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Toward a Pragmatic Model of Psychodynamic Psychotherapy
By Rana Duncan-Daston, MSW, LCSW, EdD

Social work practice in general has been assaulted by the recent economic crisis. Currently, it is possible for an outpatient clinical social worker in a community mental health center to have more than 200 clients assigned to his or her caseload. While our profession advocates on the state and national levels for more funding streams, we also need to determine how we can best care for ourselves and support colleagues in the trenches.

In this climate, an important aspect of self-care is to turn to colleagues for consultation and support. I turned to the American Psychoanalytic Association (APsaA) and submitted an application to become part of the Teachers’ Academy. In an unprecedented move to create solidarity throughout the helping professions, the APsaA designed the academy to inspire and support practice faculty to teach psychodynamic psychotherapy more effectively and invited professionals from across the nation to be involved.

A Professional Support Initiative
The Teachers’ Academy was conceived at just the right time. It is an important initiative because many professors may no longer feel supported by their departments to teach psychodynamic psychotherapy. The APsaA invited faculty from psychiatry, psychology, and social work to apply for this all-expense paid opportunity and chose two professionals from each discipline to attend.

In addition to the Teachers’ Academy workshops, participants were invited to attend the regular programming of the annual APsaA conference where psychoanalytic scholars presented on topics ranging from case studies about treating people diagnosed with schizophrenia to documentation of tribal living in the Amazon where the local shaman assists community members with sharing their dreams each morning and structures the life of the village around the emerging information.

I had the good fortune of becoming part of the first Teachers’ Academy in January 2011. I was immersed in all things psychoanalytic, and it was an epiphany.

I went to the conference half expecting to find rigid, tradition-bound thinking, and instead I was invited to join in creative clinical brainstorming that reminded me of time-honored concepts that originated in psychoanalysis, such as the careful attention to the therapeutic alliance.

In addition, I was assigned a gifted mentor, which was just one part of the program, with the strong suggestion to maintain monthly contact for one year. Confiding in and learning from a mentor is a terrific boost to self-care.

My mentor was Joyce Edward, a well-known scholar in the field of psychoanalysis who has been honored with the Pioneer designation by the National Association of Social Workers.

Edward was patient with me as I began to dust off the cobwebs of my theoretical knowledge and supportive as she let me experiment with teaching concepts over Skype. Edward was consistently “present” and held me accountable every step of the way. In other words, she modeled the behaviors of a high-caliber psychodynamic clinical social worker.

How We Got Here
Social work education regarding psychodynamic psychotherapy finds itself in its current state for multiple reasons. The “elders” in the profession came of age when schools of social work were still steeped in ego psychology, so there was an assumed knowledge and value base that arose from the common academic foundation. One reason younger social workers do not necessarily share the same knowledge base is that, in recent years, social work educators have largely moved away from adequately covering psychoanalytic concepts for many reasons (Deal, 2007, p. 185), with feminist concerns about an oppressive patriarchal theoretical orientation among them.

However, this is a situation where we have perhaps thrown the proverbial baby out with the bath water. Regardless of how we regard Freud, few would dispute that psychodynamic concepts have provided the field of clinical social work practice fertile ground in which to grow. Diverse models of psychotherapy may even adhere to psychodynamic concepts. Shedler (2010) cites research that reveals “nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize interventions that have long been central to psychodynamic theory and practice” (p. 98). He reports that recent meta-analyses show promising results for the psychodynamic evidence base.

As others have pointed out (Reardon, 2010), Shedler’s article is part of an international call to reflect differently on the evidence base of psychodynamic psychotherapy. Historically, part of the problem with the evidence base has been that the psychoanalytic paradigm for studying outcomes was the case study, whereas the behaviorist paradigm for studying outcomes has always been the scientific experiment.

Case studies are now equated with anecdotal or unscientific evidence, thus psychodynamic writings have become less convincing within the halls of academe. The APsaA has begun to address the need to collect scientific data to support psychoanalytically informed psychotherapy. Simultaneously, some members of the APsaA are trying to ensure that the case study method is not thrown overboard. Hoffman (2009) argues that while science regards the case study as only hypothesis generating for the real science of hypothesis testing, psychoanalysts use the case study in a multitude of ways, not the least of which is providing possibilities for how to understand and relate to patients.

Other analysts (Westen, Novotny, & Thompson-Brenner, 2004) have argued that “hypothesis generating clinical practice” should be granted equal status with “hypothesis testing systematic research” (p. 1046, as cited in Hoffman, 2009).

Congruence With Social Work Theory
From the earliest beginnings, psychoanalysis recognized the healing potential of the therapy relationship and encouraged professionals to be sensitive to its every nuance. Professionals are encouraged to provide a proper “holding environment” (Winnicott, 1960). The holding environment provides a safe space for clients to explore troubling feelings and thoughts, which are are clues to unconscious conflicts that may rob a person of satisfaction in life, including satisfying interpersonal relationships. Exploring these feelings can produce abundant anxiety.

The professional’s nonjudgmental empathy provides the support necessary to do this difficult work, and the work is predicated on sound therapeutic practice—that is, timely and reliable therapeutic contact. It is also based on solid professional boundaries that draw flexible but firm boundaries between the professional role and the client. These boundaries allow the client to trust the professionalism offered and to avoid coping with the complexities that are always present in more mutual relationships (Hill, 2004). I believe it is important for clinical social workers to ensure the longevity of these concepts in our practice as we look to the future.

Given academe’s avoidance of all things Freudian in the past couple decades, social workers may not be aware of the advances in psychodynamic theory. One example is the assimilative psychodynamic approach that Stricker and Gold (2008) developed that utilizes a three-tier model of personality structure and change. The model moves from overt behavior to conscious cognition and finally to unconscious motives and conflicts; all three levels are considered important to the work.

Likewise, Summers and Barber (2010) have developed what they call a pragmatic model of psychodynamic psychotherapy. This model is congruent with social work theory in that it integrates dynamic factors with the biological, psychological, and social factors in a developmental framework. They incorporate a strengths perspective by identifying the strengths that are associated with the six core problems they posit psychodynamic psychotherapy is best equipped to address.

This January ushered in a second Teachers’ Academy, further educating professionals in psychodynamic approaches. If you, too, honor these concepts and share these concerns, I hope you will consider applying. Applicants are not required to have any particular expertise in psychodynamic psychotherapy—only an interest in learning. If you would like more information, the application for the third academy will be available soon at www.apsa.org/programs/teachers_academy.aspx.

— Rana Duncan-Daston, MSW, LCSW, EdD, is an associate professor and MSW coordinator at the Radford University School of Social Work in Virginia.

References
Deal, K. H. (2007). Psychodynamic theory. Advances in Social Work, 8(1), 184-196.

Hill, M. (2004). Diary of a country therapist. New York, NY: Routledge.

Hoffman, I. Z. (2009). Doublethinking our way to “scientific” legitimacy: The desiccation of human experience. Journal of the American Psychoanalytic Association, 57, 1043-1069.

Reardon, C. (2010). Reevaluating psychodynamic psychotherapy. Social Work Today, 10(3), 18-21.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.

Stricker, G., & Gold, J. (2008). Integrative psychotherapy. In J. L. Lebow (Ed.), Twenty-first century psychotherapies: Contemporary approaches to theory and practice (pp. 389-423). Hoboken, NJ: John Wiley & Sons.

Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. New York, NY: Guilford Press.

Winnicott, D. W. (1960). The theory of the parent-infant relationship. International Journal of Psychoanalysis, 41, 585-595.