The "Something More" Than Working Alliance: Authentic Relational Moments

Addressing At-the-Moment Defenses against Painful Affects: A Core Mechanism of Change in Psychodynamic Treatment

There is an ongoing tension in the psychodynamic field between interpreting the meaning of a patient's verbal productions or actions and addressing the defenses utilized by the patient. Some authors maintain that implicit interactions between analyst and patient may be more important than the verbal interventions by the analyst. This article stresses the importance of observing and appropriately addressing how patients manage painful affects in the sessions. Focusing the patients' attention on their at-the-moment defenses as they occur in the session is an experience-near intervention and minimizes interventions that address issues far from the patient's consciousness and that require a high level of conjecture by the therapist. This technique can be utilized at any point in treatment, regardless of its duration and intensity. Several vignettes are provided that suggest that addressing defenses against painful affect is a pantheoretical construct and may be a common factor in psychodynamic treatment. A successful randomized control trial utilizing this technique with children (regulation-focused psychotherapy) is described. There have been limited empirical studies of the impact of therapists addressing defenses in sessions, but the work of J. Christopher Perry and colleagues, particularly the development of the Psychodynamic Intervention Rating Scales, offers an opportunity to further study the impact of defense interpretations and other interventions.

Therapists' defense use impacts their patients' defensive functioning: a systematic case study

Research into defensive functioning in psychotherapy has thus far focused on patients' defense use. However, also the defensive functioning of therapists might be significant because of its potential in promoting changes in the patient's overall defensive functioning by sharing their higher-level understanding of a given situation and letting the patient have the opportunity to learn how to cope more successfully. This exploratory case study is the first to examine therapist's defense mechanisms and their relationship to changes in the patient's defensive functioning evaluated at different times throughout psychoanalytic treatment. We assessed the use of defense mechanisms with the Defense Mechanisms Rating Scales in 20 sessions collected at three phases (early, middle and late) of the psychoanalytic treatment. For each session, we identified therapist's and patient's defenses, defense levels and overall defensive functioning, with particular attention to the sequence of consecutively activated defenses within the therapeutic dyad. Results showed that the patient's defensive functioning tended to gradually improve over the course of the treatment, with a slight decrease at the end. Therapists' overall defensive functioning remained stable throughout the treatment with values in the range of high-neurotic and mature defenses. Assessment of the dyadic interaction between therapist and patient's use of defenses showed that within-session, the patient tended to use the same individual defenses that the therapist used, which was especially pronounced in the initial phases of the treatment. Towards the end of the treatment, once there was a stable shared knowledge, the patient started to explore using new, higher-level defenses on her own, independent from what defenses the therapist used. Our findings emphasized the analyst's role in encouraging the development of more effective ways of coping in the patient, confirming previous theoretical and empirical research regarding the improvement of patient's defensive functioning in psychotherapy. The alterations in these coping strategies, also called high-adaptive defenses, as part of the therapist-patient interaction demonstrate the importance of studying defenses as an excellent process-based outcome measure. The measurement of the degree to which the analyst models and illustrates these superior coping methods to the patient is a prime vehicle for supporting internalization of these skills by the patient.

Agency via Awareness: A Unifying Meta-Process in Psychotherapy

To address the need for conceptual and clinical consensus within the field, psychotherapy research has increasingly focused on identifying common principles of change. While the field contends that this approach is atheoretical, we argue that principles of change cannot be fully understood or applied without the context of some theoretical framework. This article develops such a framework by identifying and explicating two theoretical assumptions that are implicitly shared by multiple therapeutic approaches: (1) that increasing agency is a fundamental aim of psychotherapy, and (2) that therapists enhance clients' agency by increasing their awareness. Building on the largely disparate empirical literatures demonstrating the importance of client agency and awareness to successful therapeutic outcomes, we provide a theoretical account of the highly iterative and synergistic meta-process by which these two factors jointly produce change. Explicit identification and empirical investigation of this Agency via Awareness psychotherapy meta-process, we argue, could facilitate scientific and clinical progress within the field. The hypothesized meta-process is discussed in relation to existing integrative models of therapeutic change, and its manifestations in the theory and practice of major therapeutic orientations are reviewed and illustrated. We discuss how this framework can facilitate psychotherapy research by providing a common language and conceptual foundation for wide-ranging therapeutic approaches, constructs, and findings. Finally, by raising clinicians' awareness of the implicit assumptions underlying their therapeutic work, we suggest that the Agency via Awareness framework can increase their agency over when and how they apply these assumptions in therapy to maximize client improvement.