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Several 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.
Ethics - Psychoanalysis
and Psychoanalytically Oriented Expressive Therapy
Ms. 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.
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:
Psychoanalytically 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.
Ethics - The
Freud 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.
What 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 approach.
Whether 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.
There 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.
Techniques 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.
Brems, C., & Johnson, M. E. (1997). Clinical implications of the co-occurrence of substance use and other psychiatric disorders. Professional Psychology: Research and Practice, 28(5), 437–447.
Peer-Reviewed Journal Article References:
Leibovich, L., Front, O., McCarthy, K. S., & Zilcha-Mano, S. (2020). How do supportive techniques bring about therapeutic change: The role of therapeutic alliance as a potential mediator. Psychotherapy, 57(2), 151–159.
Leibovich, L., Nof, A., Auerbach-Barber, S., & Zilcha-Mano, S. (2018). A practical clinical suggestion for strengthening the alliance based on a supportive–expressive framework. Psychotherapy, 55(3), 231–240.
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