The dynamically informed psychotherapies can be thought to occur on a continuum, with the most insight-oriented and exploratory types at one end and the most supportive types at the other (Goldstein, 1998). Psychoanalysis proper stands at the end of this continuum, followed by analytically oriented psychotherapy, then dynamically oriented psychotherapy. Within this classification, I view analytically oriented psychotherapy and dynamically oriented psychotherapy as two quite distinct, yet related, forms of therapy.
Differentiation between these two types, although not routinely advocated, provides a useful conceptual framework for psychotherapists. This framework is helpful for correlating types of psychotherapy (i.e., analytic versus dynamic) with types of patients (i.e., neurotic versus borderline versus psychotic), and for providing a structure for selection of therapeutic strategies and interventions.
Dynamically informed therapists generally utilize one of these two types of therapy, although they do not necessarily acknowledge this. Although various combinations of the two can be utilized, the pure forms will be described in this article.
The trappings of both analytically oriented psychotherapy and dynamically oriented psychotherapy involve regularly scheduled sessions, usually one to three times a week, held for varying periods of time. The greater the frequency of the sessions, the greater the intensity and continuity. Thus, more (rather than fewer) sessions are often recommended, especially in the analytically oriented modality.
Typically, there is no contact between patient and psychotherapist outside of the appointments. Sessions are conducted with the patient and therapist sitting across from each other in comfortable chairs. Patients are usually told that the sessions are theirs, and that they can talk about whatever they choose. In addition, patients are sometimes encouraged to report seemingly extraneous thoughts and fantasies that may occur during a session. Areas of resistance to such discussion are often mentioned.
Regarding initial guidelines, I recommend a more elaborate version of those mentioned in the last paragraph for all forms of dynamically informed psychotherapy. I spell out specific guidelines, thus establishing a much desired frame for the therapy that can be returned to whenever there is any deviation. Like Gray (1994), I do not present the guidelines as instructions or rules, as I find this is too authoritarian and rigid. It is puzzling to me that although such guidelines are standard for psychoanalysis, few therapists refer to them for psychotherapy. Kernberg (1989) is one clear exception.
A standard psychotherapy presentation that is useful for most patients is as follows: "The sessions are yours, to talk about anything you want. It will be up to you to choose the topics. Often there will be topics on your mind that you very much want to talk about. At times when you do not have topics of pressing importance, it is helpful to talk freely about anything that comes to mind. There are certain thoughts that some people find difficult to talk about and are tempted to omit. I want to urge you to do your best not to omit those types of thoughts. These include thoughts that cause uncomfortable feelings, such as anxiety, anger, embarrassment or shame, ones that you view as silly or irrelevant, ones that you are fearful that I will disapprove of, and any thoughts, positive or negative, that refer to the therapy or to me personally."
Analytically Oriented Therapy
The analytically oriented therapist attempts to conduct the sessions in a manner as similar as possible to psychoanalysis. He tries to maintain some neutrality, relies on clarifications and interpretations as much as possible, and tries to make maximum therapeutic use of the transference. He comments on resistances, tries to correlate the transference with current interactions and significant childhood relationships, and attempts to help patients to gradually understand those aspects of themselves about which they are unaware.
As in psychoanalysis, the therapist looks to the elaboration and working through of the transference to be the principal vehicle for both insight and change. This is analytically oriented psychotherapy in its pure form.
Traditionally, the neutral therapist has acted as anonymously as possible, striving to serve as a "blank screen," to provide a setting conducive for the displacement of the patient's feelings. The maintenance of neutrality was considered most important in those therapies emphasizing the transference.
The concept of neutrality has since become controversial. Many contemporary therapists view it as a theoretical ideal, impossible to attain in actuality. Nevertheless, some favor attempting to approximate this unattainable ideal, while others (e.g., Renik, 1996) view the concept as antiquated, advocating instead the acceptance of the "non-neutral" subjective therapist. Analytically oriented psychotherapy is similar to psychoanalysis regarding neutrality, its emphasis on insight-oriented techniques, and its focus on the establishment and unfolding of the transference. Differences from psychoanalysis include the use of the chair versus the couch, the lesser frequency of sessions, and the relative de-emphasis of free association.
Goldstein W (1998), A primer for beginning psychotherapy. Washington, D.C.: Brunner/Mazel.
Goldstein W (1996), Dynamic psychotherapy with borderline patients. Northvale, N.J.: Jason Aronson Inc.
Gray P (1994), The ego and analysis of defense. Northvale, N.J.: Jason Aronson Inc.
Kernberg OF, Seltzer MA, Koenigsberg H et al. (1989), Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.
Renik O (1996), The perils of neutrality. Psychoanal Q 65(3)495-517.
Lazar S, ed. (1997), Extended dynamic psychothera-py: making the case in an era of managed care. Psychoanalytic Inquiry supplement issue.
Stevenson J, Meares R (1992), An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 149(2):358-362. See comments.