Second Edition
By
and
Columbia University Department of Psychiatry, New York, USA
This second edition first published 2017 © 2017 John Wiley & Sons, Ltd.
Edition history: John Wiley & Sons Ltd. (1e, 2011)
Registered Office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
| Editorial Offices | 350 Main Street, Malden, MA 02148-5020, USA |
| 9600 Garsington Road, Oxford, OX4 2DQ, UK | |
| The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK |
For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.
The right of Deborah L. Cabaniss, Sabrina Cherry, Carolyn J. Douglas, and Anna R. Schwartz to be identified as the authors of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Limit of Liability/Disclaimer of Warranty: While the publisher and authors have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. It is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
Library of Congress Cataloging-in-Publication Data
Names: Cabaniss, Deborah L., author. | Cherry, Sabrina, author. | Douglas, Carolyn J., author. | Schwartz, Anna R., author.
Title: Psychodynamic psychotherapy : a clinical manual / Deborah L. Cabaniss and Sabrina Cherry, Carolyn J. Douglas, Anna Schwartz.
Description: Second edition. | Chichester, West Sussex ; Malden, MA : John Wiley & Sons Inc., [2017] | Preceded by Psychodynamic psychotherapy : a clinical manual / by Deborah L. Cabaniss ... [et al.]. 2011. | Includes bibliographical references and index.
Identifiers: LCCN 2016018489| ISBN 9781119141983 (cloth) | ISBN 9781119141990 (epub)
Subjects: | MESH: Psychotherapy, Psychodynamic–methods
Classification: LCC RC480 | NLM WM420.5.P75 | DDC 616.89/14–dc23 LC record available at https://lccn.loc.gov/2016018489
A catalogue record for this book is available from the British Library.
For our families
Thomas, William and Daniel
Marc, Rebecca and Ruth
Jon, William and Ben
Eric, Lena and Maia
In the four years since Psychodynamic Psychotherapy: A Clinical Manual was published, we have taken to heart the enormous amount we have learned about it from our students and readers. While the core of our “Listen/Reflect/Intervene” method is largely unchanged, we have worked hard in writing this second edition to produce a manual that truly brings this treatment into the 21st century. Here are the highlights of what's new:
We hope you'll agree that this new Psychodynamic Psychotherapy: A Clinical Manual is truly a psychotherapy manual for today and tomorrow.
That's Farsi for “Psychodynamic Psychotherapy.” Five years ago, I wouldn't have dreamed that I would know that. But since we published the first edition of this book, it has been translated into Mandarin, Korean, and Farsi, and has been adopted by training programs from Harvard to Stanford. We've been overwhelmed by the response, and delighted that it has helped students realize that psychodynamic psychotherapy can be taught in a clear way that makes sense to even the most junior learners. We've been particularly pleased that even people who are not in the field have said: “I wish I'd had that book when I was in therapy!” Our heartfelt thanks go to all of our readers, who have added “Listen/Reflect/Intervene” to the lexicon.
Once again, the dream team of Sabrina Cherry, Carolyn Douglas, and Anna Schwartz helped produced a book that no one of us could have done alone. Our “groupthink” propelled us out of ego psychology and into a psychodynamic psychotherapy manual for the 21st century. I'm sure they won't miss my late-night queries, but I will miss the incredible learning experience of working with a group like this day in and day out.
None of this could have happened without the Columbia University Department of Psychiatry Residency Program. Maria Oquendo and Melissa Arbuckle, our fearless leaders, have allowed us to experiment and innovate in order to produce something really new in psychodynamic training. And, as before, our terrific Columbia residents teach us every day what works and what doesn't.
Steven Roose provided wisdom that got us through many a conceptual sticky wicket. Darren Reed at Wiley gave us the opportunity to dive into this project again. Joshua Gordon and Richard Brockman shared their Columbia “Neuroscience of Psychodynamic Psychotherapy” curriculum. Yael Holoshitz, Lauren Havel, and Alison Lenet contributed with the “PEPPER.” William Cabaniss was there with technical support during crunch time. And a big shout-out to Maya Nair, who gave us a “pre-read” and was intrepid about offering feedback to her teachers.
Of course, our biggest thanks go to our families, who once again put up with us while we went down the drop-box rabbit hole. We're back, at least until we come up with a new three-step process to explore…
Deborah L. Cabaniss, m.d.
January 2016
Psychodynamic Psychotherapy: A Clinical Manual is a manual for conducting psychodynamic psychotherapy. It outlines the techniques used for
Like all psychotherapy manuals, it is designed to operationalize the techniques clearly so that this treatment can be taught, delivered, and studied in the most effective way. Psychotherapy manuals are not scripts or cookbooks. Rather, they are treatment guides. Here are some suggestions for optimal use of this manual:
For more detailed suggestions about the use of this manual in didactics and supervision, see Appendix 1, “How to Use Psychodynamic Psychotherapy: A Clinical Manual – A Guide for Educators.”
This book includes a companion website:
www.wiley.com/go/cabaniss/psychotherapy
with the “Listening Exercise” for Chapter 16 (Learning to Listen).
This is a short recording that will help the reader to learn about different ways we listen. It is designed to accompany a listening exercise, which is found near the beginning of Chapter 16.
“Why can't I find a good relationship?”
“Why do I keep bombing out at work?”
“Why can't I have more patience with my children?”
“Why can't I feel good about myself?”
Feeling good about ourselves, having loving relationships with others, and doing satisfying work – for most of us, those are our life goals. We all have certain patterns that guide the way we try to achieve these goals. By the time we are adults, our patterns are fairly fixed, and changing them is not so easy. The habitual nature of these patterns is akin to the way water runs down a hill – after a while, a certain groove gets carved out and the water always flows down that channel. If you want the water to flow another way, you're going to have to do some hard work to alter the path. It's the same with us – after a certain age, we're pretty consistent about the way we think and behave. But for many people, their characteristic ways of thinking about themselves and dealing with others are maladaptive and they need a way to change.
The problem is that although they know they want to change, they don't know what they want to change. That is because habitual patterns, more often than not, are motivated by wishes, thoughts, fears, and conflicts that are out of awareness. For example, take a person who never advocates for herself and doesn't know why – but who deep down feels that she deserves to be punished. Or a person who is lonely but is unaware that his fear of rejection is actually causing him to avoid others. For these people, learning about their deep-seated thoughts and fears can be unbelievably powerful. The insecure woman can understand that her self-sabotage has been a lifelong form of self-punishment, and the lonely man can begin to understand that he produces his own isolation by denying his need for others. They can start to develop new patterns of behavior. They can change their lives.
This is what psychodynamic psychotherapy is all about. It offers people a chance to create new ways of thinking and behaving in order to improve the quality of their lives. Since most of the ways we think about ourselves and deal with our environment evolved as we grew up, we can think of this process as reactivating development. One thing that is incredibly exciting about this view of psychodynamic psychotherapy is that it fits so well with advances in neural science [1–4]. For example, we now hypothesize that all learning comes with changes in our neural substrate – so adult brains change all the time. In the words of Eric Kandel, “Insofar as psychotherapy works, it works by acting on brain functions, not on single synapses, but on synapses nevertheless” [5]. New growth – new connections – new patterns.
In this model, not all environments foster new growth – you need a particular set of circumstances in which people feel safe enough to allow this to happen. If you've ever worked on changing anything that had become habitual, it's likely that the process involved another person, like a coach, teacher, or parent. In psychodynamic psychotherapy, that person is the therapist. Change happens not only because people learn new things about themselves, but also because they feel safe enough to try out new ways of thinking and behaving in the context of this new relationship.
This manual will teach you to conduct psychodynamic psychotherapy. Because it was first developed as a syllabus for teaching psychiatric residents, it has been classroom tested for many years. It will systematically take you from assessment to ending using straightforward language and carefully annotated examples. Psychodynamic psychotherapy is a specific type of therapy that requires the therapist to carefully and deliberately make a thorough assessment, establish a therapeutic framework, interact with patients in particular ways, and make choices about therapeutic strategies. As you journey through this book, you will learn all of these essential skills. Here's the basic roadmap: Part One (What Is Psychodynamic Psychotherapy?) will introduce you to psychodynamic psychotherapy and to some of the ways we hypothesize that it works. Part Two (Assessment) will teach you to assess patients for psychodynamic psychotherapy, including assessment of domains of function and defenses. In Part Three (Beginning the Treatment), you'll learn the essentials for beginning the treatment, including fostering the therapeutic alliance, setting the frame, and setting goals. Part Four (Listen/Reflect/Intervene) will teach you a systematic way of listening to patients, reflecting on what you've heard, and making choices about what to say and how. Part Five (Conducting a Psychodynamic Psychotherapy: Technique) will teach you to apply the Listen/Reflect/Intervene method to the essential elements of psychodynamic technique – affect, resistance, transference, countertransference, unconscious fantasy, conflict, and dreams. By then you'll be ready to use these methods to meet therapeutic goals, and in Part Six (Meeting Therapeutic Goals) you'll see how these techniques are used to address problems with self-esteem, relationships with others, characteristic ways of adapting, and cognitive functions. Finally, Part Seven (Working Through and Ending) will take you to the end of the treatment, addressing ways in which our technique shifts over time.
Learning is best when it's active – and thus we've included suggested activities at the end of most of the chapters. These are designed to allow you to try out the skills and techniques that you will learn in this book. They can be done alone, with a partner, or as part of a classroom activity. “Comments” are included to guide reflection and discussion; they are not meant to be definitive or “correct” answers.
We have made many deliberate choices about the use of jargon. For example, we do not extensively use terms like “transference” and “resistance” until we formally introduce them in Part Five, both because we want to define our terms carefully and because we want you to think as openly as possible as you begin learning this treatment. We all have preconceived ideas about these concepts and, as much as possible, we are trying to reduce the impact of previously held notions. We have also consciously decided to avoid discussion of particular theoretical schools of psychodynamic psychotherapy, such as object relations theory and self-psychology. Again, this decision reflects our intention to teach the technique of psychodynamic psychotherapy in the most ecumenical way possible.
So, let's begin at the beginning – on to Part One and “What Is Psychodynamic Psychotherapy?”
Literally, psychotherapy means treatment for the mind. Psychotherapy has its origins in psychoanalysis – the “talking cure” that was first developed by Sigmund Freud [1]. Consequently, the word psychotherapy has come to refer to a treatment that involves talking. But it's not just any talking – in order to be psychotherapy, the talking has to be:
And what about psychodynamic? You've probably heard this word many times – but what does it mean? Psycho comes from the Greek word psyche, which meant soul but has come to mean mind, and dynamic comes from the Greek word dynamis, which meant power but has come to mean physical force in motion. Simply stated, the word psychodynamics refers to the forces of the mind that are in motion. Freud coined this word when he realized that, as opposed to earlier conceptualizations of a static psyche, the mind was an ever-changing system, rolling with perpetually moving energized elements. These unconscious elements could explode into consciousness and vice versa, while powerful wishes and prohibitions could barrel into one another, releasing the psychic equivalent of colliding subatomic particles [2].
Freud realized not only that elements of the mind were in motion, but also that most of this frenzied mental activity was going on outside of awareness. He described this mental activity as unconscious and hypothesized that it could affect conscious thoughts, feelings, and behavior. Thus, we arrive at the two definitions that provide the foundation for this manual:
We often refer to our unconscious mental activity as the unconscious. Feelings, memories, conflicts, ways of relating to others, self-perceptions – all of these can be unconscious and can cause problems with thoughts and behavior. Unconscious thoughts and feelings develop in a person from childhood, and are a unique mix of early experiences and temperamental/genetic factors. We keep certain thoughts, feelings, and fantasies out of awareness because they threaten to overwhelm us if they become conscious. They might be too frightening or stimulating; they might fill us with shame or disgust. Because of this, we make them unconscious but they do not disappear – they remain full of energy and constantly push to reach awareness. Their energy affects us from their unconscious hiding places, and they exert their influence on the way we think, feel, and behave. A good analogy comes from Greek mythology:
Zeus, the young god, was tired of being ruled by the patriarchal Titans, so he buried them in a big pit called Tartarus. Deep beneath the earth, they no longer posed a threat to Zeus's dominance. Or did they? Though out of sight, they had not disappeared, and their rumblings were thought to cause earthquakes and tidal waves.
So too, unconscious thoughts and feelings are hidden from view but continue to rumble in their own way, causing unhappiness and suffering in the form of maladaptive thoughts and behaviors.
In many ways, the psychodynamic psychotherapist is like the plumber you call to fix your leaky ceiling. You see the dripping, but you can't see the source; you can catch the drops in a pail, but that doesn't stop the flow. The plumber knows that the rupture lies behind the plaster, somewhere in pipes that as yet can't be seen. Here, though, the plumber has an advantage over the psychodynamic psychotherapist – he can use a sledgehammer to break through the plaster, reveal the underlying pipes, find and fix the offending leak, and patch the ceiling. But the psychodynamic psychotherapist is working with a human psyche, not a plaster ceiling, and thus requires more subtle tools to seek and mend what's beneath the surface.
Like the plumber, the psychodynamic psychotherapist's first goal is to understand what lies beneath the surface – that is, to understand what's going on in the patient's unconscious. Many of the techniques of psychodynamic psychotherapy are designed to do just that. Once we think that patients are motivated by thoughts and feelings that are out of their awareness, we then have to decide how to use what we have learned in order best to help them. Sometimes we decide that making patients aware of what's going on in their unconscious will help. We call this uncovering – Freud called it “making conscious what has so far been unconscious” [3]. We have many techniques for helping patients to uncover – or become aware of – unconscious material. What we're uncovering are inner thoughts and feelings that they keep hidden from themselves but that nevertheless affect their self-perceptions, relationships with others, ways of adapting, and behavior.
Sometimes, however, we decide that making patients aware of unconscious material will not be helpful. We generally make this decision when we judge that the unconscious material could be potentially overwhelming. Then we use what we have learned about the unconscious to support functioning without uncovering thoughts and feelings. (See Chapter 18 for discussion of uncovering and supporting techniques.)
Here are two examples – one in which we would choose to uncover and one in which we would choose to support:
Ms A is a 32-year-old woman who has a trusting relationship with her husband, many close friends, and a satisfying personal career. In the past, she has used journaling, cooking, and athletics to work through short periods of anxiety. She presents to you complaining of insomnia that she believes has been triggered by a fight she is having with her younger sister, B. Ms A says that she's “mystified” by B's hostile behavior, which began about a month ago in the context of B's impending graduation from medical school. Further exploration reveals that although B wanted to become a dermatologist, she was not offered a position in this field and will have to do an interim year of internal medicine and then reapply. Ms A says that she has been very sympathetic about this setback and does not know why B is so hostile toward her. When you ask about their earlier relationship, you discover that Ms A has cruised effortlessly from one Ivy League institution to another, while B has struggled academically. You hypothesize that B's hostility toward Ms A may be fueled by envy, and that Ms A has been unconsciously keeping herself from becoming aware of this out of guilt. You think that Ms A will benefit from learning about her unconscious guilt and decide to help her uncover it. Once she grapples with her guilty feelings, she is able to recognize her sister's hostility and envy. This awareness helps her to understand their recent interpersonal difficulties and resolves the insomnia.
Ms C is a 32-year-old woman who is isolated, moves frequently from job to job, and often reacts to stress by binge eating and purging. She presents to you complaining of insomnia that she believes has been triggered by a fight with her younger sister, D. She says that she is shouldering the entire burden of caring for their chronically ill mother while D “just sits in her suburban home with the other soccer moms and sends checks.” Ms C, who is struggling to make ends meet, tells you that she thinks that her sister, who is married to a very wealthy man, is “shallow and materialistic” and that she “wouldn't switch lives with her if you paid me.” She says that she is “enraged” at D for not doing more to help their mother and that ruminations about this are causing her to stay awake at night. You hypothesize that Ms C's rage is fueled by envy of D, but you decide that learning about the way in which this might be contributing to the insomnia will not help her at this time. Instead, you decide to support Ms C's functioning by empathizing with the amount of work she is doing to care for her ailing mother, and by suggesting that she use her mother's Medicare benefits to get some help with eldercare. Once she feels validated, Ms C relaxes, her insomnia resolves, and she is better able to understand many aspects of her current situation.
In both cases, the first thing that the psychodynamic psychotherapist needed to do was to understand the way in which unconscious thoughts and feelings were affecting the patient's conscious behavior. However, in one situation the therapist decided to uncover while in the other the therapist decided to support. Thus, we can say that the basic techniques of psychodynamic psychotherapy are to:
Making the decision in Step #2 depends on careful assessment of the patient, both at the beginning and throughout the treatment, to determine what will be most helpful at any given point in time (see Part Two). When psychodynamic psychotherapy primarily uses uncovering techniques, it is often called insight-oriented, expressive, interpretive, exploratory, or psychoanalytic psychotherapy, and when it primarily uses support, it is often called supportive therapy [4]. Unfortunately, these techniques are often seen as completely separate from one another. On the contrary, uncovering and supporting do not constitute separate therapies, but rather are both used in an oscillating manner in all psychodynamic psychotherapy. One patient may benefit from therapy in which mostly uncovering techniques are used, while another may benefit from therapy in which supporting techniques predominate, but all treatments use some of each at different points.
The optimal mix of supporting and uncovering techniques will vary from patient to patient, and sometimes from moment to moment, depending on the individual person's strengths, problems, and needs. Some patients only require the implicit support conveyed in the therapist's attitude of empathy, understanding, and interest. Other patients need more explicit support throughout the treatment. Whatever the overarching goals we choose at the start of treatment, we are prepared to shift our approach flexibly depending on the patient's changing needs.
Uncovering and supporting do not happen in a vacuum – they happen in the context of the relationship between therapist and patient. This relationship is central to what defines psychodynamic psychotherapy. It not only provides a safe environment in which patients can talk about their problems, it also allows them to learn about themselves and their relationships through their interaction with the therapist. The therapeutic relationship itself is likely to be an agent of change in psychodynamic psychotherapy, both as a “relationship laboratory” from which the patient can learn, and as a direct source of support that can foster growth and change. Talking about and learning from the therapeutic relationship is called discussion of the transference (see Chapters 12 and 21) and is often a major focus of psychodynamic psychotherapy.
With this addition, we can round out our definition of psychodynamic psychotherapy in this way:
Psychodynamic psychotherapy is a talk therapy based on the idea that people are affected and motivated by thoughts and feelings that are out of their awareness. Its goals are to help people to change habitual ways of thinking and behaving by helping them learn more about how their minds work, and/or directly supporting their functioning, in the context of the relationship with the therapist.
But how does this happen? Let's move on to Chapter 2 to explore some of the theories behind the technique.