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Psychodynamic psychotherapy is a verbal treatment involving a trained therapist and a patient, which offers a relationship that is focused on decreasing psychological distress by making meaning of feelings and behaviors that may impede the patient from arriving at their goals of well being, either in love or in work. The meanings of the patient's maladaptive psychological patterns are understood to have their origins in traumatic early life experience, modified and modulated also by their biological and social realities. The impact of those early painful experiences has been unconsciously repressed out of the patient's awareness, but nonetheless interfere with the patients' access to those current solutions for achieving psychotherapy.
The following terms are used to describe the dilemma and processes described in capsule form above.
The alliance
The therapist and the patient negotiate a set of agreements that set forth the parameters of the work.
• How does the patient's chief complaint offer a window for understanding the whole personality structure?
• How does the patient hope the therapist will be of use.
The rule of free association
To the extent that the patient can give voice to confusion, anguish, and wrath, the feelings separate themselves from the mass of undifferentiated distress into more manageable particles of cognitively recognizable affects. Freud and others conceived of a process of free association that became a rule of the analytic treatment at that time and remains largely so to this day. The patient is encouraged to say whatever comes to mind, as in uncensored a flow of associations as possible. In effect, this shakes the patient free of the constraints of conscious logic and begins to illuminate the unconscious logic that dictates the associative stream.
For example, from an observation that the person leaving the waiting room just prior to her entering the doctor's office looked pretty sick, the patient may move to talking about a lunch with her sister, and to a comment about flowers on the doctor's desk. She might then remember picking wildflowers with her father on the day that her sister was born, and of the bee sting she sustained at the same outing. Since nothing is accidental, the juxtaposition of ideas that compose the patient's free associations is a clue to the internal and unconscious logic that is occurring simultaneously with the more conscious mental activity of which the patient is aware. The more proximate sting of jealousy about the competing "sibling" in the form of the other patient would lead to the feelings of earlier jealousy toward the sister at the competition for their father's love and attention, and the concomitant wish that the sister might have become ill and died. The patient may indeed find some important insight into why she always reaches for the luncheon check, although her sister is far wealthier at this point.
The transference relationship
Unresolved feelings that originated in the early and dimly remembered conflicts with parents and significant others will emerge in the attitude, assumptions, and yearnings toward the therapist, and allow both to become aware of how the past is clouding.
The counter-transference
This term refers to two levels of the therapist's feelings: those that emerge unconsciously from his or her own unresolved infantile memories, and those that are evoked by the patient's transference targeted at the therapist.
The role of the therapist
• Relative lack of personal revelations
• Neutral stance (not cold or silent)
• Limited availability between sessions, holidays, etc.
Neurosis, cathexis, yearnings, and fears
As the psychotherapy proceeds, the field is open for the emergence of the patient's neurosis. The patient experiences anxiety, or fear, stemming from unconscious fears that are mobilized and indeed invited by the therapist who offers the self as a willing target for those repressed feelings. Now that the patient is an adult with adult capacities (ego defenses), it is possible to confront (repressed fears).
The Ego, the Id and the Superego
Freud's tripartite model posited the id as a repository of instincts; the superego as the influence of parental and civilizing influenced that aim to control the instincts; and the ego that mediates between the press of primitive impulse and moral strictures.
The mechanisms of defense
A "defense mechanism" is an unconscious process that acts to reduce an aversive state, either of anxiety or emptiness.
The maturing individual develops a range of defenses to protect the self from the press of untrammeled instinct on the one hand, or from a suffocating set of constraining rules that have been externally set forth but have now been incorporated into the self.
Reality-denying defenses
• Repression: making painful conscious thoughts unconscious
• Denial: disavowing the existence of a painful reality
• Projection: assigning to another one's unacceptable wishes or feelings
• Projective identification: assigning to another one's unacceptable wishes or feelings and then acting in such a way as to get the other person to display those unacceptable feelings.
• Regression: returning to a younger mode of thought and behavior in response to stress.
Reality-distorting defenses: ("distortion" is the unconscious misrepresentation of real events)
• Reaction formation: making an unacceptable wish acceptable by adopting the antithetical affect or attitude.
• Identification: internalization of qualities of another person out of admiration, learning, and defensively to feel less vulnerable.
• Isolation of affect: separating a memory or experience from its rightful affect.
• Dissociation: walling off of emotional experience, leading to behavior or emotional responses that are not integrated into psychological functioning.
• Hypochondriasis: focus on medical symptoms in lieu of other sources of anxiety.
Reality-respecting defenses
• Rationalization: ascribing logical meaning to irrational thought or behavior.
• Humor: turning unacceptable wishes into jokes.
• Sublimation: rechanneling unacceptable id impulses into acceptable behavior.
• Intellectualization: focusing on abstract thinking to avoid affect.
• Anticipation: the ability to plan ahead to avoid unpleasant consequences.
• Altruism: generosity toward others to overcome unacceptable impulses such as envy.