I love practicing psychodynamic therapy. To me, no other approach embraces the depth of what it means to be a human being more thoroughly than the psychodynamic approach. Psychodynamic therapy is a method that originates with Freud, and while now presents quite differently from the daily free-association of the psychoanalytic couch, retains some of the essential elements of Freudian psycho-analysis, including (but certainly not limited to):
The Unconscious: Stored away out of the realm of our perception, unconscious processes, whose development begins in very early childhood (even infancy), can profoundly influence our thoughts and behavior. As we look for the roots of painful or problematic thoughts or patterns, therapists help their patients access the unconscious through dreams, exploration of transference and noticing patterns in relationships, and use of defenses.
Insight: This therapy fosters insight into the unconscious influences of past experiences and relationships, by bringing this unconscious material to light. Once exposed, through the safety and authenticity of the therapeutic environment, therapist and patient collaborate to “re-frame” past experiences, dress and heal old wounds, and bring a sense of personal agency into how a patient can function now and into the future.
Childhood: Our earliest relationships and experiences often set the trajectory for subsequent ways of relating to others and of our worldview. Adaptions surrounding the preservation of the attachment relationship can become ingrained into the unconscious. These internalized adaptions can play out again and again in relationships, long past their “expiration date”, and what was adaptive in the past can be maladaptive in the present. Disappointments and trauma in childhood can manifest in seeing the world as threatening and hostile.
The Therapeutic Relationship: In a safe and thoroughly confidential environment, the relationship between client and therapist has great therapeutic value in uncovering, through transference, repetitive relationship patterns. A good therapeutic relationship can foster a sense of a secure attachment relationship with the therapist in which the client can express his authentic self, have it met with acceptance and encouragement, and subsequently grow an develop the neglected or suppressed “true self”.
As a therapist focusing on the use of psychodynamic therapy, I am aware of the implicit long-term nature of this approach and that open-ended therapy may not be appropriate or possible for a number of reasons. DC is a city of transience, and sometimes a patient is in the area for a limited period of time. Perhaps someone only wants to address a specific issue, of which a full course of dynamic therapy is overkill or for the depths of which they are not yet prepared. Possibly logistical or financial constraints don’t permit anymore than a few sessions.
Often immediate issues or short-term concerns are addressed with approaches whose main modality is Cognitive Behavioral Therapy (CBT), which assesses behavioral problems or maladaptive thoughts, and provides specific and effective tools to minimize these issues.
While I understand and appreciate the benefits of CBT, and may occasionally adapt some CBT methods for short-term symptom relief, I do not consider myself a CBT therapist. Therefore, I want to discuss a two short-term therapies based on the psychodynamic approach. While these therapies may integrate elements of CBT and of other affect and anxiety regulation methods such as mindfulness, the driving force of these therapies are psychodynamic. As a caveat, I am neither an expert in any of these therapies, nor do I have a certificate to indicate myself as such. However, I do have varying degrees of training, supervision in and knowledge of them. As my training progresses and my competence grows, I am increasingly integrating their strategies into my practice, so far with beneficial results.
Intensive Short Term Dynamic Psychotherapy (ISTDP)
Often we are hijacked by anxiety, and this anxiety is triggered by relationships or other factors. ISTDP addresses the origin of this anxiety, which typically are underlying and often disavowed feelings. These feelings may long ago have been deemed “dangerous” by messages from caretakers or peers. Therefore, when they emerge, these feelings provoke anxiety that they are unacceptable and are met with defenses which have been evoked and learned to mitigate the painful sensation of anxiety. Sometimes these defenses are adaptive, but often they are not. Most of the symptoms and problems a patient experiences are due to these outdated defenses.
In ISTDP, the origin of this anxiety is met, which is the underlying feeling (often anger, but also grief, sadness, fear etc.). Through ISTDP method, whose primary paradigm is the triangled pattern of feeling-anxiety-defense, the therapist helps the client to become aware of the anxiety leading to the defense, block the defenses and reveal the underlying feelings. Once the feelings are identified, using the CBT method of exposure to the feelings, the patient becomes more able to tolerate these feelings. Once these feelings are able to be tolerated, the patient can begin a more authentic relationship with themselves and their true desires, and find usefulness and agency in these feelings. ISTDP typically is resolved when the defenses are exposed and managed, and feelings become tolerable and even useful.
ISTDP was developed by Dr. Habib Davanloo, a Montreal psychiatrist, as a way to cut through straight to the defenses, and in this way, to make therapy more efficient. Some of the world experts in this method are local clinicians, such as Jon Frederickson, and I am fortunate to be the beneficiary of their wisdom.
Object Relations Brief Therapy
Object Relations is a theory that focuses on the human need for relationship. This is a theory that originally developed from psychoanalysis by a loosely-related group of British analysts including Donald Winnicott, D.W Fairbairn, and Melanie Klein. Common to their theory was highlighting the earliest developmental experiences of the child in relation to their mother and other early caregivers, and how these relationships became internalized as “objects” (early conceptions of mother/caregivers which have become internalized) and how these objects significantly affected a patients subsequent relationships. Later John Bowlby, provided the capstone to this conception of the human psyche with his theory of Attachment to the primary caregiver and the ways the quality of this relationship strongly influenced a variety of factors in a person’s life. Object Relations Therapy uses the therapeutic relationship to strengthen and transform the patient’s defective internal objects into “good objects”, which impart a sense of security and self-worth.
Object Relations Brief Therapy begins by rapidly developing a therapeutic alliance and setting dual specific foci. This foci are symptomatic (for example, decrease a patient’s depression) and/or dynamic (become less reactive to mother in law). A working alliance is established through specific questions pertaining to a patient’s psychiatric, psychodynamic history, relational patterns, and whether/how a client tends to project his perceptions onto others. As the therapy progresses, patterns of behavior and relationship are revealed and worked through. Transference is used actively, as patient and therapist interpret and experience what happens between them. A paradigm of therapist-self-other is used as a guide to identify a patient’s view of their past relationships to those of the present.
Therapy uses interpretation of interactions between self and other to give insight into maladaptive patterns, and capitalizes on (as does ISTDP) the triad of feeling-anxiety-defense to further gain insight. The therapist also integrates some CBT or other non-psychodynamic symptom relief including stress management and cognitive restructuring to help address symptoms. Termination is addressed at the beginning of therapy, and the way the presenting focus of therapy will look when it has been satisfactorily addressed, in the context of brief therapy, is determined as an end goal. This modality typically lasts 6-26 sessions. After the first course of brief therapy is complete, subsequent sessions may be desired and encouraged in the future.
Objects Relations Brief Therapy was developed by highly regarded local psychologist, Dr. Michael Stadter, who, along with a primary emphasis on object relations and the therapeutic relationship, also drew on the brief therapy framework of Davanloo and other clinicians who were instrumental brief psychodynamic therapy.
Amongst my colleagues, and based on evidence, ongoing and open-ended therapy is the optimal “Gold Standard”. However, time and other constraints are often an unavoidable factors. Both of these therapies offer, colloquially, a lot of “bang for the buck”, while still incorporating the valuable time-honored tenets of psychodynamic psychotherapy. Also, some of the more targeted methods of rapidly exposing defenses can be useful in longer-term therapy when the patient is “stuck”. Brief therapy and methods within these modalities are often a valid and beneficial options. It is for these reasons I offer these methods within the realm of my competence, and continue to pursue training in brief therapy
Sevilla King, LICSW 