Psychodynamic Techniques Working with Emotion in the

Therapeutic Relationship

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© 2010 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in

a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the Publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Maroda, Karen J.
Psychodynamic techniques : working with emotion in the therapeutic
relationship / Karen J. Maroda.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-60623-492-1 (hbk. : alk. paper)
1. Psychodynamic psychotherapy. 2. Psychotherapist and patient.
3. Emotions. I. Title.
RC489.P72M336 2010
616.89′14—dc22
2009036422

Chapter 9, “Erotic Feelings: How They Help or Hinder the Therapeutic Process,” is
adapted from a paper entitled “Desire, Love and Power in the Therapeutic Relationship,”
published in the British Journal of Psychotherapy Integration, Volume 3, Issue 2, pages 6–12,
November 2006. Copyright by the United Kingdom Association for Psychotherapy
Integration. Adapted by permission.
 About the Author

Karen J. Maroda, PhD, ABPP, is Assistant Clinical Professor of Psy-

chiatry at the Medical College of Wisconsin and in private practice in
Milwaukee, Wisconsin. She is the past ethics chair and board member
of Division 39 (Psychoanalysis) of the American Psychological Asso-
ciation and past president of Division 39’s Section III, Women, Gen-
der, and Psychoanalysis. The author of two previous books, The Power
of Countertransference and Seduction, Surrender, and Transformation, Dr.
Maroda has also published numerous journal articles, book chapters,
and book reviews. She lectures nationally and internationally on a vari-
ety of aspects of the therapeutic process, including the place of affect,
self-disclosure, countertransference, legitimate authority, and the need
for clinical guidelines. Dr. Maroda is on the editorial board of two major
journals, Psychoanalytic Psychology and The Journal of Gay & Lesbian Psy-
chotherapy and is corresponding editor of Contemporary Psychoanalysis;
she actively encourages her colleagues to write and talk about what
they actually do as therapists.

v
 Acknowledgments

Writing a book on technique proved to be the most challeng-

ing project I have undertaken. The difficulty in writing such a book
centers on the dilemma of needing to be experienced to give guidance,
yet needing to write with a keen understanding of what new therapists
are experiencing. As I discussed this quandary with my friend and col-
league Michelle Waide, she offered to create a study group of experi-
enced and inexperienced therapists who would read each chapter and
give me feedback. This group comprised senior therapists Mary Grif-
fiths, Gwen Werner, and Michelle, and newer therapists Brian Smoth-
ers, Heather Kennedy, and Katie Hornada. We arranged to meet at my
house to discuss each chapter. As each person entered, the smell of fresh
coffee brewing, he or she brushed the Wisconsin snow and cold away,
settling in to talk and nibble at muffins and fresh fruit. Our meetings
were relaxed and informal. Soon our conversations became as much
about our lives and our trust in each other as they were about the book.
We revealed our own experiences as therapists, and the group gave me
valuable feedback and support on everything from clinical insights to
word choice. I am appreciative of the many hours they spent reading
and critiquing the manuscript, and for their willingness to be candid
about what worked and what didn’t. We are talking about a follow-up
project devoted to case examples, if for no other reason than to reunite
the group for our Friday morning meetings.
As always, I am grateful to my clients, especially “Nancy” and
“Rebecca,” who gave me permission to write about them extensively.
I continue to be awed by the therapeutic process and the capacity for
transformation. I also want to thank my family and friends, who pro-

vii
viii Acknowledgments

vided continued moral support, especially when I felt overwhelmed by

the size of the task I had undertaken.
Thanks to Jim Nageotte, Senior Editor at The Guilford Press, who
provided my first experience of a complete professional manuscript
edit. Never having experienced one before, I was initially nonplussed
by the sight of chapters e-mailed back awash in “red ink.” But I came to
appreciate the value of examining every word, eliminating even small
digressions, and replacing ambiguous statements with clear ones.
Finally, I want to thank the many young therapists who convinced
me that they would love to utilize psychodynamic theory more in their
work, but had no idea how to do so. They urged me to write a text that
would provide some guidance. My meetings with groups across the
country helped keep me motivated. As I was approaching the last third
of the writing, I spoke in Seattle at the Mars Hill Graduate School at
the invitation of Roy Barseness, a faculty member who had read and
taught my previous work with insight and enthusiasm. The tremen-
dous response I received over the weekend there, working with over 100
bright and curious graduate students and new therapists, reenergized
me and helped me to see how great the need was for clinical guidelines.
It is the students whom I teach, who write to me, and who approach
me after lectures that inspired me to write this book, and I dedicate it
proudly to them.
 Contents

Introduction 1

1 Emotional Engagement and Mutual Influence: 5

Basic Issues as Therapy Begins

2 Mutuality and Collaboration: Influencing Each Other 30

3 Redefining Regression: 56
Facilitating Therapeutic Vulnerability

4 Evaluating Interventions: 82
Tracking the Client’s Response

5 Self-Disclosure and Advice: Understanding How 107

and When the Therapist’s Disclosures Are Therapeutic

6 Managing Emotion: Affective Communication 136

and the Role of Interaction

7 The Special Problem of Affect Management 153

in Treating Borderline Personality Disorders

8 Confrontation and Countertransference Anger: 179

Overcoming the Therapist’s Aversion to Conflict

ix
x Contents

9 Erotic Feelings: How They Help or Hinder 204

the Therapeutic Process

10 Empowering the Client: The Road to Independence 225

Conclusion 243

Glossary 245

Annotated Bibliography 251

References 257

Author Index 267

Subject Index 271

PSYCHODYNAMIC TECHNIQUES
 Introduction

As new therapists begin their work with real clients in the real
world, they often discover that no matter how well they have been
trained, at some level they are singularly unprepared for the reality of
responding to another person’s pain. Confidence comes with knowl-
edge and experience, of course. But the central idea presented here is
that therapists can benefit from a closer examination of the therapeutic
process, especially by keeping in mind that therapy is a relationship
involving ongoing conscious and unconscious communication. The
essential aspect of that communication centers on affect and attach-
ment. I firmly believe that techniques for facilitating affective commu-
nication can be taught.
This book is written primarily for new therapists, but I believe it
has a great deal to offer experienced therapists as well. My goal in writ-
ing this book is to aid therapists in their struggle to meet the needs of
the troubled clients who come to them with the expectation that they
will be knowledgeable and helpful. I also want to illustrate that psy-
chodynamic therapy remains a vital and viable form of treatment, one
that requires skills that can be taught. A new therapist will often rely
on behavioral approaches simply because these approaches have estab-
lished techniques. Yet I invite you to step beyond practice manuals, to
explore and consider the depth and complexity of human nature that is
uniquely addressed in psychodynamic theory and practice.
The perspective offered in this volume is that the therapist and the
client achieve the best results when they establish a collaborative work-
ing relationship. When I read the literature, I find the focus is mostly on

1
2 PSYCHODYNAMIC TECHNIQUES

how the therapist thinks about the client rather than how the therapist
thinks about the relationship. Therapists tend to ask themselves “What
should I do?” rather than “What needs to happen in this relationship
right now, and what is the best way I can facilitate that?” This book
is written from the perspective of therapy as a relationship, albeit an
asymmetrical one, that exists within professional boundaries. It exam-
ines the ways both therapist and client think and feel within the rela-
tionship. More importantly, it outlines specific ways of responding to
clients based on understanding the role of emotion in the therapeutic
process.
The research on affect and attachment has revealed that we are all
emoting constantly, even though sometimes outside of our conscious
awareness. Managing this emotional flow within the therapy relation-
ship is challenging for the therapist, who requires both knowledge and
skill. When I began working with clients I did not possess that knowl-
edge and skill. The most compelling truth I faced as a new therapist was
how vulnerable I was. Optimistic, but unprepared, I remember sitting
with a client who was very likable, yet overstimulating, thinking, “I
have no idea what I am doing.” Nothing I learned in training prepared
me for the emotional roller coaster I was on.
What I had been taught got me off to a good start. I was empathic,
a good listener, genuinely concerned, attentive, and professional. My
clients responded by going deeper and deeper into their own experi-
ence. This inevitably led me to go deeper and deeper into my own feel-
ings. But I had no working knowledge of affect management. I won-
dered how I should be responding, internally and externally, to all the
emotion in the room.
Beginning my personal analysis soon after I started practicing
helped me to see what my own clients were looking for. My analyst
kept too much of a distance and refused any real conversation with
me. Soon I understood my clients’ frustration at firsthand. But I still
didn’t know what I should be doing, or even what my analyst should
be doing. I knew that everything I wished for from my analyst wasn’t
possible, or therapeutic. So what was it that I needed from her that
would be genuinely helpful? And what should I be providing for my
own clients? I didn’t know, but I wanted to find out, and began experi-
menting.
I described these early experiments in my first book, The Power of
Countertransference (1991), which addressed the moments when my cli-
ents pressed me to reveal what I was feeling toward them. I carried out
my experiments with sweaty palms and a queasy stomach, but found
 Introduction 3

they paid off when therapeutic impasses were broken. Should every
new therapist endure this kind of trial by fire, or could some shared
clinical wisdom and experience provide a smoother path?
Many of my colleagues have expressed concern that providing
clinical examples and advice will inevitably be misapplied and taken
as hard-and-fast rules. Although I admittedly cannot prevent that from
occurring, it is definitely not the spirit in which I provide guidance in
this volume. Certainly, our interactions with our clients are unique and
organic. There is no one-size-fits-all prescription for how to treat clients
effectively, even when they have very similar problems or histories. So I
agree that the notion of a step-by-step manual for doing psychotherapy
is unrealistic, but so is failing to provide new practitioners with any
practical advice or guidance.
Therapists need to have some idea of how to accompany their
clients on their journey toward transformation. What is supposed to
happen once we have gone through the initial sessions? What happens
once clients trust that we understand them and that they are safe with
us? Yes, some clients just need to talk, and be listened to, for a very long
time. But others ask for feedback and stimulate feeling in the therapist
early on. Eventually, every client needs some type of response from
the therapist that goes beyond empathy and beyond a behavioral sug-
gestion. They need a response that arises genuinely from the emotional
connection they share with the therapist.
Younger clients, in particular, often ask for advice and want to
know how the therapist sees them. Traditionally, the response was sup-
posed to be, “How do you imagine that I see you?” Clients who need
a concrete response will predictably respond to repeated evasions with
frustration, anger, or withdrawal. In this text I provide numerous clini-
cal examples showing how I have responded to my own clients during
various emotional encounters. I have included comprehensive descrip-
tions of my internal process leading up to a specific intervention, along
with what my clients had to say at the time. I realize that providing
this much information leaves me open to criticism and hindsight-based
conjecture, but it also provides the reader with an essential keyhole
look into the therapeutic process.
While the book offers specific clinical techniques, I leave plenty of
room for therapists to express themselves as individuals by adapting
these techniques to their own personal style. I am outgoing and gregar-
ious, but I do not believe in a preferred personality style for therapists.
All the interventions I recommend in this book can be executed equally
well by both introverted and extroverted therapists. The overriding
4 PSYCHODYNAMIC TECHNIQUES

principle that guides my choice of interventions is emotional honesty.

I never recommend that therapists express themselves in any manner
that they are not comfortable with, for the simple reason that it will not
be therapeutic.
This volume begins with a basic review of the shared anxieties,
hopes, and expectations of therapist and client. The chapters that fol-
low are devoted to discussing the greater emotional complexities that
arise as the process evolves—especially in a longer treatment. Included
is an exploration of less frequently discussed topics, such as how basic
empathy becomes deeper and more complex over time; how to identify
and manage regression; how to establish a collaborative therapeutic
relationship, noting the contributions of both therapist and client; how
best to implement self-disclosure and advice; how to manage affect,
including bringing emotion into the session when it is lacking; how
to recognize when sexual and loving expressions are therapeutic and
when they are not; how to use confrontation productively; and how to
evaluate interventions.
I hope readers will immerse themselves in this material and come
away with both greater insights into the therapeutic process and with
practical tools for therapeutic success. Perhaps, with a little guidance,
more therapists will feel confident enough to plumb the depths of emo-
tion within the therapeutic relationship—and in so doing will assist
their clients in their search for health, personal freedom, and fulfilling
relationships with others.
 1
p
Emotional Engagement
and Mutual Influence
Basic Issues as Therapy Begins

The most important source of resistance in the treatment

process is the therapist’s resistance to what the patient feels.
                     — Paul Russell (1998, p. 19)

A s much as we want to be present and to feel our clients’ pain,

we also naturally fear that same experience. Part of our resistance to
receiving our clients’ disturbing feelings is that psychotherapy training
has not traditionally included a discussion of the therapist’s feelings
and how to use them constructively in the therapeutic interaction. In
the last two decades, much emphasis has been placed on therapy as
a relationship. A successful treatment arguably has more to do with
the therapist–client relationship than with anything else. Navigating
any relationship that entails the expression of deep emotion is natu-
rally challenging. The premise of this book is that therapists need more
insight and more effective strategies for actively responding to their
clients. They need to better understand how and why clients express
strong emotions as the therapy unfolds, and how and why their own
feelings emerge in tandem. They also need teachable interactive skills
they can implement on a daily basis.
The literature on affect confirms that, in a relationship, the more
intensely one person expresses emotion, the more likely the other per-
son is to share that experience, both consciously and unconsciously
(Sullins, 1991). Also, the more we like and identify with the person we

5
6 PSYCHODYNAMIC TECHNIQUES

are treating, the more intensely empathic we will be (Hess & Kirouac,
2000). Nothing quite prepares any therapist for the reality of sitting
quietly in a room with another human being who is in intense emo-
tional pain. The therapist’s emotional and visceral reactions to his cli-
ent’s feelings can be moving, but also disturbing. The client’s emotional
impact on the therapist is arguably the most neglected area in therapist
training.
Trauma counselors were perhaps the first group of therapists to
openly discuss the “emotional contagion factor” for therapists. While
treating clients who had suffered severe abuse, these therapists soon
found themselves experiencing physical and emotional symptoms
similar to those of their clients, and often needed to resist the client’s
emotions to avoid what has been labeled “vicarious traumatization”
(Pearlman & Saakvitne, 1995). Although the experience of shared affect
in nontraumatized clients is not so obviously difficult to manage, it
nonetheless exists.
For decades most psychoanalysts viewed the client’s need to influ-
ence the therapist as pathological resistance. But others, like Levenson
(1972) and Searles (1979), understood that it was natural for clients
to recognize that both their feelings and their intentions are received
and processed by the therapist. Their intuitive understanding has only
recently been confirmed by affect research, demonstrating that emo-
tions are meant to be received and responded to (Kemper, 2000). One of the
many functions of affects is to influence others and stimulate a response
in them. This volume is devoted to understanding what the client is
soliciting and needing at a given point in time.
Reconceptualizing Freud’s notion of repetition compulsion,
Greenberg and Mitchell (1983) and Mitchell (1988) emphasized that all
people acquire certain relational patterns as they attach to their caretak-
ers, which they subsequently repeat in all relationships, including the
therapeutic one. These patterns include feelings, thoughts, and expec-
tations learned in early childhood that are repeated unconsciously in
adult relationships simply because they are familiar. Neuroscience con-
firms that these patterns are, indeed, laid down in the brain at an early
age and do not change easily. So now we perceive our clients’ need to
evoke an emotional response from us as an inevitable function of their
early attachments, laid down as easily triggered affect programs in the
brain (Griffiths, 1997). What we do not acknowledge is that therapists
bring the same established ways of being to every relationship. Just as
our clients seek an emotional response from us, so we, as we enter into
a relationship with them, seek their affective response. The patterns of