Lydia Khuri`s case presentation

Lydia Khuri, Psy.D.
 Framework*
Theoretical assumptions
Psychoanalytic sensibility
Multicultural/feminist critiques
Empirical research
Preparing the therapist
Preparing the client
Therapy process
 Case Material
*based on Nancy McWilliams (2004) and Jonathon Shedler (2010)
Learning Objectives
 You will be able to identify components of the
psychoanalytic psychotherapy framework
 You will be able to identify components of the
framework as applied to a case study
Contemporary Psychoanalytic
 What comprises psychodynamic psychotherapy?
(Shedler, 2010)
Focus on affect and expression of emotion
Exploration of attempts to avoid distressing thoughts and feelings
Identification of recurring themes and patterns
Discussion of past experiences (developmental focus)
Focus on interpersonal relations
Focus on therapy relationship
Exploration of fantasy life
Basic Motivational Systems
 Contemporary (Lichtenberg, 1989)
Psychic regulation of physiological requirements
Attachment and affiliation
Exploration and assertion
Aversive reaction through antagonism or withdrawal
Sensual enjoyment and sexual excitement
Psychoanalytic Sensibility
 Curiosity and awe
 Identification and empathy
 Subjectivity and attunement to affect
 Attachment
 Faith
Multicultural/feminist Critiques
 Feminist critique of inherent androcentrism
Biologically-based gender differences
Reification of power relations between men & women
Normative gender and sexual development
Deterministic (personality patterns established in
early development)
 Feminist principles
Personal is political
Commitment to change on social level
Female subjectivity
Egalitarian therapeutic relationship
Focus on strengths
Recognition of interlinking of oppression
Multicultural/feminist Critiques
 Multicultural critique of Western worldview
Role of the past
Blaming parents
Concept of trauma
Family structures
Autonomous self
 Multicultural principles
 Focus on cultural identity in relation to psychological well-
 Understand power in therapy and larger social contexts
 Understand worldviews
View of human nature
Orientation toward time
Definition of proper human activity
Definition of social relations
Understanding of relationship of people and nature
Empirical Research*
Psychoanalytic psychotherapy as effective as other
empirically-supported treatments (effect sizes similar)
2. Core processes and techniques as defined by
psychoanalytic theory are facilitative of change,
regardless of theoretical orientation
3. Effects extend beyond symptom reduction and after
therapy has ended
4. Factors of culturally sensitive therapies have not been
teased apart from “traditional” variables (Sue et al., 2008)
Shedler (2010)
Preparing the Therapist
 New therapists make lots of mistakes
 Being yourself in role of therapist
 Supervision
 Own therapy
 Broad education
Preparing the Client/patient
Psychotherapy as peculiar relationship
Physical safety
Emotional safety
Informed consent
Encourage spontaneous, candid, emotionally
expressive speech
 Introduce work of transference
 Boundaries
Therapy Process
 Listening
 Talking
 Facilitation
 Power
 Therapeutic power
 Empowering the client
 Love
Major Concepts
 As adjective: mental contents not available to conscious awareness
 As noun: component of mental system known as id, yet some aspects of ego
(defenses) and superego (moral standards) part of Ucs.
 The adjective form is generally accepted in contemporary psychoanalysis
whereas there are several models of the mental system besides Freud’s model
known as structural.
 The ego’s attempt to protect self against danger, overwhelming, or
unacceptable affect and ideas
 Repression: exclusion from awareness thoughts and feelings once felt
consciously or never felt consciously; ex., hatred directed at a sibling.
 Reaction formation: changing unacceptable thoughts and feelings to
acceptable; ex., longing for loving experience changed into hatefulness
(Moore, B E. & Fine, B. D. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press.)
Major Concepts
 Displacement of feelings, thoughts, patterns of behavior, originally experienced in
relation to significant figures during childhood, onto a current relationship.
 More intensified in psychoanalysis; reveals early patterns
(Moore, B E. & Fine, B. D. (1990). Psychoanalytic terms and concepts. New Haven, CT: Yale University Press.)
 Chance encounters
 Social invitations
 Gifts
 Request for other therapy
 Disclosure
 Touch
 Sex
Case Material: “James”
 James’s reasons for seeking therapy
 My early clinical impressions
 James’s personal history
 Phases of therapy
 Beginning
 Middle
 End (“Termination”)
 Post termination
Reasons for Seeking Therapy
 Referred by a university mental health center
for longer term psychotherapy
Crisis about major
Symptoms of depression
Sense of feeling lost
Feeling effects of parents’ divorce two years
James’s Initial Presentation
Monotone & restricted expression of affect
Image of wave (overwhelming feelings)
“Waiting” expression
Subtly vigilant
Pleased others & took on feelings of others
Didn’t want to make waves
My Early Impressions
 Earnest
 General vagueness in contrast to moments of precise insight
 Strengths
Thoughtful, intelligent
Sense of humor
Willing to try
 Types of defenses
Exhaustion/keeping extremely busy
“Fogginess”/not noticing things
 Lack of “dialogue”
 How would I need to be with him?
James’s Personal History
 19 y/o, single heterosexual, college student
 Father 1st generation Chinese American, not religious, converted to
Sacrificing, wants things to be “normal,” i.e., no conflict
 Mother European American, raised Catholic
 Alcoholic; affectionate when inebriated but otherwise enraged and
 Parents divorced when James 17 y/o
 Younger brother by 4 years
Explosive like mother
Top student in high school
Premed but struggled
Switched to another major with some success
Paying for college himself
Treatment Goals
 Not in crisis when he came to me
 Exploratory psychodynamic psychotherapy
 Feel better
 Find his niche, who he was
 Therapy lasted 3 yrs, 8 mo’s
How I worked with James
 What I did
Communicated interest and warmth
Explained how therapy works
Provided structure by asking open-ended questions
while remaining attentive to his cues
 “What’s your inside life like?”
 Reflected back
 Did not let silence lapse too long
 What I did not do
 Interpret too much
 Give advise
Initial Phase: Themes
 Sadness persisting beyond subsiding of depression
Sensitivity to emotional intrusion
Distancing from affect (speaking in second person, e.g.,
“Being alone let’s you think too much.”)
“Squashing” affect (“I don’t like to get too excited about
Trouble with initiating conversation
Ambivalence about attachment
 Foreshadow process: “I’m afraid to attach b/c it will go away.”
 Foreshadow ending: “I don’t know how to do endings.”)
Initial Phase: Progress
 Within 4 mo’s
 Symptoms of major depression remitted but
paradoxically began to experience persistent, puzzling
Met a girl he really liked
Doing better in school but questioning purpose
Insight into emotional pattern: turn anger into sadness
Insight into family dynamics: mother doesn’t “see”
him; father didn’t intervene
 By 6th Month
 Could tolerate my having separate mind to mirror him
Second Phase
 Long phase of exploration
 Talked more openly but still trouble initiating
 Sadness more accessible if not sources
 Focus on current life
 Weathered ups and downs with girlfriend
 Left school to work full time
 Attempted to integrate painful truths about his
family he learned while in therapy
 Parents marrying b/c mother was pregnant
Second Phase: Themes
 Anger
 Self-assertion
 Ambivalence about cultural identity
 Loss of closeness to father
 Ambivalence about growing up
 Fear of dependency and separation (felt less
of it in relation to me)
Second Phase: Progress
 Seeking others to express dependency needs and
allowing attachments (girlfriend; friends)
 Explore own power and authority (trusting own
feelings; role as manager)
 Able to talk about therapy itself; what needed from
 Able to take in my mirroring about positive aspects of
 “You’re sadness isn’t just buried. There’s also aliveness and
 Initiated by James
 We agreed on a date (three months hence)
 Tolerated some exploration of meaning &
 Consolidation and On-going issues
Consolidated Changes
 Behavior
Initiated separation from me
Tolerated exploration of motivation
Better social network of friends
Long lasting romantic relationship & commitment to future
Stand up to girl friend
Promotion at work
Able to set some limits/say “no” at work
Initiated separation from family w/out “cutting them off”
 Intrapsychic
Greater range of expressed affect
Moments of experiencing grief for past
Tolerate ambivalence better
Consider own needs and feelings
Saw parents in more realistic light
Acknowledge ambition
Remaining Issues
 Effects of mother’s issues & alcoholism
 Caretaker
 Substitute husband
 Persistent hope for more closeness with both
parents based on infant/childhood needs
 Unresolved issues about surpassing parents’
academically, especially father
 Fear of dependency and rage
 In behavioral terms “stimulus generalization”
 Old relational paradigm
 Took care of me by not burdening me with his needs, feelings, or
 I would be indifferent or hostile if he expressed needs
 He waited for me to take lead
 New relational paradigm
I was a calming, understanding presence (but kept at a distance)
My subjectivity did not overwhelm his
I gave him time to think (literally)
He could explore his need for me to take lead
He could initiate separation from me and not be undermined by
 Strong personality
 Fleeting moments of boredom and rage
 Different defenses to deal with dependency
 Me: action/ambition/grandiosity
 James: passivity/floating/shrinking
 Distanced from his helplessness and “inner
deadness” to avoid confronting my own
 Own on-going therapy and paid consultation
Post-therapy Contact
 Able to explore with my support
 Able to acknowledge limitations of therapy
 Relieved that he could come back (“safety
 Called several months later
 Engaged
 Doing well
 Therapist recommendation for fiancée
“If change were easy, psychotherapists would be out of a job.”
Nancy McWilliams, Psychoanalytic Psychotherapy: A Practitioner's Guide
 Suggested Reading
Lowder, G., Hansell, J., McWilliams, N. (n.d.) The enduring significance of
psychoanalytic theory and practice. Retrieved February 9, 2008 from
McWilliams, N. (2003). Psychoanalytic psychotherapy: A practitioner’s guide.
New York: Guildford press.
Milrod, et al (2007). A randomized controlled clinical trial of psychoanalytic
psychotherapy for panic disorder. American Journal of Psychiatry, 164(2): 265272.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American
Psychologist, 65(2), 98-109.

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