factors help differentiate the highly expressive therapies, which we will divide
into psychoanalytically oriented expressive psychotherapy or psychoanalysis, as
opposed to the purely supportive, middle-of-the-road, supportive-expressive psychotherapy.
and Psychoanalytically Oriented Expressive Therapy
Psychoanalysis is not
the most frequently indicated modality of treatment in working with adult survivors
of physical, sexual, or emotional abuse in childhood. However, the clinician trained
and skilled in the psychoanalytic field may identify patients with a history compatible
with trauma who could benefit from an analytic approach. At times, this particular
patient population presents an atypical manifestation of the trauma in combination
with other psychological conflicts that may be related to the trauma itself but
have been internalized, disguised to such a degree that only a highly expressive
therapeutic process can facilitate their uncovering. In fact, as we have pointed
out, Freuds initial thinking about the origin of the neurotic conflict was
embedded in a theory of trauma during the childhood.
Ms. B. came to the office seeking help for panic episodes that
were increasing, which several other therapists had unsuccessfully tried to help
her control. She was a bright, educated, young college graduate who experienced
episodes of depression but who had always been able to meet the responsibilities
of her job. Her internal turmoil grew worse in spite of supportive therapy and
medication prescribed by other therapists and reached a climax when she suddenly
became suicidal. Following a brief hospitalization and upon completion of a battery
of projective psychological testing, a past traumatic event was suspected. On
further exploration in individual therapy, she was able painfully and slowly to
recover early memories of sexual abuse she suffered from her father. She was repeatedly
sexually molested and fondled from age 3 to age 5 as recalled in her expressive
B. has been in supportive-expressive psychoanalytically oriented psychotherapy
with a frequency of two to three times per week. She is also considered a candidate
for psychoanalysis, as she has shown an increased interest in pursuing her therapy
on a more intense and frequent basis. Not only is she interested in symptom relief,
but she wishes to have a more in-depth understanding of the impact of the trauma
on her overall psychological functioning and to improve the quality of her life.
Her psychological curiosity constitutes a desirable rationale for psychoanalytic
treatment that goes beyond the working-through of the trauma.
Merton Gill defines psychoanalysis as that technique which,
employed by a neutral analyst, results in the development of the regressive transference
neurosis and the ultimate resolution of this neurosis by techniques of interpretation
aspects of the analysts neutrality, the intensive use of the transference,
and the use of interpretation are clearly the most important ingredients of a
psychoanalytic process. Ticho, in Differences between Psychoanalysis and
Psychotherapy, identifies other aspects pertinent to our patients not included
in Gills definition:
1. The goal of psychoanalysis is to obtain
a thorough personality change in the patient; the overall goal of
psychotherapy is the resolution of symptoms and the attainment of some degree
of behavioral change.
2. Countertransference (in analysis) is
much easier to control because of the neutrality and relative inactivity of the
3. The fact that the analyst does not gratify infantile
longings . . . but instead interprets them . . . is by necessity experienced by
the patient as frustration.
4. Psychoanalysis cannot be limited
ahead of time. Psychotherapy may be limited for a variety of reasons.
The area of investigation of psychotherapy is limited while in psychoanalysis
. . . is unlimited.
oriented therapy and psychoanalysis have specific indications for the treatment
of trauma victims, provided that the patient is not in the acute phase of the
trauma where other interventions could, perhaps, be more effective.
As we have discussed, there is a continuum from
psychoanalysis, the most highly expressive therapy, at one extreme, to the supportive
(whether brief, focused or long-term) psychotherapy at the other end of the psychodynamic
was the first to use a supportive (and brief) approach. As early as 1906, Freud
successfully treated the right-arm paralysis of the conductor Bruno Walter in
six sessions, using a combination of direct advice, suggestion, and ego support.
does supportive therapy support? Many trauma victims can make very good use of
a variety of supportive measures. Various mental structures need support at different
points during treatment. These may include ego support to encourage the patients
executive function, id support to encourage the therapeutic use of the patients
dormant assertive-aggressive capacity, or superego support to facilitate control
and regulation of impulses and self-esteem. The therapist should be aware of what
aspect of the mental structure is being supported or is in need of supportive
interventions in order not to lose sight of the therapeutic goals when using this
A variety of technical interventions are currently used in supportive and
supportive-expressive psychotherapies, such as clarification and confrontation,
which are insight-producing approaches. Non-insight-producing interventions include
suggestion, advice, direct recommendations, persuasion, reassurance, educational
or instructional intervention, and encouraging or prohibiting specific types of
behaviors. In general, these non-insightproducing interventions are avoided
in the more expressive modalities of therapy.
the chosen treatment modality is supportive or expressive, short- or long-term,
and whether the patient is psychologically minded or not, there are therapeutic
barriers to be dealt with and crossed for the therapeutic process to move forward.
Very frequently these barriers are present at the outset. Usually, they are related
to the mistrust generated by the internalized past and the poor quality of object
relationships, which continues to exercise control over the patients feelings
and behavior. The patient/therapist relationship is a caldron where the vicissitudes
of the patients past object relationships are played out. Fears of rejection
or of being taken advantage of, fears of exploitation and renewed victimization
are in the forefront of the beginning of any therapeutic process.
are always two types of patient/therapist relationships. The real, uninterpreted
relationship, which is like any other relationship, and the transferential relationship,
which is dominated by fantasies and expectations on the part of the patient and
usually evolves into the so-called transference neurosis. The latter may become
a therapeutic barrier when it results in a transference resistance. With either
type, in working with trauma victims, there will always be a need on the part
of the patient to discharge built-up anger and rage generated by the insult to
his or her self-integrity and the self-fragmentation that usually follow such
a severe injury.
used to facilitate the discharge of emotions include (1) exploring feelings in
connection with the trauma; (2) helping the patient to identify specific feelings
connected with the abuse and to attach the emotion to a specific situation; (3)
helping the patient abreact or discharge the feeling; (4) encouraging the patient
to verbalize the affective reaction, which leads to a working-through of the traumatic
experience and a resolution of the symptoms that brought the patient to therapy.
In other words, the ego is no longer being attacked from inside, obviating the
need for defensive operation and leading to a decrease in symptoms and behavioral
problems. Whether a supportive approach works better than an expressive approach
will be determined only by the patients character and capacity to work in
therapy and by the therapists ability to uncover all the factors about the
evaluation process. Either way, the goal is the same, that is, a resolution of
the trauma, an increase in the patients level of functioning, and an overall
improvement in the patients quality of life.
Reflection Exercise #7
The preceding section contained information on practical
strategies for resolving impasses. Write three case study examples regarding how
you might use the content of this section of the Manual in your practice.
What two types of therapist-patient relationships need to be balanced
regarding supportive versus excessive therapeutic relationships? To select and
enter your answer go to .