Discrete areas of learning are grouped together into “developmental categories.” Different numbers of categories and other organizing principles could be used, but the educational goals included here represent widely agreed-upon fundamentals in the field. Placing discrete learning tasks into larger groups is not only an organizational aid but also helps to demonstrate the interrelationships among the tasks. The developmental categories are understood to have a dynamic character: each category is composed of a variety of goals that are closely interrelated, and each depends upon learning within the other categories for optimal progression.
The five developmental categories are 1) Goals, Roles, and Boundaries; 2) Participants; 3) Verbal Flow; 4) Technique; and 5) Theory. Each group of learning goals will be briefly described over the course of its progression through the three phases of learning. This is not a comprehensive review, but rather a demonstration of the ways in which this form of organizing educational goals can be useful.
Category 1: Boundaries, Roles, and Goals
The establishment of the roles, boundaries, and goals specific to the practice of dynamic psychotherapy is a fundamental aspect of training. These dimensions define the frame in which therapy takes place, together with the expectations for participation and the purpose of the work. The educational tasks include 1) the practical aspects of structuring the relationship between patient and therapist, 2) a clear definition of the necessary attitudes and responsibilities of both participants, and 3) an understanding of the realistic goals of this method of treatment. Of particular importance are 1) the accent on a safe and stable environment against which behaviors can be observed, 2) an understanding of the characteristics of the analytic attitude, and 3) the development of open and active participation by the patient.
In Phase I, Observation and Description, the need for a stable environment, neutrality, and the nondirective stance, and the purpose of helping patients to talk freely, all require a basic conceptual framework. Residents need to understand the purpose of their activities and the requests of their patients. It is helpful for them to realize that the frame of the therapy dramatically influences the kinds of data available, the processes that unfold, and the kinds of outcomes that are attainable.
In Phase II, Conceptualization, the student begins to appreciate more conceptually the patterns of behaviors that are important to both therapist and patient. Now some of the “rules” of therapy begin to make more sense. At this time, the focus will be on observing the ways in which boundaries and roles are breached. Some understanding of the reasons why this takes place will also be possible, as will moves to restore a stable working environment. Residents can begin to understand the concept of intrapsychic change as a goal and its relationship to symptom relief and change in behaviors. This phase is also a time to educate residents further about specifying treatment goals and maintaining a focus.
During Phase III, the Synthetic phase, a deeper understanding of the importance of boundaries and therapeutic posture takes place. The resident is now able to make use of breaches in these areas as a means for deeper understanding and effective interventions. There is also a greater flexibility in setting goals in response to the needs, capabilities, and requests of particular patients. Therapists are now more comfortable with their unique styles of doing therapy while still being able to maintain a consistent treatment approach. There is also more tolerance for changes in goals over time, together with an ability to use dynamic psychotherapy in an integrated way in other approaches.
Category 2: Participants
This category contains some of the most important facets of training: the life history; in-depth description of behavior; dynamic formulations; introspection; the working alliance; and the ability to work with transference, countertransference, and resistance. Seeing psychodynamic psychotherapy as an experience occurring between and within two people is one of the most central aspects of this treatment.
The beginning therapist must learn to become a participant-observer. During Phase I, the focus is on manifest feelings and thoughts. The influences of the patient and therapist on each other and the context in which these influences are felt is a subject for observation, description, and discussion. In these ways, the resident develops the ability to observe carefully, along with vocabulary and perspectives through which to portray the richness of human behavior.
During Phase II, the student begins to link recurrent patterns to conceptual frameworks. A richer appreciation of psychoanalytically informed clinical phenomena (transference, countertransference, defense, and resistance) is fostered. Now the student can understand what is occurring in therapy in ways that can provide other levels of information about the patient and can aid in the selection of areas to intervene. By this time, for example, the student is able to understand a particular form of resistance in a patient who seems to know more than he or she professes, comes late to sessions that follow a “good” hour, and has stimulated annoyance and boredom in the therapist. The student can then go beyond a manifest affect or behavior to explore with the patient the presence of resistance and begin to understand its functions and meanings. Phase II abilities provide the developing therapist with a greater sense of control of the process and allow for interventions that deepen the work.
In Phase III, the Synthetic phase, the student confronts a matrix of intersecting educational tasks involving the interplay of transference, countertransference, resistance, the status of the working alliance, the deepening understanding of the patient's dynamics, and an ability to select and maintain a treatment focus. It is desirable for all residents to have an overview of the work at this level, even if they do not develop into competent dynamic psychotherapists. The application of analytic understanding to general clinical psychiatry is of great importance to the field,42,43
and an appreciation of interrelationships at this level is relevant to that goal.
Category 3: Verbal Flow
The patient's communication through language and the therapist's ability to recognize emerging themes are fundamental to psychotherapeutic work. Phase I involves training the resident to pay attention to the details and flow of what is being said without premature closure and to be able to summarize what has been heard. Some residents will be able to begin to quickly “hear” latent levels of meaning, but the student must first be able to absorb what the patient is saying before paying closer attention to underlying themes. The technical skills of interviewing are closely connected to this process.
Phase II learning centers upon active, flexible listening for preconscious themes. There is a shift from content to process and manifest to latent. The starting point always remains, however, with the data obtained from the patient and from the therapist's reflections. While the way in which thematic material is organized, understood, and applied will be strongly influenced by psychodynamic perspectives, the validity of this method must be repetitively demonstrated by direct links with what is observable.
Phase III, Synthesis, involves connecting the predominant themes or focal conflicts to the emerging understanding of the patient and therapy process. This connection of theme, patient, and process requires the integration of knowledge about the patient's life history, current life stressors, recurrent behaviors, character style, and manner of self-expression with the evolving dynamic formulation. This understanding must, in turn, be informed by an appreciation of the degree of transference and resistance present. In this way, the student will be able to select the most useful treatment interventions.
Category 4: Technique
Technique can be conceptualized as existing across a continuum, ranging from interviewing to the subtleties of interpretive work. These abilities must be placed within a theoretical context that defines the major areas in therapy that require intervention. This developmental line is therefore divided into 1) the acquisition of knowledge about the theory of therapy and 2) the technical skills of questioning, responding, and interpreting.
The psychoanalytic theory of therapy rests primarily on the concepts of transference, countertransference, resistance, and working through with the use of interpretation. Attaining this theoretical perspective is a necessary precondition to conceptualizing clinical phenomena and working with a traditional psychodynamic method. For example, in order for a student to make use of an important transference reaction during treatment, there must be a working definition of 1) what transference represents, 2) the way it can be used to work through unresolved conflicts, 3) its relationship to resistance, and 4) how the interpretation of this phenomenon relates to the patient's problems and the goals of treatment. This knowledge must be combined with a sense of when and how transference is to be addressed. An awareness of the degree of rapport and empathy, the status of the working alliance,25
and where the patient is on the supportive/expressive continuum34
are also necessary preconditions for the understanding of transference interpretation. Although there is considerable variation in the translation of these analytic principles to the practice of dynamic psychotherapy, an integrated overview of this aspect of therapy is essential.
In the model, the theory of technique has been divided to correspond to the phases of learning so that each area anticipates the focus of each phase. Thus, Phase I stresses the importance of a developmental history, the fact that outside relationships are paralleled in treatment, and the need to set the stage for the interpretive work that is to follow. Phase II requires some explication of transference, countertransference, resistance, and working through so that the student will be able to recognize these phenomena in clinical work. Over time, these categories are placed within an integrated model of the process of therapy, and this leads to the synthetic work of Phase III.
The technical skills needed to practice dynamic psychotherapy have only more recently received the attention they deserve. Training has shifted toward technique because of the recent emphasis on treatment specificity, variations in technique, focused goals, and outcome research. Well-defined interventions and manualized dynamic treatments33,34,44
are much more explicit about how to do the work. The considerable variety in emphases and styles of intervention continues to grow as newer approaches are validated. The basics of traditional technique are presented here, but more recent technical advances can also be added.
Phase I skills enable the listening and data-gathering process and introduce the ability to move treatment toward interpretation. They therefore begin with interviewing skills and the nondirective stance. The student learns to pay attention to the interactive process, including listening, making an intervention, and then listening again for the consequences of the intervention. The type and timing of interventions and the interplay of support and pushing the work further (as in the supportive/expressive dimension34
) are introduced here.
During Phase II, there is increasing emphasis on interpretive work. Once the student understands the presence of a resistance, for example, the technique of pointing this out to the patient and beginning interpretive work can be addressed. The major educational goals of this phase allow for the fuller development of a working alliance and early interpretive work on focal dynamic content, transference, and resistance. This level of technique is attainable by many psychiatric residents and is necessary for the practice of brief dynamic psychotherapy.
Phase III requires a more in-depth development and integration of interpretive abilities. The student is now able to learn how to rationally choose which areas within an hour to address and interpret. There is more sophisticated work on the choice, timing, depth, and content of interventions.
Category 5: Analytic Theory
Of all the areas in psychodynamic psychotherapy education, the timing and depth of exposure to theory is most open to question. This is a reversal from the earlier history of education in this discipline and reflects widespread debate about the validity of analytic theory, as well as its relevance to clinical work. Yet most educators agree that basic theory is essential. The questions are what it should consist of, how much diversity of viewpoints is desirable, and when to teach it.
This model deemphasizes theory early in training. At Phase I, what is necessary is an introduction to the notion of the dynamic unconscious and its link to development. The centrality of human relationships, attachment, psychic trauma, repetitions, and historical versus narrative truth are concepts that are readily grasped and applicable to early clinical work.
Phase II learning includes knowledge of developmental theory; the concepts of symptom formation, conflict, and defense; object relations; and a richer understanding of the repetition of patterns of behavior. Subjective reality and fantasy are also addressed. Without an awareness of these ideas, it is not possible to understand the utility of dynamic formulations and the interpretation of resistance and transference. Aspects of psychosexual stages, structural theory, object relations theory, and ego and self psychology can be introduced, but there is no attempt at a systematic presentation of these models. What is necessary is a basic conceptual framework that links development, intrapsychic life, repetitive patterns, and unconscious themes seeking expression.
Phase III education can include discussion of the classic analytic literature to promote understanding of the central tenets of each model. Recent contributions and trends are also important here. The ways in which the orientations interrelate and inform clinical work are of particular importance. Links to and comparison with cognitive, behavioral, and systems models are more understandable at this time. It is important to introduce students to the evaluation and current directions of theory. However, the study of theory in depth goes beyond the purview of residency.