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 전통적 정신분석적 치료의 목적  
 

과목: 정신분석적 사례이해

주제: 전통적 정신분석적 치료의 목표

강사: 신현근 박사

내용: 강의안

교재: McWilliams, N. (1999). The relation between case formulation and psychotherapy. In Psychoanalytic Case Formulation (pp. 9-28). New York: International Guilford Press.


Goals of Traditional Psychoanalytic Therapy

 

1.      Symptom Relief

1.1.   It probably goes without saying that the primary objective of psychotherapy is relief of the problem(s) for which the client originally requested treatment.

1.1.1.      A patient’s “presenting problem” or “chief complaint,” which has typically become unbearable at the time he or she decides to give up commonsense self-treatment and consult a professional, often ameliorates or diminishes in severity once a therapeutic relationship is secure.

1.1.2.      Given the opportunity, people tend to stay longer in analytic treatment not because they are not getting help but because they are.

1.1.3.      Analytically oriented therapy tends to go on longer than therapy conducted in accordance with other theoretical orientations, because both client and therapist are pursuing goals of general mental health that go beyond the swift removal of a particular disturbance.

1.2.   It is also rare that someone comes to a therapist with a single, delimited difficulty.

1.2.1.      In fact, many patients keep important secrets from their therapists for years, until they have built up enough trust to tolerate the anxiety that goes with revealing any area of deep shame, or until they have been helped enough in other areas to have a basis for hope that they could change in the area of the secret.

1.3.   Finally, people typically come to analytic therapy because they want to get at the attitudes and feelings that underlie their vulnerabilities to particular symptoms.

1.3.1.      One can often get someone to stop behaving in a self-destructive way, but it takes considerable time and work to get that person to a place where there is no longer a vulnerability or temptation to do so.

1.3.2.      People come to analytic therapy not just to get control over a troublesome tendency but to outgrow or master the strivings that are causing such a battle over control.

 

2.      Insight

2.1.   Early in the psychoanalytic movement, there was an idealization of understanding as the primary route to emotional health.

2.1.1.      Freud’s idea that the key to healing was to make conscious what had been unconscious derived both from his experiences of patients’ symptomatic improvements when they were able to remember and feel things they had consigned to the unthinkable and from a general scientific positivism that assumed that to understand something was to master it.

2.1.2.      The equation of truth with freedom, an association at least as old as the oracle at Delphi (whose motto was “Know thyself”) still pervades most psychoanalytic thinking.

2.2.   Although contemporary analysts consider understanding, especially the affectively charged “Aha!” kind of understanding that has usually been termed “emotional insight,” to be of immense therapeutic significance, they also credit numerous “nonspecific” factors (e.g., the therapist’s quiet modeling of realistic and self-respectful attitudes, the client’s experience and internalization of the therapist’s stance of acceptance, the fact that the therapist survives the patient’s seemingly toxic states of pain and rage) with just as much power.

2.3.   In fact, over the past couple of decades, almost all psychoanalytic writing about what is curative in therapy stresses relationship aspects of the treatment experience over traditional notions of insight (e.g., Loewald, 1957; Meissner, 1991; Mitchell, 1993).

2.4.   Even the meaning of “insight” has shifted over the years from a somewhat static concept to a process embedded in relationship.

2.4.1.      In the “modern” age of psychoanalytic evolution, the term implied the attainment in therapy, via help from a dispassionate, objective practitioner, of an accurate understanding of one’s personal history and a realistic appreciation of one’s motives and circumstances (e.g., Fenichel, 1945).

2.4.2.      In these postmodern times, the term implies that patient and therapist have created together, from their combined subjectivities and the quality of the relationship that evolves between them, a narrative that makes sense of the client’s background and predicament—a narrative truth rather than a historical one (Levenson, 1972; Spence, 1982; Atwood & Stolorow, 1984; Schafer, 1992; Gill, 1994).

2.5.   Despite the dethronement of insight from its position as the sine qua non of psychological change, for analytic therapists, and for most clients, understanding remains a central goal.

2.5.1.      Both parties in the therapy relationship try to articulate the “unthought known” (Bollas, 1987).

2.5.2.      The analytic emphasis on understanding is partly attributable to the fact that the two participants in the work need something interesting to talk about while the nonspecific relational factors are doing their quiet healing.

2.5.3.      It may also reflect the fact that the kinds of people who seek to practice or undergo psychoanalytic therapies appreciate insight as a value in itself.

2.5.4.      Knowledge is thus pursued for its own sake in dynamic therapy, as well as for the sake of specific treatment goals.

 

3.      Agency

3.1.   An internal sense of freedom is probably one of the most precious aspects of anyone’s personal psychology.

3.1.1.      Most clients come to therapists because something is compromising their subjective sense of agency.

3.1.2.      Sometimes they come because they have never felt in charge of their life, and they are beginning to imagine that such a state of mind would be possible if they were to get some help.

3.2.   A respect for the client’s sense of personal autonomy and an effort to increase that sense underlie many of the technical features of standard psychoanalytic therapy.

3.2.1.      The effort to respect, preserve, and increase the client’s personal freedom takes precedence over most other considerations in analytic treatment.

3.3.   Analytic practitioners will generally impose their will on the client only as a last resort, usually when the person’s life is at stake.

3.3.1.      Even in supportive therapy, in which suggestions are often made (see Pinsker, 1997), analytically oriented therapists make it clear that the patient is free to reject the practitioner’s advice.

3.4.   Meaning of agency (Aktar, 2009, Comprehensive Dictionary of Psychoanalysis, p. 8)

3.4.1.      ‘Agency’ refers to an inner state of awareness and choice of action.

3.4.2.      While unconscious factors might contribute to it, the experience of agency is conscious, active, and self-owned in its nature.

3.4.3.      It is not felt as reactive, and thus contains a psychostructural shadow of Donald Winnicott’s (1960) concept of ‘true self.’

 

4.      Identity

4.1.   The concept of personal identity as a formal theoretical construct did not exist until the middle of the twentieth century.

4.1.1.      Erik Erikson’s (1950, 1968) work at that time offered to the sophisticated public a new perspective on a kind of problem that was beginning to be common in the postwar years.

4.1.2.      The concern that one had to “find oneself” and the suffering of “identity crises” were distinctive complaints of the 1950s and 1960s, as Eriksonian language about the struggle for self-definition captured the ear of a public looking to attach words to previously inchoate sensibilities.

4.2.   Erikson, who had the advantage of having lived in an isolated Native American culture, was able to see how, by contrast, existence in a mobile, technologically sophisticated, mass society created unique psychological challenges.

4.3.   Contemporary clients often come to therapy needing to formulate even their conscious sense of who they are.

4.4.   The seminal works of Carl Rogers (e.g., 1951, 1961) and later of Heinz Kohut (e.g., 1971, 1977) spell out some technical therapeutic implications of the now widespread striving for a sense of identity: People need to feel understood, mirrored, accepted, validated in their subjective experiences.

4.4.1.      In the absence of dependable, predefined, lifelong roles offered by one’s culture, one must derive a sense of who one is largely from an internal integrity and authenticity, a capacity to live by one’s values and to be honest about one’s feelings, attitudes, and motivations.

4.4.1.1.            In these times, experiencing one’s identity solely by reference to connections outside the self is a dangerous practice, as people can attest whose jobs have been eliminated by the company that had defined them, or who have been recently divorced by the spouse who had given life meaning.

4.4.1.2.            In the absence of reasonably supportive contexts, people often need a therapist’s help in their efforts to experience and verbalize who they are, what they believe, how they feel, and what they want.

4.4.1.3.            The effort to develop a strong and cohesive sense of self may be a person’s primary preoccupation in therapy or it may exist more silently alongside other goals and concerns.

 

5.      Self-Esteem

5.1.   One means by which a client’s self-esteem increases in psychotherapy is the therapist’s willingness to be seen as flawed.

5.1.1.      Both because it is the truth and because it models adequate self-regard in the context of imperfection, the psychoanalytic therapist conveys a conviction of having the capacity to help the patient despite acknowledged mistakes and limitations.

5.1.2.      In my view, the most important contribution of the self psychology movement to psychotherapy technique is its emphasis on the inevitability of the patient’s disillusionment in the therapist and the importance of the therapist’s admission of responsibility for empathic failure (Wolf, 1988).

5.1.3.      It is often a new experience for a client to see an authority maintain self-esteem while acknowledging imperfections and shortcomings.

5.1.4.      It raises the possibility that the client, too, can feel good about his or her less-than-perfect self.

5.2.   Another way self-esteem becomes more solid and reliable in therapy concerns the patient’s experience of unrelenting honesty, a commitment to the truth that insists that no part of one’s experience be hidden from the self or the therapist.

5.2.1.      As the therapist accepts, often without even the need to comment, the client’s most anxious and shame-drenched disclosures, the client starts reframing these areas of personal shortcoming as ordinary rather than terrible.

5.2.1.1.            Or as terrible but not the whole story of his or her personality.

5.2.2.      The support of people’s realistically based self-esteem (as opposed to narcissistic inflation) has very little to do with saying nice things to them or “reinforcing” them for their observably stellar qualities.

5.2.2.1.            In fact, such remarks frequently backfire, as the patient silently muses, “My therapist is a very nice person who obviously has no inkling of what I’m really like.”

5.2.2.2.            Even in therapies that lack the advantage of adequate time to increase basic self-esteem, a dynamic formulation that captures the patient’s particular self-esteem economy will permit the therapist to avoid unnecessarily wounding a person, as happens all too often.

 

6.      Recognizing and Handling Feelings

6.1.   When psychoanalytic theories first crossed the Atlantic and encountered the American penchant for utopianism, numerous misconceptions filtered down to the public about the nature of psychological health, some of which are still around.

6.1.1.      One of the misconceptions that has faded in recent times but that enjoyed a great vogue in the middle of the twentieth century is the idea that the emotionally healthy person is “uninhibited.”

6.1.2.      I bring these travesties up for the sake of contrasting them with the actual aims of psychoanalytic therapy, which has a lot to do with feelings but nothing to do with an ideal that they should always be freely and spontaneously expressed.

6.2.   What one hopes will develop in psychotherapy is a set of sensibilities like those that Daniel Goleman (1995) has recently called “emotional intelligence,” qualities that an older psychoanalytic tradition referred to as “emotional maturity” (Saul, 1971); that is, practitioners want their patients to know what they are feeling, to understand why they are feeling that way, and to have the internal freedom to handle their emotions in ways that benefit themselves and others.

6.3.   In analytic psychotherapy, we invite clients to say whatever comes to mind, no matter how nasty, embarrassing, or apparently trivial it seems.

6.3.1.      We do this not because such an injunction is a prototype for how people ought to talk in social situations, but because therapy provides a unique setting in which everything that can be verbalized becomes the “material” of the work of understanding.

6.3.2.      Analysts are not hedonists, nor do they subscribe to a doctrine of “letting it all hang out” verbally.

6.3.2.1.            The operative concept is choice.

6.4.   Pennebaker’s (1997) extensive research provides solid empirical support for the notion that openness to feelings is associated with physical and mental well-being.

6.5.   A surge of contemporary work in neuropsychiatry and psychophysiology (e.g., van der Kolk, 1994; LeDoux, 1995; Schore, 1997) has begun to give us a picture of what is happening in the brain when people are experiencing strong affects, and what are the temporary and permanent physical effects of being affectively overwhelmed or traumatized.

6.5.1.      Therapists have always distinguished between intellectual and emotional insight and have known from experience that to transform into verbal expression something that first manifested as an inchoate body sensation or a feeling of impending dread or a behavioral compulsion is the route to understanding and mastery of the problem.

6.5.2.      Now we have evidence that this process involves, among other things, the differences between emotional memory, stored in the amygdala, and declarative memory, stored in the prefrontal cortex.

6.5.3.      The process, and the concrete advantages, of getting “the words to say it” (Cardinal, 1983) is becoming physically describable, as Freud originally hoped and predicted (see Share, 1994).

 

7.      Ego Strength and Self-Cohesion

7.1.   A related area that many psychoanalysts emphasized during the middle of the twentieth century (e.g., Redlich, 1957; Jahoda, 1958) is the capacity of a person to cope with life’s difficulties in a realistic, adaptive way.

7.1.1.      One of the frequent background reasons for a person’s seeking psychotherapy is his or her wish to change a tendency to “fall apart” when life gets difficult.

7.1.2.      The analytic term for the elusive capacity to cope despite adversity is ego strength.

7.2.   The term derives, of course, from Freud’s famous (1923) tripartite depiction of mental life.

7.2.1.      The id (literally, “it”) was a designation he expropriated from Georg Groddeck for the striving, demanding, primitive, prerational, prelogical part of the self.

7.2.1.1.            The id is entirely unconscious, though its contents can be partially understood by attention to “derivatives” such as fantasies and dreams.

7.2.2.      The superego (the “above-myself”) was his term for the moral overseer inside most of us—the conscience, the self-evaluator.

7.2.2.1.            It was understood to be partly conscious, as when one congratulates oneself for resisting temptation, and partly unconscious, as when one suffers in some way because of guilt that is out of awareness.

7.2.3.      Freud’s use of the term ego (literally “I”) was roughly synonymous with what most people mean by “self.”

7.2.3.1.            But he also wrote as if the ego comprised a set of functions that operate partly consciously, as in ordinary problem solving, and partly unconsciously, as in people’s use of automatic defense mechanisms.

7.3.   This hypothetical construct, the ego, theoretically mediates between the demands of the id, the superego, and reality.

7.3.1.      In analytic parlance, ascribing to someone a strong ego means that he or she does not deny or distort harsh realities but finds ways of prevailing that take them into account.

7.3.2.      Bellak and Small (1965) described three overlapping aspects of ego strength: adaptation to reality, reality testing, and sense of reality.

7.3.3.      A person with good ego strength is by definition neither paralyzed by excessive or unreasonable guilt nor vulnerable to acting on passing impulses.

7.4.   With the rethinking of psychoanalytic metapsychology initiated by Kohut, the self psychologists, and the intersubjectivists, our language for talking about this phenomenon has been shifting.

7.4.1.      The terminology of Freud’s structural theory, with its emphasis on the ego as a reified inner structure, is less resonant to many contemporary practitioners than language that refers to the self and its continuity and stability.

7.4.2.      The popular observation that some people “fall apart” under pressure or strain refers to a phenomenon that many current analysts call “lack of self-cohesion.”

7.5.   A major nonspecific outcome of good psychotherapy is increased ego strength and self-cohesion.

7.5.1.      One wants a person to be able to confront difficult challenges without the internal experience of fragmentation or annihilation.

7.5.2.      One also hopes that after therapy, a person can tolerate temporary states of regression and destabilization in the service of growth, that he or she has developed the knack of “going to pieces without falling apart,” in Epstein’s (1998) felicitous phrase.

 

8.      Love, Work, and Mature Dependency

8.1.   Freud (1933) stated that the ultimate goal of psychotherapy is the capacity to love and to work.

8.1.1.      Aside, however, from his implicit stress on the relationship between loving heterosexual attachment and acknowledging and giving up envy (in women, envy of male prestige and power, and in men, envy of female privileges to show passivity and dependency), Freud said rather little about love.

8.1.2.      Intriguingly, in a 1906 letter to Carl Jung (McGuire, 1974), he did comment that psychoanalysis was essentially a “cure through love,” something he apparently regarded as self-evident.

8.2.   Later analysts, on the other hand, have discussed love at great length (e.g., Fromm, 1956; Bergmann, 1987; Benjamin, 1988; Person, 1988; Kernberg, 1995).

8.2.1.      This is hardly surprising, since it is to improve their love lives, whether heterosexual, homosexual, bisexual, or nonsexual, that people so often seek treatment.

8.3.   When psychotherapy goes well, clients find that they feel more accepting not only of their complex internal lives and their “real” selves but also of the complexities and shortcomings of others.

8.4.   The ability to work, to find one’s creativity, to substitute problem solving for helpless lamentation also emerges from a good psychotherapy experience.

8.4.1.      Martha Stark’s (1994) eloquent exposition of the mourning process in therapy, the movement from “relentless entitlement” to a mature acceptance of what cannot be changed (and a new capacity for addressing what can be) is only the most recent description of a familiar process of growth in treatment.

8.4.2.      As Stark explains, the initial phase of therapy involves the client’s slow acceptance of the fact that his or her psychological problems reflect accidents of a complicated fate and endowment, not some personal defect or failure; the second phase involves the painful appreciation that even though this is true, no one but the client can be responsible for solving those problems.

8.4.3.      Although people in the arts and in creative roles of any kind tend to worry that psychotherapy will rob them of their emotional energy (by resolving the neurotic issues that initially compelled their activity), they typically find that their artistry is less conflicted, more disciplined, and richer after treatment.

8.4.3.1.            Chessick (1983), emphasizing the pleasures that emerge in both creation and recreation when therapy has been successful, suggested that the Freudian treatment goals of love and work should be amended to “love, work, and play.”

8.5.   In his earliest theories, Freud stressed the centrality of sexuality in human motivation.

8.5.1.      Later, impressed by the evidence of human destructiveness (especially during World War I), he acknowledged aggression as a primary drive of equal power.

8.5.2.      Temperamentally a dualist, he explained most human behavior in his later works on the basis of a tension between eros, the life instinct, and aggression or thanatos, the death instinct.

8.5.3.      In this paradigm, love is the benign and creative expression of the sexual drive, and work, the positive expression of the aggressive drive.

8.5.4.      Freud’s successors in the object relations movement have added a critical third “instinct” (if anything so complicated can still be termed as such), namely, dependency (attachment).

8.5.4.1.            Freud tended to talk about people as if they were self-contained, individual systems.

8.5.4.2.            But beginning theoretically with Fairbairn’s (1952) challenge to classical Freudian theory, in which he argued that infants seek not drive satisfaction but relationship, and empirically with Bowlby’s (1969, 1973) studies of attachment and separation in infants, analysts have become increasingly impressed with the ubiquity of human connection, of our embeddedness in an interpersonal system where our sexual and aggressive nature is only part of the story.

8.5.4.3.            A huge literature on attachment has appeared during the last generation, as researchers and clinicians are repeatedly confronted with the evidence of people’s lifelong needs for objects and arenas for their various passions.

8.5.4.4.            A related emphasis among self psychologists concerns the permanence of people’s need for “selfobjects,” those who mirror and validate us.

8.6.   All this relates to one other outcome of effective psychodynamic therapy, namely, the transformation of infantile dependency into mature adult dependency.

8.6.1.      Western myths about human independence notwithstanding, we all need each other in both emotional and practical ways throughout the lifespan.

8.6.2.      Psychotherapy does not take dependent people and make them independent; rather, it makes them capable of handling their natural dependency in their best interests.

8.6.3.      It confronts counterdependent people with their legitimate needs for others.

8.6.4.      The main differences between attachment in infancy and attachment in adulthood are that unlike adults, children cannot choose those on whom they depend, cannot ordinarily leave inadequate caretakers, and have insufficient power to influence their objects to change their behavior.

8.6.5.      Many adults come to therapy feeling like children trapped in destructive relationships and concluding that there is something dangerous about their need for others.

8.6.5.1.            Ideally, they figure out during treatment that it is not their basic needs that have been problematic but their handling of them.

 

9.      Pleasure and Serenity

9.1.   Despite the fact that most of us think we know what is meant by the term “happiness,” we are often rather self-defeating in pursuing it.

9.1.1.      Part of the blame for this can be laid on myths that permeate a commercial, market-oriented culture like ours, in which we hear unrelenting messages about how better bodies and more lavish possessions will save us from despair.

9.2.   In an individualistic, competitive culture, the promise is ubiquitously made that we each will be happy if we only have what we want.

9.2.1.      In many non-Western cultures, by contrast, the prevailing wisdom concerns how to learn to want what one has.

9.3.   Psychoanalytic thinking is a curious blend of these sensibilities: It is thoroughly Western, positivistic, individualistic, and (originally, at least) concerned with drive satisfaction and frustration.

9.3.1.      Yet from the very beginning, there has been an emphasis on deference to the “reality principle,” to delay of gratification, to becoming “civilized” so that one hangs one’s self-esteem on one’s contribution to the larger community and can renounce immediate satisfactions in favor of more deeply nourishing, lasting kinds of pleasure.

9.3.2.      Analysts emphasize how deeply conflicted we are, how we have to give up our infantile wishes, how we have to compromise.

9.4.   With the general move toward more relational models of human psychology and psychoanalytic treatment, where attachment and separation are even more important concepts than drive and conflict, a focus on mourning has replaced an emphasis on striving.

9.5.   A good dynamic formulation will illuminate the ways in which a person thinks happiness can be pursued and will consequently contain implications for intervention.

9.5.1.      People’s pathogenic beliefs and individual ways of supporting their self-esteem are often radically at odds with their prospects for genuine pleasure and contentment.

9.5.2.      Grieving over what is not possible sets the stage for enjoying what is.

9.5.3.      Very often, in the later phases of psychotherapy, a client will comment that while he or she had known previously what it was like to feel “high” or “in a good mood,” the overall peace of mind that evolved quietly during treatment was something he or she could not even have imagined.

9.5.3.1.            Genuine serenity is probably inconceivable emotionally to the person who has settled for temporary bursts of elation. 


 
 
 
 
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