Teletherapy or "E-Therapy"

Psychodynamic psychotherapy has its’ roots in the work of Sigmund Freud and psychoanalysis. Like many things since 1900, much has changed in this treatment approach. The changes that have occurred in psychodynamic therapy have received significant empirical support from psychotherapy researchers. Despite the fact that popular accounts of psychotherapy suggest, “only newer, symptom-focused treatments like cognitive-behavioral therapy or medication have scientific support,” there is ample evidence that psychodynamic therapy is as effective as these treatments and its’ effectiveness lasts over time (Shedler, 2010).

Consistent with Freud’s initial insights, psychodynamic therapy holds that our mental life is divided (though not neatly or cleanly), into conscious, pre-conscious and unconscious processes. Because of the ever-shifting boundary between these different levels of awareness, we tend to know more about ourselves than we fully understand or appreciate. Our unconscious contains the origins, hidden meanings and obscure motives of our inner life. Our preconscious offers clues, hunches and impressions about ourselves, about certain people or situations. Our conscious mind often attempts to make sense of it all by providing logical and linear, mood congruent, face-saving and historically consistent explanations of these private experiences. One-way psychodynamic therapy attempts to help clients is to provide a bridge of understanding between unconscious and conscious experiences. At its core, dynamic therapy offers a unique relationship through which there is communication that can relieve distress, promote learning, facilitate change and lead to personal growth.

Another important facet of psychodynamic therapy is the relationship between childhood development and adult personality. From infancy through adolescence our character is engraved through mutually influential processes of nature (our inherited characteristics) and nurture (our lived experiences). We enter the world extremely vulnerable, and completely dependent on our caretakers. As a result, a critically important attachment process takes place between parent and child. Adding a layer of complexity and drama to this developing bond are the unique characteristics of its’ participants. When there is a good, or “good enough” fit between child and caretaker, a secure bond occurs, self-esteem is promoted and overwhelming hurt or frustration is avoided. Problems arise when a child’s unique needs don’t fit well, (or at all), with the strengths and weaknesses of his/her caregivers, extended family or peers. Adjusting to good or poor environmental “fits” creates patterns of adaptation in how a child thinks, feels, behaves and interacts. These unconscious patterns help us cope, thrive and sometimes simply survive our childhoods as in the case of abuse or neglect. In concert with our genetic potentials, these patterns become indelible parts of our personality. When over-used, especially later in life, they can become inflexible, less adaptive and less successful and the source of much pain and confusion.

What Is Psychodynamic Therapy?

Describing psychodynamic therapy itself is not easy. Much like the difference between a biography and a resume, psychodynamic therapy assumes there is more to a person than basic facts and information. Unlike a resume, a good biography (and good therapy) looks beneath the surface. It examines both subtle and obvious forces influencing its’ subject. By exploring the intimate details, important relationships and significant events in a client’s life, psychodynamic treatment adds depth and texture to the story. Like a good biography, a course of psychodynamic psychotherapy attempts to provide order and meaning to the twists and turns in a client’s life, to his/her emotional distress, inner conflicts, confusing choices and courageous acts of love and self-sacrifice.

How Does It Work?

In therapy, my clients and I work together to clear a path between where they are and where they want to be. Through an emotionally honest conversation, the client’s initial concern is used as a catalyst for exploration, understanding and change. Together we follow threads of experience in order to uncover themes and make sense of painful patterns in their lives. Through this process insight occurs, feelings are softened, understanding is possible and a path becomes clear-though not necessarily easy. Small steps are taken. Additional hypotheses are developed. Explanations and ideas are shared, new feelings arise, even more steps are taken and meaningful change is made possible. Through this work, clients frequently come to appreciate emotional symptoms as understandable reactions to chronically endured pain- frequently experienced in low self-esteem, poor self-confidence and unfulfilling, if not blatantly unhappy relationships.

The Fit Between Therapist and Client

The psychodynamic treatment process starts in the very first session where the therapist and client begin developing a very personal yet completely professional relationship. The first session or two are used to see if there is a, “good fit” between the client and therapist. A good fit between myself, and my client, is anchored in safety, trust, curiosity and mutual respect. Without a safe, comfortable and respectful foundation there is little hope for a successful therapy experience.

An Interpersonal Approach to Psychodynamic Therapy

The majority of people who seek psychotherapy do so because they are in emotional pain. At the same time, much of their distress is due to their inability to find happiness or satisfaction in their relationships with others. Regardless of how confusing or self-defeating a client’s thoughts, feelings or behavior might appear, I have been convinced over many years of practice-every client presents for treatment trying to solve the problem of human relatedness- of being loved, wanted, accepted, appreciated and understood.

The therapeutic relationship is an invaluable resource in the client’s treatment. It can be used to support a client’s efforts to change. It can serve as a window into the hurtful or confusing aspects of a client’s relationships in the past and present. If used thoughtfully, the interactions between the therapist and client provide an appreciation for how the past can add to, or complicate, emotional distress in the present. The “here and now” of the therapeutic relationship can allow the therapist and client to understand how unconscious processes (automatic thoughts, feelings and reactions) protect us, yet can lead to problems in relationships and even more pain. The great strength of psychodynamic therapy is that it can help clients address relationship problems as well as specific symptoms (anxiety, depression, grief, anger).

In addition, there is no more important relationship than the relationship we have with ourselves- reflected in our self-concept, self-esteem and relationships with others. Psychodynamic treatment allows clients to review and reconsider how they think about, feel toward and treat themselves. As therapy concludes, clients function as their own therapist. They develop the capacities to manage stress, maintain self-esteem and reach out to others in healthy and satisfying ways. A positive treatment outcome allows a client to leave therapy with a more calm and clear inner voice, and an empathic and more accepting perspective about themselves and others.

An Existential Perspective in Psychodynamic Therapy

Beneath our difficulties and emotional distress are fundamental questions about life. These concerns are woven deeply into the fabric of what it means to be human. Philosopher Paul Tillich (1952) wrote of life’s ultimate concerns and psychiatrist Irvin Yalom (1980) distilled them into our conscious and unconscious struggles with death, isolation, meaning and freedom. These ultimate concerns encircle all of us. Nearly every psychotherapy client wrestles with questions about life and death and the nature of existence. About being connected to, yet undeniably, separate from, others in his/her life, about meaning and meaninglessness, about the responsibility we all have for our own happiness and pain. While these ultimate concerns are often neglected or pushed aside by the pressures of everyday living (or good fortune), they frequently take center stage when we are confronted with poor health or unhappiness.

Valuing Emotion in Treatment

An emotion-focused approach to psychotherapy simply acknowledges that if substantial change is to occur in treatment it must involve and include emotion. The Latin root of the word emotion means, “to move.” Without feeling emotion, deep and meaningful emotion, we are unlikely to move, or be moved, in ways that allow us to make changes in our selves or in our lives. Whenever anything of significance happens in our lives, whenever anything that truly matters begins or ends, there is emotion involved. During these times, emotion, either paralyzes us, and blocks our efforts to change, or catalyzes us, and fuels our efforts to respond and live with greater freedom and dignity.

Closing Thoughts

In addition to addressing the difficult and distressing side of life, psychodynamic therapy can contribute to and draw from a client’s positive inclinations. Every client brings strength, creativity and resilience to his/her therapy. Each client has within his/her grasp happy, healthy and adaptive attitudes (Akhtar, 2011). While I take psychotherapy very seriously, it is not an activity that must be done at all times and in all ways with grave seriousness. Any given hour can have the therapist and client exploring a painful setback or a heartfelt laugh about an experience one or the other has chosen to share. No aspect of a client’s experience is inappropriate or off limits- including but not limited to pain and sorrow, laughter and joy. I do not believe successful treatment can be any other way.

My work with couples is guided by my belief that members of a couple are attracted to each other, commit to each other and hurt each other for both conscious and unconscious reasons. A foundation of my approach is attachment theory and the work of psychoanalyst John Bowlby. As it is applied to couples therapy, attachment theory helps us appreciate, from the vulnerability of childhood often spring the insecurities, conflicts and relationship difficulties of adulthood. Children go through an attachment or bonding process with their caretakers that provides for their physical and emotional safety. This process shapes them, and their personalities. The quality of our early attachments impacts our thoughts and feelings about our self, others, intimacy and romantic relationships. It serves as a template for how we manage our emotions, maintain our self-worth, relate to our partners and derive our sense of well-being. This in part explains how threats to our intimate relationships are not only emotionally distressing but can feel like threats to our very survival.

Attachment and related emotional experiences of childhood and adolescence define our psychological comfort zones later in life (Abrahms-Spring, 1997). As a result, we are drawn to people who unconsciously complete our self-image and mental representations of intimate relationships. We “recruit” others to help us recreate familiar patterns of experience, both, positive and negative. This is apparent when we find happy and healthy partners that resemble the positive qualities we observed and enjoyed in our parents. It is also true for those of us from unstable, unhappy, alcoholic or emotionally abusive homes who often “find” critical, addicted, unavailable or controlling partners. In therapy, these clients are often dismayed to see themselves, pushing away healthy relationships and drawn to unhealthy or dysfunctional ones. Still other clients have consciously “chosen” partners who are polar opposites of their parents.’ Yet find themselves unconsciously pushing their partners into repeating hurtful patterns from the past. For example, one client who felt his mother was intrusive and controlling, intentionally chose a partner who was independent and successful and, “gave him his space.” In our couples work he criticized his partner for being aloof and uninterested in him or his career. Of course, his partner felt helpless in the wake of the mixed messages she was receiving.

As a result, most couples concerns have their roots in each partner’s unique attachment history and what Johnson (2010) refers to as attachment injuries. These injuries involve conflicts that threaten the importance and emotional security of one or both members of a couple. A couple may disagree and argue about sex, money, jealousy, in-laws and child rearing. At the core of each of these concerns is the threat they pose to the security of each partner and the safety of the relationship. When the insecurities of a partner are aroused or the survival of the relationship is in question, deep fears result. Behaviors meant to protect and defend against criticism and rejection, are used reflexively to prevent being flooded by feelings of worthlessness or abandonment. When conflicts persist over time, they erode the very relationship meant to protect us, inspire us and embolden us.

The Goal of Couples Therapy

While every couple is unique, most couples want similar things from their relationship. Most every couple wants to be able to communicate clearly and openly. They want a relationship that can provide them with a safe haven, a sanctuary and a respite from the stress and strain of the rest of their lives. They want an interesting and intimate relationship that is emotionally satisfying and physically fulfilling. Both partners want to be understood and accepted by the other for who they are. Couples want a relationship where each partner can share successes and setbacks with the confident expectation that these experiences will be met with appreciation and understanding not available from friends and family. They want to love and be loved.

Goodness of Fit

As in individual therapy, a good fit between the therapist and couple is essential for therapy to succeed. Each partner must feel understood and supported by the therapist very early in treatment. If, for whatever reason, one (or both) partners experience the therapist as unsafe, un-skilled or as leaning decidedly toward one partner or the other, these concerns must be addressed before additional work can take place. If these concerns cannot be resolved, a referral to another therapist is in order. Particularly in the case of a therapist who appears to be leaning toward or favoring one partner over the other. In couples therapy the relationship is the client. A therapist who is perceived as favoring one partner or one position over the other causes additional distress in the relationship. This perception undermines the goal of couple’s treatment; which is to strengthen the couple’s relationship, not decide who is right or wrong.

Except in extreme circumstances, if the therapist begins to lean, or align with one partner’s concerns over the other, he or she has initiated a competition rather than a thoughtful collaboration. Such leaning, stirs each partner’s fantasy that the therapist is actually a judge. As a result, both partners’ conclude that they must argue their cases ever more forcefully. In my couples work, I am not a judge or jury. There should not be a winner and a loser. If there is, the result will be certain failure. Winning and losing leads to, more conflict, even more fear and less understanding. Both partners “win,” by recognizing (what the therapist should already know) that in the course of protecting themselves both have been hurt and hurtful. This recognition is not easy and for some couples it is not possible. Dynamic therapy views relationships as open systems where our actions fuel love or fear, understanding or invalidation. We all engage in behaviors that expand or constrict, strengthen or damage our relationships. Aristotle once said, “Of all the virtues none is more important than courage, for without courage none of the other virtues is possible.” This is absolutely true in couples’ therapy where partners must work courageously to understand their vulnerabilities, acknowledge their blind spots and own their contribution to the relationship's problems.

The Heart of the Matter

At the center of nearly every couple’s conflict is a lack of emotional safety and connection. The lack of understanding and connection creates a predictable pattern of hurt and confusion in each partner and a pattern of conflict in each couple. This pattern gets re-enacted with such painful consistency that couples fall automatically into defensive roles (no matter how offensive they feel). These patterns can become vicious cycles that destroy the willingness to listen or learn, to love or even care. The enemy of the relationship is not “her” criticism or “his” withdrawal, but the corrosive cycle of protection (criticism and withdrawal) that partners use to defend themselves.

Again, it may seem that a couple’s problems are about kids, money, sex and/or the cap on the toothpaste. While these concerns are important, psychodynamic therapists see these issues as triggers to conflict not the core of it. Emotionally responsive and validating partners have the same conflicts, but address them differently. When the threat of attack or abandonment, are taken off the table, when emotional security and commitment are strong, conflicts become concerns, not life and death struggles for power and control. Carl Jung wrote, “If a relationship is not about love, it’s about power.” Beneath the need for power is fear-often the fear of failure, attack, rejection, inadequacy, abandonment, shame or humiliation. As such, the goal of my work with couples is to help them make their relationships about safety, security and love, rather than power or fear.

It’s been said, while change is inevitable, growth is optional. I view change as the tug of war between the parts of us that crave it and those parts of us that fear it. Insight and understanding, awareness and recognition can come to us quickly and provide powerful motivation to change. Yet, despite a flash of insight or a burst of awareness, real, substantial and enduring change is often a slower, more deliberate and difficult process. In myself and in my work with clients, I have found that change is resisted and familiarity defended. A friend and colleague Ken Cloke observed, “…even the most destructive patterns, dysfunctional relationships, damaging ruts and painful routines often seem safer than doing something different. That there is comfort in what is known. Every pattern repeats itself and therein is predictable, measurable, reliable, and is in some way reassuring. Change means altering the pattern and risking making things even worse.” I think Ken is right.

As I look back on my life, on those times when I needed to make a change, the comfort and familiarity of the known had a strong hold on me. It often kept me with people and in places that were clearly unhealthy or unhelpful. In fact, some of the loneliest moments of my life have been when I returned to a place or a person who had not changed and I was confronted with how much I had. The greatest risk in not resolving our conflicts, untangling our problems or confronting our fears is that we will adapt to them and accommodate them. By adapting to and accommodating our difficulties we gradually, and often unconsciously, learn to expect little or nothing from our relationships, our jobs, our lives or ourselves.

So change is not easy. And I’d like to make a case that it shouldn’t be. If we were to change easily or often who would we be? How would we know ourselves, recognize our problems or even know what mattered? How would we know our loved ones or for that matter who we loved or why we loved them? As such, we should, as Michael Mahoney (2003) has suggested, honor and respect the slow, conservative and ultimately self-protective process of personal change. There seems to be both a biological and psychological wisdom to the slow and deliberate processes of deep and meaningful change. In fact, we have names for people who change too easily, too quickly or too often. We call them fickle, impulsive, hypocritical, or childish. We, as human beings, are incredibly resilient and amazingly adaptive. Our resilience allows us to hang in and hang on through long winter nights. Yet, our resilience can also leave us reluctant, even resistant to change, even when change is needed.

Psychotherapy, (individual, couples or family therapy), should help us recognize and respond to the winds of change. But more than that, psychotherapy should help transform change into an opportunity to learn, grow, and become stronger, wiser and more confident. Carl Jung once wrote that maturation is, “…nothing more than becoming more and more of who you are and less and less of who you are not.” There is no better definition of change. Because change demands that you become who you really are and let go of whom you thought you were or felt you should be.

Describing painful and confusing situations as opportunities may sound odd (even hurtful) to someone dealing with death, divorce, illness, loss of a job or any one of a number of truly difficult circumstances. But within each of these situations and each of these losses there is hope. Hope for a different way of being. A different way of thinking, feeling and seeing one’s self and one’s life. In twenty years of practicing psychotherapy it has been my privilege to address these and many other concerns with my clients. I have been nothing less than awed by the courage clients have shown in the wake of such pain and suffering. 

For those individuals, couples, or families who have had the willingness to become more and more of who they were, who embraced change, who did so with a mix determination and patience, more often than not, they found meaning in the changes they faced and needed to make. The end result was often personal growth, greater self-awareness, stronger relationships, and a deeper appreciation for what truly matters in life. Let me be clear. I have never (offered) or provided “personal growth,” wisdom, or life’s meaning to any of my clients. But I have traveled alongside many courageous people who have accomplished some extraordinary things. I have been privileged to be a witness to, and a partner in, much hard work, as well as significant and meaningful change.

I have been immersed in both health psychology and medical family therapy since my fellowship at the University of Rochester School of Medicine in the early 1990’s. Both health psychology and medical family therapy are grounded in a bio-psycho-social model of health and illness. This model views health and illness as a combination of biological, psychological (thoughts, feelings, behaviors) and social factors. Health psychology attempts to draw on psychological principles to promote health and intervene in illness. It does not blame people for their illnesses or disabilities or find psychological causes or cures for their diseases. In my work, I seek to help client efforts to cope with chronic illness, recover from acute and serious illness and find comfort and meaning in the wake of terminal illness. Medical family therapy focuses on the role illness plays in the lives of patients and families. This approach attempts to foster collaboration between and among patients, their families and their medical team in order to facilitate the most effective treatment outcomes possible. Ultimately, medical family therapy seeks to draw from and utilize the love, support and wisdom of family and friends to help patients cope with and recover from disease and disability.

While the bio-psycho-social model provides a theoretical framework for health psychology and medical family therapy, applied research has provided the foundation for my interventions. Studies from across the field have been synthesized and integrated into three oddly named but very useful concepts-agency, communion and meaning. We know that if patients can access the experience and emotions connected with agency, communion and meaning they frequently enjoy better short and long-term outcomes whether they have an acute, chronic or terminal illness.

Agency

Agency involves feeling empowered and effective about your health, health care and medical situation. When we feel agency we feel we have choices and can take steps that influence the quality of our health and treatment. Agency is a sense of personal activism in the face of all that is unclear and uncertain about our illness and its’ treatment. Being an active agent in our illness and health care means learning all that one can about the disease, its cause, expected course and treatment. Being an active agent means collaborating and sharing decision-making with your health care team. It is the opposite of being passive, helpless or simply going along with the program. Having a sense of agency means participating in your health care actively, honestly, respectfully and collaboratively. Ultimately, it means being calm, clear and confident about what you want and need.

Communion

Communion is a peculiar name for social support. But the phrase “social support” doesn’t really do justice to what is meant by communion. Serious, chronic and terminal illness can precipitate a personal crisis that can isolate people and create additional health consequences for them. Communion refers to the strengthening of the emotional and spiritual bonds that can be frayed, damaged, even destroyed by illness. Moving through an illness and the health care system can be a very frightening, confusing and lonely experience. To minimize the isolating effects of illness it is important to develop and accept support from multiple sources- family, friends, clergy, fellow patients and available health care providers. Developing these relationships provides us with greater access to information, personal options, compassion and wisdom- all of which can buffer us against a debilitating illness, an imperfect health care system, misinformation and fear.

Meaning

Meaning is not something one can offer, provide or even suggest to another person. Yet, we know from research, people who find meaning in their pain or meaning in their suffering some how lighten the load of illness, it’s treatment and their combined impact. Finding meaning in pain and discomfort is not another form of denial. It is a way of softening the painful and often unanswerable questions of why me, why now or why this disease? Finding meaning in such suffering often involves answering the question, has anything good come of this experience? Not, do you like it? Not, could things have been worse? But has anything positive come from this pain, this discomfort or this fate? I have heard many profound answers to this question and they have come from sick children, teens and adults.