William N. Goldstein, MD

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 and the Transference

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 

to 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.

Gabbard GO, Wilkinson SM (1994), Management of Countertransference With Borderline Patients. Washington, D.C.: American Psychiatric Press Inc. 
 

Goldstein WN (1998), A Primer for Beginning Psychotherapy. Washington, D.C.: Brunner/Mazel.
 

Hoffman IZ (1996), The intimate and ironic authority of the psychoanalyst's presence. Psychoanal Q 65(1):102-136. 
 

Renik O (1996), The perils of neutrality. Psychoanal Q 65(3):495-517.

Articles

This article addresses several important theoretical issues related to dynamically oriented psychotherapy. 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.

Dynamically Based Psychotherapy: A Contemporary Overview

This article addresses several practical issues related to beginning psychotherapy: telephone contact, the initial session, referral to another therapist, discussion of arrangements, charging for missed sessions, guidelines for the patient and interactions outside the therapy hours. It takes a question-and-answer form, dealing with with questions a neophyte psychotherapist might ask. Although the article specifically relates to treatment that is dynamically oriented, it is also relevant to other forms of psychotherapy.

How Should the Therapist Handle the Initial Phone Call?

The first contact with a patient is invariably by phone. This contact can vary from simply setting up an initial appointment to a prolonged discussion. The therapist can easily answer questions regarding fees, office location, time availability, and experience and credentials. Questions regarding the therapist's comfort and expertise with

certain types of problems, in addition to the type of therapy typically utilized, are also reasonable.

It is usually advantageous for the therapist to be friendly and open, answering relevant questions in a straightforward manner. It is not advantageous at this early time to delve into the reasons for the questions, speculate on the dynamics or make any kind of interpretive comments. At this stage, these types of interventions appear intrusive and are usually not appreciated.

If the questions become more personal, or go on and on, limits need to be set-but in a very tactful way. Phone calls resembling initial sessions are best avoided. Contrary to the expectations of some, lengthy phone conversations are not positively correlated with a potential patient's ultimate decision of whether to undergo treatment with a specific therapist.

If the therapist only has five or 10 minutes when returning the call, it is reasonable to state such at the beginning of the conversation. Sometimes it is appropriate to call the patient back if additional information is desired. For example:

: Before we start, I do want to mention that I have an appointment in 10 minutes. If we don't finish by then, I'll be happy to call you back. 

 We are going to have to stop in a minute or two. If you like, we could set up an appointment. Or I'd be happy to call you back if you need more information.

What Kinds of Patients Tend to Stay on the Phone?

Long initial phone questioning is most characteristic of borderline patients. Some of these individuals are preoccupied with searches for the "ideal" therapist. Feeling quite vulnerable to the vicissitudes of relationships, they want to feel as comfortable as possible before the initial session. These patients sometimes look for therapists with whom they feel the right "vibrations, wavelengths or sensations," the ones whom they sense are similar to themselves and the ones who share similar values, philosophy and upbringing. Initial phone conversations can be reflective of these searches. With these individuals, tact and patience is of the greatest importance. Limits have to be set with the patient, but with the utmost skill and sensitivity.

The following comment was made after a 20-minute conversation in which the patient had basically found out all the necessary information and more.

: I don't want to be impolite, but I do have to go in several minutes. I do think we've covered the relevant questions about psychotherapy. Certainly I will be happy to answer additional questions when we meet. Would you like to set up an appointment?

Upon meeting the patient, I introduce myself, invite the patient in, and then say, "Why don't you have a seat." I then pause, allowing the patient to take the lead. If asked for clarification about what to say, I state, "Why don't you tell me about yourself, especially in reference to coming to see me today." I want the story to be presented in the patient's own way; thus, I do not interrupt, except to ask for relevant clarifications.

I am not concerned about obtaining all the details in the first session; rather, I am interested in hearing how patients talk and think, and in learning about their personalities, conflicts, strengths and weaknesses. I want them to feel as comfortable as possible, so that they'll continue the process. With that in mind, I make empathic comments if relevant, and try to maintain a friendly and interested stance.

If a patient's anxiety demands that I ask questions, I do so. Otherwise, I don't interrupt. I am particularly interested in the motivation for therapy. With that in mind, I often ask what ideas the patient has about treatment, what gain is hoped for from therapy, and how the patient thinks the process works.

With about 15 minutes left in the session, I note that there are about 15 minutes left, and that I want to shift focus. I state that although what the patient is saying is very important, I want to make sure that there is time to ask me questions. I find it rather important to make this intervention, because many patients have definite questions they "need" to ask. However, they typically do not ask unless invited to do so, at least not until the end of the hour. Then, either the session has to be extended or the patient leaves frustrated.

When making a referral, a common practice is to give patients three names, so that they can interview each and make their own selection. I do not agree with this approach. I do not know how a patient can make a rational decision about which of three therapists will ultimately be best on the basis of one or two interviews.

With the above in mind, I prefer to give only one name. I tell the patient that, although I think that the therapist selected should work out, if there are any problems, to please call me. Before referring, I discuss with the patient the type of therapist desired, finances, geographical location and any other relevant issues. With that information in mind, I select a therapist whom I think will work. Additionally, I find out if the therapist has hours available that are suitable for the patient and is willing to see the referred individual. If the patient is dissatisfied with this referral, I am then willing to discuss the relevant details, making another referral when appropriate. One name, given in this manner, works out the vast majority of the times. If, however, the patient is insistent on getting three names, I go ahead and give them.

What Initial Arrangements Need To Be Discussed With the Patient?

Arrangements that need to be discussed early on include scheduling of appointments, payments, handling of missed appointments, guidelines for the patient and, on occasion, expectations regarding interactions outside the sessions. Scheduling appointments convenient to both patient and therapist is, of course, ideal. Payment arrangements that need to be addressed include both fee and collection policy. Many therapists have some flexibility in their fees, with some ability to make adjustments in accordance with the patient's income. In these situations, frank discussion of the patient's finances and insurance coverage need to be part of the fee-setting. It is important that both therapist and patient are comfortable with the fee.

A usual practice is to bill at the end of the month and collect shortly thereafter. Payment can be due the session after the bill, two weeks later or a month later. Sometimes there is an agreement to wait until the patient has collected from insurance. Whatever the arrangements, they need to be clearly agreed upon. Deviations from the agreement then can be focused on in the treatment hours, as they occur. Charging for missed sessions, guidelines for the patient, and interactions between therapist and patient outside the sessions will be discussed in the final three questions.

Some patients enter treatment with some urgency, in some state of crisis or regression. They are preoccupied with their problems, and want to address them as soon as possible. For these patients, discussion of the above arrangements can be burdensome, seeming like a distraction. For patients in this category, I discuss the arrangements piecemeal, after some of the presenting issues have been addressed, and when the patient is in a calmer state. The patient is then able to approach the arrangements both with more interest and more cooperation.

Should Patients Be Charged for Missed Appointments?

Not long ago, the usual rule regarding missed appointments was for the therapist to charge unless the time was filled. A reasonable addition to this was that, given advance notice, the therapist was willing to reschedule, if possible. Although still reasonable in many cases, this rule appears to be going out of favor. Some therapists have a rather liberal policy of not charging if notice is given a certain number of hours in advance (like 24 or 72). Others do not charge if there is a good reason for the missed appointment. The latter is never a good idea. Illness, car problems, college examinations or other important appointments, although reasonable on the surface, are often used as resistance. Evaluation of the reasons for missing appointments puts the therapist in the unwanted position of an authority figure, inviting the patient to rebel.

The therapist can show some flexibility in establishing agreements regarding missed sessions. I favor telling the patient that my usual policy is to charge for missed sessions unless I fill the time. An exception is that I am willing to reschedule hours, if possible, when given advance notice. I state that I understand many have difficulty with such a policy. Thus, if the patient has any misgivings, I am willing to discuss them.

I do believe that the policy as stated is beyond the usual experience of many. Some patients see it as overly rigid, greedy, one-sided and unfair. With those who are not able to understand it from the therapist's perspective, the policy is not a good one. In these cases, modifications are necessary. With some patients, where I sense that there will be clear antipathy toward the usual policy, I do not bring it up. If and when a problem arises with these patients, I approach it in a flexible manner.

It is useful for the patient to be given a set of guidelines regarding psychotherapy near the initiation of treatment. These guidelines establish a frame for the therapy, one that can be returned to whenever there is a deviation. A standard presentation that is useful for most patients is as follows:

Therapist: These sessions are yours, to talk about anything you want. It will be up to you to choose the topics. Often there will be topics that are on your mind that you very much want to talk about. At other times, this will be less clear. At times when you do not have topics of pressing importance, it is helpful to talk freely about anything that comes to mind. In fact, whenever you have extraneous thoughts or fantasies, it is useful to talk about them. 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.

Regarding interactions between patient and therapist outside the therapy hours, the general rule is the less, the better. The therapist can make it clear that calls at times of true emergency are welcome and even expected; otherwise phone calls are not desired. Emergencies necessitating calls sometimes need to be spelled out; many so-called emergencies can be easily handled without the therapist. The generalization here is that psychotherapy proceeds best when it is confined to the therapy sessions. If there is not enough time during the sessions, the frequency of the sessions can be increased.

Of course, there are numerous exceptions. Some patients, for example, need very brief occasional contact to confirm the reality of the therapist. Others need various kinds of brief contact to avoid overwhelming anxiety. Under these circumstances, therapist and patient can arrange for limited telephone conversations.

Specific agreements regarding phone calls need not come up at the beginning of treatment, unless an obvious problem is anticipated. Discussion can wait until after the first or even second call. At that time, the rationale for any limits can be stated and discussed. Limits set in a reasonable way can make the difference between virtually no phone calls or daily phone calls. To set these limits well, the therapist needs to have good boundaries regarding the therapy hours, plus the belief that therapy is best carried out when it is confined to well-defined sessions.

Practical Questions Beginning Psychotherapy

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."

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.

The main difference between dynamically oriented psychotherapy and analytically oriented psychotherapy is downplaying transference as a therapeutic modality in the latter. Although transference reactions are noted, especially when they occur as resistances, the elaboration of the transference is not a major ingredient in this form of psychotherapy. 

Rather, therapists and patients focus more exclusively on present-day interactions and relationships, and their correlation to the patients' past. Patients and therapists work together to try to understand these present-day interactions on the basis of each patient's sensitivities, vulnerabilities and distortions, which originate in the past. A positive therapeutic alliance is fostered, and therapists are sometimes mildly idealized. Occasional suggestions, education and other supportive techniques are employed, along with the insight-oriented interventions of clarification, confrontation and interpretation. Supportive interventions include suggestion, therapeutic manipulation, abreaction, advice, reassurance, education, limit setting, reality testing, and giving encouragement and praise.

Analytically oriented psychotherapy is the preferred treatment for those patients who can form an intense transference in psychotherapy, and then use that transference constructively without regression. Some healthier (i.e., neurotic) patients can form an intense transference in psychotherapy, but many have difficulty accomplishing this. Psychoanalysis proper (with the use of the couch, free association and the increased number of sessions) is especially designed to help induce an intense (and regressed) transference in neurotic patients. Only psychoanalysis can attain this result for many neurotic individuals, to whom intensity and regression do not come naturally.

When psychoanalysis-for whatever reason-is excluded, one faces the question of which kind of psychotherapy to pursue. There are two contrasting opinions. One opinion favors simulating analysis as much as possible, with an all-out attempt to establish and utilize an intense transference. A second opinion, emphasizing the difficulty in attaining transference regression with neurotic patients in psychotherapy, favors using a dynamically oriented approach. Many therapists lean toward an analytically oriented modality for those neurotic patients (often hysterical in personality type) who can form a somewhat intense transference in psychotherapy. These therapists would employ a dynamically oriented model for other neurotic patients (often more obsessive in personality type) who have greater difficulty regressing.

The typical borderline patient, in contrast to the neurotic, has little difficulty forming an intense and regressed transference in the psychotherapy situation. In fact, the rapid mobilization of transference often distinguishes the borderline individual from the neurotic. Thus, analytically oriented psychotherapy is usually the treatment of choice. The common problem with these patients is in containing the transference regression. 

With this in mind, modifications in technique (from the pure form of analytically oriented psychotherapy) are needed. Modifications include continual focus on the working alliance, more supportive interventions and alterations in style (such as more attention to an empathic and affirmative stance, the use of preparatory comments and the use of increased input from the patient). Elaboration of these modifications are described elsewhere (Goldstein, 1996).

For psychotic patients, to whom intense transferences can be clearly disruptive, the dynamically oriented approach is recommended. With these patients, supportive interventions predominate over insight-oriented ones.

When recommending either analytically oriented or dynamically oriented psychotherapy, one must often contemplate a long-term proposal. With managed health care, where duration of treatment is vastly limited, a long-term model rarely fits. Yet this kind of treatment is highly valued and desired by many individuals. Studies (Lazar, 1997; Stevenson and Meares, 1992) demonstrate the clear worth of such therapy and its necessity for certain groups of patients. One answer is to go outside of the managed health care system. 

Some individuals are able to pay out-of-pocket; others can find good therapists who will charge lower fees when longer-term therapy is indicated. In the District of Columbia area, I am almost always able to place very motivated patients in a reduced-fee setting with a reasonably experienced therapist; I do not know how easily this can be accomplished in other areas.

Being familiar with the details and nuances of analytically oriented and dynamically oriented psychotherapy is an advantage even to therapists who operate within the managed health care system. Although modifications are often needed, many of the strategies and therapeutic techniques of dynamically informed psychotherapy are applicable to shorter-term work. Additionally, there is an expanding literature on dynamically informed short-term approaches. In my opinion, it behooves the managed health care therapist to learn traditional psychotherapy first, then to supplement this knowledge with that of the shorter-term approaches.

Dr. Goldstein is a teaching analyst and the director of the Adult Psychotherapy Training Program at the Baltimore-Washington Institute for Psychoanalysis, as well as clinical professor of psychiatry at the Georgetown University Medical Center. He has written extensively in professional journals and has published three books: An Introduction to the Borderline Conditions (Jason Aronson 1985), Dynamic Psychotherapy with the Borderline Patient (Jason Aronson 1996), and A Primer for Beginning Psychotherapy (Brunner/Mazel 1998).

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.

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. Psychoanalysis proper stands at the end of this continuum, followed by analytically oriented psychotherapy, then dynamically oriented psychotherapy. Within this classification, analytical oriented psychotherapy and dynamic oriented psychotherapy are two quite distinct, yet related, forms of therapy.

Author | William N. Goldstein, MD

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