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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Chapter 4:

PSYCHODYNAMIC AND PSYCHODYNAMIC

COUNSELING AND PSYCHOTHERAPY

1  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Lay of the Land

Psychoanalytic and Psychodynamic Approaches:

q  Psychoanalysis

q  Ego Psychology

q  Object-Relations Theories

q  Interpersonal Analysis

q  Self Psychology

q  Relational and Intersubjectivity Theories

2  
q  Jungian Analysis
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychoanalytic and Psychodynamic Approaches:

q Psychoanalysis
§  Based on Freud’s original theories.
§  Classic psychoanalysis relatively rare but still
practiced
§  Approach that focuses on analysis of innate
drives and transference issues.

q Ego Psychology:
§  Similar to Freudian theory in terms of the working
relationship.
§  Focuses on analysis of how the ego uses
defense mechanisms to manage innate drives.
3  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychoanalytic and Psychodynamic Approaches:

q Object-Relations Theories:

§  Uses a more empathetic and warmer counseling

relationship.
§  Object relations theorists focus on repairing the
client’s early “object” and relational patterns, often
through corrective experiences the counseling
relationship.
§  There are several schools of object relations
theory
a)  Integrate drive theory
b)  Those that are purely relational.
4  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychoanalytic and Psychodynamic Approaches:

q Interpersonal Analysis:
§  Related to object relations
§  Unique in that the analysis process
§  relies heavily on observable data and
§  focuses almost exclusively on interpersonal
interactions rather than unconscious
processes.
§  Early roots of family therapy
q Self Psychology:
§  Based on the work of Kohut
§  Involves empathic immersion in the client’s inner
world, analysis of selfobjects, and a focus on
building self-esteem. 5  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychoanalytic and Psychodynamic Approaches:

q Relational and Intersubjectivity Theories:

§  Recent approaches that emphasize the
intersubjective nature of reality and employ a
more collaborative counseling relationship
§  It Includes the co-construction of interpretations
with clients.

q Jungian Analysis:
§  Posits a collective unconscious that shapes our
personalities based on universal, archetypical
patterns.
§  Aims to help people self actualize, living up to
one’s full potential. 6  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Basic Psychodynamic Assumptions

§  History: A person’s history affects present behaviors
and relationships.
§  Unconscious: There is an unconscious mind that
exerts significant influence over present behavior.
§  Personality: The personality is structured into various
substructures, such as ego, id, and superego.
§  Early Life: A person’s personality is significantly
impacted by early relationships in life, especially with
one’s mother.
§  Insight: Insight into one’s personality and internal
dynamics can help resolve various psychopathologies.
§  Transference: Clients project onto the counselor
interrelational patterns from earlier unresolved issues;
the transference of these patterns can be analyzed and 7  
used to promote change in the counseling relationship.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Least You Need to Know

Drive Ego Object Self Inter- Relational/
Theory Psychology Relations Psychology personal Intersubjectivity
Theorist S. Freud A. Freud Kernberg Kohut Sullivan Mitchell
Erickson Klein Greenberg
Horney Fairbairn Stolorow
Mahler
Winnicott
Focus of Drive Ego; defense Intrapsychic Relationship Observable Interpersonal
Analysis theory; id; mechanisms representations with self and interactions; world; relational
instincts of caregivers selfobjects Self system matrix
Root cause Conflicts Defense Pathological Distorted Keeping Distorted
of problems between id mechanisms internal object images of elements of expectations of
and used to relations self interpersonal interpersonal
superego manage interactions world
infantile out of
drives awareness
Mechanism Making Developing Integration of Developing a Developing Developing more
of Change unconscious more mature good and bad more the ability to realistic
conscious defense in objects; realistic self- maintain expectations and
mechanisms; release bad image and health interpretations of
increase ego objects from sense of self interpersonal relationships
strength subconscious; worth. relations
realistic view
of others
Client- Detached Detached Empathetic; Empathetic; Uses Uses relationship
counselor expert; blank expert; blank uses uses relationship to explore
relationship slate for slate for relationship to mirroring to to explore interpersonal
client client reflect on help restore interpersonal relationship
object relation self image dynamics patterns
patterns
Commonly Free Analysis of Analysis of Analysis of Analysis of Exploring
used association; defense; free early selfobject behaviors in client’s
techniques dream association; relationships, relations; interpersonal experience of the
analysis dream
analysis
present
relationship
mirroring;
empathy
relationships relationship with
counselor
8  
with counselor
and others

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Significant Contributions to the Field

Transference: Refers to when a client projects on the
counselor attributes that stem from unresolved issues
with primary caregivers; therapists use the immediacy of
these interactions to promote client insight and work
through these conflicts. Examples:

§  Drive theorist/ego psychologist: “When I sit here

quietly listening, you seem to think that I am judging you
to be inadequate, much the same way your father used
to do when you were little.”

§  Object relations, Self Psychology and Relational

approaches: “You seem to think that my quietly listening
implies that I am somehow judging you. Would it surprise 9  
you to know that I am not? I am simply listening intently.”
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Significant Contributions to the Field

Countertransference: Counselors project back onto
clients, losing their therapeutic neutrality and having
strong emotional reactions to the client.

§  Countertransference as unconscious projection:

§  Needs to be explored in supervision and it is often
inappropriate to discuss with clients.
§  Countertransference as conscious experiencing of
the other:
§  If the counselor has self-awareness and can
accurately sort out the sources of
countertransference, it can be used to help the better
understand how others experience the client
§  Sometimes used with the client to promote insight.
10  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Significant Contributions to the Field

•  Corrective Emotional Experience

•  Therapists responds differently than the client

experienced in childhood to facilitate resolution
of an inner conflict.

11  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Drive Theory
Sigmund Freud
§  Developed the first psychoanalytic theory and was
the first to use the “talking cure” that is common
place today.
§  The majority of his ideas (the unconscious,
transference, and defense mechanism) are still at
the heart of modern counseling practice and current
understandings of the human psyche.
§  He found free association and dream analysis to be
more effective means for curing psychopathology.
§  His other significant theories include
§  the psychosexual theory of development
§  the structures of the personality (id, ego,
12  
superego)
§  drive theory.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Ego Psychology

q  Ana Freud: build upon her father’s work on the id and drive
theory.
q  Added analysis of
q  ego functioning and
q  defense mechanisms.
q  Unlike father, she recognized that motivation can come
from external sources not just internal drives.

q  Erik Erickson: most significant contribution was an eight-

stage model of psychosocial development.

q  Karen Horney: critically examined Freud’s theories and

their applicability for women’s psychosocial development.
13  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Object Relations Theorists who Incorporate Drive
Theory
q  Otto Kernberg (American School of Object Relations):
•  Integrated drive theory and object relations theory and
focused his work on borderline personality disorder.
q  Melanie Klein (British School of Object Relations):
•  Developed a unique form of object relations therapy that
incorporates both Freud’s drive theory and object relations
theory and is considered to be the most influential person in
the field since Freud.
•  Worked directly with troubled children, a pioneer in child
and play therapy.
q  Margaret Mahler (American School of Object Relations):
•  Developed a theory of separation and individuation that details
the process of “psychological birth,” by which an infant
becomes psychologically separate from its caregivers 14  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Object Relations Theorists who Do NOT Use Drive
Theory
q  W. R. D. Fairbairn (British School of Object
Relations)
•  Developed a “pure” objects relations model—purely
psychological—without biological drive elements.
•  Understood ego in terms of the ego striving for a
relationship with an object, not merely satisfaction.

q  Donald Winnicott (British School of Object

Relations):
•  Highly influential ideas:
•  Transitional object,
•  Good-enough mothering,
•  True and false self. 15  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Interpersonal
Henry Stack Sullivan
§  His work represents a more optimistic view of human nature
as well as an approach that better reflects American ways of
life.
§  His approach emphasized a drive for relatedness as the
primary drive rather than sex or aggression and is referred to
as interpersonal theory, a distinct form of object relations
analysis.
§  His work was among the first to consider the impact of culture
and relationships in understanding mental illness.
§  He did not emphasize “depth” and the unconscious, he
advocated analyzing verifiable observable data rather than
the unconscious mind.
§  His approach was seminal in the development of other
approaches, including relational psychoanalysis and systemic 16  
family therapy.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Self Psychology

Heinz Kohut

§  Developed the psychoanalytic approach of self

psychology,.

§  He developed primarily with narcissistic patients for

whom traditional analysis did not work.

§  He rejected Freud’s structure of the self: id, ego,

and superego instead Focused on a person’s
sense of self and self worth.
17  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The People and their Stories

Relational Model
q  Jay Greenberg: Laid the foundation for relational theory.
Divided psychoanalysis into two broad and what they believe
to be theoretically irreconcilable approaches: Freud’s drive
model and the relational model, which includes psychologically
oriented object relations approaches, self psychology, and the
newly emerging relational psychoanalysis.

q  Stephen Mitchell: Detailed a relational model for

psychoanalysis that focuses on the internal structures that are
developed from the individual’s interpersonal experiences.

q  Robert Stolorow: Leader in bring the Intersubjectivity

perspective to psychodynamic work, a perspective the
challenges the prevailing belief in a discrete, individual mind
and instead posits that emotional experience occurs within
18  
interconnected psychological systems or fields that are created
by two or more people in relationship.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Overview of the Counseling Process

§  Listening and Empathy
§  Primary tool of psychoanalytic therapists
§  Listening objectively to the client’s story without offering
advice, reassurance, validation, or confrontation.
§  Empathy may be used to help the client open to non-
defensively hearing the therapist’s interpretation of
unconscious dynamics.
§  Interpretation and Promoting Insight
§  Encourage insights into personal and interpersonal
dynamics.
§  Offer interpretations to the client using various case
conceptualization approaches
§  Working Through
§  Process of repeatedly getting in touch with repressed
strivings and defense responses, so that the unconscious
can be made conscious. 19  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Overview of the Counseling Process

Basic Psychodynamic Process

Assess
New
personality thoughts,
dynamics Facilitate Work
client through feelings,
and
insight insight behaviors
unconscious
processes

20  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Overview of the Counseling Process

Psychodynamic Counseling
Psychoanalysis and Psychotherapy

•  Intensive approach designed •  Target specific symptoms or

to create significant and problems, such as depression
sustainable personality or recovering from a divorce,
change. with sessions typically
•  Analysts meets with patients •  Occurring once per week and
•  3-5 days per week for several lasting several months to a
years. couple of years depending on
•  Basic process of analysis- client needs.
insight-working through-action •  brief forms of psychodynamic
•  Frequently repeating at deeper counseling have been
and more profound levels. developed to last 12-16
sessions
21  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
§  Most of the work in psychodynamic counseling
is in the viewing, the case conceptualization.

§  When conceptualizing, many psychodynamic

practitioners borrow freely from one school or
another—drive theory, ego psychology, object
relations, self psychology, relational theory, and
even brief approaches (Jung is generally left
out of this).

§  Counselors custom tailor case

conceptualizations for a single client. 22  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

13 Areas of Potential Assessment

1.  Levels of Consciousness
2.  Structures of the Self: Id, Ego, and Superego
3.  Drive Theory
4.  Psychosexual Stages of Development /Oedipal
Complex
5.  Symptoms as Intrapsychic Conflict: Primary and
Secondary Gains
6.  Defense Mechanisms
7.  Erickson’s Psychosocial Stages of Development
8.  Object Relations Theory
9.  Good Enough Mothering and the True Self
10.  Stages of Separation and Individuation
11.  Narcissism and Selfobjects
12.  Relational Matrix 23  
13.  Unconscious Organizing Principles and Culture
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
1.  Levels of Consciousness (Drive Theory)

§  Conscious mind

§  Includes sensations and experiences that the person is
aware of
§  Freud believed the conscious mind comprised a small
part of mental life.
§  Preconscious mind
§  Memories and experiences that a person can easily
retrieve at will
§  Unconscious mind
§  Memories, thoughts, and desires that the conscious
mind cannot tolerate and is the source of innate drives.
§  Freud believed this to be the largest level of
consciousness and focused his work on making
24  
conscious material conscious.

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
2.  Structures of the Self: (Drive Theory)
Self
§  Id.
§  Unorganized part of the personality that is motivated by
instinctual drives
§  Inspires us to act according to the “pleasure principle.”
§  Ego.
§  Operates according to the “reality principle,” striving to
meet the needs of the Id in socially appropriate ways.
§  The part of the personality that involves intellect,
cognition, defense mechanisms
§  Mediator between the Id and Superego.
§  Superego
§  Striving for perfection, the superego represents ego and
social ideals
25  
§  Generally prohibits the Id’s drives and fantasies that are
not socially acceptable.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
3.  Drive Theory (Drive Theory & Ego Psychology)

Instinctual Drives: Part of being human

§  Libido: A sexual energy drive

§  Death Drive: After World War I added the death
drive: the source of aggressive energy.
§  When these drives are not properly acknowledged
and managed, symptoms can develop.

26  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
4.  Psychosexual Stages of Development (Drive Theory)

§  Oral Stage: Dependency and Security (Birth-18 months).

§  Anal Stage: Control (18 months-3 years)
§  Phallic Stage: Morality and Superego (3 to 6 years)
§  Oedipus/Electra complexes, castration anxiety, and penis
envy.
§  Latency Stage: Sexuality Latent (6-12 years)
§  Libidinal energy is channeled to normal childhood activities
§  Genital Stage: Adult Sexuality (12+years)
§  Sexual energy is focused on members of the opposite sex.
§  If issues were not appropriately resolved in earlier stages,
they are likely to create difficulties and symptoms in
adulthood.
27  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
5.  Symptoms as Intrapsychic Conflict:
Primary and Secondary Gains
§  Presenting symptoms (phobia, depression, or psychosomatic
complaint) areviewed as expressions of inner or intrapsychic
conflict.
§  Therapy Goal
§  Gain awareness and enable safe expression of these
emotions.
§  Primary Gains
§  Primary benefit of the symptom (e.g. attention from being
depressed)
§  Secondary gains
§  Benefits that are not immediately related but a natural
consequence nonetheless (e.g., more influence in
household decisions due to OCD)
28  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
6.  Defense Mechanisms (Drive theory, Ego
Psychology, Object Relations, & Self Psychology)

Defense mechanisms: Automatic responses to perceived

psychological threats. Often activated on an unconscious level.

§  Denial
§  Refusal to accept/acknowledge an external reality or
fact because it is too threatening.
§  May involve the reversal of facts.

§  Introjection
§  Describes when one “takes in whole” behaviors, beliefs,
and attitudes of another, e.g. the opinions, style, and
characteristics of others in order to identify with them or 29  
gain their approval.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
6.  Defense Mechanisms (Drive theory, Ego
Psychology, Object Relations, & Self Psychology)
§  Splitting (Object Relations and Self Psychology)
§  Inability to see an individual as an integrated whole that
has both positive and negative qualities.
§  Switch from seeing people as all-good or all-bad:
idealizing and then villainizing.

§  Projection
§  Falsely attributing one’s own unacceptable feelings,
impulses, or wishes onto another, typically without
being aware of what one is doing.

30  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
6.  Defense Mechanisms (Drive theory, Ego
Psychology, Object Relations, & Self Psychology)

§  Projective Identification

§  Falsely attributing to another one’s own
unacceptable feelings.
§  What is projected is not simply discrete impulses,
but a part of the self—not just aggressive
impulses, but a bad self, now located in another.
§  Example: Jealousy.

31  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
6.  Defense Mechanisms (Drive theory, Ego
Psychology, Object Relations, & Self Psychology)
§  Repression
§  Describes the unconscious process that occurs when
the Superego seeks to repress the Id’s innate impulses
and drives.
§  Cause of a wide range of neurotic symptoms:
obsessions, compulsions, hallucinations,
psychosomatic complaints, anxiety, and depression.
§  Suppression
§  Intentional avoidance of difficult inner thoughts,
feelings, and desires.

Note: When used periodically, defense mechanisms can

be adaptive ways of coping with stress; when used 32  
regularly they may become problematic.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
7.  Erickson’s Psychosocial Stages of Development
(Ego Psychology)
Developmental crises that must be negotiated at eight significant
points in life. If these crises are not mastered, difficulties are
encountered in subsequent stages.
§  Trust vs. Mistrust. Infant stage
§  Infants develop a healthy balance of trust and mistrust
based on their experiences with early caregivers.
§  Autonomy vs. Shame and Doubt. Toddler stage
§  Children develop a sense of autonomy and influence in
their lives while also learning the limits of their abilities.
§  Initiative vs. Guilt. Preschool and Kindergarten age
§  Develop a sense of initiative and purpose tempered by guilt
when their actions hurt others.

33  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
7.  Erickson’s Psychosocial Stages of Development
(Ego Psychology)

§  Industry vs. Inferiority. School age

§  Engaging in industrious activities to build confidence
in their abilities.

§  Identity vs. Identity Confusion. Adolescence

§  Time of identity development when a person first
begins to answer questions, such as who am I and
how do I fit in?
§  Explore possible identities and social roles

34  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
7.  Erickson’s Psychosocial Stages of Development
(Ego Psychology)
§  Intimacy vs. Isolation. Young adulthood
§  Establishing intimate relationships in their personal,
social, and work life
§  Developing own families and social network.

§  Generativity vs. Stagnation. Adulthood

§  Making meaningful contributes to society and the
succeeding generations
§  Often measured by whether one is satisfied with life
accomplishments.

§  Integrity vs. Despair. Late Adulthood

§  Balances a sense of integrity with a sense of despair 35  
§  Look back over their life and face the inevitability of
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
8.  Object Relations Theory
q  Object
§  Refers to the “object” of a person’s desire, attention, or
“drive.” Most often: one’s mother.
§  Objects can be internal: operating in one’s internal
world.
§  Objects can be external: existing in the “real” world.

q  Object Relations Theory

§  Explores how a person relates to external and internal
objects to understand personality dynamics.

q  Primary Care Givers

q  Templates for all future relationships
q  Assessed and analyzed to understand problems later in life.
36  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
9.  Good Enough Mothering and the True Self
(Object Relations. Winnicott)
§  Good Enough Mothering
§  Generally (but not perfectly) able to respond to
their infant’s communication and needs while
allowing them to move toward independence
§  Enables child to develop a true self.
§  Through therapy, person can repair damage of
not having good enough mothering.

§  Brain Develop Research

§  Modern research on brain development provides
some support for theory
§  Healthy brain development linked with the quality 37  
of parental interaction (Siegel, 1999).
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
10. Stages of Separation and Individuation
(Mahler’s Object Relations)
Stage 1: Normal Infant Autism
•  During the first month, unable to differentiate their
actions from that of their caretakers
•  Primary task: maintain homeostatic equilibrium
Stage 2: Normal Symbiosis
•  During the second month, a psychological shell
begins to form that encloses the symbiotic relationship
of mother and child as a dual entity.
Stage 3: Separation and Individuation
•  From five months to three years old, the child:
a)  individuates, developing intrapsychic autonomy
b)  separates, creating psychological differentiation from
38  
the mother.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
10. Stages of Separation and Individuation
Subphase 1: Differentiation and body image
•  Child begins to physically distance from the mother when
practicing motor skills, “checking back” to ensure mother there.
Subphase 2: Practicing
•  As begin to walk, infants increasingly venture away with periodic
returns for emotional connection; feel omnipotent
Subphase 3: Rapproachement
•  2.5-3 years: more aware of physical separateness, sense of
omnipotence declines, reexperience separation anxiety.
•  Inner conflicts resulting in demands for closeness alternating
with demands for autonomy.
Subphase 4: Emotional Object Constancy and Individuality
•  Beginning at 3, begin to develop emotional object constancy
•  Integrated inner image of the good/bad aspects of parent that
provides comfort in her physical absence.
39  
•  Whole object representation allows child to develop unified self
image.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
11. Narcissism and Selfobjects (Self Psychology)

§  Selfobjects
§  Persons or objects that are experienced as part of the self
or are used in service of the self to provide identity.
§  No whole objects but a series of unconscious patterns and
themes.

§  Idealized and Grandiose: Young children two selfobjects:

a)  Idealized image of the parents: “my parents are perfect”
b)  Grandiose part of the self: “I deserve to get what I want”.
§  Tension:
§  Between what the child should do (the idealized selfobject)
and what the child wants to do (the grandiose self).

40  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
12.  Relational Matrix
Relational Matrix: Used by Relational psychoanalyst to
organize, frame, and interpret clinical information.

§  Relational Maxtrix

§  Includes the self, object, and transactional patterns
§  Redefines the how “mind” is defined.
§  “Self”
§  Always understood in interpersonal relationships.
§  Meaning
§  Generated in relation, and therefore nothing is innate in
quite the same way as it is in the drive model
§  Interactional Field
§  considering the person-in-context at all times, making it
more applicable for diverse clients. 41  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Case Conceptualization
13. Unconscious Organizing Principles and Culture

§  Unconscious Organizing Principles

§  People experience the world through the lens of
their particular organizing frameworks (unique
unconscious principles or templates)
§  Formed based on early relational experiences.
§  Inherent
§  One cannot not have these principles or
templates; without them a person cannot
organize their experiences.
§  Culture
§  These unconscious organizing principles are
shaped not only by early childhood relationships 42  
but also by culture.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

General Goals of Psychoanalysis

Early and Middle Phase
§  Decreased irrational impulses
§  Increased ability to manage stress; decreased use
of defense mechanisms.
Middle Phase and Late Phase
§  Increased ego strength, self esteem, and self
cohesion.
§  Increased insight followed by agency.
§  Increased emotional maturity and intelligence.
§  Decreased perfectionism.
Late Phase
§  Decreased internal conflict and personality
integration
§  Increased ability to experience mature dependency 43  
and intimacy.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Doing: Interventions

Interpretation
•  The most basic technique, all psychoanalytic
approaches. Interpretation of unconscious material
to facilitate client insight.

Numerous possibilities exist for interpretation:

§  Dreams, fantasies, and daydreams
§  Symptoms
§  Transference and countertransference
§  Favorite metaphors and word choice
§  “Freudian” slips of the tongue: accidentally
misspoken words that reveal unconscious
motivations. 44  
§  Jokes and asides
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Doing: Interventions

Steps for Providing Effective Interpretation

1.  Begin with Case Conceptualization

2.  Wait for the “Moment”

3.  Work from the Present to Past

4.  Assess Client Response:

Resist: I don’t think that is what is happening at all?
Agree: Wow. I never thought of it before, but I think you are
right?
Somewhere in between: I don’t know. Some of that might be
true?

45  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Doing: Interventions

Empathy: Understanding-Explaining Sequence

Two phases:
1.  Understanding: An expression of empathy: “I can
understand how my being late must have been upsetting for
you.”
2.  Explanation: Provides some form of interpretation that helps
the client understand the source of the emotion: “We all care
about how those around us see us and treat us, especially
those who are important to use, much like are parents were
to us years ago. Given your mother’s unpredictability and
your father’s disinterest in you, my actions must have been
especially upsetting.”

Kohut used these two together to express a therapeutic

expression of empathy that provides a corrective emotional 46  
experience and helps clients develop more cohesive sense of
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Doing: Interventions

Free Association
§  Involves asking a client to “just say what comes to
mind” on a given topic such as “your mother,”
allowing unconscious material to arise.
§  The client may describe recent events, memories,
feelings, fantasies, bodily sensations, or any other
material.
§  The analyst listens carefully for unusual
connections, idiosyncratic logic, slips of the tongue,
and efforts to edit or hold back.
§  After this process the analyst may provide
interpretations to help promote insight into the
client’s process. 47  
 
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Doing: Interventions

Dream Interpretation
§  In the tradition of Freud, the dreamer—not the
analyst—is the key to symbolic meaning of the
dreams; there are no predetermined
meanings: “some times a cigar is just a cigar!”

§  Dreams have two layers of meaning:

•  the manifest content: the literal content
of the dream
•  the latent content: is the underlying,
unconscious material that must be
interpreted to be accessed. 48  
 
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

The Doing: Interventions

Intersubjectivity Responding
§  Relational psychodynamic counselors rely on the
counseling relationship itself to create opportunities
for clients to gain insight and make change.

§  Using postmodern approach: they do not

necessarily relate every experience in the
counseling relationship to childhood experiences,
but instead stay focused on the present
relationship and the client’s interpretations of it,
which may be related to culture, gender, economic
status, or education, as well as childhood
experiences. 49  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

Initial Phase of Treatment (First 1-3 sessions)
Initial Phase Counseling Tasks
1. Develop working counseling relationship. Diversity
note: Adapt style for ethnicity, gender, age, etc.
Relationship building approach:
a. Use empathy and mirroring to provide a
supportive, holding environment for client.

2. Assess individual, systemic, and broader cultural

dynamics. Diversity note: Adapt for family structure,
ethnic/religious norms, gender, age, ability, sexual/
gender orientation, etc.
50  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

Initial Phase of Treatment (First 1-3 sessions)
Initial Phase Counseling Tasks
Assessment strategies:
a. Analyze unconscious conflict underlying
symptoms and role of defense mechanisms in
managing them.
b. Analyze object relations and selfobjects
patterns, including expressions in current
relationships and historical development during
infancy.
c. Assess relational matrix and culturally
defined unconscious organizing principles
that shape the client’s worldview.
51  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

Initial Phase Client Goal (1-2 Goals): Manage crisis
issues and/or reduce most distressing symptoms
1. Decrease emotional reactivity to perceived threats
to self to reduce [specific crisis symptoms].

Interventions:
a. Provide empathy using understanding-
explaining sequence to reduce client’s
inaccurate perceptions of external threat to
self.
b. Interpretation to reduce need to use reactive
defense mechanisms in response to
incorrectly perceived threats.  
52  

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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

Working Phase of Treatment (Sessions 3+)
Working Phase Counseling Task
1. Monitor quality of the working alliance. Diversity note:
Remain sensitive to relationship and conflict
management patterns that may be related to gender,
cultural, socioeconomic status, family dynamics, etc.
Assessment Intervention:
a. Monitor and work through transference and
counter-transference.

Working Phase Client Goals (2-3 Goals). Target

individual and relational dynamics using theoretical
language (e.g., decrease avoidance of intimacy, increase
awareness of emotion, increase agency, etc.) 53  
   
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

1. Decrease use of [specify defense mechanism] to protect self
from [specify perceived threat] to reduce [specific symptom:
depression, anxiety, etc.].
Interventions:
a. Interpretation of role of defense mechanism and how it
developed in early childhood experiences and is being
inappropriately used currently.
b. Analysis of transference in session when defenses are
used in relationship to counselor.
2. Increase ego strength and self coherence to reduce
[specific symptom: depression, anxiety, etc.].
Interventions:
a. Mirroring to confirm client’s sense of worth and value.
b. Empathy using the understanding-explaining
sequence to increase client’s sense of coherence.
c. Dream interpretation and free association to bring 54  
sources of inner conflict to conscious awareness.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

3. Increase sense of personal agency informed by emotional
intelligence to reduce [specific symptom: depression, anxiety,
etc.].
Interventions:
a. Intersubjective responding to increase client’s
awareness of self in sessions vs. various emotional-
relational contexts.
b. Working through resistance to translating insight into
action.
Closing Phase of Treatment (Last 2+ weeks)
Closing Phase Counseling Task
1. Develop aftercare plan and maintain gains. Diversity
Diversity note: Manage end of counseling by adjusting for
socio-cultural and gender expectations for handling loss.
Intervention:
a. Analyzing transference and abandonment issues as 55  
impending termination approaches.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

Closing Client Goals (1-2 Goals): Determined by
theory’s definition of health and normalcy
1. Decrease internal conflict while increasing
personality integration to reduce potential for
relapse in [specific symptom: depression, anxiety,
etc.].
Interventions:
a. Dream analysis, free association, and analysis
of transference to identify internal conflicts
generally and those related to ending treatment
specifically.
b. Enable client to identify, consciously contain,
and successfully manage internal conflicts to
56  
allow for fuller personality integration.
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Chapter 4: Theory and Treatment Planning in Counseling and Psychotherapy by D. Gehart

Psychodynamic Treatment Plan Template

Closing Client Goals (1-2 Goals):
2. Increase ability to experience mature dependency
and intimacy to reduce potential for relapse in
[specific symptom: depression, anxiety, etc.].

Interventions:
a. Analyze transference and work through
resistance to intimacy in in-session and out-of-
session relationships.
b. Intersubjective responding to critically examine
the unconscious organizing principles the client
uses to relate to others.
57  

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29