1. The Principles of Psychodynamic Psychotherapy
Section V of Division 39
The Section of Applied Clinical Psychoanalysis
January, 2017
Copyright 2018© Larry M Rosenberg, Ph.D. & Steven S. Spitz, Ph.D.

2. The Unconscious
The vast majority of what goes on in our minds occurs outside of consciousness
This is an empirically determined fact
Thoughts, feelings and motivations influence our behavior in ways that are outside of our conscious awareness
This is part of what the therapist and the patient are to discover together
About 85% or more of what takes place in our brains occurs outside of our awareness.
We typically don’t think about the physiological things that we do, like walking, breathing, etc. in order for us to be doing them unless there is some handicap that we’re dealing with. We don’t even know exactly what we’re going to say before we say it most of the time. We only know approximately where we’re going and then just begin to speak.
Many times we are aware of the fact that we don’t know why we did what we did, what made us think of something, etc. We often times find ourselves saying something like, “I don’t know what made me do that”, I don’t know what got me thinking about this” , I don’t know why I dreamt this, etc. We say these things even though sometimes we do have an idea as to why, but it’s often only a vague idea and sometimes we have no idea at all. In fact, there are times when we’re shocked by our behavior and say, meaning it, that I don’t know what the hell I was thinking about.
The fact is that thoughts and feelings and motivations that are outside of our awareness are at play. E.g., An 8 yo boy is brought in by his parents because he gets in trouble at school for fighting with other kids. He’s a , articulate bi-racial boy who is well built, musically and athletically talented but a boy who struggles with reading. In particular he gets into scuffles, physically initiated by him, with a boy who he competes with for being the alpha in the room. My patient competes intensely and his mother and father agree when I raise the possibility that his lack of frustration tolerance and aggression, must speak to something else that is at play. My pt has no idea as to what that may be, though it is likely his sense of inadequacy and inferiority re his reading, and his parent’s divorce may have something to do with it.

3. Making Meaning out of Behavior
All behavior has meaning
It is our job to join the client in figuring out what their behavior means
That meaning will, initially, not likely be conscious to the client (e.g. A patient comes late for appointment)
Might say something here about the difference between DSM and PDM.
A 16 yo pt is a bright sweet kid. His mother is furious about his procrastination. She has bi-polar disorder that is somewhat managed, but she is worried that this, her potentially successful and reasonably healthy child will miss out on his opportunity. His internalization of his mother’s demands for perfection, and his wish to keep her regulated, have led him to behave, like a good boy, frightened of disappointing her and himself on the one hand, but as passively defiant and on the other. It is that dynamic which plays a large role in his procrastination.

4. Psychic Causality Stuff (behaviors, events) happens for reasons
They are not always as accidental or random as they seem
Things are over-determined
They have multiple causes
Symptoms/behaviors are also not randomly determined
They happen for reasons outside of our awareness
They are adaptations, compromises with ourselves
The previous patient talked about can serve as an example.
Another boy, 16, wants to go to an elite college. He’s taken 4 or 5 AP courses in this his junior year. But he can’t get himself to really study, instead convincing himself that he’s bright enough to do well without it. He holds to this despite going into tests and freezing with anxiety for reasons unknown to him. In fact, claiming that he’s not really anxious about the test, though he is concerned about getting into the school of his choice. We should throw into the mix that he is a twin, that his brother is nearly as bright, but that his brother is a boy who is obsessively prepared and is doing extremely well. My patient has always been in the same class as his brother, has not been able to make friends without his brother’s help and claims to not be concerned that they might wind up being accepted at different schools. Add to this that my pt is an extremely dependent boy who has never been away from home on his own, or out socially without his brother. All of these factors contribute to him being consumed with time spent on his cell phone playing games; an effort at mastery but also to more anonymously connect and compete, while at the same time avoiding his studies, or beginning to look at or consider more detailed questions about where he might want to go to school both of which cause considerable anxiety.

5. Internal Conflict
It is not uncommon for people to have mixed and opposing feelings that exist within themselves and may be of an unconscious nature (e.g., I want to be promoted but keep sabotaging myself because I am unconsciously scared that I can’t do the job; or, a student reports that he forgot to bring a book he had to read, and then realizes that it had caused him to have a nightmare
This is distinct from conflict between people
Internal conflict is the source of many unwanted behaviors
The conflict previously described is one that is internal. A part of him wants something for himself, while another part wants to avoid it. Struggles like this are most often not experienced as internal but rather are externalized in the form of battles between children and parents where it is experienced by both parties that the battle is not within the child but between the parents and the child. E.g., “You care about how I do in school but I really don’t.” “You think I need help but I really don’t”, “You’re the one who wants me to run for school office, not me”, etc.

6. Symptoms
Just as with medical findings, a symptom is a reflection of an underlying problem (e.g., A cough or a headache could be caused by a number of underlying problems
These symptoms are compromises struck by the patient with themselves as a way of managing undesired feelings and thoughts
The less tolerable side of these conflicts is kept from consciousness by way of defense mechanisms
What we’ve already discussed overlaps with all of this. My 15 yo male pt is struggling at school. His mother is a bright successful woman, his dad the same and a former number 1 in the world at his sport. A 17 yo female sib is a superstar student headed to whatever college she wants to attend. My pt. stayed up into the early morning successfully figuring out and succeeding in how to hack into people’s computers. He does no harm to common people, but instead messes with other hackers. He enjoys doing this, but knows he’s breaking the law and wants to be able to stop before something bad happens.

7. Defense
Defenses help to manage our unwanted thoughts feelings and behaviors
Defensive processes, in the psychoanalytic sense, are unconscious in nature
Defenses always compromise reality to one degree or another
They can be more subtle or primitive in nature
The more primitive the defense the greater the distortion of reality (e.g. sublimation vs. denial
Defenses also serve an adaptive function so there is a reluctance to give them up
The distinction between coping mechanisms and defense mechanisms.
We all use all or nearly all defenses. The question of higher and lower level defenses is a matter of what the dominant defensive style.
The parents of a beautiful, bright, Hispanic teen age girl divorced when she was 4. The immediate precipitant for the breakup was her mother’s discovery that her father was having an affair. It was dad’s second marriage. He now has a third. Prior to the divorce there was domestic violence perpetrated against the mom. She has not worked or remarried since. She slept in the same bed as the patient until the girl was 12.
The patient’s primary complaint is that she is out of control about boys. She sleeps around but is particularly interested in one boy who cheats on her and who she “stalks” on line. She is having unprotected sex, and hasn’t had her period in 2 months. She insists that she’s not pregnant and will not see a doctor. There is no overt signs of anxiety about this. Her only conscious source of anxiety relates to the idea of losing the boy that she’s after. That her mother gave birth to her older half sister when mom was the same age as she is now, has not entered into her thinking either. Rather she says that she never wants to have children, and hates little kids.

8. Past Informs Present Past experiences shape us
How we think about ourselves
How we think about others
Our beliefs about ourselves and the world around us
The past has an ongoing influence
It lives in the present
We are not trying to discover the past, but the ways in which it evidences itself in present symptoms and relationships
It lives within the therapeutic relationship
Both trauma and complex trauma cases are clear examples of this.
A little girl of 6 is brought in after her mother has fled the country in which the child was born and raised until then. Both parents hold white collar jobs. The mom states that she fled with her daughter to protect her from her father who was sexually abusing her. The mother video taped (using her phone) the child telling her about the sexual game she played with her dad, but it was not admitted in court in the child’s home country. Dad claims that mom left to be with the man she was having an affair with back home, and that the mom was a run around and a negligent parent. Calling their relationship acrimonious doesn’t quite capture the loathing each has for the other.
The child trusts no one. Sees herself as bad, and believes others see her in the same way. She is impulsive, dysregulated, manipulative and off-putting and aggressive with peers, and fiercely oppositional with authority figures. Her fantasy play is disorganized and aggressive with images of baby animals being ridiculed and left behind, while parents are preoccupied with trying to destroy each other.

9. Transference and Countertransference
We don’t experience any new relationship in an entirely new manner
Our approach, wishes, and expectations are shaped by prior relationships
Transference refers to the influence of these past relationships on the patients experience of the therapist and the therapeutic relationship
There is empirical evidence to support the idea that those therapies that include work with transference phenomenon have better outcomes than those that do not
In the case just talked about, the child is at times seductive, but was more often rejecting at the outset of treatment. She excluded me from play, or insisted that play be physical, as in me playing tag with her in the office, or her making believe she is a hungry animal wanting to eat me, or her being someone who pretends to want to feed me but gives me poisonous food that she threatens to force me to eat against my will. I am left feeling overwhelmed and helpless in the face of her intensity, sadism and concern with what happens if I don’t comply. At the same time, I am aware that she is herself a hungry little girl who longs for something which she can’t identify.

10. Transference and Countertransference
Refers to the influence of the therapist’s past on his/her reaction to the patient
The term countertransference has had multiple meanings over time
We all have emotional reactions to our patients
These reactions can inform us about ourselves but also provide important information about what may be occurring for our patients
The exploration of both transference and countertransference are useful to the therapeutic process
My countertransference informs me of how scared and helpless she must feel and how difficult it is to trust caregivers. It also lets me know more about why she seems so angry, defiant and untrusting. It not only allows me to make sense of her behavior, it allows me to empathize with her at times when I might otherwise only feel angry and rejecting.

11. How the Psychodynamic Process is Viewed
Non-Directive
Psychoanalytic therapy is not something done to or practiced on another person. It is something done with another person.
It is based on mutual respect and trust and assumes that this takes time to fully develop
The therapist is trying to understand something and assist with something that cannot be attained without partnership with the patient
There is a humility about this
Requires tolerance of ambiguity and deprivation on the part of both
The humility for me is about a number of things: Knowing that only 1/3 of cases really do substantially better. That despite the efforts to make our work more scientific in nature, putting a bunch of therapists together in the same room, listening to the same material, will produce a variety of interpretations of what’s taking place and how to respond.
It’s also true that we are not entirely in control of what happens and that this is particularly the case with child patients. They are speaking to us in the metaphor of play and we only see them for mins a week.
The ambiguity of psychodynamic work requires the tolerance of not knowing and this is doubly so in working with children. They don’t fully report on their lives, they may be dissuaded from telling us things going on at home, and what we are told comes indirectly thru the medium of play.

12. Listening At several levels Manifest Content Latent Content Sequence
Affect
Self
Add to this context as a way of organizing material
Affect and manner of presentation can be thought about as listening to the music instead of just the lyrics.

13. How the Psychodynamic Supervision Process is Viewed
A collaboration between supervisor and supervisee
A reflective process
A process that is not directive
One that is based on mutual respect and trust