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(p. 18) Goals of Psychodynamic Therapy 

(p. 18) Goals of Psychodynamic Therapy
Chapter:
(p. 18) Goals of Psychodynamic Therapy
Author(s):

Brian A. Sharpless

DOI:
10.1093/med-psych/9780190676278.003.0003
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date: 19 March 2019

In psychotherapy, as in life more generally, it is usually a good idea to know where you want to go and what you would like to happen. Goals are an important part of this, and patients come to therapy with many of their own. They may want to “feel better,” “get over the past,” or “understand” themselves. Some may want other people in their life to be more amenable to their needs and wishes (i.e., they want to change others). Part of the therapist’s job is to “translate” the patient’s ideas into specific psychodynamic goals. This sometimes requires education on the limits of psychotherapy (e.g., patients can change themselves but not necessarily other people). Once goals are identified and the therapist makes a case formulation, specific techniques can be deduced from the latter and used to reach the former. Therefore, identifying good goals is critically important.

Therapists should always try to be realistic with goals. It is best to strike a middle ground between those that are too easy or superficial (i.e., we underestimate our patients and enact what Michael Gerson termed “the soft bigotry of low expectations”) and those that are not realistically attainable (i.e., we wildly overestimate our patients’ capacities for change). If our goals are not located well between these two extremes, feelings of annoyance or disappointment for both patient and therapist will likely result. Relatedly, we should not be naïve in thinking that some goals could ever truly be reached (e.g., see Thomä & Kächele, 1992, p. 320).

Therapists also need to be flexible. Unlike some other human activities (e.g., traveling to a specific location, trying to fix a leaky faucet), therapeutic goals sometimes shift in the process of trying to reach them. Matters that seemed important in the beginning of treatment may recede over time as new concerns enter the spotlight. Therefore, we need to be open to the possibility that some (or all) goals may need to be modified.

(p. 19) Relatedly, it may also be worth noting that goals in any form of therapy, psychodynamic therapy included, are often “fuzzier” than those found in medicine and certain other scientific disciplines. This is not necessarily a bad thing. As Aristotle (1984) noted over 2,300 years ago (and reiterated more recently by the eminent Sigmund Koch (Koch, 1999), it is unreasonable to expect the same degree of precision from wildly different fields. Each discipline has its own objects of inquiry and unique methodological requirements.

Some goals relevant to psychodynamic therapy can be found in Box 3.1. This list is not meant to be exhaustive but may provide a useful starting point. Options for assessing progress toward goals can be found at the ends of each of the following sections. In general, we should synthesize all of the available information that we collect (e.g., standardized measures, patient report, therapist observations, “objective” life changes) prior to deciding that a goal has been reached.

Specific Psychodynamic Therapy Goals

An Increased Ability to Love and Work

Although insight and making the unconscious conscious (Freud, 1964) were the main goals discussed in the early days of psychoanalysis, Freud himself was supposed to have said that the best indicators of mental health were the capacities to love and work (lieben und arbeiten). I qualify this statement with “supposedly” because the phrase does not appear in any of the 24 volumes of the Standard Edition of the Complete Psychological Works of Sigmund Freud. It instead comes to us indirectly via Erik Erikson (Erikson, 1963). Regardless, these goals certainly have an intuitive appeal. They also have a characteristically Freudian flavor: (a) at first glance they appear to be simple but are, in actuality, anything but; (b) they seem to be imbued with clear evolutionary importance; and (c) they are not overly optimistic. “Happiness” in a traditional sense is not a foregone conclusion even if these goals are successfully reached.1

(p. 20) Love/Relationships

It is important to be clear with Freud’s terms. What he seemed to have meant by romantic love was a reality-based interdependence where sexual and affectionate feelings were integrated (Sharpless, 2015). Ambivalence was meant to be accepted as well. In other words, Freud believed that strong feelings of love for the other person were inevitably accompanied by strong feelings of dislike or even hate. This may seem counterintuitive, and it is sometimes difficult for patients to grasp this concept, but a closer look at patient–partner interactions will make ambivalence more apparent (e.g., the way patients may bring up the things they “hate” about their beloved during fights). Neither the positive nor the negative feelings are inaccurate, of course, and dynamic therapists believe that both need to be acknowledged for romantic love to flourish. Healthy and satisfying nonromantic relationships also indicate health. Many patients suffer from profound loneliness, destructive interpersonal patterns, and difficulties connecting with others. This is especially the case in patients who require one of the more supportive therapeutic approaches (see Chapters 5, 14, and 15). As such, forming healthy and nonexploitative friendships could be a very important therapy goal2 and one that is directly facilitated through the therapeutic relationship. It is well-known that psychodynamic theories presuppose that patients’ patterns in the “outside world” will repeat in session. These include maladaptive interpersonal problems as well as those that may be “healthier.”

However, the therapeutic relationship can be a double-edged sword. Namely, some of our lonelier patients may find therapy to be so safe and satisfying that it essentially becomes a substitute for “real-world” relationships. This form of resistance to the therapy process can be quite subtle and may only be made apparent through meaningful jokes. For example, when I noted that a male patient had not described any attempts to connect with others for quite some time (a self-identified goal), he laughed and replied, “Oh, well, that’s what I’ve got you for.” We then discussed his recurrent pattern of only connecting with one person at a time. This repetition, which minimized the patient’s anxiety, also left him in a precarious state such that loneliness was assured when that one special person left.

More generally, a patient’s quality of object relations is important to note. Although poorer object relations are associated with higher levels of pretherapy symptomatology and can moderate outcome, improvements do tend to happen over the course of treatment. Further, these changes coincide with changes in symptomatology (Barber, Muran, McCarthy, & Keefe, 2013).

Work

Work, much like love, is part of our identity and our humanness. It may overlap with the goals of meaning and purpose described in the following discussion. So, did Freud believe that people could not be healthy unless they complete a standard 35- to 40-hour work week? I doubt he was that concrete but instead wanted to note that work served many positive functions. Even if the work in question was an unpaid volunteer position—which can be a good goal for our sicker patients—it still allows for the possibility of accomplishment, advancement, (p. 21) a sense of purpose, and a structure/routine. In our healthier patients, jobs and the revenue they generate allow patients to be more independent and take care of the people they love. With a livable salary, they gain the ability to be more fully autonomous and make their own decisions without having to worry about limits imposed by outside agencies.3 However, moderation is important. The other extreme of being a “workaholic” is not recommended either. A healthy ability to work presupposes the ability to tolerate not working and to engage in other aspects of life (Etchegoyen, 2012; Rickman, 1950).

Assessment

The assessment of a patient’s capacities for love and work is usually based upon ongoing therapist observations and information gathered at intake (e.g., relationship and employment histories). Therapists need to listen to patient narratives carefully, with empathy, and with a reasonable amount of psychodynamic suspicion (see Chapter 4). This is because many of the issues surrounding relationships and employment are complicated and delicate. For instance, deficits in either of these areas could be associated with powerful feelings of shame. Shame may not only impact a patient’s willingness to disclose difficulties but may also make them reluctant to accept needed assistance (e.g., strong pride may make a patient unwilling to use government food stamps). It is also important for therapists to be mindful of any secondary gain that may interfere with therapy goals. Examples could include a reluctance to secure employment because of social dependency and/or fear of losing disability benefits (Yeomans, Clarkin, & Kernberg, 2015, pp. 131–133) or not seeking out new friendships for fear of causing jealousy in a current romantic relationship. Care should also be taken in deciding the “endpoints” for reaching the goals of love and work, as patients clearly vary in their capacities.

There are also some more objective means available to assess the nature and quality of patient relationships (see Table 3.1). All of them have some degree of psychometric validation and are good supplements to traditional interviewing.

Table 3.1. Some Measures Used to Assess Psychodynamic Goals

Measures

Description

Source

relationship measures

Quality of Object Relations Scale

Semi-structured interview assessing lifetime relational patterns with five possible rating levels ranging from “primitive” to “mature”

Azim, Piper, Segal, Nixon, and Duncan (1991)

Inventory of Interpersonal Problems

Self-report measure assessing problems associated with each octant of the interpersonal circumplex (i.e., two orthogonal axes of power and affiliation)

Horowitz, Rosenberg, Baer, Ureno, and Villasenor (1988); Horowitz, Alden, Wiggins, and Pincus (2000)

Psychodynamic Functioning Scales

Broad, clinician-rated measure assessing family relations, friendships, romantic relationships, tolerance for affects, insight, and problem-solving/adaptive capacity using separate zero-to-100 scales

Hoglend et al. (2000)

insight measures

Patient Insight Scale

Seven-item clinician-rated scale

Luborsky et al. (1980)

Self-Awareness Q Sort

Q-sort to assess convergence between patient and independent observer ratings of patient behaviors

Kelman and Parloff (1957)

Rutgers Psychotherapy Progress Scale

Clinician-rated measure of eight aspects of patient progress including insight. Ratings are based upon session material and scores range from zero to 4

Holland, Roberts, and Messer (1998)

personality measures

Structured Clinical Interview for DSM-5 Personality Disorders

Semi-structured clinical interview assessing DSM-5 personality disorders

First, Williams, Benjamin, and Spitzer (2016)

International Personality Disorders Evaluation

Semi-structured clinical interview assessing 11 DSM-IV (or ICD 10) personality disorders

Loranger (1999)

Structural Interview

Semi-structured interview assessing overall levels of personality organization (i.e., neurotic, borderline, or psychotic) via defensive functioning, identity, and reality testing

Kernberg (1984)

symptom measures

Anxiety and Related Disorders Interview Schedule for DSM-5

Semi-structured diagnostic interview assessing disorders and individual symptoms on zero-to-8 severity scales. Though primarily focusing on anxiety disorder, other relevant conditions are also assessed.

Brown and Barlow (2014)

Structured Clinical Interview for DSM-5 Disorders

Semi-structured diagnostic interview assessing a broad range of disorders

First, Williams, Karg, and Spitzer (2014)

Outcome Questionnaire–45 (OQ-45)

A repeatable self-report measure consisting of 45 items yielding a total score (0–180) and three subscales rated on five-point scale

Lambert et al. (1996)

Treatment Outcome Package (TOP)

A repeatable self-report measure consisting of 58 items and 11 subscales rated on six-point scales

Krause and Seligman (2005)

Notes: DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 1994). ICD 10 = International Classification of Disease, 10th edition (World Health Organization, 1990).

Increased Insight

One of the shibboleths of classic psychoanalysis would be that insight is the primary treatment goal. In fact, Hoffer (1950) listed insight as his first criterion for deciding upon termination. Despite its level of importance, though, insight has not been discussed consistently in the literature (Connolly Gibbons, Crits-Christoph, Barber, & Schamberger, 2007). So what is it? I wish I could provide a precise and universally-acceptable definition, but if you think about it, insight has a vague and wispy, “I know it when I see it” quality that defies easy categorization. Even how it occurs is debatable. Is it an abrupt and sudden moment of clarity (Elliott et al., 1994) or something that develops more gradually over time (Jones, Parke, & Pulos, 1992)? More fundamentally, is it a process of making the unconscious conscious (Freud, 1964), connecting past experiences to present behaviors (Strachey, 1934), or even the natural consequence of processing a safe and shared (p. 22) (p. 23) relationship with the therapist (Hirsch, 1998)? Could it be all of the above? Karl Menninger (1958) described it quite broadly (and poetically) when he wrote:

For what is it that we . . . want of the patient? We want him to see himself. We want him to see that as a result of his being a human being who came into contact (long ago) with other human beings who were not perfect, and as a result of misunderstanding certain things and being misunderstood by certain people, he experienced pain and fright from which he tried to protect himself by devices which he still continues to use not from the present necessity, but from a kind of habit. We want him to see that he persists in the same unprofitable formulae of adaptation. We want him to see that he expects the wrong things from the right (p. 24) people and the right things from the wrong people. And, finally, we want him to see that he doesn’t want to see it, that he wants to get well—in a way—but is afraid to; that he wants to change, but fights against it. (pp. 135–136)

What is particularly good about his description is the fact that it recognizes the patient’s own contributions to their troubles (unconscious or not) while affirming the possibilities for real insight and change (Levy, 1990).

A useful and relatively straightforward definition of insight was proposed by the Rutgers’ group (for a review, see Messer & McWilliams, 2007). They defined insight as “the development of new understanding on the part of the patient . . . which is related to the issues he or she is presenting in therapy” (p. 21). The group proposed several specific guideposts. For example, the recognition of patterns/connections and the ability to observe one’s own internal processes are both indicative of insight. They also noted that the elimination of pathological beliefs was a positive consequence that accompanied insight gains.

The empirical research on insight was recently reviewed by Barber et al. (2013), and their synthesis provides us with a number us of clinically relevant implications. First, and as would be expected, insight/self-understanding does indeed increase over the course of psychodynamic treatment.4 Second, gains in insight are associated with symptom reduction. Interestingly, though, pretherapy levels of insight do not appear to be associated with pretreatment symptom levels, and there is mixed evidence for whether low levels of pretherapy insight predict a poorer outcome. Therefore, less insightful patients may still benefit from treatment in much the same way that a physically weaker person may benefit from weight training. In general, though, much about insight remains unknown.

Assessment

Several assessment options and rating procedures for insight/self-understanding are available, but none are yet considered to be “gold standards.” Three are listed in Table 3.1 (see also Connolly Gibbons et al., 2007).

Character/Personality Change

A goal of psychoanalysis and long-term psychodynamic therapy is the alteration of maladaptive personality patterns. This has also been described as “character change” or a large-scale modification of “psychic structure.” In classical psychoanalytic parlance, psychic structure refers to an organization of experience with a slow rate of change (i.e., it is relatively stable; Rapaport, 1967, p. 701). Therapists infer the existence of psychic structures (e.g., the superego) from a patient’s observable behaviors, especially those that seem to be repetitive and problematic (Rockland, 1989).

The form that character change takes can be highly variable. For patients suffering from personality disorders, reductions in psychopathology or, even better, a remission of the actual diagnosis would probably be the clearest evidence that this (p. 25) treatment goal has been reached (Bateman & Fonagy, 2008). Thinking in terms of overall personality organization (i.e., normal, neurotic, borderline, and psychotic; Kernberg, 1984; Yeomans et al., 2015) as opposed to more specific personality disorders, the goal might be movement toward a healthier level of organization (i.e., borderline to neurotic). Progress could also be indicated via the modification of stable characteristics associated with personality (e.g., move toward a secure attachment style; Levy et al., 2006).

Personality changes are often expected in brief dynamic therapies as well but are usually more limited. For instance, working through conflicts over separation in panic disorder (Busch, Milrod, Singer, & Aronson, 2012) or reducing narcissistic vulnerabilities in depression (Busch, Rudden, & Shapiro, 2016) are reasonable short-term treatment goals.

Fortunately for therapists, a number of good books have been written on personality traits and styles (McWilliams, 2011). These resources can inform treatment goals and are particularly helpful for beginning therapists. When using them, though, it is important not to lose sight of two of the primary strengths of psychodynamic therapy: flexibility and responsiveness to patient needs. If used correctly, psychodynamic principles help clinicians identify extremely subtle personality traits that may not fit neatly into existing categories.

In ending this section, it may be important to note that the line separating “personality traits” and “symptoms” is far from firm. For example, where does social anxiety disorder end and avoidant personality disorder begin (Eikenaes, Hummelen, Abrahamsen, Andrea, & Wilberg, 2013)? The answers to such questions await additional empirical developments.

Assessment

Many good options for assessing personality disorders are available (see Table 3.1). There is also an interview for personality structure (Kernberg, 1984), and several psychodynamic psychotherapy manuals detail the ways in which more limited forms of personality change can be assessed (Book, 1998; also see the appendix). Projective testing methods are also available (e.g., use of the Rorschach; Huprich, 2015).

Acceptance of That Which Cannot Be Changed

Another goal relates to some of the more disagreeable aspects of the human experience. Namely, we were all born into a world not of our choosing. For instance, none of us had a choice in deciding where or when we were born. It could just as easily have been 20th-century America as 4th-century Egypt. None of us also had any say in selecting the bodies we were given or the parents who bequeathed them to us. We could have been born healthy or sickly to present or absent parents. These and other seemingly arbitrary facts constitute the unshakable parts of our existence. They just are. The German philosopher Heidegger described this state of affairs as our “thrownness” (geworfenheit; Heidegger, 2010).

(p. 26) Many things in life are like this, and some do not make us happy. For instance, few people relish the thought that they will eventually die. It is similarly difficult to accept a major injury (e.g., amputation of a limb), unalterable life event (e.g., a sexual assault), or loss of a loved one (through death or a romantic break-up). Though these things might not feel good to face, they cannot be changed. Dynamic therapists believe that acknowledging and eventually accepting these things is a necessary part of a healthy human life (Gaston, 1995). This holds true for patients and therapists alike.

Clearly, such matters require both accepting and integrating these facts into oneself, as there are no real options for alteration. This has been noted in other orientations as well. Edna Foa and colleagues created a posttraumatic stress disorder analogy that I have always found helpful, but that could just as easily be applied to other losses and injuries. They noted that trauma was sort of like eating spoiled food. Until the bad meal is fully digested and incorporated, the nausea and stomachaches continue (Foa, Hembree, & Rothbaum, 2007, p. 82). In other words, there are negative consequences for avoiding reality, and acceptance may not be a pleasant process. Behavioral and psychodynamic therapies may differ in terms of when and how trauma is best addressed but would agree that traumas do indeed need to be faced and integrated (Sharpless & Barber, 2009a). So how can this goal of acceptance be reached?

Many relevant techniques will be described in Sections II and III, but it may be useful to provide a few brief comments here. First, the therapist must be willing to face unpleasant realities. Patients and therapists both have unhealthy capacities for denial (e.g., a therapist giving well-meaning, but unrealistic reassurance to a patient recently diagnosed with terminal cancer), and it will be even harder for patients to accept what their therapists cannot. Second, good timing and clinical judgment are needed to determine how and when the patient needs help in confronting that which they do not want to face (see Chapter 6). Third, hope should be furnished to the patient only if it is realistic. Finally, it is important for therapists (and patients) to identify ways that losses/weaknesses can be turned into gains/strengths. Questions such as “What can be learned from this?” or “What can the patient do to make better use of this fact?” should always be in the back of the therapist’s mind. Historically, an ability to turn weakness to one’s advantage has been associated with health.5 Even if there are no “objective” benefits to be found—a grim picture, to be sure—patients may learn that they have greater capacities for coping than they realized. This is an important lesson to learn.6

Acceptance of One’s “Shadow”

A related aspect of acceptance is facing one’s “dark side.” All of us have one. Just as humans have the potential for great love, beauty, and creativity, they have equal capacities for petty hate, ugliness, and destruction. Freud and other analysts certainly discussed these ideas (Freud, 1961b; Kernberg, 1992; May, 1983) but not quite to the extent of Carl Jung did (Jung, 1969). Though I disagree with several of Jung’s core concepts, I find his idea of the “shadow” to be clinically useful and compelling.

(p. 27) At the risk of gross oversimplification, Jung noted that we all have negative aspects of ourselves that are unconscious and not identified with, but are nonetheless real (Jung, 1969). These parts are often seen as “not me” and are usually rejected or ignored. They remain in operation, though, even if they are not accepted. Even worse, these undesirable traits are often projected onto others and, in effect, may distort reality. As Jung (1969) noted, “projections change the world into the replica of one’s own unknown face” (p. 9). For example, imagine a selfish person who does not recognize this quality in herself but always seems to find (and criticize) it in others.

Jung believed that the shadow (i.e., “shadow aspect”) could not truly be ignored but had to be faced and accepted as a real part of the self. If not, it continues to operate outside of awareness. To be clear, an honest confrontation with one’s dark side is not easy, but Jung and others believed that it was worth the effort, as a lack of integration could be detrimental to relationships and a good life in general.

“Ego Strength” and Reality-Testing

The psychodynamic phrase for a person’s capacity to acknowledge unpleasant realities without utilizing unhealthy defenses is “ego strength” (Bellak, Hurvich, & Gediman, 1973). It is one component of the broader and transtheoretical idea of “reality-testing.” Both can certainly improve through treatment and may be the initial steps toward an acceptance of unpleasant facts.

Improving a patient’s attunement to consensual reality could be an important general therapy goal (Rockland, 1989). This is especially the case when treating psychotic patients (see Chapters 14 and 15), but higher-functioning individuals may benefit as well. For instance, many patients have difficulties viewing themselves, their behaviors, or the world objectively.7 Some may ascribe to paranoid beliefs or conspiracy theories that do not coincide with consensual reality (Brotherton & French, 2017). Others hold fast to unrealistic childhood fantasies that keep them from progressing in life. However, it is important to recognize that any person can experience temporary deficits in reality testing when the unexpected occurs (i.e., a momentary regression upon hearing bad news), but some people reliably demonstrate trait-like problems (e.g., a borderline patient who continually distorts the intentions of others).

Assessment

I am not aware of any measures designed to assess acceptance of that which cannot be changed. The presence of thought disorder can be assessed via numerous of means (e.g., the Minnesota Multiphasic Personality Inventory-2; Butcher et al., 2001). The Ego Impairment Index (EII, Perry, & Viglione, 1991) of the Rorschach taps into facets of a patient’s ego strength.

General progress with psychotic individuals would be indicated through decreases in hallucinations and delusions, more sustained attention during sessions, and an ability to begin and maintain “appropriate” conversations. Regardless of the level of thought disturbance, there should also an increase in (p. 28) overall cognitive flexibility as indicated by more realistic appraisals of self, others, and real-world events.

Better Adaptation

For some problems, acceptance is not the most appropriate therapeutic goal. Instead of resignation or “overcoming,” some problems require adaptation. Adaptation is the process of getting needs met and wishes fulfilled within the limitations imposed by the outside world. It can occur through modifying oneself to better fit the environment (i.e., an autoplastic change, possibly through therapy) or altering the environment to better fit oneself (i.e., an alloplastic change; Rado, 1969).

This goal of patient-driven adaptation has been part of psychoanalytic thought for a long time. Freud’s writings are suffused with Darwinian influence, but Heinz Hartmann is probably the analytic theorist who emphasized adaptation the most (Hartmann, 1939). Hartmann, the father of ego psychology (with Anna Freud as mother), noted that we are all born with some innate capacities for adaptation but that others appeared later. When raised in what he termed an “average, expectable environment” (p. 24), people inevitably developed the tools they needed to navigate life’s many demands. The environment for many of our patients was far from ideal, though, and as a result, certain development achievements were thwarted.

Indeed, many of our patients have profound difficulties getting by in their respective worlds; others may even not want to adapt to the demands placed upon them. The therapist’s role in most cases is certainly not to be an agent of social control and decide for them (as that would be a deviation from the psychodynamic “stance” discussed in Chapter 4). Instead, it is our job to help patients understand the relevant psychodynamic factors involved and assist them in deciding whether they even want to adapt. Therapists can also help patients work through the potential ramifications of their decisions.

When thinking about adaptation, it is also important to recognize the fact that patients spend far more time in the outside world than in session. For example, if you meet with a patient for two hours every week, you are together only 1.2% of the time. It goes without saying that many important events transpire outside of the therapy hour. A great amount of detail is needed to adequately understand a patient’s actual environment.

Assessment

Assessment of adaptation is generally unstructured and based upon patient report and therapist observation. Patients may note that aspects of their life feel more “seamless” or that they are more successful in their various life roles. They may also experience subjective feelings of success as well as less anxiety and alienation. For more impaired patients, adaptive functioning could be assessed in a more structured form by using the Vineland Adaptive Behavioral Scales (Sparo, Cichetti, & Saulnier, 2016).

(p. 29) Symptom Relief

Readers trained in nonpsychodynamic approaches may be surprised that symptom relief was not yet discussed. Though Freud certainly possessed medical model leanings, “symptoms” in the contemporary sense of the term were not emphasized in traditional psychoanalysis as much as they would come to be. Some dynamic therapists remain suspicious (or even dismissive) of current diagnostic trends. This is not a completely unreasonable position to take. For instance, since the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1980) was published in 1980, the main diagnostic compendium of the United States has explicitly claimed to be “atheoretical” (p. 7). Say what you will of this dubious contention,8 but some dynamic practitioners view these symptom sets/codes as possessing little clinical relevance.

However, other theorists (Summers & Barber, 2010) argue that use of the DSM or the International Classifications of Diseases (ICD; World Health Organization, 2018) is an important and inescapable part of contemporary practice. Even though there are clear weaknesses in the current systems (e.g., lack of sharp boundaries between disorders), they provide several benefits. At the most practical level, if you want to get paid by insurance companies, it is fairly important to utilize accurate diagnostic billing codes. Similarly, if you want to practice independently in the United States, you have to know the DSM categories at least well enough to pass the professional licensure exam (Sharpless & Barber, 2009b).

Fiscal realities aside, there are at least three other important reasons to be a skilled DSM/ICD diagnostician. First, having a good sense of a patient’s symptom topography will help flesh out the particular ways in which they are suffering. This is presumably why the assessment of symptomology is a necessary part of Kernberg’s (1984) Structural Interview, a component of many case formulations (Gabbard, 2014; Summers & Barber, 2010), Axis-5 of the Operationalized Psychodynamic Diagnosis (OPD Task Force, 2008), and the S-Axis of the Psychodynamic Diagnostic Manual-2 (Lingiardi & McWilliams, 2017).

Second, the use of traditional diagnosis facilitates communication with other professionals and may help keep psychodynamic therapy as “part of the mainstream” (Barber & Sharpless, 2015). Regrettably, some theorists continue to mischaracterize dynamic therapy as unscientific or isolationist. These misperceptions can be partially combatted through using our own methods while simultaneously adhering to the broader conventions of psychology and psychiatry (i.e., using DSM or ICD; randomized control trial study designs). Given the fact that almost the entirety of the empirical psychodynamic outcome literature followed these conventions (Leichsenring et al., 2013), proper utilization of therapy manuals presupposes accurate DSM or ICD diagnoses. Relatedly, accurate diagnosis may help clinicians more easily engage in joint empirical research (e.g., through practice–research networks; Borkovec, 2002; (p. 30) Castonguay, Barkham, Lutz, & McAleavey, 2013) and help narrow the ever-widening schism between researchers and practitioners.

Finally, many of our patients think in terms of symptoms and may monitor their treatment progress accordingly. The Internet makes it incredibly easy to access formerly esoteric information (e.g., diagnostic criteria for posttraumatic stress disorder), and patients may present for treatment with their own symptom-based goals. From my perspective, this is not necessarily a bad thing, as they may be more amenable to regular symptom monitoring via questionnaires. Research on session-by-session assessment has shown numerous patient benefits (Lambert, Kahler, Harmon, Shimokawa, & Burlingame, 2011), and this typical cognitive-behavioral strategy is not antithetical to psychodynamic practice. Though some practitioners may fear that regular symptom assessment could interfere with dynamic processes or result in a corruption of the transference, it can also be viewed as an additional source of psychodynamic information. Not only are questionnaires an efficient means for assessing symptom severity without having to barrage patients with questions during every session, but they also serve as another avenue through which patient issues manifest. For example, some patients may disclose information on a self-report measure (e.g., symptom intensification, alliance problems) that they do not report during session, and this interesting pattern could be explored. Some patients use questionnaires to act out their feelings for the therapist (e.g., obstinately and angrily “withholding” material) or as a not-so-subtle form of resistance (i.e., “forgetting” to fill out the form). For some, filling out the measure could be a symptom manifestation in its own right (e.g., obsessively filling it out to such a degree that the purpose and meaning are lost). Any of these reactions serve as windows into the patient’s typical conflicts.

Assessment

Table 3.1 lists some of the more widely used “global” diagnostic instruments as well as two brief, repeatable (i.e., usable session-per-session), and psychometrically valid questionnaires. Multiple resources are available for more specific symptom assessments (Barlow, 2014; also see other therapy manuals).

Increased Sense of Meaning and Purpose

Many patients come to therapy not to remove symptoms or improve relationships but because they feel lost. Something is missing. They may not even know what it is, but they have a troubling and ineffable sense of emptiness. It could be an absence of meaning or purpose or even just a vague and restless sense that they are wasting the limited time they have in life. These feelings are troubling, and many patients try to avoid them by seeking out the many sensations and distractions that contemporary life offers. We know that this can cause problems.

A lack of meaning and purpose can color all experiences and make life feel unbearable. Alternately, these same things, if present, can be powerful buffers. A sense of meaning can allow people to find their way through even terrible (p. 31) events (Frankl, 2006). As Nietzsche (2005) noted, “if you have your ‘why?’ in life, you can get along with almost any ‘how?’ ” (p. 157).

Many of our patients lack this “why?” They may have lived their lives in such a way that they essentially ignored their needs or foreclosed on their own futures in favor of following the paths chosen for them by others. Alternately, some patients may have actually reached their goals (e.g., a successful career or a family) only to find that they remain unsatisfied. Others realize that their fears kept them so chained to comfortable safety that they missed out on important opportunities (i.e., they did not take enough chances in life). Now, they find themselves overwhelmed by anxious regrets and dread for the future.

Psychodynamic therapy has a lot to offer these patients. Although not often thought of as dealing with “existential issues,” it is important to remember that psychoanalysis and existentialism arose from similar cultural contexts (May, 1983). Further, several dynamic suborientations have focused on these concerns to a greater or lesser degree (Binswanger, 1968, 1967; Kohut, 1977; Rank, Taft, & Rank, 1945).

Many “basic skills” and techniques of dynamic therapy can be helpful to patients struggling with these all-too-human issues. There is no manual that I am aware of, but in a very real sense every patient must write their own manual with the help of their therapist. This is facilitated by giving patients enough space (and enough silence) to explore matters they normally avoid (see Chapter 9), helping them alter their life narratives, and casting a light on the many ways that they may avoid important topics (e.g., noting and analyzing defenses). Therapists can also help patients become who they want to be—within reason, of course—through better articulating their nascent wishes, hopes, and values. When combined with a good therapeutic stance, these and other expressive techniques can facilitate the creation or discovery of meaning.

Assessment

The Meaning in Life Questionnaire (Steger, Frazier, Oishi, & Kaler, 2006) can be used to assess some of these existential concerns. In general, though, when patients make progress in this area they report less feelings of being “lost,” less nihilism, less “stuckness,” and often fewer symptoms. They report a subjective sense of wholeness and authenticity that feels novel (and hopefully good). Patients with purpose and meaning feel more passionately committed to their families, friends, careers, or even important ideas. They may report more “steadiness” in life.

To be clear, these loftier goals are not incompatible with short-term treatment. For instance, in Supportive-Expressive Psychotherapy (Book, 1998), therapists and patients focus on the patient’s core conflictual relationship theme (CCRT; Luborsky, 1984). The CCRT is a repetitive interpersonal pattern consisting of a patient wish (W), the response of another (RO), and the response of the self (RS). Therapists help patients actualize their healthy, (i.e., nonregressive) Ws through understanding the RO as either a transference distortion or repetition compulsion (Book, 1998). Though not every patient will experience a profound shift in their sense of personal meaning, it is certainly a possibility.

(p. 32) Autonomy from the Therapist

Last, but certainly not least,9 one of the most important things we can do for our patients is to make ourselves obsolete. Doing good clinical work inevitably entails the loss of a relationship for both parties. This is another inevitable reality that needs to be accepted. However, if you believe in object relations theory and, specifically, the idea that external objects (e.g., other people) can be internalized to become a permanent part of one’s own character, then in a real sense you will always be with your patients and they will always be with you. There is a bit of empirical evidence that this may be case. Geller and Farber (1993) found that patients reported internalizing representations of their therapists. Some noted that they used their “internalized therapists” to continue their therapy long past termination. This is consistent with a more general psychodynamic goal to have patients develop increasingly greater capacities for self-analysis and self-reliance (Strupp & Binder, 1984; Thomä & Kächele, 1992).

Assessment

Readiness for termination is usually assessed via mutual agreement that goals have been reached. As termination can be experienced as a profound loss, it is important to take notice of patients for whom separation or dependence may be tender issues. A recrudescence of symptoms or acting out behaviors may occur after the subject of termination is broached. Any unhealthy attempts to maintain the relationship and/or deny therapeutic progress can be handled more skillfully if they are anticipated and discussed before they actually manifest.

Notes:

1. He wrote in an early work with Breuer that “much would be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health, you will be better armed against that unhappiness” (Breuer & Freud, 1955, p. 305). So, for Freud, everyday unhappiness is preferable to misery, but people may have a limited ability to move beyond that. Not all subsequent psychoanalysts have been so pessimistic.

2. For a psychodynamic therapy case in which nonromantic love (i.e., friendship) was a target of treatment, see the case of Fred described in Sharpless (2014).

3. In the United States at least, government assistance agencies often impose limits on how patients can utilize their benefits. Further, many of our intellectually disabled patients have a case worker or family member who oversees their day-to-day finances.

4. Part II details the “classic” techniques thought to increase patient insight.

5. One of Nietzsche’s (1967) more memorable quotes is, “I assess the power of a will by how much resistance, pain, torture it endures and knows how to turn to its advantage. . . .” (p. 206)”

6. As Freud noted, “it is something, at any rate, to know that one is thrown upon one’s own resources. One learns then to make a proper use of them. . . . And as for the great necessities of Fate, against which there is no help, they will learn to endure them with resignation” (1961a, p. 50).

7. In other words, some patients may need help developing an observing as opposed to an experiencing ego (i.e., the “good split” discussed in Chapter 8).

8. There are clearly a number of problems with this idea. In general, if you believe that you are being atheoretical, you are likely operating with a theory you are not aware of.

9. This list could obviously go on, as there are many more specific goals. For instance, increasing mentalization, changing maladaptive narratives, or increasing feelings of coherence in the self (Kohut, 2001) could be the main goals for certain patients.