Tice Counseling and Consultation

Many psychoanalytically oriented therapists are attempting to creatively meet modern challenges while retaining their original focus on depth and inner life. These therapists support the move to the use of briefer therapy when this is indicated by the client’s needs rather than by arbitrary limits set by a managed care system. Although there are different approaches to brief psychodynamic therapy, Prochaska and Norcross believe they all share these common characteristics:

• Work within the framework of time-limited therapy

• Target a specific interpersonal problem during the initial session.

• Assume a less neutral therapeutic stance than is true of traditional analytic approaches.

• Establish a strong working alliance.

• Use interpretation relatively early in the therapy relationship.

In keeping with the context of brief, time-limited therapy, Messer and Warren describe brief psychodynamic therapy (BPT) as a promising approach. This adaptation applies the principles of psychodynamic theory and therapy to treating selective disorders within a pre established time limit of, generally, 10 to 25 sessions. BPT makes use of key psychodynamic concepts such as the enduring impact of psychosexual, psychosocial, and object relational stages of development; the existence of unconscious processes and resistance; the usefulness of interpretation; the importance of the working alliance; and reenactment of the client’s past emotional issues in relation to the therapist. Most forms of this time-limited approach call upon the therapist to assume an active and directive role in quickly formulating a therapeutic focus that goes beneath the surface of presenting problems and symptoms and treats underlying issues. Some possible goals of this approach might include conflict resolution, greater access to feelings, increasing choice possibilities, improving interpersonal relationships, and symptom remission. Messer and Warren state that the objective of BPT is “to understand and treat people’s problems in the context of their current situation and earlier life experience”. The goals, therapeutic focus, and active role of the therapist have implications for the practice of individual therapy. Although BPT is not suitable for all clients, it meets a variety of clients’ needs.

In writing about the characteristics of time-limited dynamic psychotherapy, Levenson emphasizes that the aim of therapy is not simply symptom reduction but changing a client’s ingrained, repetitive patterns of interpersonal relatedness. This is accomplished by using the client–therapist relationship as a way to understand how the person interacts in the world. It is assumed that clients interact with the therapist in the same dysfunctional ways they interact with significant others. Levenson maintains that “the first and major goal in conducting TLDP is for the client to have a new relational experience composed of a set of focused experiences throughout the therapy in which the client has a different appreciation of self, of therapist, and of their interaction. These new experiences provide the client with experiential learning so that old patterns may be relinquished and new patterns may evolve”. The short-term goals of TLDP are “to give the client repeated tastes of what it is like to interact more fully and flexibly within the therapy and to some extent to experiment with what is being learned in his or her outside world”.

By the end of brief therapy, clients tend to acquire a richer range of interactions with others. Although formal therapy ends, clients have opportunities to practice functional behaviors in daily life, and in this sense, therapy continues in the real world. At some future time, clients may have a need for additional therapy sessions to address different concerns. Instead of thinking of TLDP as a definitive intervention, it is best to view this approach as offering multiple, brief therapy experiences over an individual’s life span.

Strupp maintains that the various contemporary modifications of psychoanalysis have infused psychodynamic psychotherapy with renewed vitality and vigor. Some of the current trends and directions in psychodynamic theory and practice that Strupp identifies are summarized here:

• Increased attention is being given to disturbances during childhood and adolescence.

• The emphasis on treatment has shifted from the “classical” interest in curing neurotic disorders to the problems of dealing therapeutically with chronic personality disorders, borderline conditions, and narcissistic personality disorders. There is also a movement toward devising specific treatments for specific disorders.

• Increased attention is being paid to establishing a good therapeutic alliance early in therapy. A collaborative working relationship is now viewed as a key factor in a positive therapeutic outcome.

• There is a renewed interest in the development of briefer forms of psychodynamic therapy, largely due to societal pressures for accountability and cost-effectiveness. The indications are that time-limited dynamic therapy will be used more in the future.

Borderline and narcissistic disorders seem to be rooted in traumas and developmental disturbances during the separation–individuation phase. However, the full manifestations of the personality and behavioral symptoms tend to develop in early adulthood. Borderline and narcissistic symptoms such as splitting (a defensive process of keeping incompatible perceptions separate) and notions of grandiosity are behavioral manifestations of developmental tasks that were disturbed or not completed earlier.

Some of the most powerful tools for understanding borderline and narcissistic personality organizations have emerged from the psychoanalytic models. Among the most significant theorists in this area are Kernberg. Although this book does not emphasize diagnostic issues, a great deal of recent psychoanalytic writing deals with the nature and treatment of borderline and narcissistic personality disorders and sheds new light on the understanding of these disorders. Kohut (1984) maintains that people are their healthiest and best when they can feel both independence and attachment, taking joy in themselves and also being able to idealize others. Mature adults feel a basic security grounded in a sense of freedom, self-sufficiency, and self-esteem; they are not compulsively dependent on others but also do not have to fear closeness.

The contemporary psychoanalytic theories center on predictable developmental sequences in which the early experiences of the self shift in relation to an expanding awareness of others. Once self–other patterns are established, it is assumed they influence later interpersonal relationships. Specifically, people search for relationships that match the patterns established by their earlier experiences. People who are either overly dependent or overly detached, for example, can be repeating patterns of relating they established with their mother when they were toddlers. These newer theories provide insight into how an individual’s inner would can cause difficulties in living in the actual world of people and relationships.

A central influence on contemporary object-relations theory is Margaret Mahler, a pediatrician who emphasized the observation of children. In her view, the resolution of the Oedipus complex during Freud’s proposed phallic stage is less critical than the child’s progression from a symbiotic relationship with a maternal figure toward separation and individuation. Her studies focus on the interactions between the child and the mother in the first 3 years of life. Mahler conceptualizes the development of the self somewhat differently from the traditional Freudian psychosexual stages. Her belief is that the individual begins in a state of psychological fusion with the mother and progresses gradually to separation. The unfinished crises and residues of the earlier state of fusion, as well as the process of separating and individuating, have a profound influence on later relationships. Object relations of later life build on the child’s search for a reconnection with the mother. Psychological development can be thought of as the evolution of the way in which individuals separate and differentiate themselves from others.

Mahler calls the fi rst 3 or 4 weeks of life normal infantile autism. Here the infant is presumed to be responding more to states of physiological tension than to psychological processes. Mahler believes the infant is unable to differentiate itself from its mother in many respects at this age. According to Melanie Klein, another major contributor to the object-relations perspective, the infant perceives parts—breasts, face, hands, and mouth—rather than a unified self. In this undifferentiated state there is no whole self, and there are no whole objects. When adults show the most extreme lack of psychological organization and sense of self, they may be thought of as returning to this most primitive infantile stage. Subsequent infant research by Daniel Stern has challenged this aspect of Mahler’s theory, maintaining that infants are interested in others practically from birth.

Mahler’s next phase, called symbiosis, is recognizable by the 3rd month and extends roughly through the 8th month. At this age the infant has a pronounced dependency on the mother. She (or the primary caregiver) is clearly a partner and not just an interchangeable part. The infant seems to expect a very high degree of emotional attunement with its mother. The separation–individuation process begins in the 4th or 5th month. During this time the child moves away from symbiotic forms of relating. The child experiences separation from significant others yet still turns to them for a sense of confirmation and comfort. The child may demonstrate ambivalence, torn between enjoying separate states of independence and dependence. The toddler who proudly steps away from the parents and then runs back to be swept up in approving arms illustrates some of the main issues of this period. Others are looked to as approving mirrors for the child’s developing sense of self; optimally, these relationships can provide a healthy self esteem. Children who do not experience the opportunity to differentiate, and those who lack the opportunity to idealize others while also taking pride in themselves, may later suffer from narcissistic character disorders and problems of self-esteem. The narcissistic personality is characterized by a grandiose and exaggerated sense of self-importance and an exploitive attitude toward others, which serve the function of masking a frail self-concept. Such individuals seek attention and admiration from others. They unrealistically exaggerate their accomplishments, and they have a tendency toward extreme self-absorption.