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The author presents a fictionalized case based on a real patient to encourage colleagues to pursue psychodynamic psychiatry.
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.
I learned that Sophia was born to married parents in the suburbs, with 2 siblings (she is the middle child). She had graduated at the top of her class in high school and attended a prestigious college, where she had a double major in the biological sciences and humanities. She had intended to go to medical school after receiving her BA. Yet, she continually questioned her capabilities, constantly comparing herself with her peers, which negatively affected her self-confidence and left her questioning whether she had what it took to become a physician.
Sophia described her father as an energetic, personable man “who values intelligence and education.” He has his own consulting firm and also teaches at a local college. Her mother, “a depressive woman,” gave up her career as an accounting assistant to join her husband’s consulting firm, which she now regrets. Sophia’s mother believes the firm is struggling financially because of the rigidly obsessional nature of Sophia’s father and resulting inability to complete projects and bill clients on time.
Sophia’s mother often asked her for money. Before her treatment, Sophia would always readily give it to her, yet worried about ever being able to own a house or even a car. When I questioned Sophia about this, she expressed guilt over being so fortunate in life and felt a duty to help others in need. Sophia regularly paid for lunches and dinners out with friends and family and showered them with extravagant gifts, even when they could well afford to pay for themselves. They rarely, if ever, reciprocated.
Sophia’s older brother is single (previously engaged) and a successful investment banker. Sophia described their relationship as contentious and competitive. For example, they did not speak for a year after she won a game of Monopoly. Her younger sister is single and lives with roommates in another city and works as a paralegal. She and Sophia are extremely close and speak on the phone or text daily. Sophia describes her sister as outgoing, athletic, and adventurous and wonders why “such a catch” remains single.
Sophia has had 2 heterosexual relationships in her lifetime. The first relationship was in high school, and the second was with a man that she met in college and dated on and off over the years. The first relationship was primarily sexual, with a boy who would not acknowledge her as his girlfriend. She described him as athletic, outgoing, and ambitious. Sophia was heartbroken to discover that he was seeing other girls. She became very depressed with increased tearfulness, anhedonia, and loss of appetite; she dropped out of intramural sports and became increasingly socially isolated.
Her second relationship began in her freshman year of college. He was not a student but lived in town and was a distant friend of the family. He held a series of manual labor jobs and had dropped out of school in the eighth grade. They dated on and off while she was in college and maintained a long-distance relationship after she graduated. They became engaged around that time, but Sophia developed cold feet and broke off the engagement. Soon after, he met someone else and fathered a child. Learning this news was the main trigger for Sophia’s second depressive episode.
Over the years, their relationship continued in an on-again, off-again manner; his marriage eventually dissolved and they continued to maintain contact, even living together for a brief time. Each time they spoke of marriage and children, Sophia got cold feet and ended things, although she desperately wanted a partner and children.
In treatment, Sophia initially presented herself as a model patient, showing up early for appointments, rarely canceling, and paying on time, if not early. This continued for the first 2 years, after which things began to change. Around that time, she began canceling and missing sessions, showing up and paying late, and questioning the treatment in general.
When this shift occurred, I initially found myself colluding with Sophia’s passive-aggressive behaviors, allowing myself to become distracted by her apologies and promises that she was going to improve her behavior. This assuaged my anger until the next time. I soon began to realize that we were avoiding speaking about what might be going on in the treatment that made her cancel or be late for her appointments.
This eventually came to a head after I came back from vacation one summer. Sophia returned from the break stating that she wanted to have fewer sessions each week and also requested early morning appointments. Rather than exploring these requests and what they meant to her, I discouraged her from doing so and told her that I did not have any early morning appointments available. I was commuting into the city daily and felt very reluctant to give her early appointments in order to avoid the heavy rush hour traffic.
Sophia responded by canceling more sessions in the following months, showing up late on a number of occasions, and questioning the treatment and whether we were suited to be working together. After I repeatedly asked her about and tried to explore the missed and late sessions, one day she exclaimed:
Sophia: It would be easier to get here on time than talk about why I was 45 minutes late. It would just be easier to be on time. I don’t really enjoy having to dissect why I was late. I get that it says something, I guess I just don’t want to explore what it is saying. I’d just rather be on time.
Me: But you haven’t been. What’s that about?
Sophia: Being late all the time says something about how much or little I prioritize being here. It’s not something I would come out and say, necessarily. Well, I guess I just did. . . . Yeah, but I guess being late says maybe I don’t respect your time as much as I should.
At the time, I was struck by how devalued and not prioritized I felt as a result of Sophia’s declaration. Suddenly, I realized that perhaps she was making me feel the way she feels most of the time out in the world. Knowing this intellectually and really feeling it firsthand emotionally were 2 completely different things, and I REALLY felt it in this moment. I also realized that I had not been prioritizing Sophia either. So I responded:
Me: You saying that, makes me wonder how much of a priority you feel you are with me and with others.
Sophia: Um, priority, I don’t think I’m top priority for anyone. I factor into peoples’ priorities, like my parents. But now that I’m older I don’t feel top priority with them either. With you, I don’t know what priority I am. As MUCH as I’ve been coming here and we’ve been working together, that says something. But like, I guess I don’t know what kind of priority I am to other people.
Me: Maybe sometimes it’s just better not to look, than to look and realize you are not a priority.
Sophia: Well, yeah, definitely. If you’re not looking at it, then you don’t need to be concerned. I’d rather just not be aware. It creeps into my awareness at times, but it’s pretty simple to think of other things and distract myself.
At the time, and even now in looking back, I experienced this session as a turning point in my work with Sophia. I was beginning to prioritize and think more about her. Perhaps she found both my emotional absence and then my renewed interest equally distressing. I wish I had said that to her in this session, that sometimes it’s just as difficult to realize that you are being noticed and paid attention to by another as it is to realize that you may not be.
I wish I could say this session marked a magical turning point with Sophia, and that after this breakthrough she suddenly started coming more regularly to sessions and stopped being late. It did help somewhat, but not drastically, and certainly not right away. More importantly, however, it helped provide me with more insight into Sophia’s experience of being in the world, which she had carefully kept hidden, and her conflicted feelings about me realizing it. Furthermore, she surprised me with her willingness to show up and reflect on events such as these during the sessions. As a result, I have begun to realize that this has been the goal all along, and that the behavioral changes were secondary to being able to consistently show up and reflect on what is going on in the treatment.
Over time, I have observed positive changes in Sophia’s mental status. She has become better groomed; her hair is longer and attractively styled. She went clothes shopping for the first time in years, began to develop a style, and became interested in accessories, spending a few sessions discussing purses and shoes with me. She also started to wear contact lenses, which has further helped in gauging her increased eye contact. She consistently attempts to be more social (attending parties, going out with men, considering online dating, and reaching out to family and friends for increased contact). In the beginning, Sophia’s affect was very constricted. Her countenance has since relaxed considerably, and she now shows a spontaneous range of emotions during sessions, including laughing, smiling, and expressing sadness.
I often say that a key difference between general psychiatry and psychodynamic psychiatry lies in how psychodynamic psychiatrists view clinical material, evaluate patients, and make-or know when to withhold, depending on timing-interpretations.
Her cloudy, vague disposition has gradually given way to a more clearly expressed sense of self and an improved memory (she continued to do remarkably well in her graduate classes, often earning top scores on exams). Both she and I have come to understand the vagueness and confusion as defenses that prevent others from seeing and knowing her. She has become more aware of and in touch with her anger, envy, and competitive strivings, and better able to tolerate emotional intimacy without fleeing.
Since the early days, I have carried with me a mental image of Sophia, beautiful and strong, laughing in a carefree manner with her peers. A consultant remarked on this being reminiscent of Hans Loewald, who believed it was important in analytic work to have such a mental snapshot in mind: “An image of the patient, not as he is at the moment, but as he may yet become. The analyst, in other words, holds this image safe in keeping for the patient until such a time as he may lay claim to it as his own.” I have often thought, in looking back, that it was perhaps this very image of Sophia that kept me going when things felt most difficult. I like to think that she sensed it too-my faith in her-and that this is what helped keep her in treatment despite her worst doubts and wishes to defeat me by proving me wrong.
Dr. A and my consultant were right: psychoanalysis was ultimately the treatment that helped Sophia change. Her predominant defenses are in fact higher order and include intellectualization, reaction formation, and repression. She possesses several strengths, including her formidable intelligence, subtle humor, considerable compassion, and strong work ethic. She does not and has never abused substances or alcohol, remains adherent with her medications, and has been able to maintain many long-term relationships with friends-dating back to childhood.
One day, early in treatment, I asked whether she thought she had a sense of herself but kept it hidden from others and, to some extent, herself. Or did she really not know? Without missing a beat, she firmly said the former. Something in me believed her, or wanted to believe her. Sure enough, this hidden self has slowly but surely begun to unfurl. And (perhaps as a result) we have certainly had our share of rough patches, yet we both still continue to show up and talk about it, which ultimately is what matters.
Acknowledgment-I am grateful to David Lopez, MD, and Jennifer Downey, MD, of the American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP) for their assistance in publishing this article. AAPDP is the affiliate society of the American Psychiatric Association, dedicated to the field of psychodynamic psychiatry. Its mission is to promote the continuing education of psychodynamic principles in the evaluation and treatment of patients in clinical, medical education, and residency training settings.
Jacobs TJ. Hans Loewald: an appreciation. In: Jacobs TJ. The Possible Profession: The Analytic Process of Change. New York, London: Routledge; 2013:232.
Loewald H. On the therapeutic action of psychoanalysis. Int J Psychoanal. 1960;41:16-33.
Dr. Hyun is Assistant Clinical Professor of Psychiatry at Columbia University in New York and is former Trustee of the American Academy of Psychoanalysis and Dynamic Psychiatry. She has a private practice in New York and New Jersey. Dr. Hyun reports no conflicts of interest concerning the subject matter of this article.