Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
In Psychodynamic Psychotherapy: A Clinical Manual, Deborah L. Cabaniss and her three coauthors have sought to create a reference book for clinicians that systematically and methodically delineates each step in the psychodynamic psychotherapy process, from the initial evaluation to termination. They have succeeded. This book fills a needed gap in clinical literature on psychodynamic treatment precisely because it does not get bogged down in theoretical complexity; this is a book about the technique of psychodynamic treatment. Inspired by a psychodynamic psychotherapy course the authors taught for psychiatry residents at the New York State Psychiatric Institute/Columbia University, this book combines the clarity and simplicity needed for a beginning practitioner with the depth and complexity that would appeal to a more experienced therapist.
Part One (“What is Psychodynamic Psychotherapy?”) introduces the reader to how psychodynamic psychotherapy works. It differentiates uncovering versus supporting therapeutic techniques and describes three theories of therapeutic action: making the unconscious conscious, supporting weakened ego function, and reactivating development.
Part Two (“The Evaluation”) describes how to evaluate the suitability of a candidate for psychodynamic psychotherapy, including an assessment of ego function, superego function, psychological mindedness, capacity for self-reflection, motivation, and characteristic psychodynamic defenses.
Part Three (“Beginning the Treatment”) focuses on the induction phase, including topics of informed consent, goal setting, frame and boundaries, therapeutic alliance, therapeutic neutrality, and empathic listening. This section also addresses the clinical implications of integrating psychodynamic and phenomenological models of treatment: combining therapy and medication.
Part Four (“List/Reflect/Intervene”) teaches a systematic way of listening to patients, reflecting on what you have heard, and choosing an appropriate response. An interactive companion website is included with this book to help the reader learn about the three different ways we listen: ambient listening, filtered listening, and focused listening. As listening becomes more filtered and focused, repeated words, symbols, and points of clarity generally signal the presence of nodal points or bridges to unconscious material. Basic, supporting, and uncovering interventions are discussed in detail, and three principles for choosing an effective intervention are presented: surface to depth, follow the affect, and attend to the countertransference.
Part Five (“Conducting a Psychodynamic Psychotherapy: Technique”) builds upon the previous chapter by expanding the domains of the readers “listening” to include the dominant affect, resistance, transference, countertransference, unconscious fantasy, conflict, and dreams. The authors teach how to identify the above seven features in every psychotherapy session and provide review exercises at the end of the chapter to practice this complex skill. This chapter also provides instruction on how to shift flexibly between uncovering and supporting techniques, depending on the needs and abilities of the patient at the time.
Part Six (“Meeting Therapeutic Goals”) describes the midphase of therapy: applying the aforementioned techniques to addressing problems of self-esteem, relationships, adaptation to change, and weakened ego function. For instance, self-esteem regulation can be improved via supportive techniques (supporting weakened ego function), uncovering techniques (making unconscious self-perceptions conscious), and exploration of superego function (correcting superego induced distortions in self-perception). In contrast, relationship difficulties result from people’s unconscious fantasies and expectations of others or impairment in ego functions like the capacity for empathy and ability to read social cues. Although uncovering interventions may be more appropriate for the former problem, supportive interventions are more suited for the latter.
Part Seven (“Working Through and Ending”) addresses ways the above techniques shift over time until the process of termination. The three phases of working through—limited awareness, increased awareness and practicing, and lasting change in thought and behavior patterns—are discussed in detail, as are the interventions necessary for this progression. Bilateral versus unilateral terminations are contrasted, and characteristic aspects of this affect-filled phase are discussed, including regression, mourning, and finding a replacement relationship. Each chapter ends with suggested activities designed to apply the learned skills and concepts. These exercises are interesting, challenging, and accompanied by thoughtful answers and comments.
Although the clear prose, well-organized format, and rich insights make this book a pleasure to read, it is the abundance of carefully annotated case examples on almost every page that differentiates this book from others like it. The cases bring the described techniques to life and provide a wealth of learning in and of themselves. It is clear that this book is written by those who themselves have devoted their lives to the practice and teaching of psychodynamic psychotherapy and, subsequently, developed a capacity to distill each case down to the single most profound psychodynamic conflict.
One self-acknowledged limitation of this book is the omission of certain schools ofthought of psychodynamic psychotherapy, such as object relationships and self-psychology. However, the “less is more” principle applies here. Rather than presenting a multiplicity of complex theories, this book focuses primarily on the practice and technique of psychodynamic psychotherapy.
At a time when many psychiatry residency programs do not provide adequate training in psychodynamic psychotherapy, this book provides a much-needed corrective. Although it is meant as a book for initial learning, this is the kind of book that will remain on the reader’s desk as a frequently thumbed companion and reference.