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Psychodynamic Psychiatry: A Case Report

Psychodynamic Psychiatry: A Case Report

I am often asked by psychiatrists who are not trained in psychodynamic psychiatry about what I do and how I think about patients and their treatments. In response, I often say that a key difference lies in how psychodynamic psychiatrists view clinical material, evaluate patients, and make—or know when to withhold, depending on timing—interpretations. We also often turn to supervisors, consultants, and peers. With the goal of engaging more colleagues and encouraging them to pursue this particular mode of treatment, I present the following fictionalized case based on a real patient but with fabricated identifying information.

Sophia is single, in her early 30s, and lives with a roommate in an apartment in the city in which I practice. She commutes into the city daily, where she works full time as an executive administrative assistant. Many years ago, she received a diagnosis of depression and was treated with an SSRI and psychotherapy. She has no medical history and has never been suicidal.

Sophia initially presented to me for evaluation with the chief complaint of “I don’t feel that connected to my life.” She was referred by her longtime psychiatrist (Dr. A), who initially treated her with psychotherapy and later with medication. Dr. A recognized early on that Sophia might benefit from psychoanalysis and discussed this as an option with her. She was interested but did not feel ready to commit until many years later.

During my evaluation, Sophia stated that she was now able to commit the time and effort for psychodynamic psychotherapy, since she was planning to leave her job and return to school full time. She was interested in improving her relationships with people, especially men, and wanted to figure out why she has had such difficulty in choosing a satisfying career path. Sophia had begun to feel that time was running out and wanted resolve these matters before life passed her by.

At the time of my evaluation, Sophia was planning to pursue a career in medicine. She had enrolled in a graduate program but continued to work full time. For the first year of treatment with me (consisting of twice-weekly psychotherapy for 3 years and then converting to 4-times-a-week, on-the-couch psychoanalysis), she continued to struggle with whether she wanted to commit to a career in medicine, become a therapist, or perhaps choose a different career path altogether, such as one as a physicist (she was doing very well in her physics classes).

Her vague way of relating, complaints of poor memory, and not knowing what she wanted to do with her life or whom she wanted to be with made me quite skeptical about the benefits of psychoanalytic treatment for this patient. Her identity diffusion as well as a significant Axis I MDD that might well deteriorate in the face of such an intensive treatment made me initially question Dr. A’s recommendation for psychoanalysis. Furthermore, she had fled treatment with Dr. A on several occasions over the years.

Sophia presented herself and others in her life in a vague, 2-dimensional manner. I think she sensed my wariness and countered in like fashion, often reminding me that she was not committed to staying in town (she was seriously considering transferring to a school in a distant city), to her current job or plans to attend medical school, and therefore by inference to our treatment. In addition to Dr. A, a consultant at the time of the evaluation also considered Sophia to be sufficiently structured to tolerate psychoanalysis. I tentatively agreed but reserved judgment in the early years of treatment, as I kept treating her in a psychodynamic psychotherapy.

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