Psychotherapy: A Dynamic Approach(S2640)

by Paul A. Dewald, M.D. | Health, Mind & Body |
ISBN: Global Overview for this book
Registered by SAMMY-SAMSEL of St. Louis, Missouri USA on 4/8/2006
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Journal Entry 1 by SAMMY-SAMSEL from St. Louis, Missouri USA on Saturday, April 8, 2006
Pre-numbered label used for registration.

322pp including index
published, 1971
copyright, 1964

Paul A. Dewald, M.D.
Training and Supervising Analyst (Geographic),
Chicago Institute for Psychoanalysis

Clinical Professor of Psychiatry,
St. Louis University School of Medicine

Director of Treatment Service,
Psychoanalytic Foundation of St. Louis

Consultant, St. Louis State Hospital

I. The Mental Apparatus
II. Psychic Conflict and the Dynamic Steady State
III. Psychic Determinism and the Continuity of Mental Life

IV. Symptom Formation
V. Reality and the Choice of Neurosis
VI. Classification

VII. The Strategy of the Therapeutic Process
VIII. Indications for Psychotherapy and Evaluation of the Patient
IX. The Beginning of Therapy: The Therapeutic Contract
X. The Therapeutic Process: The Patient’s Role
XI. The Therapeutic Process: The Therapist’s Role
XII. Transference
XIII. The Therapeutic Process: Resistance, Regression and Conflict
XIV. The Therapeutic Process: Insight and Working Through
XV. Counter-Transference
XVI. The Therapeutic Process: The Use of Drugs
XVII. The Therapeutic Process: Termination
XVIII. Psychoanalysis and Insight-Directed Psychotherapy
XIX. Implications for Community Psychiatry
XX. Evaluation of Therapy

In the years since the first edition of this volume was published, psychoanalysis has come under increasing attack from a large number of sources, both inside and outside the field of psychiatry. Most of this criticism and depreciation is directed toward psychoanalysis as a specific treatment-method, and involves such things as the occurrence of therapeutic limitations, issues of statistical cure rates, and its lack of applicability as a general therapeutic instrument for the treatment of the majority of psychiatrically ill patients.

In the area of the general understanding of human behaviour, and in the further development of psychoanalytic theory, there have likewise been continuing pressures for modification and change. Generally speaking these criticisms have been more temperate, and focused at the substance of elaborations or modifications of basic theory, and of continuing attempts to derive methods for verification or validation of psychoanalytic observations and postulates. Many of these criticisms and suggested modifications arise from scientific work using both the psychoanalytic method and experimental or observational approaches other than psychoanalysis per se. These issues generally represent the applications of the scientific method and a progressive evolution of concepts which occur as part of any scientific discipline that seeks to advance human knowledge and understanding.

However, most of the basic concepts with which this book deals (such as the existence of unconscious motivational forces within the mind, the dynamic steady state, homeostasis and psychic equilibrium, the structural model of mental functioning, concepts of transference and counter-transference, the genetic and dynamic approaches to understanding of human behaviour, the interrelationships between the individual’s intra-psychic experience and his external environment, etc.) remain as cornerstones of present-day psychiatric understanding. Although the vocabulary and semantics may differ somewhat, such conceptualizations from psychoanalytic experience and understanding are deeply imbedded in the current stream of thinking in modern psychiatry. Whether the focus of therapeutic interest and intent is the individual, the family, or the community, the basic data and conceptual extrapolations remain meaningful and pertinent to the understanding of behaviour, whether seen individually or in the setting of larger groups. Indeed, psychoanalytic observations and theory aid in understanding the group process itself.

With the changing patterns in the delivery of health care and in the expectations of the population at large, and with successful efforts at community education in regard to mental health and mental illness, ever larger numbers of individuals are presenting themselves for psychiatric evaluation and treatment. Psychiatry is being asked to contribute its understand, as well as its therapeutic efforts, into much broader and more inclusive areas of human behaviour and interaction than ever before. The pressures of therapeutic need are increasing, and there is likewise an increased interest in developing methods of preventive psychiatry. The growing emphasis on psychiatric services for the poor, the shift of psychiatric interest away from the traditional middle- or upper-class patient, and the extension of psychiatric services into the community are illustrated by the rapid development of the community mental health movement in the United States. There are pressing needs to develop new therapeutic methods applicable to a variety of different social classes and types of patients, and applicable in a more effective and generally economical fashion than have been available heretofore.

However, such pressures for service, and the increasing awareness of the impact of social and cultural forces on the individual, do not in any way negate the existence or importance of internal intra-psychic factors, and the complexity of interrelationship between the individual and his environment. The needs for the development of new approaches to therapy should not lead us to discard or minimize the knowledge or lessons painstakingly acquired and learned through years of clinical observation and research. The needs for the development of brief forms of therapy do not offset or wipe out the technical and theoretical advances achieved from the long-term and intensive study of patients. Instead, these latter experiences and the conceptualizations derived from them can provide the theoretical principles from which more practical and immediate therapeutic experimentation and development can occur. Random, non-conceptualized, impulsive, or anti-theoretical attempts at therapy, no matter how well intentioned, may prove uneconomical in the long run.

Psychoanalysis as a generalized theory of behaviour can shed conceptual light and understanding upon the multiple varieties of human behaviour and interrelationships, including all forms of therapeutic interchange, whether conducted with individual patients or with larger groups of people. Its lessons and its understanding should not be overlooked in the search for new therapeutic modalities, even though extensive modifications of technique may occur as therapeutic applications are broadened. The rationale and effects of such treatment modalities as Behaviour Therapy, Learning Theory, Conditioning, Reciprocal Innervation, etc., can be effectively understood within the framework of general psychoanalytic theory. Psychoanalytic theory can offer significant insights for the further development of effective therapeutic techniques applicable to larger numbers and types of patients.

It is for these reasons that the decision was made to publish a second edition of this book. This book remains the only systematic and definitive attempt to apply the insights of psychoanalytic theory to supportive, active, or non-analytic psychotherapies. It is an attempt to develop a rational, consistent, and communicable theory of supportive treatment, and to delineate and compare such forms of therapy from more traditionally insight-directed analytic approaches to the treatment of mental disability. Supportive treatment as developed here includes treatments of long or brief duration, treatments aimed at suppression of symptoms or modification of behaviour, and treatments applicable to the total social class spectrum. It is the thesis of this book that if the basic understanding of human motivation and behaviour supplied by psychoanalysis are systematically applied to non-analytic therapeutic methods, a theoretical structure for such methods can be developed and they can be carried out with increased effectiveness.

Proficiency in psychotherapy is a clinical skill which is acquired only gradually, and in large measure is the result of continuing and varied experience in the therapeutic setting with patients. As with any clinical skill, the more intensive and varied is the young therapist’s experience, the greater are the opportunities for learning and for improving himself in his therapeutic capacity. The technique of psychotherapy cannot be taught or learned in purely didactic fashion. However, in the process of obtaining the clinical experience necessary to develop these skills, the young therapist is faced with difficulties and problems which may interfere with his learning progress, or may impair his ability to make constructive use of his contacts with patients. Most people starting in this field have only a vague or incomplete theoretical orientation, and generally a minimum of clinical experience as a background. In spite of careful or frequent supervision, the young therapist is on his own in most of his contacts with patients.

Although the use of a clinical trial-and-error method can provide valuable learning experiences, this is not the most efficient or economical way of developing a skill. Different from other clinical specialties, psychotherapy is for the most part a private process between patient and therapist, and the introduction of a third person as an observer (either the trainee observing the supervisor, or the supervisor observing the trainee), drastically changes the total therapeutic situation. The use of closed circuit TV, one-way mirrors and tape recordings has helped in the teaching and learning of this technique, but there are still many limitations.

During his training and early experience, the young psychiatrist is usually reading or hearing from people who are much his senior in experience about problems or techniques with which he has had little personal contact. Not infrequently, he becomes discouraged that in his own work with patients he cannot demonstrate or find the same things mentioned by others, or at times he may take things out of context and attempt to apply them somewhat inappropriately to his own case material and experience.

Furthermore, the structure of most training programmes results in the relatively inexperienced therapist often being assigned patients who represent the most advanced degrees of psychopathology and who therefore often have the poorest therapeutic prognosis, and create some of the most difficult therapeutic problems. This is frequently accompanied with the recommendation, ‘Just give this patient supportive treatment’, but little attention is paid in an organized way as to what constitutes support and how this is to be accomplished. This is also at times accompanied by a directly or indirectly expressed depreciation of supportive treatment. Pushed by his own therapeutic ambition, and comparing himself with somewhat more advanced colleagues, the young therapist may at times be bewildered, unclear and unsure of himself in the therapeutic situation.

In the face of these problems and stresses on the developing therapist, a number of responses are common. Some people lose interest in therapy, and instead turn to research. While this may offer hope for the future, it does not meet the therapeutic needs and challenges of today. Others come to rely exclusively on drug chemistry or somatic therapies. Some develop a ‘defeatist attitude’ which borders on therapeutic nihilism, with the feeling that it doesn’t make any difference what is done in psychotherapy, since the patient will either get well or not get well regardless. Still others respond to the patient on the basis of intuition or common sense, and in a trial-and-error fashion, and gradually evolve a technique based partly on their own personal experiences and partly on those of their supervisors. Their concepts of treatment are often vague or unstructured, and in essence they must acquire in their own individual learning much of the cumulative knowledge obtained in other settings by other people.

Other therapists deal with their uncertainties by asking a variety of highly specific questions, such as: ‘What does the therapist do when the patient says thus’, or, ‘How do you handle this situation?’ This leads to a type of ‘cook-book’ psychotherapy, in which the young therapist is essentially looking for a recipe which he can apply in specific quantities and at specified times in hopes thereby of bringing some order to his thinking and treatment. The problem here is that such questions are not readily ansered by simple responses since they vary in accordance with a number of factors in the specific situation, and an answer which does not take account of these factors can only be partially helpful at best. If the therapist attempts to apply in a rote or memorized fashion specific interactions or interventions without a general understanding of why they are being made, he becomes more of a mechanical technician, and much of the skill and effectiveness of psychotherapy is lost.

The inexperienced psychotherapist is in need of a theoretical frame of reference and orientation to the problems and technique of psychotherapy. This can provide him with a background on which to make observations in his own clinical experience, and against which to weigh and judge the particular therapeutic interventions or interactions that he makes. Such a background can also provide a number of unifying concepts, whereby he can begin to appreciate some of the similarities and differences in therapeutic technique as applied to various patients and settings.

It is in this connection that a book such as this on the “theory and technique of psychotherapy” can serve a useful function. And psychoanalysis can serve effectively as a theoretical and unifying framework within which the various clinical observations can be organized and conceptualized.

Psychoanalysis as a specific method of therapy is an extremely intense, long-term and difficult type of treatment. In proportion to the total number of people with emotional and mental disturbances and disorders, only a relatively small number have thus far been treated in formal psychoanalysis. As a specific method of treatment, psychoanalysis cannot fulfill the therapeutic needs of the majority of psychiatric patients. The investment of time, effort and money are too great, and the number of qualified psychoanalysts (and the rate at which new ones are trained) is too small for this method of treatment to be applied on a mass scale. Furthermore, for a variety of reasons to be considered later, formal psychoanalysis would not be the treatment of choice for the majority of psychiatric patients, even if an analyst and the necessary time and money were available. Although many of the patients who have successfully completed a full psychoanalysis consider the required investments to have been worth while, it remains a form of treatment applicable to a relatively small number of patients.

Psychoanalysis, however, is also a general theory of behaviour, apart from its specific therapeutic application. Based on the intensive and ‘microscopic’ study of relatively normal as well as pathological phenomena, psychoanalytic theory offers a comprehensive conceptualization of the functioning of the human mind in states of health and of psychopathology. It provides an internally consistent theory of total behaviour based on clinical observation and the conceptualization derived from it. One of the areas of human interaction which can be conveniently and systematically understood within the psychoanalytic theoretical framework is the process and technique of other forms of psychotherapy.

This book is an attempt to apply the unifying concepts of psychoanalysis to the broad spectrum of interactions of the psychotherapeutic process. The main focus is on individual psychotherapy, although some of the concepts elaborated will have applicability to other variations of treatment such as group therapy, family treatment, or the milieu therapy of a hospital setting.

The book is based on material presented by the author in a seminar form to groups of psychiatric residents and fellows at the University of Rochester Medical Center, at Washington University School of Medicine, and at St. Louis University School of Medicine.

Section I of the book may be considered as a presentation of the general problem of psychodynamics. It is a highly condensed summary of some of the aspects of general psychoanalytic theory which have a particular pertinence to the theory and technique of psychotherapy. Section II is likewise a condensation of the psychoanalytic theory of psychopathology, as formulated within the more general theory of human behaviour. Neither of these sections should be construed as a complete exposition of their respective areas, but rather they should be considered as a summarized general background and basis for the theory and technique of psychotherapy which is developed in Section III.

Since the book is primarily addressed to the relatively inexperienced psychiatrist in training, there has been a deliberate omission of the more highly theoretical, abstract and controversial aspects of basic theory. The greater the reader’s familiarity with the basic concepts of psychoanalytic theory, the more useful will be the condensations presented here. The suggested references at the end of each chapter are designed to help the reader expand his understanding of the basic general theoretical framework. However, in none of the chapters has there been an attempt systematically to survey the literature, or to present a complete bibliography on the particular subject.

In Section III on psychotherapy, the material is deliberately presented in the form of a somewhat artificial dichotomy of supportive versus insight-directed psychotherapy. This is being done for pedagogic reasons, with full recognition that in the usual clinical situation such sharp dichotomies do not always exist or persist. However, the emphasis is on providing the relatively inexperienced therapist with a framework of orientation in which the similarities and differences of therapeutic approaches can become more readily apparent. Once the general framework and structure of psychotherapy have been grasped and understood, the therapist can avoid random or contradictory responses or interventions and instead he can integrate his behaviour in keeping with an internally consistent overall theory of therapeutic technique.

Supportive and brief forms of psychotherapy offer a considerable challenge to the skill of the therapist. The patient population is frequently severely and seriously disabled, time is often a pressing factor and decisions must frequently be made on the basis of incomplete evidence, data or understanding. However, if the therapist has a clear understanding of the basic principles of psychopathology and behaviour, as well as the theory of therapy, he can begin to develop rational and consistent therapeutic techniques which will permit the broadest possible application to the various clinical problems that he faces.

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