A Psychoanalyst’s Experience as a Patient in an Empirically-Supported Psychodynamic Psychotherapy

by William Gottdiener

There is a growing body of empirical research, mostly in the form of randomized controlled clinical trials, that supports the efficacy and effectiveness of psychoanalytic treatments (Leichsenring & Klein, 2014; Shedler, 2010). The now decades long turn to testing the efficacy and effectiveness of psychoanalytic treatments via empirical research methods has been controversial in some quarters within the psychoanalytic community because some people believe that clinical case studies are the best method to advance psychoanalysis (Hoffman, 2009). Arguments for the case study approach are that it supports the idiosyncrasy of each treatment, the humanity of the experience, and the focus on the individual. Arguments against empirical research are that it proscribes and prescribes treatment and therapeutic technique, eliminating the clinician’s freedom and creativity to make new clinical and theoretical discoveries and to offer the best treatment for the individual person who is before them.

Are empirical research and the art and freedom of the clinician that is found in the case study method at odds? Can they co-exist or even be complementary? I am a practicing psychoanalyst and psychoanalytic researcher who has made contributions to the science of psychoanalytic treatments (Gottdiener, 2006; Gottdiener & Suh, 2015) and I am someone who has argued that the case study and empirical research are complementary and not mutually exclusive (Gottdiener & Suh, 2012). I decided to go a step further by going through an empirically-supported psychodynamic treatment, rather than solely rely on making academic arguments, when I recently decided to return to psychotherapy to continue to work on some personal problems. I had several questions about what I might experience in an empirically-supported psychodynamic treatment. Would my therapy follow a lockstep formula based on a treatment manual, lack creativity, humanity, and not offer me anything idiosyncratic that would tailor the treatment to me? Would the treatment be effective? How would it compare with my previous personal and training analyses?

My Experiences as a Patient in Psychoanalysis

I have been in psychoanalysis twice. Each was a classical analysis where I laid down on the couch and was seen between four to five times weekly. My first analysis began when I was 20 and ended when I was 30. My second began when I was 35 and ended when I was 39. The first analysis was a personal analysis and the second was a training analysis. I entered each treatment with similar problems and similar goals. Both of my analysts were Caucasian males. They were psychiatrists trained at a classical analytic institute with a focus on ego psychology.

My psychoanalyses helped me accomplish many of the therapeutic goals I had. I increased my capacity for intimacy, had better relationships, and was more successful academically and professionally. Importantly, both of my psychoanalyses helped me to engage in self-analysis and that helped me to better understand myself and continue to grow personally and professionally during and following each treatment. My self-analyses also helped me to realize the limitations of each analysis and to appreciate what I liked and disliked about each treatment and the treatment results.

Upon reflection, I found classical psychoanalysis was limited in its attention to my emotions, especially as my feelings appeared in sessions in the transference. Although I was outwardly successful in my professional and personal life, I continued to live with attenuated forms of the same problems that originally brought me to my first analysis. I concluded that my continued problems were due to my difficulty using free-association. I realized it was a technique that I was able to use with limited success, in part, because it was too cognitively focused and did not focus on emotions and how I defended against them. Whenever I was silent on the couch my analysts would ask me “What are you thinking?” and never “What are you feeling?” As a result of the cognitive focus of free association, I never became fully consciously aware of the transference relationship with either of my analysts and, therefore, never experienced a resolution of those transference dynamics and the defenses that helped to maintain them. And, as a result, I was unable to effectively see how transference lived in my relationships outside of my analyses and never resolved the transferences in those relationships.

I wanted to return to treatment after finishing my training analysis, but was hesitant to return to formal psychoanalysis because I was concerned that an analyst would use free association again and that it would have too much of a cognitive focus. As noted above, I did a lot of self-analysis and read a lot about different forms of psychodynamic therapies. Several forms impressed me: The psychodynamic approach developed by David Shapiro (Shapiro, 1989, 2000), the Supportive-Expressive Therapy approach developed by Lester Luborsky (Book, 1998; Leichsenring & Leibing, 2007; Luborsky, 1984) and the Intensive Short-Term Dynamic Psychotherapy developed by Habib Davanloo (Abbass et al., 2012; Coughlin Della Selva, 2004; Coughlin, 2017; Davanloo, 1992). I read and conducted self-analysis for nearly 14 years, influenced by my analyses and by my readings, before deciding that my self-analysis and reading were also limited in their effectiveness. I wanted to resolve my problems and I decided that I needed an emotion-focused experiential psychodynamic therapy and chose to begin treatment using ISTDP, which is an empirically-supported emotion-focused experiential psychodynamic treatment (Abbass et al., 2012; Coughlin Della Selva, 2004; Coughlin, 2017).

My Experience as a Patient in ISTDP

Intensive Short-Term Dynamic Psychotherapy (ISTDP) begins with a 90 minute to four-hour initial session (Coughlin Della Selva, 2004). The long duration of the first session serves several aims. First, it provides the patient and therapist with a trial therapy that assesses the patient’s psychopathology. Second, it helps both people to determine if ISTDP is the appropriate treatment for the patient’s problems by giving the patient and therapist an experience of a session and an opportunity to begin resolving the problems the patient has come to address. Third, the long session helps to establish all three components of the therapeutic alliance: the therapeutic goal(s), the therapeutic tasks, and the positive emotional bond between therapist and patient (Bordin, 1979). Fourth, the long session aims to help patients to begin to experience and resolve the complexities of the transference. This is done by trying to help patients focus on their feelings and the defenses against those feelings, especially as they arise toward the therapist. A considerable body of research shows that ISTDP benefits people with a wide range of problems and that people often make significant progress during the first session because the techniques “unlock” the unconscious (Abbass et al., 2012; Coughlin, 2017). In this model, feelings are the royal road to the unconscious. The “short-term” in ISTDP is a misnomer in that the treatment is not artificially short and limited to a specific duration. It is usually practiced once weekly, but in an open-ended manner with research showing that most patients find resolution to their problems after approximately six months of therapy while others might take as long as several years (Abbass, 2002).

Feelings in the Transference

One of the differences in my experience of psychoanalysis compared with ISTDP is that while I was in psychoanalysis, I was never able to directly address my anger toward others, especially people I love and like, and I did not address my guilt and shame over that anger. Instead, I frequently used defenses to avoid fully being aware of my anger and expressing it directly.

Addressing my anger and the guilt and shame I experienced over it in my ISTDP treatment, helped create intimacy in the therapeutic relationship and increase my capacity for intimacy. My therapist doggedly pursued my feelings that I felt toward her, including anger, in the first session. She pursued my feelings toward her compassionately and addressed my defenses against those feelings in real-time as they occurred, which I experienced as a life-line and a love-line. My experience in classical psychoanalysis laying on the couch, while my analysts gave me the freedom to free associate, did not help me address my defenses against experiencing and expressing my feelings. I needed a therapist who could actively and consistently engage my silent withdrawal and what was happening inside me emotionally at the moment, which happened rarely. In this way, classical analysis became a cognitively-focused intellectualized and overly long process for me that caused me to continue to have painful problems after completing both of my psychoanalyses.

Treatment Outcome and Termination

As mentioned above, my previous analyses had lasted 10 and four plus years, respectively. My ISTDP therapy lasted two years, which is on the longer side for ISTDP. Also, as noted, although my psychoanalyses helped me, I was left with attenuated versions of the same problems at the end of each treatment and I still had considerable difficulty identifying, experiencing, and expressing my feelings at the end of those analyses. I no longer had the same problems at the end of my ISTDP therapy and, in particular, I was much better able to be in touch with my feelings and express them to others.

Despite the long analyses I had previously, neither of those treatments addressed the complex feelings I had toward my analysts, including when I terminated those treatments. I rarely expressed my feelings towards my analysts—any feelings. The inhibitions I experienced in daily life were ever present in the transferential relationships with my analysts, but they were not addressed fully in my analyses. I could not express anger, love, or grief toward them when finishing my analyses because those feelings had not come up previously to be expressed to them and I never analyzed the difficulty I had expressing my feelings toward them. My complex feelings toward my ISTDP therapist were addressed in the first session and continued to be revisited, especially during termination. Termination also addressed what I had accomplished and what remained to be worked on via self-analysis, something which also occurred in my previous analyses.

Conclusions

It is possible to think of this essay as a form of comparative psychoanalysis with an n of 1 sample (Tuckett, 2008). I clearly benefitted from my experiences of classical psychoanalysis and from my ISTDP therapy. Classical psychoanalysis and ISTDP are grounded in ego psychological conflict theory (Abbass, 2002; Brenner, 1982; Coughlin Della Selva, 2004). Both are supposed to focus on transference and defense analysis, but in my experience, my ISTDP therapy did a better job of it than my classical analyses. Of course, my ISTDP treatment benefited from my previous experiences of classical analyses, but ISTDP was a different type of therapy experience and one that I ultimately valued more because of its focus on my feelings in the transference.

My ISTDP treatment was on the longer side, which gave me a chance to work through my problems and resolve the transference conflicts that arose in it. My current way of practicing combines aspects of classical analysis with a focus on transference conflicts that manifest in a wish-fear manner and a focus on conflicts between defense and feelings. I use free-association, but instead of asking what people are thinking, I usually ask them what they are feeling and what they are feeling toward me (Frederickson, 2013). Asking people about their feelings will ultimately also get them to discuss what they are thinking. Asking people about their thoughts tends to support intellectualization and isolation of affect, defenses that lead people to have an intellectual understanding of their problems, but that do little to stimulate internal and behavioral change.

The Case Study and Empirical Research Revisited

I return to the questions that began this essay:

Would my therapist follow a lockstep formula based on a treatment manual, lacking in creativity, humanity, and anything idiosyncratic that would be tailored to me? No. My ISTDP therapist did not follow a treatment manual. She was creative and discussed a variety of ways to help me get in touch with my feelings. She valued my humanity and tailored the treatment to meet my needs.

Would the treatment be effective? Yes. The treatment was effective. I became able to identify, experience, and express my feelings toward others. This enhanced my professional life: I was a better teacher, supervisor, clinician, and scientist. Being more emotionally aware and expressive especially enhanced my personal life, by enabling me to be able to create greater intimacy in my relationships. These effects have lasted for over two years since the completion of my treatment.

How would ISTDP compare with my previous personal and training analyses? My ISTDP treatment was shorter, less frequent, face-to-face, more emotional, more intimate, and more immediately focused on transference analysis than my classical psychoanalyses.

This essay was a personal case study of me and my experience in an empirically-supported psychodynamic treatment. I hope that I have shown that psychoanalysis continues to benefit from case studies and empirical research and that psychoanalysts can benefit from both too.

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CONTRIBUTOR

William Gottdiener, Ph.D., ABPP, FIPA is a licensed and board certified clinical psychologist, psychoanalyst, and tenured full professor of psychology at John Jay College of Criminal Justice of the City University of New York (CUNY). Dr. Gottdiener received his PhD in clinical psychology from The New School for Social Research. He is the Director of Clinical Training of the Clinical Psychology Doctoral Program of the Graduate Center—CUNY that is housed at John Jay College. He is the chair of the Division 39 Fellows committee and he was also previously President of the Division 39 Psychoanalytic Research Society. He has published over 50 articles, book chapters, commentaries, and reviews and is on the editorial boards of the journals Psychoanalytic Psychology, Journal of the American Psychoanalytic Association, and Psychological Bulletin. He is an APA Fellow in the divisions of Addictions, Clinical Psychology, General Psychology, and Psychoanalysis, and he is a Fellow of the International Psychoanalytic Association. He was honored by Division 39 with its prestigious Research and Scholarship Award in 2015.