Mentalization‐based psychodynamic psychotherapy for psychosis

This article discusses and illustrates the use of mentalization‐based psychodynamic psychotherapy for disturbances of awareness of the self and others in patients with psychotic‐spectrum disorders. The literature on impairments of mental processes involved in self‐awareness and awareness of others occurring in psychotic illnesses and the relationship between childhood trauma and the emergence of psychotic symptoms is reviewed. A case illustrates how mentalization‐based treatment can facilitate treatment engagement and be used to manage enactments in the psychotherapy with a patient with a psychotic disorder. Mentalization‐based psychotherapy may offer a useful adjunct to antipsychotic medication and psychosocial evidence‐based treatments in the care of individuals in the early phase of psychotic disorders. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:1–12, 2009.     

Drug addiction from a psychodynamic perspective: Methadone maintenance treatment (MMT) as transitional phenomena

Purpose. To present a psychodynamic (specifically object‐relations) approach to the understanding of drug addiction and recovery among patients in Methadone Maintenance Treatment (MMT), and to discuss the role of psychodynamic psychotherapy among drug addicts, focusing on the processes which patients undergo during counselling. Methods. We review some psychodynamic explanations of the drug addiction phenomenon, and illustrate the psychodynamic comprehension framework of the issue according to Winnicott's theory, by describing a few psychotherapeutic interventions with our MMT patients. Results. The main premise is that treatment in a MMT program is accompanied by changes in‐patients' life‐styles and behaviour, which are parallel to transitional phenomena. As such, methadone and counselling serve as transitional objects during these processes. Conclusions. Drug addiction is a widespread phenomenon that affects many areas in the addicts' life; therefore, some eclecticism from therapists has a beneficial effect on the outcome.     

The Facilitating Function of the Setting

This paper addresses the issue of what facilitates creativity in psychoanalytic work. Although creativity may seem to imply a creatively interpreting analyst/therapist, dictionary usage of the term ‘creativity’ supports an alternative reading. The author finds a more apt standpoint in the theory of the analytic site that Donnet has extrapolated from Freud's papers on technique. From this viewpoint, creativity in psychoanalysis is the autonomous or spontaneously flowing analytic process, and the factor that facilitates it is the carefully constructed and maintained setting, or site, and the patient's transformational introjection of it. A comparable standpoint applies to creativity in psychotherapy and psychodynamic social work. Provided that the setting/site proper to that treatment modality is adequately constructed and maintained, the psychoanalytical psychotherapy site and the even more radically different psychodynamic social work site can both be comparably introjected, resulting in each case in a spontaneously flowing or autonomous therapeutic process that is analogous to the analytic process. The author discusses the uniqueness of each ‘site’, and illustrates, from a once weekly psychotherapy, the patient's gradual, created/found encounter with elements of the psychoanalytical psychotherapy site and cumulative introjection of them to a critical point of metamorphosis that ushered in an autonomous therapeutic process.     

A pilot study of psychodynamic psychotherapy for adult survivors of childhood sexual abuse

Clinical samples of child sexual abuse survivors report a variety of psychiatric symptoms and interpersonal difficulties. The treatment outcome literature for this population is often incomplete due to numerous methodological constraints. The purpose of this study was to evaluate the effectiveness of an open trial of individual short‐term, psychodynamic psychotherapy with a naturalistic sample of adult survivors of childhood sexual abuse. Sexual abuse survivors demonstrated significant improvement in symptomatic distress, level of functioning and dynamic personality variables according to self‐report measures and clinical rating scales. Abuse survivors developed positive therapeutic alliances, which remained high throughout the course of treatment, and comparable to the non‐abused clinical sample. Sexual abuse survivors' response to treatment was similar to that of non‐abused patients, with the potential for greater change in feelings about the self. These findings demonstrate that psychodynamic psychotherapy may be useful for childhood sexual abuse survivors presenting with depressive symptoms and interpersonal difficulties. Copyright © 2004 John Wiley & Sons, Ltd.     

I was being myself but being an actor too: The experience of a Black male in interracial psychotherapy

In recent years, investigators have indicated that the psychotherapy process is of considerable importance in the context of interracial psychotherapy. Despite the interest in the area, minimal research has examined how racial difference impacts the psychotherapy process. This study examines the lived experience of interracial psychodynamic psychotherapy via an in‐depth interview with an African‐American man who had been in therapy with a European American therapist. This qualitative study utilizes a hermeneutic phenomenological approach, which accepts that understanding is contingent on both sociohistorical situatedness and relational dynamics. The study participant was chosen because of his interest in the area and willingness to explore it in detail with the interviewer. A number of themes emerged, the most salient of which are the multidimensionality of the experience and the ‘absent presence’ of race in the therapy process. This client's experience was both positive and negative, and in many cases, the same process‐related variables contributed both positively and negatively to the client's therapeutic experience. Issues of trust, perceived cultural issues and therapy focus contributed to and detracted from the therapy experience. The depth of the therapy experience was limited by the therapist not explicitly addressing race.     

Utilizing psychoanalytic psychotherapy in the treatment of substance abusers

The traditional treatment of substance abuse based on the medical disease model has neglected psychological approaches to substance abuse, partly influenced by misconceptions regarding therapy. Other forms of treatment such as Cognitive‐Behavioural, Motivation Enhancement, and Transtheoretical Models have also been recently utilized. While these approaches have been effective for many individuals, they are not typically guided by a psychodynamic understanding of the individual nor do they address the interpersonal factors that influence psychotherapy. Psychoanalytic therapies do address these issues, although they have been an underutilized form of psychological treatment. The scope of this paper addresses how psychoanalytic models, that are not necessarily incompatible with other approaches may be utilized. Wurmser's Conflict Model and Khantzian's Self and Ego Deficit Model are discussed, and clinical case examples are provided to elucidate the application of psychoanalytic psychotherapy in practice. Copyright © 2002 John Wiley & Sons, Ltd.     

Mentalizing countertransference? A model for research on the elaboration of countertransference experience in psychotherapy

As a construct, the elaboration of countertransference experience (ECE) is intended to depict the implicit and explicit psychological work to which therapists submit their experiences with clients. Through ECE, defined as a mentalizing process of a particular kind, therapists' experiences are presumed to acquire and increase in mental quality and become available for meaning‐making and judicious clinical use. In this paper, we claim that such an ongoing process facilitates engagement with common therapeutic factors, such as the therapeutic alliance and countertransference management, enhancing therapist responsiveness in psychotherapy. We synthesize relevant literature on countertransference, mentalization, and, in particular, therapists' mentalization, informed by a systematic literature review. As a result, we propose a model for assessing ECE in psychotherapy, comprising 6 diversely mentalized countertransference positions (factual‐concrete, abstract‐rational, projective‐impulsive, argumentative, contemplative‐mindful, and mentalizing), 2 underlying primary dimensions (experiencing, reflective elaboration), and 5 complementary dimensions of elaboration. Strengths and limitations of the model are discussed.     

Object relations assessment predicts outpatients' attrition,early working alliance and psychotherapy process

This study investigated the predictive utility of assessing clients' object relations functioning to prognosticate therapy dropout, quality of the early working alliance and psychotherapy process events reported by clients after their first five sessions. Clients accepting a recruitment invitation were administered the thematic apperception test (TAT) shortly after intake, and those still in treatment three to four sessions later rated the working alliance and psychotherapy process events. Participants were 47 clients beginning psychotherapy with advanced doctoral practicum students at a university-based community-serving training clinic. The Social Cognition and Object Relations Scales (SCORS), an object relations scoring system for TAT stories, was used to assess object relations functioning. The California Psychotherapy Alliance Scales—Patient form measured four dimensions of the alliance. The Therapy Orientation Process Scales, created from the Psychotherapy Process Q-set, measured clients' perceptions of therapy process events as involving relatively more psychodynamic or cognitive behavioural techniques. The SCORS significantly predicted remaining in therapy, client ratings of stronger working alliance and typical therapy process as more psychodynamic than cognitive behavioural. SCORS complexity of representations and capacity for emotional investment in relationships scales were the strongest predictors, especially of the patient commitment facet of the alliance. The findings suggest that (1) beginning psychotherapy with object relations assessment can be useful for treatment planning and (2) the relationship between clients' object relations functioning, working alliance and greater sensitivity to psychodynamic than to cognitive behavioural interventions depends on the aspect of object relations that is being assessed.     

Initial Improvement in Adult Psychodynamic Psychotherapy

This study aimed to determine predictors of initial improvement regarding quality of life, symptoms, and defensive style of adult patients in psychodynamic psychotherapy. This is a naturalistic quantitative study conducted at a mental health outpatient clinic. Patients were assessed before starting psychotherapy and in the 6th month of treatment using the same instruments. Patients who were still in treatment at the 6th month of psychotherapy reported, in general, better quality of life, less symptoms, reduced severity of symptoms, and changes in some aspects of their defensive style. Those patients who sought treatment because of anxiety problems were associated with higher risk of no initial improvement. Clinicians and researchers find it difficult to predict the outcome of patients starting psychodynamic psychotherapy; other clinical settings should be investigated to enable the understanding of this complex phenomenon. Although psychodynamic psychotherapy is a long‐term treatment, patients show evidence of improvement from the beginning of the treatment. Follow‐up studies of these patients are needed to monitor the process of improvement after this initial period.     

Treating anxiety disorders by emotion‐focused psychodynamic psychotherapy (EFPP)—An integrative,transdiagnostic approach

Anxiety disorders are characterized by high levels of anxiety and avoidance of anxiety‐inducing situations and of negative emotions such as anger. Emotion‐focused therapy (EFT) and psychodynamic psychotherapy (PP) have underscored the therapeutic significance of processing and transforming repressed or disowned conflicted or painful emotions. Although PP provides sophisticated means of processing intrapsychic and interpersonal conflict, EFT has empirically tested a set of techniques to access, deepen, symbolize, and transform emotions consistent with current conceptualizations of emotions and memory. Based on our clinical experience, we propose that an integrative emotion‐focused and psychodynamic approach opens new avenues for treating anxiety disorders effectively, and we present a transdiagnostic manual for emotion‐focused psychodynamic psychotherapy. The therapeutic approach takes into account both the activation, processing, and modification of emotion and the underlying intrapsychic and interpersonal conflicts. The short‐term treatment is based on the three phases of initiating treatment, therapeutic work with anxiety, and termination. Emotional poignancy (or liveliness) is an important marker for emotional processing throughout treatment. Instead of exposure to avoided situations, we endorse enacting the internal process of generating anxiety in the session providing a sense of agency and access to warded‐off emotions. Interpretation serves to tie together emotional experience and insight into the patterns and the nature of underlying intrapersonal and interpersonal conflict. Treatment modules are illustrated by brief vignettes from pilot treatments.     

Examining the relationship between object relations and interpersonal distress in a clinical sample

The goal of the present study was to explore the relationship between patients' object relational functioning (Social Cognition and Object Relations Scale‐Global Ratings) as rated by clinicians during the course of outpatient psychodynamic psychotherapy in a university‐based clinic and patient self‐reported interpersonal vulnerabilities (Inventory of Interpersonal Problems‐64). Participants (n = 112) were outpatients entering treatment at a university‐based psychotherapy clinic and were diagnosed primarily with mood disorders as well as Axis II relational problems and features. Participants completed the IIP‐64 prior to receiving therapy, and SCORS‐G ratings were based on patients' level of relational functioning during the evaluation process (i.e., the semistructured interview, follow‐up and feedback) and across the first two psychotherapy sessions. Results showed a significant relationship between the IIP‐64 Total score with SCORS‐GSelf‐Esteem (r = ?.21, p < .05) and Affective Quality of Representations (r = ?.20, p < .05), wherein self‐reported interpersonal dysfunction was greater among patients who had lower self‐worth and perceived others as more malevolent. These findings suggest that patients who rated themselves as having more significant interpersonal difficulty reported more negative expectations and experiences of relationships in their psychotherapy narratives. The utility of the SCORS‐G and the IIP‐64 as two different avenues of assessing patient relational functioning is explored.     

Planned brief psychotherapy in clinical practice

A workshop was set up at the Tavistock Clinic to study the application in other clinical settings of techniques of brief psychotherapy developed there. Five people from mixed professional backgrounds met for three years and treated patients, unselected for brief therapy, utilizing these techniques. Of the 15 patients who embarked on treatment, 13 completed it, and 12 of these were followed up for periods ranging from three months to two and a half years. Forms were developed by the workshop to chart the clinical progress of therapy, and to evaluate data on the patient, the psychodynamic focus and treatment process. These data were compared with outcome, rated behaviourally and psychodynamically. At non-significant levels, results indicated that outcome was better for those patients who experienced high levels of distress subjectively but who functioned well externally, those who had a supportive relationship outside therapy and those for whom a psychodynamic focus could be formulated and worked with. Unrelated to outcome were: the extent of early deprivation, severity of damage to object-relations capacities, time of onset and all of the practical aspects of therapy. Clinical illustrations are given and three exceptions to the trend of results are discussed. In general, the findings corroborate Malan's (1976) work. The claim is made that these results justify further exploration of the technique's applicability in NHS out-patient psychotherapy clinics.     

Psychodynamic Psychotherapy for Persons in States of Psychosis: Some Research Perspectives

This paper describes some basic problems and assumptions in supportive psychodynamic psychotherapy with persons in states of psychosis. It starts out by addressing changes in the views of science – from the case study method to the evidence‐based medicine paradigm – and continues with a discussion of the necessity for psychotherapy integration and conceptual clarification in delineating psychodynamic psychotherapy in the field of psychosis. Over a period of decades a small number of comparative studies have been conducted in which psychodynamic psychotherapy of patients with schizophrenia has been compared with treatment as usual. The latest of these, a Danish prospective multicentre study, is described. Some basic arguments for calling this study ‘psychodynamic’ and ‘supportive’ are outlined, and a few overall aims are described, including the desired abilities of the therapists in this particular field. Even though the use of randomized controlled trials, scientifically, is a difficult paradigm for psychodynamic psychotherapy, studies like the Danish one support the use of psychodynamic treatment in the National Health Service.     

Focusing on Reflections: Mentalization and Mirroring in Brief Dynamic Therapy

The author begins by noting the growing recognition of the contribution that addressing a client's capacity to mentalize can make to therapeutic effectiveness in short‐term psychodynamic work. He outlines the developmental origins of the capacity for reflective function or mentalization in the earliest experiences of infancy and how the primary carer's changing levels of contingency to the infant's feeling states promotes the infant's development of a sense of his or her own mind as well as a sense of the minds of others as sources of the motivation of behaviour. The author compares and contrasts the concept of mentalization with that of mirroring and how the latter contributes to the realization of the self. The contribution that a focus which captures the aesthetic of a client's idiom can make to the experience of being mirrored and contained by the therapist is highlighted. The author also identifies ways in which working with the components of a focus, as it is tracked through a client's narrative, can enhance a client's capacity to mentalize. These themes are illustrated by a case example which involves complex loss and trauma resulting in unmet adult attachment needs and a diminished capacity to mentalize.     

An interview study of people with learning disabilities' experience of,and satisfaction with,group analytic therapy

A number of clinicians have developed psychodynamic treatments for people with learning disabilities, but there have been few studies assessing the impact of psychodynamic therapy with this population. In particular, there have been no studies in which investigators have asked clients about their experience of psychodynamic treatment. The current study is an attempt to rectify this by exploring people with learning disabilities' experiences of, and satisfaction with, two psychodynamic groups provided by an inner city service. Nine learning‐disabled clients, four from a sexual offenders' group and five from a women's group, were interviewed about their experience of psychodynamic group psychotherapy. Their responses were analysed using Interpretive Phenomenological Analysis. Participants suggested that they valued the therapists and the group, and appreciated the opportunity to talk about painful experiences and be included and valued in the group. However, participants also indicated that they found the group emotionally painful, on occasion found it hard to identify with other group members, and were often unaware of any positive change in themselves. These interview findings complement ongoing quantitative attempts to establish the impact of psychodynamic treatment for this population.     

Collaboration in Psychodynamic Psychotherapy

The concept of the collaborative relationship between patient and therapist has its roots in the psychodynamic literature. We trace the concept of collaboration in psychodynamic psychotherapy from classical psychoanalysis to contemporary psychoanalysis and psychodynamic therapies. The active collaboration between the participants central to Bordin's pan‐theoretical perspective on the alliance is highlighted. Developments in alliance‐fostering techniques and in relational therapy offer the clinician innovative ways to enhance the collaboration and to repair strained or ruptured collaboration. A case study illustrates how the collaborative work in psychodynamic therapy serves as both a means of productive work and as an arena for exploring the evolving here‐and‐now matrix of the relationship.