Questions & explanations
1. How can a supervisor help a trainee develop the skill of identifying and working with transference in psychodynamic therapy?
The supervisor can ask the trainee to recount a session in detail and notice any strong feelings the trainee had toward the client. Then, the supervisor can help the trainee see if those feelings might be the client's transference—where the client projects feelings from past relationships onto the therapist. For instance, if the trainee feels disrespected by a client, the supervisor might explore whether the client is treating the trainee like a disrespectful father. The supervisor can role-play with the trainee how to gently address the transference in session, such as asking 'I wonder if you feel I am judging you like your father did?' This builds the trainee's ability to use transference therapeutically.
2. How does a relational psychoanalyst use their own feelings in therapy, and why is that similar to humanistic therapy?
The therapist pays attention to their own emotional reactions to the client, called 'countertransference.' They see these reactions as useful information about the client's relational patterns. This is similar to humanistic therapy's emphasis on authenticity and congruence—the therapist being real with their feelings. For example, if the therapist feels frustrated, they might explore that with the client openly. The goal is to use the therapist's experience to understand the client better. Both approaches believe the therapist's genuine presence matters. However, relational psychoanalysis interprets the feelings as clues to unconscious dynamics, while humanistic therapy focuses on providing acceptance.
3. How would a CBT conceptualization for a depressed client differ from one for a client with social anxiety?
For depression, the conceptualization often highlights negative beliefs about self, world, and future (the 'cognitive triad'), inactivity, and withdrawal from others. Maintenance factors include low energy and avoiding tasks. For social anxiety, the core belief is about being judged negatively, leading to safety behaviors like speaking little or avoiding eye contact. The maintenance cycle includes overfocus on anxiety symptoms and avoiding social situations. Both share the idea that behaviors keep thoughts alive. But the specific beliefs and behaviors differ: depression focuses on worthlessness and social withdrawal, while social anxiety focuses on fear of humiliation and avoidance of performance.
4. Give a clinical manifestation of repetition compulsion that a therapist might see in a client with a history of childhood neglect.
A client who was neglected as a child might repeatedly put themselves in situations where they are ignored or abandoned. For example, they might cancel therapy sessions or arrive late, reenacting the feeling of being unattended. Alternatively, they might form friendships or romantic relationships with people who are emotionally unavailable, then feel hurt when their needs go unmet. In therapy, they might expect the therapist to neglect them, so they test the therapist by pulling away. The therapist can notice this pattern and gently point it out, linking it to the past: 'I wonder if you are expecting me to forget about you, like your parents did?' This helps the client become aware of the cycle.
5. How can a psychodynamic therapist incorporate traditional healing practices when working with a client from a non-Western background, while staying within ethical boundaries?
The therapist can ask the client about any traditional healers or practices they use, like rituals or herbal remedies, and respect their importance. They can frame this as part of the client's support system. However, the therapist must ensure that the traditional practice does not harm the client, such as consulting a healer who gives unsafe substances. If the client wishes, the therapist might collaborate with the healer (with permission) to align goals. The therapist should not endorse unscientific claims but can acknowledge the cultural value. For example, a client might attend a cleansing ceremony; the therapist can explore its emotional meaning while maintaining a psychodynamic focus.
6. Compare two different models of psychodynamic supervision: one that focuses on the trainee's personal therapy and one that focuses only on clinical technique.
A supervision model that includes the trainee's personal therapy emphasizes that the trainee must understand their own unconscious conflicts to avoid interfering with client work. For example, if a trainee has unresolved issues with dependency, they might avoid exploring a client's dependency needs. The supervisor might encourage the trainee to get personal therapy to address this. In contrast, a model focused only on clinical technique teaches specific skills, like how to interpret defenses, without requiring self-exploration. The first model can lead to deeper self-awareness but may be intrusive; the second is more straightforward but may miss how the trainee's own issues affect therapy.
7. Compare how a purely humanistic therapist and an integrated psychodynamic-humanistic therapist would handle a client's resistance in session.
A purely humanistic therapist might see resistance as a sign that the client's authentic self is not being accepted, so they would offer unconditional positive regard and empathy. They would avoid interpreting the resistance, focusing instead on creating a safe space. An integrated therapist would also offer empathy but would explore the resistance as a defense shaped by past relationships. For example, if a client stays silent, the humanistic therapist might say 'I accept your silence,' while the integrated therapist might add, 'I wonder if staying silent keeps you safe, like when you were a child.' This adds a layer of insight without undermining the supportive stance.
8. Compare CBASP to standard CBT for someone with depression that has lasted many years without getting fully better.
Standard CBT works mainly on current negative thoughts and behaviors. For a person with chronic depression, these patterns are deeply stuck because of past experiences. CBASP adds a focus on interpersonal patterns: the client often has a history of trauma or neglect that taught them that trying is useless. CBT might challenge the thought 'nobody cares,' but CBASP would first help the client see how they themselves act in a way that keeps people at a distance. CBASP also uses a technique where the therapist 'disciplines' inappropriate behavior in session, which is different from CBT's collaborative style. For chronic cases, CBASP has shown better results than CBT alone.
9. During therapy, a client's panic attacks stop, but she still avoids driving on highways. How does the conceptualization need to change?
The original conceptualization likely focused on the panic cycle: catastrophic thoughts -> anxiety -> avoidance, with safety behaviors. Now that the panic attacks are gone, the conceptualization should include 'residual anxiety' and 'avoidance as a safety behavior.' The core belief may still be 'driving is dangerous' even though panic no longer occurs. The new conceptualization would highlight that avoidance prevents the client from learning that she can drive safely without panic. Treatment would shift to graded exposure to highways to test the belief. The conceptualization is updated to reflect the new maintaining factor: avoidance despite absence of panic.
10. Give an example of a therapeutic technique that comes from both humanistic therapy and CEST.
A technique called 'experiential challenging' combines both. The therapist asks the client to describe a troubling situation and pay attention to their immediate feelings (humanistic focus on experience). Then they gently question the beliefs behind those feelings, a CBT method. For instance, if a client feels 'I'm a failure,' the therapist might ask, 'What does that feeling tell you about yourself?' and later, 'Is there evidence that contradicts that belief?' The client stays connected to their emotions while examining thoughts. This honors the client's experience and promotes rational reevaluation. It's a direct blend of humanistic and cognitive approaches.
11. How does relational psychoanalysis incorporate the humanistic concept of 'self-actualization'?
Humanistic therapy often talks about self-actualization as the innate drive to become one's best self. Relational psychoanalysis does not use that term, but it shares the goal of helping the client live more fully and authentically. The relational focus on repairing early relational injuries helps the client develop a more secure sense of self. Through the therapeutic relationship, the client internalizes a more positive view of themselves and others. This process enables the client to form healthier relationships and pursue their potentials. In essence, both approaches aim for the client to grow beyond their limitations, though they use different concepts.
12. How does the concept of the death instinct relate to repetition compulsion, and what is a modern criticism of this idea?
Freud proposed the death instinct (Thanatos) as a drive toward death and destruction, which he thought explained repetition compulsion as a return to an inorganic state. He believed some repetitive self-destructive behaviors came from this instinct. However, many modern therapists criticize the death instinct as too speculative and not supported by evidence. They instead explain repetition compulsion as an attempt to master trauma or as a result of attachment patterns. Contemporary views focus on early relationships and the need for safety, not an innate death drive. Most psychodynamic therapists today prefer relational or attachment-based explanations.