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by Patricia Coughlin
Routledge , 2016
Review by Sebastian Petzolt, DPhil on May 16th 2017
With her Maximizing Effectiveness in Dynamic Psychotherapy (MEDP), Patricia Coughlin presents an ambitious attempt both to illustrate and justify the practice of short-term dynamic therapy. Integrating research and technique, the volume instructs the reader in a number of clinical skills and presents the empirical evidence that supports their efficacy. As such, MEDP is a comprehensive guide to short-term dynamic therapy, teaching its readers both how and why it works. That said, the book addresses few of the theoretical questions it raises.
Throughout MEDP, Coughlin references Intensive Short-Term Dynamic Therapy, as developed by Davanloo (1990, 2000). However, the current volume is intended not just for practitioners of this particular treatment modality: as the book's blurb announces, therapists "of every stripe [can] integrate the clinical skills presented". Borrowing from the book's title, I shall therefore speak of Dynamic Psychotherapy to mean the therapeutic method described in MEDP.
The book consists of eight chapters. The first two introduce pertinent research findings and explain how psychic conflict is conceptualised and assessed in Dynamic Psychotherapy. The remaining six chapters then illustrate the various techniques and interventions that this modality employs. Instead of summarising each chapter separately, I'll outline Dynamic Psychotherapy directly and will then comment on Coughlin's presentation thereof.
As the book's title suggests, Coughlin's main concern is with the effectiveness of psychotherapy. In turn, a therapy model effective if it "consistently produces deep and lasting change" (p.5), if it is "both rapid and pervasive" (p.227). However, "restricting the therapist's focus to the patient's conscious thoughts has proven ineffective" (p.7) when it comes to achieving this type of therapeutic change. Instead, it is necessary to "identify and resolve the underlying emotional problems causing symptomatic suffering" (p.8), by putting patients in touch with their "affective unconscious" (ibid.).
To apply this to clinical practice, Coughlin presents the central dynamic sequence (p.19). Here, the patient is "pressured" (ibid.) from the start to experience the feelings involved in the concerns that bring her to therapy -- cf. cap.2. In response to this pressure, the patient's anxiety levels are likely to rise and must be monitored. E.g., dizziness and headaches are signs that the patient's anxiety must be down-regulated before treatment can continue -- cf. cap.3. Further, defences such as projection, displacement, and intellectualisation will be triggered and must be blocked. This is done by pointing out to the patient the psychological cost of maintaining the defences -- cf. cap.4. Next, as the patient slowly abandons her defences, emotions will begin to surface. When this happens, the patient must be encouraged to experience these fully. That is, she must (a) cognitively recognise each emotion and label it, e.g. as sadness or anger; (b) feel the emotion in her body, e.g. as heaviness or heat; and (c) express a motoric impulse, e.g. to scream or punch somebody -- cf. caps.5&6. Following this breakthrough of emotions, patients often report dreams and previously repressed memories, or spontaneously make associations to their emotional experience. The penultimate step in the sequence is to make sense of this material -- cf. cap.7. Finally, as the therapy comes to an end, insights must be consolidated. In this last step, the therapist helps the client link present to past, and also reinforces the connection between defences and symptoms -- cf. cap.8.
Turning from summary to critique, Coughlin names research, technique, and theory as the three components of therapeutic competence, and states that the "master clinician is knowledgeable and skilled in all three areas" (p.5). Let me comment, therefore, on how MEDP fares in each area.
Starting with research, Coughlin is careful to provide ample evidential support for the methods she describes. While this evidence cannot be presented here, Coughlin's close attention to it achieves at least three goals. Most immediately, it provides the reader with a concrete measure of the reliability and, indeed, effectiveness of Dynamic Psychotherapy. Secondly, it offers an extensive bibliography of contemporary research papers and books in the area for further study. Thirdly, it shows that contrary to a popular myth, treatment modalities in the psychodynamic tradition can be tested empirically -- and don't do at all badly in those tests.
Using research, MEDP tries to achieve a fourth goal: to challenge -- and perhaps even discredit -- alternative treatment modalities. To cite just one example, Coughlin writes about CBT that the "notion that a patient's emotional disturbances are the result of faulty thinking has little scientific evidence or support" (p.7). However, whether or not such evidence exists, Coughlin's stance seems unnecessarily aggressive. How effective Dynamic Psychotherapy is, does not depend on the (in)effectiveness of other therapy types: the reader learns little about Dynamic Psychotherapy from the hostility Coughlin displays in some places.
As a second point of criticism, Coughlin presents substantially less research in MEDP's later chapters. This is particularly unfortunate as these chapters concern more 'speculative' notions like "inner being" (p.175), "authentic connection with others" (p.177), and "emotional truths" (p.200). An attempt to link these concepts to ones that are empirically more traceable, would have further supported the claim that Dynamic Psychotherapy is founded on solid research.
Moving on to technique, Coughlin uses detailed case vignettes, each several pages long, to illustrate the methods and interventions employed in Dynamic Psychotherapy. These vignettes not only serve to illustrate the individual steps of the central dynamic sequence. They also allow the reader to trace the effects these interventions have on the patient. In almost all cases, a change in attitude and affect is immediately noticeable, making the technique's effectiveness concretely tangible for the reader. The claim that Dynamic Psychotherapy is "both rapid and pervasive" (p.227) is demonstrated well.
In total, MEDP contains around thirty vignettes from about twenty different patients. This makes it somewhat difficult for the reader to appreciate each individual case and patient. Often, one vignette 'blends into' in the next. Perhaps it would have been better, therefore, to discuss only four or five patients, and to present their treatment from start to finish. This likely would have offered the reader a deeper insight into each case, and an opportunity to empathize more with each patient. It also would have helped clarify which phase of the treatment a particular vignette stems from -- beginning, middle phase, or ending.
Turning finally to theory, this is the area where MEDP has the least to offer. One way to see this is by asking: what exactly makes Dynamic Psychotherapy a psychodynamic form of therapy? While Coughlin talks a lot about defenses and the unconscious, other distinctly psychodynamic concepts are missing entirely. E.g. while the transference is discussed, there is no mention of the counter-transference. Is this therapeutic tool not employed in Dynamic Psychotherapy? If not, is it not needed, is it ineffective, is it not "rapid and pervasive" (p.227) enough?
To mention just one more concept, at the intersection between theory and practice, Coughlin says nothing about the so-called therapeutic or analytic frame. (Cf. e.g. Jacobs 2010, cap 4; Howard 2010, cap.4; Lemma 2016, cap.4). Apparently, intake session can last several hours (cf. p.19); "a three-day block therapy" is mentioned (p.211) as an alternative to weekly sessions. However, the reader does not learn how therapists are meant to choose between these options. Is this merely a matter of convenience, or does Dynamic Psychotherapy espouse that there is a deeper significance to time-keeping and boundary issues? As these examples show, MEDP leaves unclear which theoretical commitments a practitioner of Dynamic Psychotherapy is required (not) to make.
In sum, MEDP is "a resource for novice and experienced therapist alike" (p.13), insofar as these therapists are looking to expand their therapeutic repertoire with interventions that have evidential support. However, since the volume does not describe the conceptual framework in which the practice Dynamic Psychotherapy takes place, at least some readers will likely be hesitant to use this resource.
Davanloo, H. (1990). Unlocking the Unconscious, Wiley.
-- -- -- (2000). Intensive Short Term Dynamic Psychotherapy, Wiley.
Lemma, A. (2016). Introduction to the Practice of Psychoanalytic Psychotherapy, 2nd ed., Wiley.
Jacobs, M. (2010). Psychodynamic Counselling in Action, 4th ed., Sage.
Howard, S. (2010). Skills in Psychodynamic Counselling and Psychotherapy, Sage.
© 2017 Sebastian Petzolt
Sebastian Petzolt, DPhil