of deficiency and shame attending them—may be repressed via a range of pathological attitudes and behaviors, further reducing opportunities for more mature self-selfobject relations. The priority in a self psychological treatment is the patient’s experience of the therapist’s sustained empathic responsiveness. Although the therapist interpretively explains the patient’s transference experience of unmet selfobject needs, the therapist’s acceptance of performing a role as a selfobject to the patient is of critical importance. To give an oversimplified example, some patients with archaic selfobject deficiencies may gain little from interpretive interventions when in states of experiencing the therapist as a needed mirroring selfobject, while others may draw self-cohesion through idealized perceptions of the therapist. Indeed, in such instances, interpretations or other behaviors on the part of the therapist could— from the patient’s subjective perspective—disrupt the selfobject experience obtained through the therapeutic relationship and utilized by the patient to restore and strengthen the self. Disruptions in the self-selfobject relationship are of special importance in self psychology. Kohut considered the inevitable ruptures and frustrations in therapy (as paralleled in child development) to be opportunities for “optimal frustration” that contribute—in the context of an overall empathically responsive milieu—to the patient’s gradual internalization of selfobject functions (Gehrie, 2011). In other words, optimal frustration contributes to the eventual strengthening of a fragile or arrested self, though what may be most crucial in such instances is the therapist’s empathic attunement to the patient’s subjective experience of the rupture, privileging this over an attempt to discern the objective “truth” of what occurred (Bacal & Newman, 1990; Eagle, 2011). In this way, the therapist demonstrates an effort to understand the patient’s subjectivity—the experience of which, for the patient, contributes to the building of new self-structure. In other words, the empathic understanding and repair of a therapeutic rupture may be a heightened form of selfobject experience that can be internalized by the patient. Bacal (1998) elaborated other possibilities for selfobject “optimal responsiveness” to occur in therapy, beyond those surrounding frustration experiences. Through placing the subjectivity of the patient—and the legitimacy of the patient’s need to feel understood—at the very center of therapeutic focus, self psychology expands the range of potentially therapeutic responses. Depending on the patient’s experience, optimal responsiveness may thus take various forms: It may entail an inquiring attitude or a quiet noninquiring presence, an echoing confirmation, or a confrontational challenge. Its form will be determined not only by the issues that the patient and the analyst are working on but also by the strength of the patient’s self, and by the patient’s operative level of developmental achievement (Bacal, 1994, p. 27).

12

Contemporary Psychodynamic Psychotherapy

In this way, psychotherapy—at least for patients with disorders of the self—is less of an exercise in unearthing relics from the patient’s unconscious and more of a developmental experience in which new modes of functioning are evoked through the therapist’s understanding and responsiveness (Emde, 1990). The contributions of control-mastery theory further emphasize the patient’s subjectivity in determining the therapeutic value of interventions and highlight the patient’s active role in seeking corrective experiences in the therapy relationship. From the control-mastery perspective formulated by Weiss (1993), patients seek to address pathogenic beliefs—grim beliefs that severely constrict the self—in a variety of ways. As in other object relations theories, pathogenic beliefs about the self and others are viewed in control-mastery theory as forming largely in re