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Complexities of Therapeutic Process Raise Difficult Issues When should transference work be used in psychodynamic psychotherapy? That was one of the questions addressed by Glen O. Gabbard, M.D., in a master course titled “Challenges in Psychodynamic Psychotherapy” at APA’s 2012 annual meeting in Philadelphia today. The goal of the course was to address some of the thorny problems with which clinicians grapple when they are immersed in the practice of psychotherapy. Gabbard noted that transference work can be useful in some instances but counterproductive in others. He pointed out that recent psychotherapy research suggests that in once-weekly therapy, working within the transference is most useful for patients with disturbed object relationships. With high-functioning patients with mutually supportive relationships, transference interpretation does not necessarily add additional improvement. Mantosh Dewan, M.D., emphasized the key principle in brief therapy of finding a focus and linking the patient’s symptoms to it. Patients must be brought back again and again to the focus when they wish to ramble into other areas that may be peripheral and unrelated to that focus, he advised. Valdesha Ball, M.D., and Gabbard also explicated how racial and ethnic issues may be relevant to many psychotherapy processes, but are among the most difficult themes to address. Microtrauma, white privilege, and the narcissism of minor differences may all enter into therapeutic dialogue. Gabrielle Hobday, M.D., spoke about the complexities that emerge when one therapist treats two patients who know each other well. From an ethical perspective, therapists cannot acknowledge that they treat the other patient, even if the current patient in their office knows it. Nor can the therapist use any information with one patient that he or she learned through the other patient. This challenge requires an emphasis on compartmentalizing what one hears and from whom. Using case material, Holly Crisp-Han, M.D., illustrated the transference and countertransference implications of the patient who berates the therapist for incompetence but persists in attending sessions. Each therapist has a different level of tolerance, she noted. When clinicians are being berated, they must become attuned to when they become unable to think because of the countertransference anger or hatred that is evoked by the patient and put a stop to the berating. The course ended with a detailed consideration of terminating dynamic psychotherapy. Gabbard stressed that termination of dynamic psychotherapy is highly individualized and idiosyncratic, and the therapist must be able to respect the patient's decision even when it is at odds with what the therapist thinks is best.
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