Tasks of the Psychoanalytic Psychotherapist
What are the challenges of the psychotherapist in performing psychoanalytic psychotherapy? First, the therapist must ensure that the patient can feel both emotionally and physically safe within the therapeutic relationship. This is accomplished by ac-knowledging the goals of the treatment and defining the role of the therapist and through establishing professional boundaries. Boundaries refer to those constant and highly predictable com-ponents of the treatment situation that constitute the framework of the working relationship. For example, agreeing to meet withthe patient for a specified amount of time, in a professional office, and for an established fee are some of the elements of the profes-sional framework.
Boundaries also have ethical dimensions best summarized as the absolute adherence by the therapist to the rule of never taking advantage of the patient: through sexual behavior; for per-sonal, financial, or emotional gain; or by exploiting the patient’s need and love for the therapist in any fashion (e.g., by using the therapy sessions to discuss the therapist’s own problems). The concepts of neutrality, abstinence and confidentiality further de-fine the role of the therapist. A critical task of the psychoanalytic psychotherapist is to detect when a breach in either role or bound-ary has occurred and to restore the patient’s security through clarifying and interpreting the meaningfulness of such a breach.
The explication of a boundary violation is but one spe-cific example of the technique of interpretation. Successful in-terpretation is based on a number of prerequisite skills. These include the capacity to empathize with the patient’s plight, the ability to recognize the meaning of one’s own fantasies about, and responses to, a patient (countertransference), the ability to maintain the patient’s verbal flow through the use of open-ended or focused questions, and the capacity to tolerate a relatively high level of ambiguity within the therapeutic relationship. One im-portant professional characteristic of the skilled psychotherapist is patience. Psychotherapy is often arduous, and the capacity to “stay in the chair” with the patient is critical.
The identification of repeated patterns of behavior both within the therapy and in the patient’s outside life is a funda-mental technique in making sense of the patient’s emotional life. This, of course, involves the appreciation of transference and the art of knowing how and when to share this recognition with the patient. Interpretation relies on both appropriate timing and dos-age. That is, the psychoanalytic psychotherapist must appreciate when the patient can best integrate the therapist’s observations and must respect the patient’s defenses, taking care not to over-whelm the patient by insisting that she or he confront more than is tolerable.
Psychoanalytic psychotherapy requires the successful en-gagement of the patient and the establishment of a therapeutic or working alliance. The alliance can be threatened by a number of phenomena including, but not limited to, the following
· The therapist’s countertransferences or other limitations in his or her capacity to tolerate the emotions stirred by the patient, resulting in empathic failures and mistakes.
· The emergence of intense feelings and needs within the pa-tient, for example, when an accurate well-timed intervention evokes feelings in relation to the therapist of appreciation and love accompanied by feelings of vulnerability, erotic desire, or inferiority which the patient wants to flee.
· The patient’s being reminded of the existence of others in the therapist’s life, such as other patients or family (e.g., during in-terruptions due to the therapist’s vacations), triggering painful and embarrassing feelings of jealousy and possessiveness.
The therapist’s ability to appreciate and respectfully to acknowl-edge to the patient the impact of these temporal events is critical to the progress of treatment.
All of the psychotherapist’s skills and techniques must be embedded in a consistent and coherent theoretical viewpoint that provides the therapist with a framework to understand the eti-ology and meaning of a patient’s symptoms and dysfunctional behaviors both in the past and in the present in each of the phases of psychotherapy (Table 66.7).
This includes an organized method for understanding the therapist’s unconscious and conscious responses to the patient as well. It requires that the therapist listen to the patient’s commu-nications in a manner that is markedly different from other forms of social discourse. So-called “process communication” speaks to the therapist on multiple levels and through displacement, through passing remarks and jokes, through shifts in topics, and through metaphors and symbols. To assist in understanding com-plicated process communication, psychiatrists often ask them-selves, Why is the patient telling me this now? What might the patient be trying to say about his or her uncomfortable feelings? Is something being said about the therapeutic relationship?
The objective of this type of treatment is to improve the patient’s quality of life largely through enhancing interpersonal relationships by promoting greater insight into perceptual distor-tion and intrapsychic and interpersonal conflict. Psychoanalytic psychotherapy accomplishes this objective by focusing on the pa-tient’s current predicaments as manifested in both life activities and relationship with the therapist. It is at times less concerned with the analysis of transference and the complete discovery of the underlying genetic precursors of the patient’s current psycho-logical problems, depending on the specific clinical situation.