Counseling and Psychotherapy

Psychodynamic interpersonal therapy is a time-limited treatment that integrates psychodynamic, humanistic, and interpersonal concepts. The emphasis of the sessions is on the counselor and client collaborating to develop a feeling of partnership through a mutual understanding of language and communication, resulting in a conversational style of insight-driven dialogue. The counselor’s role is to remain unbiased and help the client consolidate their own identity and to exhibit total acceptance of the client by engaging in an ongoing, self-reflective awareness of any bias that can lead to therapeutic ineptitude and impairment. The duration of the treatment is approximately 12 weeks and is delivered in three phases. The counselor first identifies the diagnosis and the interpersonal contexts in which it presents. The counselor then links the diagnosis to an interpersonal focus and brings the client into the second phase of treatment, during which the counselor uses specific strategies to help the client identify and resolve clear interpersonal problem areas. The final phase consists of the counselor and client discussing role transition and rebuilding interpersonal deficits with a focus on termination and maintenance beyond counseling (Markowitz & Weissman, 2004). Attention to cultural dynamics is emphasized; psychodynamic techniques may reveal the influences of trauma that were caused or shaped by diversity inequities.

Transactional analysis suggests that emotional conflicts do not arise from the superego mediating the id and ego but instead emerge from unhealthy mutual interactions among the three. A therapist gains significant understanding of a problem by observing verbal and nonverbal communications between two or more people, which helps the therapist and client identify the source of the crossed, or unhealthy, response style. The three styles of responding are the parent, the child, and the adult. The first ego state, the parent, holds the memory of rules and norms absorbed by exposure to external events in childhood. The second ego state, the child, holds the emotional memory of the client, including emotional responses to interactions with caregivers. The final ego state, the adult, assimilates the thoughts, feelings, and behavioral responses learned from childhood differentiation of rules and norms versus internal motivations. The therapist can use this triadic ego model to help clients understand their communication styles; for example, they might have learned a dominant ego state as a reactive response to child-rearing practices in the first 5 years of life, and their identified problems emerged because of inefficient reinforcement of healthy human interaction patterns (Berne, 1961).

Past experiences provide valuable insight into the client’s current functioning and object relations themes and may be included in a dialogue with the client to meaningfully frame current difficulties in the context of contributed experiences. This concept provides the foundation for the counselor working with clients with challenging diagnoses and serious mental health issues. Using a psychodynamic model, the counselor focuses on a core segment of the client’s interpersonal functioning, which is closely connected with the presenting symptoms causing functional impairment. The unconscious, recognizable as urges and impulsivity or a flattened affect, remains the primary focus of treatment, and the aim in the treatment of serious mental illness is to trace the overt symptoms of the diagnosis back to their unconscious origins and analyze them through the use of rational thought and processing. This is an active and directive process for the counselor in the beginning, and the goal is to develop a sense of stability in the client by creating a conscious link between historical processing and current circumstances, thereby synthesizing personality components into one functional unit as the client develops a sense of empowerment (see Sidebar 3.2).

Traditional psychoanalytic theory suggests that all psychological disorders are the result of unconscious conflicts manifesting in emotional dysregulation with behavioral consequences, which cause intrusions of hidden drives into voluntary behavior when defense mechanisms fail. Current approaches consider all presenting symptoms meaningful and relevant to the client’s subjective experience and are therefore useful in treatment. Brief psychodynamic approaches have emerged from traditional psychoanalytic theory with clinical success among populations diagnosed with serious mental health disorders, including chronic depression, borderline personality disorder, and posttraumatic stress disorder. The emphasis on insight varies by client functionality, and the focus remains on transference and countertransference, with consideration placed on the event, neuropsycho-logical function, and current circumstances (Bond, 2006). Current psychodynamic approaches that emphasize time limit, therapeutic focus, and counselor directiveness are particularly relevant for addressing disorders that require intensive intervention (see Sidebar 3.3).

A strong trend in counseling is a growing interest in the relationship between personality disorders, attachment theory, and links to neuroscience. This relationship is being explored by using neuroimaging techniques to discern the difference between psychodynamics (or the motivational influences that are actively blocked from awareness) and etiology (or causes of pathological behaviors). Counselors may use this information to understand how different brain structures react with incredible precision to a variety of stimuli, whether they are cognitive, pharmacological, or emotional. For example, data acquired from neuroimaging techniques show that explicit memory is defined as conscious memory, whereas implicit memory is defined as unconscious. The hippocampus, which is responsible for coding memory, is directly affected by the amygdala, the emotion center of the brain. Thus, when a client experiences an emotional trauma, the perception of the trauma is coded into memory as conscious or unconscious content (Barry, 2014).

The degree to which structure and support are generally provided by the counselor depends on the functional level of the client. Experienced counselors who have incorporated psychodynamic techniques into their practice with clients with serious mental illness suggest taking the following steps during interventions (Lemma et al., 2011):

1 Identify an attachment-related problem with a specific relational-emotional focus that the client identifies as the cause for diagnostic symptoms.

2 Collaborate with the client to create a concrete conceptualization of interpersonal issues raised by the problem.

3 Attend to the structure of the dialogue between counselor and client and examine transference as a relational theme to generate alternative ways of thinking and feeling.

4 Attend to the therapeutic process and invite the client to evaluate the process of change as it is happening.

5 Provide the client with a written summary of the collaboratively created view of the client’s area of unconscious conflict. This serves as a tangible reference for the client in moments of relapse.

Psychoanalytic theory has been both acclaimed for its effectiveness and highly criticized for its limitations. Traditional psychoanalysis used structural, developmental, and motivational constructs to describe the complexity of human personality functioning. Many theorists and practitioners focus their criticisms on the lack of specific attention to the present and future and, in particular, on the lack of attention to cross-cultural applications and the potential for bias toward specific client populations. Others favor the theory because of the dynamic foundation of development and structural components used to explain personality development and its contemporary applications to present maladaptive functioning (Petrocelli et al., 2001).