Progress in Psychodynamic Therapies
Kate (not her real name) came into my office because she was having difficulty balancing the stress of her work life, as well as controlling her temper when having disagreements with her partner. So, as we say, her presenting concerns were work-related stress and her anger management.
Within the therapy world today, with managed care playing such a dominant role, it seems that there is so much talk around symptom reduction as the standard for an effective treatment. Cognitive behavioral therapies (CBT) have been pushed front and center in many minds as the standard of care. Other therapies, such as humanistic or psychodynamic approaches, have been relegated to the sidelines as inferior and lacking empirical evidence (on why this isn’t the case visit https://jonathanshedler.com/). As the narrative goes: a client comes into therapy with a presenting concern; there is a standardized treatment for that concern that is then put into place; the symptoms are reduced,and voila, the treatment is deemed effective.
It’s not my goal here to disparage CBT, but, rather, to promote psychodynamic approaches. Furthermore, it’s not my goal to say why psychodynamic approaches are, in fact, successful. I’ll leave that to the Jonathan Shedlers out there. My goal is much more modest: to talk briefly about how psychodynamic approaches measure success in treatment.
Why Symptom Reduction Is and Isn’t the Goal
Clients come into our offices all the time because they are suffering. They want help, they want us to give them a cure. Most of the time, in their minds, they want symptom reduction. When Kate came to see me, she was plagued by work stress, and shocked at just how angry she could get when fighting with her partner. It didn’t take long in our treatment to see that “stress” and “anger management,” while central in her mind as the presenting issues, were not in fact the main issues.
With most behavioral therapies, the symptoms would be addressed until reduced to a desired degree. In psychodynamic therapy, we don’t view the symptom in isolation, but try to understand the patient in his or her context, and out of that context, try to understand what the symptom might be saying (this is what we mean by “depth psychology”). For this reason, it could be detrimental to get rid of a symptom before it has had the opportunity to pass on its message.
So Then, What’s the Goal?
Obviously, all well-intentioned therapists will want to reduce the suffering of their patients. But there are other ways to conceptualize goals in therapy, and, ironically, as these goals get “reached,” some of these other symptoms are reduced. So what are some “goals” that could be worked towards in psychodynamic therapy? Below is a list, taken from Barsness’ book (2018) Core Competencies of Relational Psychoanalysis.nwn
1) Increased capacity to experience multiple affective states
2) Increased access to multiple aspects of self without shame
3)Ability to comfort and soothe oneself
4)Ability to accept responsibility
5)Ability to be truthful with oneself
6)Ability to think creatively
7)Ability to tolerate ambiguity and uncertainty
8)Relief from internal strains that become problematic
9)Ability to think about past creatively without repeating it
10)Increased capacity to love and to work; self-efficacy
11)Engage in more meaningful relationships
Unfortunately, Kate didn’t remain long in therapy with me. As some things began getting stirred up within her, as well as between us, the feelings for her became overwhelmingly shameful and intolerable (goals # 1,2,3,5,9,11). I tried my best to convince her that this was the work of therapy, naming and working through these dynamics (transference-countertransference). Alas, she left.
Psychodynamic therapies are about making the unconscious conscious, but beyond that, helping the patient to reevaluate their relationship with that shameful aspect that has been made conscious (what good is it to have something conscious if you feel like shit because of it?). Contemporary psychodynamic thinking utilizes the therapeutic relationship for this. Questions such as: What’s happening between us right now? How is this dynamic similar to the patient’s earlier relationships? What’s being said and what’s being unsaid? – these are the kinds of questions that we ask.
So it becomes pretty clear pretty quickly that for psychodynamic thinking, the issue is rarely the issue. This is why symptom reduction can’t be the standard for measuring an effective treatment.
Barsness, R.E. (Ed.). (2018). Core Competencies in Relational Psychoanalysis: A guide to practice, study, and research. Routledge.