Psychodynamic Therapy Techniques: A

Guide to Expressive and Supportive

Interventions Brian A Sharpless
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i

Psychodynamic Therapy Techniques

ii
iii

Psychodynamic Therapy
Techniques
A Guide to Expressive and
Supportive Interventions

BRIAN A. SHARPLESS

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
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© Brian A. Sharpless 2019

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Library of Congress Cataloging-​in-​Publication Data

Names: Sharpless, Brian A., author.
Title: Psychodynamic therapy techniques : a guide to expressive and
supportive interventions /​Brian A. Sharpless.
Description: New York, NY : Oxford University Press, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018039422 (print) | LCCN 2018050440 (ebook) |
ISBN 9780190676285 (UPDF) | ISBN 9780190676292 (EPUB) |
ISBN 9780190676278 (paperback : alk. paper)
Subjects: LCSH: Psychodynamic psychotherapy—​Technique.
Classification: LCC RC489. P72 (ebook) | LCC RC489. P72 S53 2019 (print) |
DDC 616.89/​14—​dc23
LC record available at https://​lccn.loc.gov/​2018039422

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v

This book is dedicated to the continued inspiration—​literary or otherwise—​

of Friedrich Nietzsche, Jimi Hendrix, Arthur Schopenhauer, Indiana Jones,
Søren Kierkegaard, Christopher Hitchens, Mark Manning, John Waters,
and the Ramones.
vi
vi

CONTENTS

Preface ix
Acknowledgments xi

1. Introduction 1

SECTION I Background Information for Psychodynamic Therapy

Techniques
2. Do We REALLY Need Psychodynamic Therapy? 7
3. Goals of Psychodynamic Therapy 18
4. The Psychodynamic “Stance” 34
5. The Supportive–​Expressive Continuum 52
6. Characteristics of “Good” Psychodynamic Interventions 62
7. How to Assess the Impacts of Interventions 72

SECTION II The “Classic” Psychodynamic Therapy Techniques in

Contemporary Practice
8. Foundational Techniques Part I 85
9. Foundational Techniques Part II 102
10. The Process of Questioning 114
11. The Process of Clarification 122
12. The Process of Confrontation 135
13. The Process of Interpretation 152

SECTION III The Expanded Range of Psychodynamic Therapy Techniques

14. Supportive Therapy Techniques Part I 179
15. Supportive Therapy Techniques Part II 192
16. Repairing Ruptures in the Therapeutic Alliance 208

Afterword 219
Appendix A: Psychodynamic Therapy Manuals and Models 221
References 229
Index 257
vi
ix

PREFACE

I begin this book with a personal confession: I love psychodynamic psychotherapy.

However, mine is not a young, wide-​eyed love where I only see the good. Instead,
it is a mature and nuanced love where, as Freud might say, I have owned my am-
bivalence. To be perfectly blunt, there are aspects of psychodynamic therapy that
I hate with the white hot heat of a thousand suns.1 For instance, I hate the un-
necessary obscurantism found in some of our books and constructs. I dislike the
fact that some psychodynamic therapists remain uninterested in testing our most
cherished beliefs.2 I also hate the nasty, reductionistic side of certain theories that
view people through myopic eyes. But despite these criticisms, there is also so
much to love. My hope is that the remainder of this book will more fully explain
this pronouncement.
I have gravitated toward psychodynamic therapy’s realistic view of people since
my undergraduate days. It is neither optimistic nor pessimistic. Though it may
not be fun to think about, I fear that Freud, Nietzsche, Schopenhauer, and other
depth psychologists were correct in realizing that there were practical limits for
how well we can really know ourselves and others. Whatever progress we make
in these regards is hard won. As one example, people often desire and dread the
exact same thing and sometimes at the exact same moment.3 These confusing
experiences do not make self-​understanding easy. We are also fantastically good
at deceiving ourselves.
Psychodynamic theory assumes this to be the case, and, in fact, some of its
main techniques are predicated upon it. For example, interpretations—​the most
“psychodynamic” of psychodynamic techniques—​presuppose that patients are
unaware of at least one aspect of their subjective experience (see Chapter 13).
The therapist helps remedy this state of affairs by presenting them with an inter-
pretive hypothesis. Further, one subtype of confrontation encourages patients to
resolve their personal inconsistencies (see Chapter 12). Through these and other
efforts, psychodynamic therapy helps people become more transparent to them-
selves. Regardless of how sick or healthy we are, all of us could use a bit of help in
this area.
x

x Preface

However, as anyone who studies the subject knows, it is difficult to write any-
thing general about psychodynamic therapy (e.g., a book on techniques) without
alienating large portions of the field.4 This text, though intended to be as neutral as
possible, will nevertheless reflect my own preferred theories and prior training.5
However, my hope is that the descriptions of techniques, and the procedures
for formulating them, will be applicable across the many forms of psychody-
namic therapy. At present, all these viewpoints are needed, as they each provide
a slightly different conceptual lens through which to view people and pathology.
Psychotherapy is no small task. Given the sheer range and intricacy of human suf-
fering, a plurality of views seems far preferable to a hegemony.
After all, humans are nothing if not complex and full of contradictions. This
is strikingly apparent to me at the present moment. I drafted this preface while
walking around the crumbling ruins of a castle owned by a long dead 16th-​
century countess. By all accounts she was a brilliant woman, a polymath, a patriot,
and a very good mother. However, she was also a sexual sadist and a serial killer—​
perhaps the most prolific in all recorded human history. If the trial records are to
be believed, she may have been responsible for the deaths of up to 650 women and
girls.6 Again, people are nothing if not complex and full of contradictions.
Regardless of the person or the patient involved, psychodynamic therapy is a
useful, albeit imperfect method for peeling back the light, dark, and gray layers of
human existence. A possibility for better relationships and an end to old patterns
could result from using its techniques. More generally, psychodynamic therapy
is a means to help people move forward in their lives or, at least, to better under-
stand themselves and their many confusing contradictions.
—​Čachtice, Slovakia, 2018

NOTES

1. The reader will hopefully forgive me for adapting this particularly dramatic quote
from the Bhagavad Gita (2009, p. 464).
2. However, as described in Chapter 2, there are a number of top-​notch psychody-
namic researchers currently hard at work.
3. For instance, see Sharpless (2013).
4. Jacques Barber and I (2015) recently argued that these internecine struggles might
be a legitimate danger to the future of psychodynamic therapy.
5. This includes the broad suborientations of ego psychology and object relations as
well as the more specific approaches of supportive–​expressive therapy, transference-​
focused psychotherapy, and mentalization-​based treatments. I also have experience
in cognitive-​behavior and existential approaches.
6. See McNally (1983) and Craft (2014).
xi

ACKNOWLEDGMENTS

A number of people contributed to making this book a reality. I would first like
to express my gratitude to Sarah Harrington at Oxford University Press. Sarah
is not only great at her job, but a lot of fun to work with. Second, I would like
to thank all of my patients and clinical supervisors. Next, I would like to thank
my colleagues, friends, and students at the American School of Professional
Psychology, the University of Pennsylvania, Pennsylvania State University, and
Washington State University. And last, but certainly not least, I would like to indi-
vidually thank Gary Sharpless, Linda Sharpless, Jamie Weaver, Peter Arnett, Jason
Baker, Jacques Barber, Larry Blum, Thomas Borkovec, Louis Castonguay, Dianne
Chambless, Amanda Cummings, Homer Curtis, Dan Denis, Mariana Dobre,
Karl Doghramji, Christopher French, Reed Goldstein, William Gottdiener, Alice
Gregory, Laena Huffaker, Michael Kowitt, Ken Levy, Peter Lilliengren, James
Martin, Dakota Mauzay, Kevin McCarthy, Victoria Merritt, Jessie Meyer, Barbara
Milrod, the Nationals Capital Area Skeptics, Niels Nielsen, Debra O’Connell,
Desmond Oathes, Aaron Pincus, the Psychodynamic Research listerve, the Ratio
Organization of Popular Science, Michael Roche, Gowen Roper, Matt Rothrock,
Ayelet Ruscio, Jeremy Safran, Debbie Seagull, Skeptics in the Pub UK, Christina
Temes, Sandra Testa, Joseph Tse, Bo Vinnars, Deborah Wachter, Ernest Wachter,
Kenneth Wachter, Thomas Wachter, and Jacob Zimmerman.
xi
xi

Psychodynamic Therapy Techniques

xvi
1

Introduction

Psychotherapy is a strange business. It is also very hard to do well. Both these

statements make sense if you consider what psychotherapy really entails. At its
core, psychotherapy is intended to alleviate human suffering through only a com-
bination of words and a relationship. Other fields may use drugs, surgeries, deep
brain stimulation, etc., but this is not the case in psychotherapy. For better or
worse, it has always been a “talking cure” (Breuer & Freud, 1955, p. 30) and re-
mains so to this day. The various modalities—​psychodynamic therapy included—​
just tend to speak a bit differently and create different types of relationships.
Given these limited tools, good therapists need to know not only what to in-
tervene on (i.e., a problem derived from a good case formulation) but also how to
intervene (i.e., which techniques to use and when to use them).1 Both are viewed
as necessary pieces of the psychotherapy puzzle (Anderson & Hill, 2017; Caspar,
2017). For instance, technical skill will be unlikely to help patients unless guided
by a good case formulation. This is because techniques are believed to be most
beneficial when applied in a deliberate manner using a long-​term time horizon
(i.e., not haphazardly or reactively). Similarly, even the best of case formulations
will be of limited value unless therapists know how to use them when they are
in the room with patients. Building upon a famous quote from Immanuel Kant
(1996, p. 107), formulations without techniques are empty; techniques without
formulations are blind.
But how can therapists best learn these skills? A number of readable and
“experience-​near” introductory psychodynamic texts are fortunately available
(e.g., Cabaniss, Cherry, Douglas, & Schwartz, 2011; Gabbard, 2014; McWilliams,
2011; Summers & Barber, 2010). When used in conjunction with appropriate su-
pervision, they provide useful introductions to psychodynamic practice (e.g., case
2

2 P sychodynamic T herapy T echniques

formulation, use of countertransference) and help beginning therapists feel more

comfortable with patients. Given the breadth of their coverage, though, it is un-
derstandable that they are unable to devote extensive attention to every topic.
Therefore, the present work has the narrower aims of (a) describing many of the
techniques of psychodynamic psychotherapy and (b) explaining how to prepare
them for clinical use.

ON THE DEFINITIONS OF SPECIFIC PSYCHODYNAMIC

TECHNIQUES

However, these two simple goals quickly became complicated. The long his-
tory of our field is in many ways a strength,2 but it also has some unintended
consequences. For example, a number of techniques have been defined inconsist-
ently across authors. One person’s confrontation might be another author’s clar-
ification, or vice versa (see Chapters 11 and 12). Making the matter even more
complex, certain technical terms have undergone such heavy theoretical modifi-
cation over the years that they are viewed quite differently in 2019 than they would
have been in the early days of psychoanalysis (e.g., evenly-​hovering attention as
described in Chapter 8). A solution to these conceptual difficulties—​imperfect
though it may be—​was to separate the main techniques according to their ther-
apeutic intentions.3 Therefore, all the specific psychodynamic interventions
were distinguished from one another according to their specific a priori clinical
functions. This will hopefully make the book easier to use.

BACKGROUND TRAINING

This book was primarily written to be an intermediate-​beginner level text for

graduate students and psychiatric residents. It may also be useful for practitioners
of other orientations, those interested in psychotherapy integration (Stricker,
2010), and psychotherapy researchers. Regardless, proper use of these techniques
presupposes:

• experience with psychodynamic case formulation;

• a basic knowledge of psychodynamic theories and concepts;
• diagnostic interviewing skills;
• comfort assuming a therapist role with patient; and
• knowledge of risk assessment (e.g., how to assess for suicidal or
homicidal risk).

If any of these knowledge bases have not yet been acquired, this book might best
be supplemented with one of the previously mentioned psychodynamic texts and
other relevant resources. Of course, it is also strongly recommended that readers
receive clinical supervision from licensed providers intimately familiar with these
3

Introduction3

techniques (i.e., trained psychodynamic psychotherapists or psychoanalysts). The

process of psychodynamic therapy has a steep learning curve, and it will take
time, patience, repetition, and careful self-​observation to effectively use these
interventions. Therefore, therapists may want to begin this process by working
through any suggested technical procedures (e.g., the six steps in the process of
interpretation listed in Chapter 13) until each technique begins to feel more ef-
fortless and “natural.”4

OVER VIEW OF THE BOOK STRUCTURE

This book is divided into three sections and one appendix. The first section
focuses on information relevant to understanding and applying psychodynamic
techniques. It begins with a chapter on the empirical status of psychodynamic
therapy and makes the case for its importance in the contemporary clinical
landscape. Next, individual chapters describe psychodynamic treatment goals,
components of the psychodynamic stance, and the “supportive–​expressive” con-
tinuum of techniques/​treatments. The last two chapters detail the characteristics
of good psychodynamic interventions and suggest ways to assess clinical impacts
during session (i.e., were they effective?).
The second section of this book focuses on what many practitioners consider
to be the classic psychodynamic techniques (e.g., Yeomans, Clarkin, & Kernberg,
2015).5 Eleven foundational techniques are described first (e.g., how to listen in
a psychodynamic manner, abstinence, technical neutrality). They are considered
foundational because they lay the groundwork for more specific interventions.
Next, individual chapters are devoted to each of the “big four” techniques of
questions, clarifications, confrontations, and interpretations. Clinical vignettes6
are interspersed among the historical, theoretical, and practical discussions.
Methods for formulating these techniques are suggested along with tips on
phrasing.
Section III focuses on the expanded range of psychodynamic practice by
outlining supportive therapy techniques. As is well known, not every patient is
appropriate for traditional, insight-​oriented therapy. In fact, this approach may
even be contraindicated for sicker patients (especially for those with a psychotic
personality organization or those in a state of acute crisis; see Rockland, 1989).
Six sets of supportive techniques are described. The intentions of these range
from supporting self-​esteem and reducing patient anxiety to improving adapt­
ive life skills. The final chapter focuses specifically on ways to identify and re-
pair therapeutic alliance ruptures. These events, common to all forms of therapy
(i.e., expressive, supportive, or otherwise), can lead to poor therapy outcome and
premature termination (Eubanks-​Carter, Muran, & Safran, 2015). However, if
managed properly, ruptures can also serve as an impetus for meaningful clinical
change (Safran & Muran, 2000).
Finally, the appendix, co-​authored with Peter Lilliengren, serves as a resource
for those interested in exploring the empirical literatures or locating specific
4

4 P sychodynamic T herapy T echniques

clinical tools. It lists psychodynamic models (e.g., supportive-​expressive therapy)

as well as disorder-​specific manuals (e.g., panic-​focused psychodynamic psycho-
therapy) and compiles their corresponding references. As discussed more fully in
the next chapter, psychodynamic researchers have made significant contributions
to psychotherapy research. Manualized treatments were—​and continue to be—​
a useful means to this end. Further, many of these manuals can also serve as
helpful guides for therapists interested in learning how to apply psychodynamic
techniques to specific patient populations.

NOTES

1. This also presupposes some skill in managing therapeutic relationships.

2. For example, this long history resulted in the many subfields we have today (e.g.,
object relations, self psychology) and the different clinical viewpoints that they each
provide.
3. Therefore, for the sake of consistency, certain authors are prioritized over others.
4. There is obviously not only one “correct” way to enact psychodynamic techniques.
The suggested procedures are included for didactic purposes. Responsiveness to a
particular patient is key.
5. The majority of these have been in use since the earliest days of psychoanalysis.
6. To preserve patient and supervisee confidentiality, clinical vignettes are a combina-
tion of de-​identified (i.e., their identities and details have been heavily distorted),
aggregated (i.e., blends of actual people), and hypothetical patients/​supervisees.
5

SECTION I

Background Information
for Psychodynamic Therapy
Techniques
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