Natasha Govender has just completed her internship as a psychologist at the University of the Witwatersrand’s Counselling and Careers Development Unit. She is registering as a aCounselling Psychologist. She is passionate about psychodynamic therapy and has no real preference for particular kinds of psychological issues to work with (everything interests her).
For as long as I can remember, I have wanted to help people. I realised, however quite early on during my studies in psychology, that there is a lot more to helping people than well meaning intentions. I was once told that what distinguishes a therapist from a well meaning friend who provides advice and support is theory. To be effective, a therapist must be well grounded in theory, theory of both personality and of counselling (Corey, 2005). Your conception of the person affects the interventions you make (McWilliams, 2004). I would therefore argue one of the most crucial but also most difficult questions that can be put to a therapist, especially a beginning therapist such as myself, is ‘which theoretical framework informs your practice’. In this paper, I would like to share with the reader some of my struggles in attempting to answer the question about which theoretical framework/s provide the foundation for my therapy work.
Person-centered and Psychodynamic orientations : between Two Standpoints
In beginning the task of writing this paper, I recalled another paper I had written a few years ago while completing my honours degree. At the time, I had been asked to write about my personal theory of counselling. In this paper, I happily declared person centred theory as the framework which would provide the foundation for my personal style and theory of counselling. My choice of person centred theory was based on my feeling that person centered theory held a similarly positive view of human nature as I (Corsini & Wedding, 2000). Hence I argued that this theory embodied my basic beliefs and personal values that human beings are essentially good. I vehemently stated that even those who perform the most atrocious of acts are essentially good at their core. It was my belief that what is often referred to as the darker side of human nature i.e. aggression, violence etc are a product of people’s experiences in the world and not innate characteristics of human nature.
Given the above views, it is no surprise that when I was first introduced to it, I was immediately drawn to the person centered theory of personality and of therapy. Carl Rogers’ statement that ‘if one is able to get to the core of an individual, one finds a trustworthy, positive center’ (Rogers in Corey, 2005), was particularly compelling. Equally compelling was the underlying vision of the person centered philosophy as captured by the metaphor of how an acorn, if provided with appropriate conditions, will “automatically” grow in positive ways, pushed naturally towards actualization as an oak (Rogers, 1951). This metaphor conveys the thesis that human beings have an innate basic tendency to strive towards positive growth and self actualization (Rogers, 1951). In other words, each individual has an innate capacity and drive to move away from maladjustment, to reach his/her full potential and to become a fully functioning person (Corsini & Wedding, 2000). The natural course of the actualizing tendency is often blocked by psychosocial conditions. When this happens, people become estranged from their true nature and may then behave harmfully, anti-socially, destructively (Rogers, 1961). However, the innate tendency towards growth and self actualization, according to person centered theory, will materialize if the right conditions fostering growth are present (Rogers, 1961).
Looking back at my faith in the person centred philosophy of the essentially positive nature of human beings, I do not miss the irony of the fact that I now consider myself to be an aspiring psychodynamic therapist. If I was drawn to person centred theory, then I am enamoured with psychoanalytic theory. I would be hard pressed to explain the reasons for this shift from humanistic/person centred theory to psychoanalytic theory. They are many and varied. For one, my masters course at Wits did have a strong focus on psychoanalytic understandings of human beings and on psychodynamic therapy. Secondly, to borrow from McWilliams (2004), perhaps my own dynamics are sufficiently Freudian and/or Kleinian that I find their writing utterly compelling. In addition, in work with clients during my M1 year, I literally saw the theory come alive in the therapy room. I could see the processes and dynamics which Freud and Klein wrote about operate in the lives of my clients. This was heady stuff. Hence, I now find myself attracted to a theory which has a very different view of human beings than I had originally started out with, at the beginning of my journey to becoming a psychologist.
According to psychoanalytic theory, as put forward by Freud, human behaviour is determined by irrational forces, unconscious motives and instinctual drives (Leiper & Maltby, 2004). This view of human behaviour as driven by sexual and aggressive impulses as well as unconscious motives and conflicts, is less than positive. According to Freud’s dual drive theory, operating in all of us at the time of birth is the life (Eros) and death (Thanatos) drive. Libido and aggression, respectively are two descriptions of these internal drives (Leiper & Maltby, 2004). Libido is usually thought of as a sexual drive, a life preserving drive, a pleasure seeking drive (Leiper & Maltby, 2004).The death instinct, on the other hand, is thought to refer to the hatred of life itself (Ivey, 2002). A drive to regress, a sadistic and masochistic drive. This manifests as violently destructive fantasies and threatened destruction and annihilation from within the individual (Ivey, 2002). Klein contends that from birth the death instinct is partly deflected outwards onto the maternal breast, in the form of oral-sadistic aggression in order to protect the infant from annihilation from within (Klein, 1946). This aggression is expressed in phantasisied attacks against the maternal breast, involving sadistic onslaughts on her body, aimed at devouring and annihilating her (Klein, 1963). Hence, in Kleinian theory aggression arises out of the need to expel the destructive death instinct from the self (Ivey, 2002). This view that masochistic, sadistic drives and aggression are in fact innate to the individual are in stark contrast to the person centred view that people are driven to aggression by an external thwarting of an innate drive towards positive growth.
In as much as I my fervour for psychoanalytic theory cannot be denied, I find within myself remaining echoes of the belief that at their core people have a good, trustworthy, positive center. I find myself debating whether the view that people have choice, freedom and the potential for self actualisation is compatible with the view that human beings are driven by internal, often unconscious forces which include profoundly destructive drives (Lapworth, Sills, & Fish, 2001). This struggle often plays itself out when I am dealing with a relatively well adjusted client. In these instances, I sometimes become exasperated by the task of formulating such a client in the somewhat pessimistic terms of psychodynamic theory.
At the Heart of the Psychodynamic approach – The Unconscious
Corresponding to the afore mentioned view of human beings as driven by unconscious drives and motives, psychoanalytic theory, especially as formulated by Freud, holds the conviction that the causes of emotional disturbance are deeply unconscious (McWilliams , 2004). A fundamental idea which constitutes the core of the psychodynamic approach is the focus on psychological pain, thought of as anxiety and conceptualised in terms of unconscious internal conflict. This psychological pain is seen as being due to internal conflict between parts of the self (Leiper & Maltby, 2004). Perhaps the most useful and flexible way of conceptualising this view of emotional disturbance is what is commonly known as the ‘triangle of conflict’ (Malan in Leiper & Maltby, 2004). This portrays conflict as arising from a ‘hidden feeling’ which can be an unconscious wish or an impulse. The hidden feeling, arouses anxiety because it is in conflict with another perceived need, so that it is feared to have catastrophic consequences (Leiper & Maltby, 2004). In Freud’s theorising, anxiety related to hidden feeling is of two general types, the fear of loosing control and being overwhelmed by one’s impulses and the fear of transgressing internalised social standards and of being punished for it. To summarise, anxiety is a signal of an internal danger and that action must be taken to avert the threat posed by conflictual aspects of self. The third element of the triangle of conflict is defence. Defence arises as a ‘solution’ to avoid conscious acknowledgement of the conflict between ‘hidden feeling’ and other parts of self. Hence, defence mechanisms are employed in a defensive alteration of experience in which some aspect of the self is disguised in order to reduce anxiety (Leiper & Maltby, 2004).
From the above, it is clear that in psychoanalytic terms, unconscious processes are at the root of all forms of neurotic symptoms and behaviours (Sadock & Sadock, 2003). Hope of treatment for neurotic symptoms, lies in making unconscious conflicts and motives conscious. Only by rendering unconscious irrational elements conscious can individuals begin to exercise choice rather than being controlled by unconscious forces (Blackman, 2004). In other words, as famously stated by Freud ‘where id was, there ego shall be’(Blackman, 2004). McWilliams (2004) contends that a common theme among psychodynamic approaches is that the more honest we are with ourselves, the better our chances for living a satisfying and useful life. It is only in becoming aware of and accepting the wishful, painful and conflictual aspects of ourselves that we can become better friends with ourselves and so with others (Leiper & Maltby, 2004). The diverse therapeutic approaches within the psychoanalytic stable share the aim then, of cultivating an increased capacity to acknowledge what is not conscious i.e. to admit what is difficult or painful to seen in ourselves (McWilliams, 2004). Hence, the process of understanding or interpreting the meaning latent in the material that emerges in therapy is central to ‘analytic’ work (Leiper & Maltby, 2004)
In the previous section, the centrality of insight and interpretation in the psychodynamic approach was highlighted. However, equally central to this approach is the development of an emotional relationship between client and therapist. It has been argued that psychoanalysis has from it’s inception swung between insight and interpretation on the one hand and emotional relationship on the other (Bateman & Holmes, 1995). One might conceive of psychodynamic therapy then, as a process of finding the right balance between ‘being with’ the client and ‘doing to’ the client (Bateman & Holmes, 1995). ‘Being with’ would refer to developing an emotional relationship with the client, whereas ‘doing to’ would refer to using techniques, including making interpretations to further client insight (Bateman & Holmes, 1995). As pointed out by Bateman & Holmes (1995) a well established ‘being with’ relationship is often required as a foundation for ‘doing to’ interventions.
The relationship between ‘being with’ and ‘doing to’ has usefully been represented as a continuum with the following elements; support – affirmation – reassurance – empathy – encouragement – elaboration – clarification – confrontation – interpretation. With regards to my own therapeutic work, I find ‘being with’ clients to be much easier than ‘doing to’ clients. Confronting resistance and making interpretations are somewhat daunting. Showing empathy and developing an emotional relationship with my clients are things which I do not have great difficulty with. However, I find that I tend to shy away from deepening the therapeutic process by leading clients into difficult and painful territory. In exploring my difficulty in this regard, I am encouraged by Bion’s comments that a therapist functions as a container for affect overload (Lindy & Wilson, 2001). In other words, in not making judgements or demands, or stimulating shame, the therapist provides a temporary psychic structure to contain the unbearable feelings of the client (Lindy & Wilson, 2001). In accompanying a client through the expression of difficult emotion the therapist contains and transforms these unbearable emotions in the same way that a mother would soothe an infant in distress and translate unmanageable feelings into words and symbols so as to render them less distressing (Eagle, 2000).
Transference and Countertransference
The classical definition of transference describes it as a process by which the client transfers onto the therapist past experiences and strong emotions which he/she previously experienced in relation to significant persons in earlier life (Bateman & Holmes, 1995). From a Kleinian perspective, the therapist is not merely a mirror onto which clients displace their impulses, but rather is a receptacle into which internal figures and the feelings that surround them are projected (Puget, 2006). Either way, it is clear that the relationship between the client and therapist, serves as a pathway to the early life of the client. Hence, transference plays an important role in achieving the therapeutic goal of working through past material, by offering entrance door to the past with the possibility of modifying it (Puget, 2006). The centrality of the transference in the psychodynamic approach means that a key question for the therapist should be “Who am I to the patient now?” (Ireland & Widlocher, 2004). This is a question which I have thus far found useful in my own practice of therapy, though I do not profess to always know the answer to this question.
An important element in working through transference is analysis of transference in the here and now. This however is an emotionally potent arena that can lead to resistance on the part of both the therapist and the patient. I can certainly attest to this. However, though anxiety provoking for myself as I’m sure it is for my clients, in instances where I have worked in the here and now I have found this to be incredibly powerful, especially in deepening the relationship between myself and a client.
Countertransference refers to the activity of the therapist in the therapeutic relationship (Lapworth, et al., 2001). It might be defined as the whole of the therapists unconscious reactions to the individual client, including the therapists own transference. Perhaps a more useful view of countertransference is to see it as referring to specific emotional responses aroused in the analyst by the specific qualities of her client. Countertransference reactions can result from two sources. Firstly, they can result from the therapist’s own unresolved conflicts and pathologies. In this case, countertransference feelings if not recognised and managed can negatively affect the therapeutic relationship. Countertransference feelings do however also stem from the unconscious communications of the client to the therapist. In this case countertransference feelings may convey important diagnostic clues for understanding elusive communications from the client (Casement, 1985). In other words, feelings aroused in the therapist during session provide the therapist with insight into the unconscious of the client (Casement, 1985). In light of this, Casement (1985) advocated a careful monitoring one’s feeling towards a client to provide one with insight into the processes behind the content of what the client is saying. While I do carefully monitor my countertransference feeling towards my clients, I also recognise that an area of development for me would be to make greater use of these feelings in making interpretations to clients.
The activity of interpretation, i.e. finding the unconscious meaning in the client’s material, has been at the centre of psychodynamic practice ever since psychoanalysis proper was born out of Freud’s move away from the cathartic method (Leiper & Maltby, 2004). Interpretation involves a process of viewing everything the client says and does as hinting at hidden unconscious meaning, the task of the therapist is to discover what the hidden meaning is (Freud, 1888-1938). In this way the unconscious is made conscious. While interpretation has been always been part of psychodynamic practice, the focus of interpretation, what is regarded as the most important and therapeutically effective place to seek unconscious meaning has changed over time (Leiper & Maltby, 2004). Freud focused on interpreting symptoms and their historical roots. Interpretation of transference was also recognised and continues to be recognised as one of the principle vehicle for therapeutic change. Resistance has also always been a significant area of interpretive interest, but with the growth of ego psychology, the analysis of clients’ defensive structures came to the fore. The focus was less on symptoms or historical roots than the total structure of the personality, thought of as largely made up of typical defensive patterns (Leiper & Maltby, 2004). Thus the interpretation of defence became the mainstay of ‘character analysis’
It is essential that interpretations are well timed or they will fall on deaf ears. It is thus important that interpretive work is done slowly and carefully as what seems apparent to the therapist may not always be apparent to the client. Secondly, it is also imperative that one’s interpretations are based on reasonable assumptions and need to be well-grounded in what one knows about the client, their world, their internal dynamics and mechanisms of defence (Lasky, 1993).
The Frame and Boundaries
The therapeutic frame marks off the different kinds of reality that is within the therapeutic space from that which is outside it. In psycho-analysis it is the existence of this frame that makes possible the “full development of that creative illusion that analysts call transference” (Milner in Casement, 1985, p. 158). In other words, the therapeutic frame acts as a mean of separating the therapeutic relationship from the outside world, allowing space for the development of transference. It plays an essential role in preventing any, besides the client’s past, from entering the therapeutic space. Even though there is much debate regarding what aspects of therapy fall within the therapeutic frame, it can be defined as the ground rules of psychotherapy, that characterises and distinguishes it from other kinds of environments and relationships (Casement, 1985). This includes ground rules relating to the regularity and timing of sessions, fees, consistency and physical setting, privacy and confidentiality to name a few. Casement (1985) argues that besides these rules, the therapeutic frame also reflects the importance of boundaries. Casement (1985) argues that in all intimate relationship there is an important need for boundaries, which allow for mental and emotional space. However, in many intimate relationship one tends to find the one’s boundaries are not always respected and that one is not always provided the space that one needs. Casement (1985) contends that barriers or boundaries in the therapeutic relationship make the relationship different from any other. Winnicott related the idea of boundaries to the ‘good enough mother’ who supplies her infant with a safe space, and clear boundaries (Leiper & Maltby, 2004). This boundary provides the infant with a space in which they can experiment, be creative, and think.
In light of the above, the need for clear and consistent therapeutic boundaries in the context of therapy cannot therefore be overestimated. However, the maintenance of the therapeutic frame is not easy task. The intimacy of the therapeutic relationship both stimulates and frustrates fundamental and universal longings, including (a) the desire for unity (to be loved totally and without separateness), (b) the desire for purity (to be loved without hate and unreservedly), (c) the desire for reciprocity (to love and be loved in return), and finally, (d) the desire for omnipotence (to be so powerful that one is loved by everyone everywhere at all times) (Celenza, 2007). However, due the necessity of maintaining the therapeutic frame and boundaries, it often the responsibility of the therapist to frustrate the above mentioned needs and desires. According to Celenza (2007) it is essential that the therapist resists the unconscious attempts made by the client to break down the therapeutic boundary and thus transform the relationship into a real one. Rather, the therapist must maintain the boundary and in so doing allow for the effectiveness of the therapeutic relationship to transpire (Celenza, 2007).
Developing a Therapeutic Style – On Being Myself
One of the things which attracted me to person centred therapy was the fact that person it demands that the therapist be freely and deeply him\herself (Feltham & Horton, 2000). In my experience of psychodynamic therapy, albeit limited, I have not found the same ‘permission’, as it were, to be myself. In fact, a particular challenge for me has been to be myself in the therapy room while at the same time maintaining the therapeutic frame and boundaries. For me, uncertainty about what is allowed and what isn’t, as well as a constant awareness that everything I do and say unconscious meaning and significance, at times make it difficult to express my usual warmth and empathy in the therapeutic space. In light of these challenges it was particularly heartening to come across McWilliams’ (2004) comments that despite the fact that psychodynamic practice is often mistakenly conceived as a set of ‘rules’, there is in fact room for flexibility and individual difference in the practice of psychoanalysis. Even the most classical, ‘orthodox’ writers on technique, however emphatic they were about the value of neutrality and abstinence did not intend for therapists to try to eradicate their natural warmth or to become robotic caricatures of human being (McWilliams, 2004). It is these comments which I hold dear in my own endeavour to relax more and let my own personality become my therapeutic instrument.
Winnicott (1960) wrote about the universal need of the young human being to maintain the sense of true self in the face of whatever adaptations and compromises his or her environment requires. In this paper I have documented some of my own struggles in maintaining a sense of my true self while at the same time embracing the psychodynamic approach to therapy. I have discussed the challenges I face in reconciling my rather positive view of human nature with the psychodynamic view of human nature. I also explored the areas of personal growth in terms of working in the psychoanalytic process. To conclude, it must be said that despite the challenges discussed in this paper, I strongly believe that the psychodynamic approach can be reconciled with my basic beliefs, values and personality characteristics. I remain enamoured.
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