Autobiography in Five Short Chapters by Portia Nelson (1993)

Chapter One

I walk down the street.
There is a deep hole in the sidewalk.
I fall in. I am lost. . . . I am helpless.
It isn’t my fault.
It takes forever to find a way out.

Chapter Two

I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don’t see it.
I fall in again.
I can’t believe I am in this same place.
But, it isn’t my fault.
It still takes a long time to get out.

Chapter Three

I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall in . . . it’s a habit . . . but,
my eyes are open.
I know where I am.
It is my fault.
I get out immediately.

Chapter Four

I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.

Chapter Five

I walk down another street.

For each psychological model, there are specific interventions and methods that have been developed, founded on the core ideas in the model, to treat the client’s symptoms and problems. Starting with the psychoanalytic and psychodynamic model, for the rest of this module we will present the major treatment approaches relevant to each model after describing the model (Table 1). Keep in mind that these major approaches have branched out over time with many specific variations. As noted above, there are now over 400 different types of psychotherapy. The goal here is to help you understand core elements and approaches within each major area.

Psychotherapy Approaches and Methods: Psychoanalysis

Figure 1. Unlike the famous couch in Freud’s consulting room, where patients were instructed to lie down and face away from Freud, most patients today choose to sit on a couch or chair facing a therapist, as shown in this room.

Psychoanalysis was developed by Sigmund Freud and was the first form of psychotherapy. It was the dominant therapeutic technique in the early 20th century, but it has since waned significantly in popularity. Because Freud believed most of our psychological problems are the result of repressed impulses and trauma experienced in childhood, he developed psychoanalytic methods that he thought would help uncover long-buried feelings and personality conflicts. In a psychoanalyst’s office, you might see a patient lying on a couch speaking of dreams or childhood memories, and the therapist using various Freudian methods such as free association and dream analysis (Figure 1). In free association, the patient relaxes and then says whatever comes to mind at the moment without attempting to edit or worry how the therapist might react. This enables the therapist to discern unconscious emotions, motives, and drives. Sometimes, free association exercises are applied specifically to childhood recollections. That is, psychoanalysts believe a person’s childhood relationships with caregivers often determine the way that person relates to others, and predicts later psychiatric difficulties. However, Freud felt that the ego would at times try to block, or repress, unacceptable urges or painful conflicts during free association. Consequently, a patient would demonstrate resistance to recalling these thoughts or situations. Another approach is dream analysis. In Freudian theory, dreams contain not only manifest (or literal) content, but also latent (or symbolic) content. For example, someone may have a dream that his/her teeth are falling out—the manifest or actual content of the dream. However, dreaming that one’s teeth are falling out could be a reflection of the person’s unconscious concern about losing their physical attractiveness—the latent or metaphorical content of the dream. It is the therapist’s job to help discover the latent content underlying the client’s manifest content through dream analysis.

Psychoanalysis is a therapy approach that typically takes years. Over the course of time, the patient reveals a great deal about themselves to the therapist. Freud suggested that during this patient-therapist relationship, the patient comes to develop strong feelings for the therapist—maybe positive feelings, maybe negative feelings. Freud called this transference: the patient transfers all the positive or negative emotions associated with the patient’s other relationships to the psychoanalyst. For example, Crystal is seeing a psychoanalyst. During the years of therapy, she comes to see her therapist as a father figure. She transfers her feelings about her father onto her therapist, perhaps in an effort to gain the love and attention she did not receive from her own father.

Psychoanalysis was once the only type of psychotherapy available, but presently the number of therapists practicing this approach is decreasing around the world. Psychoanalysis is not appropriate for some types of patients, including those with severe psychopathology (including suicidal thinking or intention) or intellectual development disorder (intellectual disability). Further, psychoanalysis is often expensive because treatment usually lasts many years. Still, some patients and therapists find the prolonged and detailed analysis very rewarding. Perhaps the greatest disadvantage of psychoanalysis is the lack of empirical support for its effectiveness. The limited research that has been conducted on psychoanalytic treatments suggests that they do not reliably lead to better mental health outcomes for most people (e.g., Driessen et al., 2010).

Today, Freud’s psychoanalytical perspective has been expanded upon by the developments of subsequent theories and methodologies: the psychodynamic perspective. This approach to therapy remains centered on the role of people’s internal drives and forces, but treatment is less intensive than Freud’s original model.

Psychodynamic Approaches to Treatment

Deriving from psychoanalysis, modern psychodynamic therapies share many common elements with psychoanalysis and other psychodynamic treatments, although each approach has its own theories and may not use all the common methods; psychodynamic therapists are usually not formally trained psychoanalysts. These common elements include

• an emphasis on the central importance of internal and unconscious conflicts and their relation to development;
• the identification of defenses mechanisms as behaviors used to avoid unpleasant consequences of conflict;
• a belief that psychopathology develops especially from early childhood experiences;
• a view that internal representations of experiences are organized around interpersonal relations;
• a conviction that life issues and dynamics will re-emerge in the context of the client-therapist relationship as transference and counter-transference;
• the use of free association as a major method for exploration of internal conflicts and problems;
• a focus on interpretations of transference, defense mechanisms, and current symptoms and the working through of these present problems; and
• a trust in insight as critically important for success in therapy.

Although there were many “spin-offs” or descendants of Freud’s original psychoanalytic approach, there are at least three major variations: ego psychology, object relations approaches, and self psychology in addition to a more modern form of treatment called brief psychodynamic therapy.

Ego psychology resulted from the primary work of Anna Freud (Freud’s youngest child), Heinz Hartmann, and David Rapaport. Ego psychology therapists tend to focus primarily on supporting and analyzing the client’s ego functioning and ability to adapt to reality. They are mostly concerned with defense mechanisms; ability to adapt to situations; and reality testing, meaning the ability to respond effectively to real-world stresses and demands.

Object relations therapy was primarily expanded by Melanie Klein, Donald Winnicott, Harry Guntrip, and others. In this approach, an object is the internal representation in one’s mind of a person that one has a relationship with. Typically, in infants, the mother of the child is the first relationship, and the child’s internal representation of their mother is the first object. Therapy focuses primarily on seeking to explore and understand the client’s relationships with others while the person works to maintain a sense of independence as well. Consistent with Freud’s emphasis on early childhood experiences, therapists using this approach also assume that the early self and other representations and relationships often play out as the person grows and can affect adult relationships.

Heinz Kohut created self psychology, which is based on the idea that one’s sense of self is grounded in a person’s personal experiences and the development or lack of self-esteem as a result. Issues of how one differentiates the self from others while still maintaining relationships and establishing boundaries is also central to this approach. These forms of psychodynamic therapies typically do not last as long as psychoanalysis and sessions are not as frequent, although they still tend to be longer treatments than other forms of psychotherapy, mostly because the goals of treatment are to help the person develop more fully or overcome long repressed issues and conflicts. Therapists also often sit facing the client, and there is more direct interpersonal interactions than in psychoanalysis. There are ongoing debates and discussions about the effectiveness of these forms of therapy, but some evidence suggests that they may be effective for some individuals.

Another form of psychodynamic therapy today is called brief psychodynamic therapy. Like other forms of psychodynamic approaches, it still focuses on many of the core ideas and approaches but is much shorter and more focused; use of free association, for example, is not used very much. Many therapists practicing these more intensive forms of psychodynamic approaches are not trying to help the person’s personality mature or develop, but instead believe that an intensive focus on one core problem or issue can begin a process of change that is more lasting and does not necessarily require the consistent interventions by the therapist. Initial assessment is very important in this process, and together the therapist and client identify an important issue the client is facing and agree to work on that issue. Because of this assessment, the therapist is more active and involved in discussions and interpretations of behaviors with the client than is typical in longer forms of psychodynamic treatment in order to help the client stay on track and focus on the issue the client decided on. There is some evidence suggesting that these briefer forms of psychodynamic therapy may be more effective overall than other forms of psychodynamic treatment, and aspects of this approach have even been included in more integrative forms of therapy.

Figure 2. This type of play therapy is known as sandplay or sandtray therapy. Children can set up a three-dimensional world using various figures and objects that correspond to their inner state (Kalff, 1991). (credit: Kristina Walter)

Play Therapy

Play therapy (Figure 2) is often used with children since they are not likely to sit on a couch and recall their dreams or engage in traditional talk therapy. It was originally developed to extend the psychodynamic approach to children, who are not as verbal as adults. It is usually used with children at least three years old into adolescence. This technique uses a therapeutic process of play to “help clients prevent or resolve psychosocial difficulties and achieve optimal growth” (O’Connor, 2000, p. 7). The idea is that children play out their hopes, fantasies, and traumas while using dolls, toys, stuffed animals, and sandbox figurines and are able to find release from their emotions (sadness, anger, anxiety) in a productive way. 

Play therapy can also be used to help a therapist make a diagnosis. The therapist observes how the child interacts with toys (e.g., dolls, animals, and home settings) in an effort to understand the roots of the child’s disturbed behavior. Play therapy can be nondirective or directive. In nondirective play therapy, children are encouraged to work through their problems by playing freely while the therapist observes (LeBlanc & Ritchie, 2001). In directive play therapy, the therapist provides more structure and guidance in the play session by suggesting topics, asking questions, and even playing with the child (Harter, 1977). Although the origins of play therapy were in psychodynamic thought, therapists from humanistic and cognitive-behavioral approaches have adapted play therapy to align with their core concepts as well.