Psychodynamic Therapies

What separates the psychodynamic tradition from classical psychoanalysis is not a smaller dose of the same thing. It is a different claim about what a person fundamentally is. For Freud, the individual is a pressure system seeking discharge, and other people are the objects through which discharge occurs. For the neo-Freudians and everything downstream of them, the person is constituted by relationship from the beginning; there is no self that precedes its relations.

The relational turn, stated plainly

The internal working model

Bowlby’s attachment theory supplied the developmental evidence base the tradition had lacked. Early caregiving produces an internal working model — an expectation about whether needs will be met, and about what kind of person one must be to be cared for. Those models are stable, largely out of awareness, and they organise adult intimacy. Attachment classifications (secure, anxious-preoccupied, dismissing-avoidant, disorganised) are the most empirically defensible piece of developmental theory this tradition has, and they map onto therapy behaviour with some precision.

Horney’s three trends

Moving toward people

Compliance and self-effacement; safety through being needed and inoffensive. The neurotic version cannot tolerate its own aggression.

Moving against people

Expansiveness and control; safety through mastery and being unassailable. The neurotic version cannot tolerate dependency.

Moving away from people

Detachment and self-sufficiency; safety through needing nothing. The neurotic version cannot tolerate wanting.

Health, for Horney, is the flexible availability of all three. Neurosis is the compulsive use of one, and the ferocity with which the other two are disowned.

Symptoms are the visible end of a relational pattern that was once necessary. The child of an unpredictable parent learns hypervigilance, which was adaptive; the adult carries hypervigilance into a marriage where it corrodes. Nothing is wrong with the learning; what is wrong is that it has outlived the conditions that made it sensible and is now protected from revision by the very avoidance it produces.

The two triangles

Malan’s two triangles remain the most useful teaching device in brief dynamic work, because together they tell you both what to look for and where to look for it.

What contemporary dynamic therapists actually look for

• A recurring relational theme, extracted from concrete episodes rather than asserted
• The affect that is missing from an account that should contain it
• The defense operating in the room, now, in the last thirty seconds
• Discrepancies between what is said and how it is said
• What the patient is doing to the therapist, and what the therapist has been recruited into

Brief dynamic therapy makes a bet: that a single focus, identified early and pursued relentlessly, produces more change in twenty sessions than a broad exploration produces in a hundred. Everything about the technique follows from that bet — the early formulation, the active maintenance of the focus, the willingness to set a termination date at the start.

1. 1Identify a focal conflict or relational theme within the first few sessions and state it aloud to the patient.
2. 2Keep returning to it, declining the material that does not serve it — the discipline that trainees find hardest.
3. 3Use the transference as the sharpest instance of the theme, but do not over-dose it.
4. 4Attend to affect: the theory holds that change requires the warded-off feeling to be experienced, not merely identified.
5. 5Work through in current life, so the insight becomes behaviour.
6. 6Use termination deliberately: the ending activates the theme, which is why setting the date early is a technique rather than an administrative act.