Dynamically Based Psychotherapy: A Contemporary Overview

This article addresses several important theoretical issues related to dynamically oriented psychotherapy (Goldstein, 1998). These issues include the therapeutic alliance and transference, the authority of the therapist and neutrality, the stability of the therapeutic environment, countertransference, empathy, and basic strategy. Efforts are made to present these issues in a contemporary context.

The therapeutic alliance is the collaborative relationship between patient and therapist, established to facilitate the work of psychotherapy. It demands the patient maintain an observing ego that continually focuses on the therapeutic process. This observing ego is in alliance with the therapist against the patient's conflicts and resistances. Although it can include unconscious components, the therapeutic alliance operates mainly on a conscious level.

In contrast, the transference is an unconscious process in which the patient, in a regressed state, displaces or "transfers" onto the therapist feelings and thoughts originally directed toward the important people of early childhood. The transference includes these feelings and thoughts, and defenses against them. It is based on both the actual and fantasized past as experienced by the patient.

In the traditional or classical view (originally proposed for psychoanalysis, but also applied to analytically oriented psychotherapy), the therapist was thought to be capable of standing outside of the interaction with the patient-acting as a "blank screen"-and being the individual onto whom the patient transferred his feelings and thoughts. The blank screen stance was thought to be enhanced by the therapist's neutrality, abstinence and anonymity.

In contemporary times, this positivist position (where the therapist is thought to stand outside the interaction in search of the objective truth) has been challenged by newer perspectives. These include relational models, self-psychology, intersubjectivity, social constructivism and postmodern thinking. Many therapists of the classical school have changed some of their views in accordance with these newer perspectives.

This change includes a shift toward viewing the psychotherapeutic process as more interactional, interpersonal and subjective in nature, with a mingling of transference and countertransference between patient and therapist. The therapist is viewed as a unique individual, with his own theory of how therapy works, his own idiosyncrasies and his own past, all of which contribute to the unfolding of the psychotherapeutic process.

Some posit that the therapist, in addition to the patient, is involved in the construction of the transference. Many integrate the positivist approach with more contemporary approaches by conceptualizing the patient as coming to analysis with pre-existing feelings, ideas and personality traits. The patient then transfers these onto the analyst, who also has pre-existing feelings, ideas and personality traits that influence and skew the transference.

With these changing perspectives, the concepts of the authority of the therapist and neutrality have been questioned. Now, therapy is sometimes viewed more as a process between equals than between an uninformed patient and a knowledgeable authority. Some emphasize a dialectic between the therapist as an authority and the therapist as a person like the patient (Hoffman, 1996). Contemporary thinkers often view neutrality as a theoretical ideal, impossible to attain in actuality. Nevertheless, some continue to favor attempting to approximate this unattainable ideal. Others view the concept as antiquated and even harmful, advocating instead the acceptance of the non-neutral subjective analyst (Renik, 1996).

A useful modern concept of neutrality posits a therapist who steers clear of judgment and criticism. He aims to use the therapy sessions to listen to and understand the patient, and to make interventions based on this listening and understanding. The interventions always focus on the patient, his problems and his life. Although the therapist will sometimes react emotionally to the patient, as much as possible he uses his reactions to understand the patient.

Countertransference has been defined in the narrow sense as the therapist's unconscious reactions to the patient's transference. In the broad sense, countertransference includes all emotional feelings the therapist has for the patient, both conscious and unconscious. These include reactions to the patient's transference, his personality and reactions actively elicited by the patient. Although some prefer the narrow definition, there is somewhat of a consensus toward using this broad definition.

With all patients, the therapist must be on the alert for countertransference feelings. He needs to keep overt countertransference acting-out to a minimum, and he must use his countertransference to aid in his understanding and his interventions. The therapist's own psychoanalysis is most relevant to his ability to deal with these feelings. No matter how well-analyzed, however, all therapists will demonstrate countertransference with all patients. Often more subtle with healthier patients, countertransference intensifies when these patients regress. It is the borderline patients, however, who are most famous for creating difficult countertransference situations.

Borderline patients are known for their ability to elicit emotional reactions in the therapist. It is not unusual for these patients to sense the therapist's areas of weakness and subtly attack those areas. Sometimes the attacks are not so subtle. In projective identification the patient projects his own feelings onto the therapist, then does everything in his power to force the therapist to accept the projections. Situations are created where virtually every therapist responds. Gabbard and Wilkinson (1994) have categorized typical countertransference reactions to borderline patients. These include guilt feelings, rescue fantasies, transgressions of professional boundaries, rage and hatred, helplessness, worthlessness, anxiety, and terror. Some of these feelings are inevitable for all therapists when working with borderline patients; others occur more selectively with certain therapists working with certain borderline patients.

An empathic stance-where the therapist identifies with the patient to the extent that he tries to experience what the patient feels, his way of thinking and his point of view-is of obvious value to the psychotherapeutic process. Not only does this stance help the therapist to understand the patient, it helps in establishing an environment where trust is enhanced and the patient becomes freer to talk about inner feelings and thoughts. Additionally, it is useful in assisting the therapist in choosing and framing interventions.

There are at least two basic strategies for psychotherapy. With the underlying assumption that permanent change is best effected when the patient re-experiences and works through his conflicts with the therapist, one strategy attempts to maximize the development and resolution of the transference. Using techniques analogous to those of psychoanalysis, the therapist tries to obtain an intense transference. Initially he comments on resistances to the formation of the transference; later the therapist helps the patient to understand himself by correlating the transference with both current and childhood relationships. This is the strategy underlying analytically oriented psychotherapy. It is useful in patients who are easily able to form intense transferences in the psychotherapy situation.

A second strategy emphasizes the formation and maintenance of a positive therapeutic alliance, and the use of that alliance to explore and gain insight into the patient's conflicts. Focus is on present-day interactions and relationships and their correlation to the past. This strategy downplays the transference as a therapeutic modality. Although transference reactions are noted, especially when they occur as resistances, the elaboration and resolution of the transference does not play a major role. This strategy is particularly useful with patients who cannot form a reasonably intense transference within the psychotherapy situation. It is also used with patients who easily form very regressed transferences, with tendencies for destructive acting-out and disruptive fragmentation. I use the term dynamically oriented psychotherapyto describe this second strategy and to differentiate it from one that is more exclusively focused on the transference.

Neurotic (healthier) patients often have difficulty forming intense transferences outside of psychoanalysis. With this factor in mind, many therapists favor a dynamically oriented strategy for this group if psychoanalysis itself cannot be utilized. Other therapists, however, always attempt to utilize an analytically oriented approach. Still others employ a transference-oriented strategy for those neurotic patients who seem easily able to regress (often hysterical in personality type), while favoring a nontransference-oriented approach for those less able to regress sufficiently (often obsessive in personality type).

Because many borderline patients regress easily and become rapidly involved with the therapist and the transference (even without the use of the couch), the opportunity to use analytically oriented psychotherapy is clear. However, because of ego weaknesses and the propensity for too much regression, modifications in technique with the analytically oriented strategy (as compared with more neurotic patients) are usually necessary.