What is the change agent in relational psychodynamic therapy
The history and theory of psychodynamic psychotherapy since Freud’s time is complex, and his ideas have undergone numerous permutations and iterations. This evolution has paralleled paradigm shifts in science in the 20th century, which emphasize interconnections, mutual interactions, and subjectivity of phenomenon (Curtis & Hirsch, 2003). Each psychodynamic model evolved from the others before establishing a new perspective placing different emphasis on human development and motivation for behavior. New perspectives addressed what was seen as the failure of Freud’s theory (Mitchell, 1988). These competing schools of thought—freudian, ego, self, existential, lacanian, analytic, object relations, interpersonal, relational, and intersubjective—are somewhat insular and fragmented in that each seems to take little notice of the others. Each school developed its own theoretical constructs and techniques. The following overview highlights selected theorists and does not do justice to the complexity, richness, and nuances of psychoanalytic theory.
Sigmund Freud’s classic model of psychoanalytic psychotherapy is based on drive theory; all behavior is determined by unconscious forces or instincts, either sexual or aggressive. Freud’s structural model of the id, ego, and superego explains the idea of psychic conflict. Symptoms are thought to develop through a conflict between an instinctual wish (id) and the defense against the wish (ego). The superego is part of the unconscious and is formed through internalization of moral standards of parents and society, and it acts to censor and restrain the ego. The concept of psychic determinism is embedded within this model and refers to the idea that nothing happens by chance and that everything on a person’s mind and all behavior, pathologic and nonpathologic, has a cause and is multiply determined. Freud delineated the psychosexual stages of development based on the idea that libidinal energy shifts from various erogenous zones in each stage. Freud posited that if a person had not successfully negotiated the previous stage, specific problematic character traits or psychopathology would continue throughout life (see Table 8-1).
In the 1960s, the scope of psychoanalysis was widened by interpersonal theorists such as Harry Stack Sullivan, Karen Horney, and Eric Fromm, who stressed the importance of relationship. Sullivan believed that the details of the patient’s interactions with others provided insight into what would help resolve intrapsychic difficulties. Using Sullivan’s framework, Hildegard Peplau developed the psychodynamic interpersonal model for psychiatric nursing. Sullivan’s perspective of the therapist as participant-observer expanded the prevailing paradigm. Sullivan believed that the therapist was not just a passive observer of what was going on in the patient but was a participant in the process of psychotherapy.
Ego psychology and object relations theorists such as Margaret Mahler followed with increased emphasis on relationship in producing change. Mahler’s object relation theory evolved from her observations of infants and children and analysis of this qualitative data (Mahler et al., 1975). Stages of development based on separation-individuation were described, explaining how children develop a sense of identity separate from their mothers (see Table 8-2). The infant was described as being totally dependent, with relatively little self-other differentiation, and the child develops through a relationship into a separate person with a high degree of differentiation.
Klein and Fairburn combined intrapsychic theory and drive theory with the idea that the primary motivation of the child is to seek objects (Curtis & Hirsch, 2003). Object means the internalization of experiences with other people. Object relations theorists posit that people are primarily motivated to seek other people and that this is the central motivating force in development rather than drive gratification (Winnicott, 1976). Winnicott (1976) speculated that for a child to develop a healthy, genuine self, as opposed to a false self, the mother must be a “good enough mother” who relates to the child with “primary maternal preoccupation.” The child then can grow and explore without overwhelming anxiety feeling that the world is safe. The child develops a sense of “me,” and those aspects that are not part of him or her create a potential space between him/herself and the mother. This is the area of play and is an important dimension of the development of the self. Winnicott (1976) said that the therapist’s chief task is to provide such a “holding environment” for the patient so that the patient can have the opportunity to meet neglected ego needs and allow the true self to emerge. In contrast to the good enough mother, the “not good enough mother” is thought to create a dynamic in subsequent relationships in adult life, in which the person feels never good enough. Alice Miller (1981) in her widely recognized book, The Drama of the Gifted Child, describes eloquently the adverse effects of certain types of parenting on the development of the child’s true self.
Building on Freud’s ideas about intrapsychic conflict, Erik Erikson, a lay psychoanalyst, expanded the theory of development to encompass the entire life cycle. He conceptualized life as a struggle of conflicting needs in the quest toward self-actualization (Erikson, 1964). These conflicting needs revolved around the need for stability versus the need for growth at each stage of development. Table 8-3 shows Erikson’s stages of development. As we move from infancy to old age, Erikson posited that we face a stage-specific conflict that involves themes of inhibition versus desire. Although similar symptoms may be experienced in each stage, each of the eight stage-specific conflicts may have a different meaning, depending on unique issues and emotions for that particular stage, and success at resolution depends on how successfully the person has negotiated the previous stages. For example, a 21-year-old woman came to therapy after being raped in college. She had become significantly depressed and attempted suicide shortly after the rape. Her depression reflected a loss of identity that was shattered beyond repair. She had previously functioned as her parents expected her to and was generally motivated to meet others’ expectations. Her depression precipitated an exploration of her own values and who she really was, a process that gradually allowed her to rebel against the need to conform. Finding her own voice was integral to the treatment, and she eventually was able to articulate the differences between her opinions and those of her parents. Her depressive symptoms represented the conflicting need for stability and conformity versus the need for self-awareness and growth.
Significantly departing from the idea of intrapsychic conflict, Heinz Kohut developed self-psychology based on a deficit model of development. Kohut posited that the self was the central organizing frame of reference and that the self seeks out responses from others to maintain self-cohesion (Kohut & Wolf, 1978). Contrary to Freud’s conception of the individual as primarily being driven by the quest for pleasure, Kohut’s self strives for competence, self-esteem, and order, and these are the sine qua non motivators of behavior. Others serve self-object functions for the individual, and these include mirroring, idealizing, and alter-ego experiences. Individuals never lose the need for self-object experiences throughout life. If self-object experiences are less than adequate in early life, the person may later in life have difficulty with self-soothing, self-regulation, and maintenance of self-cohesion. Kohut based this idea on the clinical observation that a certain subgroup of patients developed an idiosyncratic transference in therapy, which he called the narcissistic transference. These patients, unlike the typical analytic patient, needed mirroring and idealized the analyst. Those with this type of self-pathology formed attachments based on these needs. Kohut posited that empathy played a central role in the psychotherapy of those with narcissistic psychopathology.
The relational model evolved in the 1980s from object relations, self, interpersonal, existential, and feminist models. This significant shift in the psychoanalytic paradigm changed what was called a one-person psychology to a two-person psychology (Gabbard, 2004). This awareness of two separate minds interacting with one another is also referred to as intersubjectivity. The therapist is considered a co-participant in the co-construction of the relationship, not an outside observer. It is only in the present moment as the process is unfolding that both participants’ understanding is deepened. The need for relationship derives from the physical closeness to the mother and is thought to be the prime motivator for behavior. The presence of the other is necessary and inescapable in human development and in the therapeutic relationship. Self-regulation results from mutually regulatory interactions with caretakers and evolves within the mother-infant dyad. Relational psychodynamic theory heightens our understanding about the need for attachments for psychophysiologic stability.
Schore’s (2003, 2006) neurobiologic research on attachment provides a scientific basis for relational theory and the importance of relationship to therapeutic action in psychotherapy. The growing capacity to self-regulate is contingent on transformations of underdeveloped functions that exist in the infant through early attachment experiences that assist the developing psychobiologic, homeostatic regulatory processes. Cumulative early attachment problems are thought to produce chronic dysregulation in central and autonomic arousal, with deficits in mind and body. Chapter 2 discusses the neurophysiology underlying this dysregulation. Problems in self-regulation include difficulties in tension regulation, such as addictive disorders, eating disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder, and mood disorders.
A basic tenet of the contemporary relational model is that the therapist and patient are always participating in a relational configuration and that understanding this process is how change occurs. Before relational theory, much discussion ensued about the differences between the transference relationship and the “real” relationship between the therapist and patient. The transference and the patient’s feelings toward the therapist were artifacts of the past, whereas the real relationship was what was going on in the present. In the relational model, however, this is irrelevant, because there are multiple truths, and there is no real relationship, only a co-constructed interaction that is at best subjective (Safran & Muran, 2000). This interaction coupled with mindfulness is the agent of change, and developing and repairing problems in the therapeutic alliance is considered the work of relational psychodynamic psychotherapy.
Embedded in this idea of multiple truths is the concept of multiple selves; there is no unitary true self, but each person is constructed with many self-states. Different self-states are based on the various states of consciousness that we flicker in and out of throughout the day. Chapter 2 discusses the neurophysiology supporting this idea. These shifting, multiple self-states elicit complementary self-states in others through relationship. Dissociated self-states that are experienced as potentially dangerous are kept from the person’s awareness. By “potentially dangerous,” Safran and Muran (2000) explain that these states are associated with actual traumatic experiences or disruptions of relatedness to significant others. Assisting the patient to experience and accept the various dimensions of the self through enhanced awareness of these traumatic states is considered crucial to the relational psychodynamic therapy process.
A synthesis of the literature on the relational model reveals significant differences between freudian psychodynamic psychotherapy and relational psychodynamic therapy. Table 8-4 compares and contrasts these models.