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Supportive and directive interventions in psychodynamic therapy

Supportive techniques are used both explicitly and implicitly in psychodynamic treatment. They include offering explicit support and affirmation, offering reassurances concerning, for example, irrational anxieties about the therapeutic arrangements, expressing concern and sympathy to a patient who has suffered a recent loss, and general empathy for the patient's anxieties and struggles with the treatment.

From a psychodynamic point of view, such supportive interventions are by no means straightforward. For example, Feldman (62) illustrated how patients may experience the therapist's submission to a demand for reassurance as a source of anxiety rather than comfort. They may be unconsciously aware that the therapist's true stance is not compatible with reassurance and therefore face anxieties about the therapist's weakness in allowing themselves to be manipulated. By contrast, Kohut's(!2) emphasis on interpersonal empathy was probably a welcome antidote to the somewhat rigid interpretive stance of American ego psychologists, particularly for those whose history of psychosocial deprivation meant that they had experienced little by way of genuine warmth or concern in the past.

The most common use of supportive and directive techniques in psychodynamic psychotherapy are in the service of the therapy itself. Elaborative techniques (e.g. the simple question: 'Could you tell me more?') are undoubtedly directive in specifying a topic of interest, but at the same time may be crucial antecedants to interpretive work. Clarification stands in between supportive and interpretive interventions. It is a restatement in the therapist's words of the patient's communication. It may also be crucial in offering a verbal (symbolic) label for a confused set of internal experiences which the patient is poorly equipped to coherently represent. Confrontation is also in between a directive and an interpretive approach. At its gentlest, confrontation may involve the therapist simply identifying an inconsistency in the patient's communication and bringing this to the patient's attention. For example, 'You seem to express no sadness about this loss, yet in the past you claimed to have cared a great deal for him'.

Regression

An important facet of psychoanalysis and long-term psychodynamic therapy is the activation and exploration of parts of the patient's personality which may be normally hidden behind an over-riding demand to adapt to the demands of everyday life. Access to these aspects of personality is achieved through the process of regression. It has been suggested that rather than encouraging regression, the process is best conceived of as inhibiting 'an anti-regressive function' in much the same way that certain intimate interpersonal experiences, large group situations, and alcohol appear to bring out the more infantile aspects of our character. (63) Some psychoanalysts consider regression to be crucial to successful psychoanalytic treatment. (64) The extent to which a particular treatment involves significant regression appears to be a function of the patient's personality as well as the therapist's particular approach. Fear of regression is an important source of resistance to long-term psychotherapy, particularly amongst those with previous experience of psychotic episodes. (63)

Resistance

Resistance is inevitably encountered in any long-term psychodynamic treatment. In fact, the presence of resistance is implied by the term 'dynamic', which suggests psychic forces both pulling against and pushing towards change. Like regression, resistance fluctuates in the middle stage of treatment. In borderline and narcissistic disorders, the patient's intense resistance signals the patient's desperation to protect extremely fragile self-esteem. In less severe cases, what appears to be at issue is preventing a painful integration of experience, such as the integration of love and hate directed towards the same object. (38)

In clinical practice resistance takes a variety of forms. In repression resistance, the patient may experience a temporary difficulty in gaining access to particular ideas and feelings; for example, failing to remember dreams. In transference resistance the patient may appear to wish to keep their relationship with their therapist at an extremely superficial level. In a negative therapeutic reaction the increase of symptomatology occurs alongside therapeutic progress. In Freud's formulation this may be attributed to unconscious guilt. It is quite likely that in at least some patients this form of resistance against psychotherapy is part of a pervasive envious predisposition to eradicate any aspect of their life that they experience as 'good' but beyond their immediate control. (65)

The experience of transference

Patients may experience a whole range of feelings about an analyst including love, admiration, excitement or anger, disappointment, and suspicion. The feelings appear to have little to do with the therapist's actual personality as different patients are likely to bring quite disparate feelings about the same analyst at the same time. While clearly not realistic, the actual nature of the transference experience is quite controversial. Object-relations theorists consider the analyst a vehicle onto which an internal object (a person, an aspect of a person, the self, or an aspect of the self) is projected. (66) Clearly, internal objects are representations which are heavily distorted by both fantasy and defensive processes.

For John Bowlby(6) such feelings are based on expectations gathered through past relationship experience with an attachment figure. They resist understanding of the past relationship by insisting on repeating it. Many analysts do not accept such an isomorphism between past and present. Rather, they see it as something which gives coherence to the patient's experience of the analytic relationship—an aspect of narrative rather than a representation of the historical realities of the patient's experience/67» In contrast, analysts who work in the Klein-Bion frame of reference see transference as providing an inevitably accurate picture of the patient's current internal world/7) For example, a transference where the analyst is idealized may reflect psychotic anxieties in the patient linked to an intensification of the death instinct. The idealization serves to protect both the patient and the analyst from fantasized destruction which threatens to engulf them both. Marcia Cavell (68) demonstrated that these alternative models of transference have their philosophical roots in the debate between correspondence and coherence models of truth.

There is significant debate regarding from what point and how much psychoanalytic therapists should work 'in the transference'. Some analysts are inclined to see transference as pertinent to every aspect of the psychoanalytic situation. For example, Joseph (7) considers the therapeutic situation in toto as mirroring the internal state of the patient. Thus, the therapeutic alliance or the 'real relationship' (43) are regarded as subsumed under the transference relationship. In this context it makes little sense to interpret anything other than the transference from the very beginning of the analysis. By contrast, Strachey (69) understood transference as an attempted externalization of the patient's superego. Unlike other people in the patient's life, the analyst does not accept this externalization, whether it is idealized, denigratory, or judgemental. The analyst conveys his or her understanding of the externalization by a so-called 'mutative interpretation'. While Strachey implied that only interpretation of the transference is therapeutic, his view clearly admits other aspects of the therapeutic relationship. Other therapists, particularly Freudian psychoanalysts, regard transference interpretations as an important but not uniquely therapeutic way of providing the patient with insight. (79

The nature of the transference appears to systematically relate to specific clinical groups and hence may have an aetiological significance. For example, specific transference patterns appear to characterize particular groups of narcissistic patients. (12) The 'mirroring' transference is one where patients crave for the approbation and admiration of the therapist which may be a consequence of the failure of the original self-objects (parents) in their mirroring function. If this transference is undermined by premature interpretations, an opportunity for restoring self-esteem is lost. The 'idealizing' transference also enables the patient to address a deficiency in self-esteem by secretly identifying with the object of admiration (the analyst). If the analyst destroys this idealized image, within Kohut's framework, this is equivalent to a direct attack on the patient's self regard. Other analysts would suspect that behind such an exaggeratedly positive image lies the patient's true image of the analyst as frustrating or inadequate, an image which is simply placed out of harm's way by the idealization.

Commonly, transference includes an erotic component, regardless of the age or even the gender of the analyst. Admitting to such feelings may border on the unacceptable for some patients. Attachment theorists may suggest that sexual fantasies are used in the service of obtaining the attention of an unresponsive attachment figure.*71 Eroticized transference, relatively common in severely traumatized patients, represents an expression of a need for sexual gratification which, in the context of the therapy, is not considered by the patient as unrealistic. (39> Some view this phenomenon as an indication of an immature mode of representing internal reality, (72» where only the physically observable outcome is believed to be real.

Experience of countertransference

Countertransference is a somewhat controversial concept in psychoanalytic clinical work. During the course of an intensive long-term treatment the therapist is likely to have a range of feelings which are related to the patient's current experience but which may serve to either illuminate or obscure this. Some countertransference experiences may be instances of projective identification and thus can be appropriately attributed to the patient, whereas others are likely to be the analyst's neurotic emotional reactions to the patient's behaviour or the material he or she brings. For Freud, (73> countertransference was always of this latter type, a neurotic reaction which was likely to obstruct psychoanalytic treatment. It was not until Paula Heimann(74) pointed out that the analyst's feelings and thoughts could contain important clues about the patient's unconscious mental state that countertransference started to be seriously considered as part of the analyst's therapeutic armamentarium. Those following an interpersonalist tradition saw the recognition of the complementarity of the therapeutic relationship as highly appropriate. From this point of view, the assumption of perfect neutrality on the part of the analyst who is a participant as well as an observer is both an anathema and an anachronism. (Z5> The psychotherapeutic process is more accurately viewed as a complex mixture of complementary interpersonal processes which establish themselves in 'custom-designed' configurations in each treatment. k0)

The therapist's feelings may be either complementary to or concordant with those of the patient. (76> Concordant countertransferences are the product of primitive empathic processes within the therapist who 'feels' for the patient, who may unconsciously react to experiences implied but not yet verbalized by the patient; for example, inexplicable overwhelming sadness. Complementary countertransferences tend to occur when the patient treats the analyst in a manner consistent with interpersonal interactions within a past relationship. Most commonly this occurs when the patient treats the therapist as he or she experienced being treated as a child. This is known as 'reverse transference'. (7í»

The mechanisms of countertransference are poorly understood. To assert that countertransference functions via projective identification merely brings one poorly understood phenomenon to account for a second even less well understood one. Sandler (78> suggested that an instantaneous process of automatic mirroring of one's partner in an act of communication accounted for concordant countertransference. The process, which he termed primary identification, was non-conscious and could be brought into awareness only upon reflection. The literature on the observation of infants and their mothers offers some evidence in support of such a process. (79) An alternative account is offered by Fonagy and Fonagy. These authors suggest that a secondary mode of encoding is available within language whereby the use of a language of pretend gestures at the phonemic, syntactic, or even semantic level enables the communicator to directly address the unconscious of the recipient of the communication. In other words, anything that can be said in gestures may be communicated unconsciously through language, through phonemic distortion, intonation, and other paralinguistic features.

When either concordant or complementary countertransferences mobilize defensive processes within the analyst, countertransference is in danger of becoming disruptive to therapeutic understanding. The analyst may react by unconsciously withdrawing from the therapeutic relationship. For example, in the case of a concordant countertransference where the patient's feelings of inadequacy create a similar feeling in the analyst, the analyst's vulnerability in this area may lead him or her to become defensively angry or excessively motivated to demonstrate his or her efficacy. There may be no simple way of regulating such reactions and the only reasonable strategy might be to carefully monitor one's style of relating, noting anything that is unusual. A number of analysts have pointed to the importance of reflectiveness in this context.

Some feelings in relation to the patient are not provoked either by the patient's projections or the neurotic feelings these give rise to in the therapist. It required someone of the stature of Donald Winnicott(81 to make the self-evident observation that the provocative behaviour of certain patients (particularly those in the borderline spectrum) can lead to a normal reaction of 'objective hate'. These reactions are merely indications of the therapist's humanity. Analytic understanding of these sometimes intense reactions to patients helps, but models of countertransference fit such experiences poorly.

Interpretation

Interpretive interventions are at the core of psychoanalytic and psychodynamic treatment. Its importance, however, is often exaggerated in relation to other aspects of the therapy. It is a sobering reminder that follow-up studies of long-term psychodynamic therapies invariably demonstrate that patients remember their analyst not for their interpretive interventions, rarely remembering individual interpretations, but rather for their 'emotional presence', regardless of the analyst's therapeutic perspective.

Interpretations may be classified according to the aspect of a conflict they aim to address: (82 the defence, the anxiety, or the underlying wish or feeling. Similarly, the content of the interpretation may be used in classifying interpretations: whether it relates to external reality, the transference relationship, or childhood relationships. In principal, in the earliest phases of treatment, interpretations relating to current events are most common and, as the treatment progresses, transference issues and the patient's past may increasingly take over as foci of analytic work. Interpretations should start with the patient's anxiety, by identifying the defence used by the patient to protect him- or herself from repudiated wishes and affects. In reality, these are guidelines that are rarely followed in practice. For example, very long-term treatments tend to end up being principally supportive exploration of the patient's current experience. (83> Furthermore, interpretations of the distant past tend to be least helpful to individuals with severe personality disorders. Working in the here and now is more effective with those patients whose representation of the past is unreliable and distorted.

Since Strachey's landmark paper,(69) transference interpretations have had a unique place in psychodynamic work. Strachey's justification for giving primacy to such interventions was in terms of the mutative aspect of the patient internalizing the analyst as a benign object in place of the patient's excessively harsh superego. Other analysts have justified the focus on the transference differently. Hoffa, (84> for example, emphasized the opportunity such interpretations created for the patient to internalize the thinking function of the therapist; Kohut (85> saw such interventions as opportunities for the analyst to undo the damage which experience with inadequate self-objects created.

Steiner(86 distinguished analyst-centred from patient-centred interpretations. The former refers to comments on the patient's reactions in terms of what the patient thinks may be going on in the analyst's mind, while the latter directly addresses the analyst's perception of the patient's non-conscious mental state. In either case the patient is directly learning about how minds interact in the context of social relationships. The distinction is important since when patient-centred interpretations are used exclusively the therapist may appear to be persecutory and not to be cognizant of the patient's genuine difficulties in being in an intimate relationship with another person.

The idealization of the transference has led some therapists to neglect interpretation of the patient's behaviour outside of the therapy. Most clinicians now agree that a balance needs to be struck between these two approaches. Treatment which is overfocused on the transference becomes a claustrophobic enclave. (87> In certain instances, the direct communication of the therapist's experience of frustration (objective hate in Winnicott's terms) may help to break a rigid repetitive pattern in the therapy. (88>

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