November 2017
BOOK REVIEWS: Long-term Psychodynamic Psychotherapy: A Basic Text. Third Edition
Psychodynamic psychotherapy has been frequently and mistakenly equated with psychoanalysis. As Glen Gabbard, MD, points out, this is not the case. He defines long-term psychodynamic psychotherapy as “a set of psychotherapeutic treatments, some specifically tailored to disorders and others more general, that are based on a thoroughgoing understanding of human subjectivity and how it interacts with the individual’s relationship with both the external and internal environments. It occurs on a continuum from expressive or interpretive interventions, on the one hand, to supportive and empathic interventions, on the other, and incorporates unconscious conflict, internal representations of relationships, and idiosyncratic and complicated meaning that are attached to experience. It is also linked to a search for the truth about the self and a greater sense of authenticity. The conceptual models for this therapy include ego psychology, object relations theory, intersubjective theory, self psychology, and attachment theory” (p 2-3). The distinctive features of techniques in psychodynamic psychotherapy include a focus on affect and expression of emotions; exploration of attempts to avoid aspects of experience; identification of recurrent themes and patterns; discussion of past experiences; focus on interpersonal relations; focus on the therapeutic relationship; and exploration of wishes, dreams, and fantasies (p 3).
Gabbard also touches on the length of psychodynamic psychotherapy. He writes “although long-term psychodynamic psychotherapy once meant an exclusively open-ended process that did not have a defined end point, today there are therapies of 40 to 52 sessions that have targeted end points from the beginning but still use many of the same principles inherent in long-term psychodynamic psychotherapy” (p 3). He uses an arbitrary definition of “long term” as a duration longer than 24 sessions or 6 months.
Gabbard’s volume provides a comprehensive introduction and guidance to long-term psychodynamic psychotherapy in 11 chapters (3 of which are enriched by video-illustrated vignettes): (1) “Key concepts”; (2) “Assessment, indications, and formulation”; (3) “The nuts and bolts of psychotherapy: getting started”; (4) “Therapeutic interventions: what does the therapist say and do?”; (5) “Goals and therapeutic action”; (6) “Working with resistance”; (7) “Use of dreams and fantasies in dynamic psychotherapy”; (8) “Identifying and working with countertransference”; (9) “Working through and termination”; (10) “Use of supervision”; and (11) “Evaluating core competencies in long-term psychodynamic psychotherapy.” The chapters are well-written and well-organized, explain difficult psychodynamic concepts with Gabbard’s easy, understandable, comprehensive writing style, and are filled with wisdom and good advice.
In the first chapter, Gabbard cautions readers that “… symptomatic improvement is not the only goal of psychotherapy. Many patients who come to therapy wish to grapple with fundamental truths about what it is to be human—the inevitability of conflict in relationships, the inability to control external events, the fact that love is inextricably tied to hate, and the essential task of mourning that accompanies each developmental phase of adult life” (p 19). This is important advice to all beginning therapists. At the end of this chapter, Gabbard explains that in addition to core theoretical models (eg, ego psychology, attachment theory), psychodynamic psychotherapy is guided by a set of key concepts: “1) much of mental life is unconscious; 2) childhood experiences in concert with genetic factors shape the adult; 3) the patient’s transference to the therapist is a primary source of understanding; 4) the therapist’s countertransference provides valuable understanding about what the patient induces in others; 5) the patient’s resistance to the therapy process is a major focus of the therapy; 6) symptoms and behaviors serve multiple functions and are determined by complex and often unconscious forces; and 7) a psychodynamic therapist assists the patient in achieving a sense of authenticity and uniqueness” (p 25).
The next chapter on assessment, indication, and formulation explains that the success of psychodynamic psychotherapy depends on selecting patients who are truly suited for it (p 31). Two principal questions need to be answered at the initial evaluation: “1) Are the patient’s clinical concerns likely to respond to long-term psychodynamic psychotherapy? and 2) Does the patient have the psychological characteristics that are suited to a psychodynamic approach?” (p 31). Gabbard also emphasizes that the patient must be a collaborator in the psychodynamic interview. In discussing defense mechanisms (this chapter includes a good table on defense mechanisms that covers almost 3 pages), he notes that one should view a patient’s defenses “as preserving a sense of self-esteem in the face of shame and narcissistic vulnerability, ensuring a sense of safety when one feels dangerously threatened by abandonment or other perils, and insulating oneself from external dangers (through denial, for example, or minimization)” (p 35). I liked that Gabbard also tackles the issue of patients who are not truly suitable for pure psychodynamic psychotherapy and require a balance between expressive and supportive work. These include borderline level or personality organization, patients in the midst of a severe life crisis, poor frustration or anxiety tolerance, excessive concreteness leading to a lack of psychological mindedness, low intelligence, little capacity for self-observation, and difficulty forming a trusting relationship with the evaluator (p 43). He also mentions that direct treatment of symptoms of obsessive-compulsive disorder is a contraindication for psychodynamic psychotherapy, and a combination of behavior therapy and selective serotonin reuptake inhibitors should be used for this disorder. This advice was not available when I was exposed to psychodynamic psychotherapy and supervision as a resident, which would certainly have made my training more understandable, practical, and enjoyable.
In discussing the nuts and bolts of psychodynamic psychotherapy, Gabbard dispels some myths about this treatment modality: “The therapist is not totally silent. The therapist cannot read minds. The therapy does not last forever. The therapist is not interested in changing the patient’s sexual orientation. The patient does not have to lie on a couch and free-associate. The process is not an archeological dig for buried remnants of the past that must be recovered through hypnosis in a dramatic emotional catharsis or abreaction” (p 57). In this part, Gabbard also discusses many practical issues, such as personal questions and degree of self-revelation; boundaries and frame issues; note-taking; psychotherapy process notes; boundaries in cyberspace; gifts and seating arrangement (obligatory eye contact may be distressing to both parties; a 2-chair arrangement in a 45-degree angle toward the wall makes eye contact less obligatory and more comfortable); and clock placement. Another important “management” issue of patient lateness and missed sessions is discussed in the chapter on working with resistance. Gabbard emphasizes that some “patients are characterologically late and are virtually never on time, whereas others are late only when something about the therapy is troubling them” (p 136). The issue of boundaries returns in the discussion of termination, which, as Gabbard warns us, “is a time when boundaries may become a little more permeable” (p 195).
The remaining chapters are as detailed and practical as the ones I have discussed, demonstrating the usefulness and comprehensiveness of Gabbard’s writing. For example, I liked the review of the varieties of countertransference, which include rescue fantasies, the bored and sleepy therapist, erotic countertransference, and incapacitating countertransference. The chapter on supervision also is valuable. On the other hand, the last chapter on evaluating competencies is—not to belittle it—a not-so-useful, obligatory part of educational texts these days.
This is another great book of Gabbard’s that helps readers understand psychodynamic psychotherapy and will help them learn to practice it. It is sophisticated, yet simple and easy to understand, even when explaining complicated concepts. I wish this book was around when I struggled with psychodynamic concepts and the nuts and bolts of psychodynamic psychotherapy as a resident. Novices in this area and teachers of psychodynamic psychotherapy will find this book useful, as will many practicing therapists who want to refresh their knowledge.
CORRESPONDENCE
Richard Balon, MD
Department of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Drive
Detroit, MI 48201 USA
E-MAIL
[email protected]
REFERENCES
By Glen O. Gabbard; Arlington, Virginia; American Psychiatric Association Publishing; 2017; ISBN 978-1-61537-053-5; pp 239; $78 (paperback, video illustrated).