Concise Guide to Psychodynamic Psychotherapy (Concise Guides)

265 Pages·2004·1.17 MB·English

by  Robert J. Ursano, Stephen M. Sonnenberg, Susan G. Lazar

CONCISE GUIDE TO
Psychodynamic Psychotherapy
Principles and Techniques of
Brief, Intermittent, and Long-Term
Psychodynamic Psychotherapy
Third Edition
CONCISE GUIDE TO
Psychodynamic Psychotherapy
Principles and Techniques of
Brief, Intermittent, and Long-Term
Psychodynamic Psychotherapy
Third Edition
Robert J. Ursano, M.D.
Stephen M. Sonnenberg, M.D.
Susan G. Lazar, M.D.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accurate at the time of
publication and consistent with general psychiatric and medical standards, and that information
concerning drug dosages, schedules, and routes of administration is accurate at the time of publication
and consistent with standards set by the U.S. Food and Drug Administration and the general medical
community. As medical research and practice continue to advance, however, therapeutic standards
may change. Moreover, specific situations may require a specific therapeutic response not included
in this book. For these reasons and because human and mechanical errors sometimes occur, we
recommend that readers follow the advice of physicians directly involved in their care or the care of
a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the
individual authors and do not necessarily represent the policies and opinions of APPI or the American
Psychiatric Association.
Copyright © 2004 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Typeset in Adobe’s Times and Helvetica
Manufactured in the United States of America on acid-free paper
08 07 06 05 04 5 4 3 2 1
Third Edition
American Psychiatric Publishing, Inc.
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Library of Congress Cataloging-in-Publication Data
Ursano, Robert J., 1947–
Concise guide to psychodynamic psychotherapy : principles and techniques of brief, intermittent,
and long-term psychodynamic psychotherapy / Robert J. Ursano, Stephen M. Sonnenberg, Susan G.
Lazar.—3rd ed.
p. ; cm. — (Concise guides / American Psychiatric Publishing)
Includes bibliographical references and index.
ISBN 1-58562-173-0 (pbk. : alk. paper)
1. Psychodynamic psychotherapy. 2. Psychotherapist and patient. I. Title: Psychodynamic
psychotherapy. II. Sonnenberg, Stephen M., 1940– III. Lazar, Susan G., 1944– IV. Title. V. Concise
guides (American Psychiatric Publishing).
[DNLM: 1. Psychotherapy—methods. WM 420 U82c 2004]
RC489.P72U77 2004
616.89′14—dc22 2004050260
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
About the Authors . . . . . . . . . . . . . . . . . . . . . .xv
Introduction to the
Concise Guides Series . . . . . . . . . . . . . . .xvii
Preface to the Third Edition . . . . . . . . . . . . . xix
1 Why Psychotherapy? . . . . . . . . . . . . . . . . . . . .1
Psychiatric Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Contribution of Psychotherapy . . . . . . . . . . . . . . . . . . . 2
Psychotherapy and Medical Illness. . . . . . . . . . . . . . . . . . . . 4
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . .13
The Focus of Psychodynamic Psychotherapy . . . . . . . . . . 14
The Setting of Psychodynamic Psychotherapy. . . . . . . . . . 17
The Technique of Psychodynamic Psychotherapy . . . . . . . 18
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3 Patient Evaluation, I:
Assessment, Diagnosis, and
the Prescription of Psychotherapy . . . . . . . .23
Beginning the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Selection Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4 Patient Evaluation, II:
Psychodynamic Listening. . . . . . . . . . . . . . . .33
The Four Psychologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
The Clinical Moment and Clinical Assessment . . . . . . . . . 36
Psychodynamic Listening in a Consultation-Liaison
Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Psychodynamic Listening in a Psychotherapy Evaluation . 43
Psychodynamic Listening in a
Psychodynamic Psychotherapy Context . . . . . . . . . . . . . . 46
Listening to Oneself Outside of the Consulting Room . . . . 50
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5 Patient Evaluation, III:
Psychodynamic Evaluation. . . . . . . . . . . . . . .53
The Chief Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
The History of the Present Illness, the Past History,
and the Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Early Memories and Trauma . . . . . . . . . . . . . . . . . . . . . . . . 62
Developmental Deficit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Assessment of the Patient’s Conscience . . . . . . . . . . . . . . . 69
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
6 Beginning Treatment . . . . . . . . . . . . . . . . . . . .73
First, Do No Harm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Abstinence and Free Association . . . . . . . . . . . . . . . . . . . . 75
The Atmosphere of Safety. . . . . . . . . . . . . . . . . . . . . . . . . . 78
The Attitude of Physicianly Concern . . . . . . . . . . . . . . . . . 80
Disappointment in the Opening Phase . . . . . . . . . . . . . . . . 81
The Early Experience of Transference, Defense,
and Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Initial Use of Dreams in Therapy . . . . . . . . . . . . . . . . . . . . 85
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7 Resistance and Defense . . . . . . . . . . . . . . . . .89
Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Repression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Reaction Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Reversal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Identification With the Aggressor . . . . . . . . . . . . . . . . . 93
Asceticism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Intellectualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Isolation of Affect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Sublimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Interpreting Resistances and Defense Mechanisms . . . . . . 94
Transference Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
8 Transference . . . . . . . . . . . . . . . . . . . . . . . . .103
The Need to Repeat the Past . . . . . . . . . . . . . . . . . . . . . . . 104
Transference in Psychodynamic Psychotherapy. . . . . . . . 105
Forms of Transference . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Working With the Transference . . . . . . . . . . . . . . . . . . . . 107
Transference as Resistance . . . . . . . . . . . . . . . . . . . . . . . . 109
Erotic and Aggressive Transferences . . . . . . . . . . . . . . . . 112
Working Through the Transference . . . . . . . . . . . . . . . . . 113
Enactment and Projective Identification. . . . . . . . . . . . . . 114
Dealing With “No” Transference . . . . . . . . . . . . . . . . . . . 115
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
9 Countertransference . . . . . . . . . . . . . . . . . . .119
Concordant and Complementary Countertransferences . . 122
Countertransference in Work With
Borderline Personality Disorder Patients . . . . . . . . . . . . 127
Other Countertransferences . . . . . . . . . . . . . . . . . . . . . . . . 129
The Therapist’s Need for Personal Psychoanalysis
and Supervision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
10 Dreams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
The Use of Dreams in Psychotherapy . . . . . . . . . . . . . . . . 133
Introducing the Patient to the Use of Dreams . . . . . . . 133
Use of Dreams During the Middle Phase of Therapy . 135
Use of Dreams During the Latter Phases of Therapy . 136
The Dream as an Indicator of Unconscious Conflict . . . . 138
The Dream as an Indicator of Transference . . . . . . . . . . . 139
The Dream as Indicator of Genetic Data
or Adaptational Style . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Dreams as a Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
The Termination Dream . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Words of Caution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
11 Termination. . . . . . . . . . . . . . . . . . . . . . . . . . .147
Recognizing When the Termination Phase
Is Approaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Tasks of the Termination Phase . . . . . . . . . . . . . . . . . . . . 149
Review the Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 149
Experience the Loss of the Psychotherapy
and the Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Reexperience and Remaster the Transference . . . . . . . 151
Increase Skills in Self-Inquiry as a
Method of Problem Solving . . . . . . . . . . . . . . . . . . . 151
Disappointment in the Termination Phase . . . . . . . . . . . . 152
When the Treatment Is Unsuccessful . . . . . . . . . . . . . . . . 154
When the Patient Refuses to Terminate Despite
Successful Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Leave-Taking: The Reactions of the Therapist. . . . . . . . . 157
Terminations That Do Not Take Place . . . . . . . . . . . . . . . 159
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
12 Practical Problems and
Their Management . . . . . . . . . . . . . . . . . . .163
The Office: Decor and Setting . . . . . . . . . . . . . . . . . . . . . 163
Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Medical Insurance and Managed Care . . . . . . . . . . . . . . . 168
Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Telephone Calls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Vacation Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Suicidal Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Dangerous Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Gifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Advice Giving: The Psychotherapist as Physician . . . . . . 173
Illness in the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Therapist Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
General Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
13 Brief Psychotherapy . . . . . . . . . . . . . . . . . . .177
Selection of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Duration of Treatment and Termination . . . . . . . . . . . . . . 182
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186