Biomedical subjects
Publications and source records attributed to P A Dewald.
For psychodynamic thinking and understanding to feel relevant to psychiatric residents in current training programs, it must focus on the clinical problems they encounter with patients. It must be presented in everyday language and in a form applicable to their own clinical experience. Abstract theory or "deep" formulation may alienate rather than attract interest.
Multiple external life events and vicissitudes can impinge upon the traditional privacy and isolation of the usual psychotherapy situation and relationship. Among these are major illness and disability in the therapist, which will activate conscious and unconscious responses in both patient and therapist. If worked with and well handled by the participants, such events may stimulate therapeutic growth and working through of multiple issues related to illness, separation, death, anxiety, and fantasies of omnipotence and idealization. However, multiple factors in both patient and therapist may combine to foster avoidance of the conflicts that have been activated. To the extent that countertransference responses in the therapist interfere with his/her ability to bring conscious attention to these issues, a potentially valuable therapeutic opportunity may be lost. It is important for therapists to therapists to anticipate such situations, and to make use of colleague consultation to assist in managing them.
I have attempted to survey and outline the conceptual differences between expressive and supportive forms of psychotherapy based on the construct of a spectrum with these forms of treatment at each end. As one moves toward the middle of the spectrum, the situation becomes more difficult to define and, to a certain extent, elements of each may be present in the other form of treatment. However, the more that the therapist can consistently maintain an understanding of the differences between these forms of therapy, and the more consistently he or she can apply them in terms of the tactics and the technical interventions used, the more likely is it that the goals of the treatment process will be achieved. If there is too much overlap or if too much confusion exists between the different strategic approaches (and the appropriate tactics involved), the therapist may inadvertently reinforce disturbed and regressive behavior; or the therapist may inadvertently keep the patient from benefiting optimally from the kind of treatment that has been undertaken. There is no way to catalog or describe all of the different available types of intervention, but it is possible to generalize and conceptually predict what the effects are likely to be given the nature of the treatment process being undertaken. The vast majority of psychiatric patients will probably make use primarily of supportive elements in the treatment experience and only a relatively small proportion of the total population will be optimally helped by an expressive treatment undertaking. It therefore becomes necessary to use creative and consistently organized ways of being supportive and to base the choice of tactics on the psychodynamic understanding of the strategy and technique of the therapeutic process.
A demonstrable psychoanalytic process involves elaborate and sustained intrapsychic experiences and phenomena for both analysand and analyst. It also includes a complex and at times subtle interpersonal relationship in which each participant is actively sensitive and responsive to verbal and nonverbal input from the other. These interpersonal experiences stimulate further intrapsychic responses which in turn may have further interpersonal effects. Within the framework of the psychoanalytic situation, these combined intrapsychic and interpersonal responses lead first to facilitative and ultimately to definitive changes in the patient's psychological organization and function. A method for demonstrating a psychoanalytic process is described.
Recognition of the widespread incidence of overt incest in childhood has significantly increased in recent years. The described long-term effects range from severe psychopathology and behavioral disorder to mild and subtle manifestations. The interplay of the child's sexual developmental processes and intrapsychic fantasies with the overtly incestuous behaviors adds complexity to the understanding of longterm effects. In this case presentation successful analysis revealed previously repressed extensive father-daughter incest resulting in typically autoplastic neurotic symptomatology and character formation. Effects on ego development and function were traced, and an attempt was made to develop recognition of cues suggestive of past overt incest. The case suggests that many additional factors contribute to the final long-term effects of overt incest in childhood.
Many elements are involved in the process of change and cure in psychoanalysis, some of which are seen as facilitative and others as definitive. I attempted to establish and illustrate the role of the interpersonal interactions between analysand and analyst. As a result of the traditional analytic process, the patient relives at a regressive level some of the unresolved developmental conflicts and crises in the relationship with the analyst. Thus, he has an opportunity to find, through the current experience, a more satisfactory and appropriate developmental resolution of previous psychopathology.
Serious illness in the analyst has a disruptive effect on the therapeutic process. Transference and countertransference responses are highly idiosyncratic and variable, but must be dealt with effectively when the therapeutic process is resumed. Some effects are relatively brief and immediate; others become manifest only after a significant delay. This paper uses the experience of such an illness to call attention to this topic which has been relatively ignored in the psychoanalytic literature.
This presentation has somewhat artificially separated tactical from strategic resistances, and has singled out the handling of resistance from other aspects of the theory and practice of psychoanalytic technique. In the actual clinical situation, the handling of resistance is an integral and major component in over-all technique and practice. It is intertwined continuously with all the other technical elements and processes of psychoanalytic intervention. But the understanding of resistance and the systematic, continuous, and ever deepening ways by which the analyst helps the patient to deal with them is one of the crucial differences that separate psychoanalysis from all the other forms of psychiatric treatment.
The patient in psychoanalytic psychotherapy experiences a variety of psychological and emotional responses during the treatment process. These are described and conceptualized as related to the structure of the therapeutic situation, the therapeutic relationship, the mobilization of conflict, the experience of affects and drive derivatives, the phenomenon of reinforcement, and the working through of the termination phase. The distinction between "core" and "derivative" psychic functions is developed, permitting a conceptual understanding of how this form of psychotherapy can produce significant and lasting intrapsychic change. Some of the differences between psychoanalytic psychotherapy and psychoanalysis are described. The general concepts are illustrated by clinical vignettes from a case of successful psychotherapy.
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At the patient's level of reality testing and integration in the transference neurosis, the analyst serves as an effective parent who halpd the 'child' master various danger situations. This results in the patients relearning and development as the analyst provides new experiences for the regressive childhood components of the patient's personality. There is also a sequential or simultaneous cognitive element which is important in the ultimate development of mastery and is particularly useful in the process of working through. This cognitive element, however, cannot be effectively used until there have been repeated new and real experiences for the fixated and/or regressive components of the patient's personality.
Using clinical psychoanalytic theory as a unifying concept, an attempt is made to observe, interpret, and integrate the therapeutic process in a wide variety of psychotherapies. All psychotherapy, regardless of specific form or technique, is viewed as an interpersonal or intrapersonal process, and should be understandable from a psychoanalytic perspective. Ten common factors are selected: structure of the therapeutic situation; the therapeutic relationship; management of anxiety; drives and their derivatives; mechanisms of defense; identification; regression; catharsis and abbreaction; external reinforcement; structural change. The various psychotherapies are compared regarding each of the ten factors.
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