Clinical Concepts of Psychodynamic Theory and Mindfulness-Based Approaches to Psychotherapy

Deciding to go to therapy is hard.  Deciding which therapist to see is even more challenging because the decision is fraught with questions that are often unanswerable until a relationship begins to develop between client and therapist.  Perhaps the most unanswerable initial question is “Will we get along?”  The relationship, best termed the therapeutic alliance, may depend not only on the client and therapist’s personalities but also on the theoretical framework to which the therapist prescribes and the techniques the therapist relies on to facilitate change.  In fact, psychodynamic and mindfulness-based approaches to psychotherapy both make use of the concepts of self and attachment to build connections and facilitate healing. However, these two approaches to therapy share only clinical concepts’ name: The way these concepts are manifested are categorically different.

After a brief overview of each theoretical perspective, this paper explores the disparate ways in which psychodynamic theory and mindfulness-based approaches frame the same clinical terminology, self, to explore patterns of relating, reacting and interacting. It then details the concept of attachment according to each theoretical framework. This paper concludes with a reflection of the personal events leading to this interest, a discussion of implications for my own clinical practice, and a hopeful trajectory for my continued personal and professional growth.

Theory

Psychodynamic Theory

Beginning with the critiques on Freud’s first generation psychoanalysis, Levenson (2010) discusses the evolution of psychodynamic theory from the second through fourth generations. Where second generation psychodynamic therapies sought to shorten the time spent in session, third generation worked to ground sessions in research (Levenson, 2010). Fourth generation psychodynamic theory is eclectic and integrative, offers in-session experiential factors, and is influenced by both pragmatic and efficient sociopolitical forces, like insurance companies (Levenson & Burg, 2000 cited in Levenson, 2010). While each generation has distinguishing characteristics, there are a variety of therapeutic frameworks that fall under that psychodynamic banner.

While there are a variety of psychodynamic therapies, primary clinical concepts guide the work performed under the psychodynamic banner. All of these frameworks use clinical concepts like countertransference and transference, unconscious processes, regulation of anxiety, and attachment and acceptance of self to help facilitate change (Levenson, 2010; Watchel 2011). Each of these clinical concepts utilize John Bowlby and Mary Ainsworth’s work on attachment theory to explore the client’s relational interaction patterns (Watchel, 2011). Different styles of attachment provide important insight into why an adult (i.e. the client) behaves a specific way (Gerhardt, 2004). Part of the therapist’s job is to compassionately provide the client with a new internal working model for relationships by virtue of the secure attachment formed in session (Levenson, 2010; Watchel, 2011). While psychodynamic theory has roots grounded in empirical evidence, a large part of the therapist’s technical skills remain an art and a challenge to manualize.

Mindfulness-Based Approach

The past 25 years have seen a tremendous increase in mindfulness-based approaches to therapy, and mindfulness has begun to influence a variety of other theoretical frameworks, including psychodynamic theory (Siegel & Germer, 2012). The mindfulness-based approach to therapy has deep roots in Buddhism and Buddhist Psychology (Kornfield, 2009), behavioral and cognitive therapies (Siegel & Germer, 2012) and uses meditation as the mechanism to accept change. Regardless of the secular connection, a mindfulness-based approach remains non-secular and widely accessible due to its simplicity and portability.

Mindfulness-based approaches are based on creating new ways of relating and reacting to the emotions that arise within the client. The therapist is the meditation facilitator, Kabat-Zinn (2013) even says that “we don’t really do anything for them…(inviting) them to do something radically new for themselves,” and therapy is often in the group format of an 8-week program (p. 5). Three fundamental elements of a mindfulness-based approach can be seen in Kabat-Zinn’s (2013) definition of mindfulness as 1) non-judgmental and/or accepting 2) awareness 3) of the present moment. Siegel and Germer (2012) discuss the meditation skills required to be mindful: “Concentration…open-field awareness, and… loving-kindness” (p.11). As difficult emotions are likely to arise in a practicing mindfulness-based approach, specific meditations have been crafted throughout the history of Buddhism to assist in managing these challenges (Siegel & Germer, 2012). Part of the therapist’s charge is to assist the client in developing wisdom with compassion and self-compassion, provide a non-judgmental space to discuss their meditation experience, and acknowledge the shared human struggle of suffering caused by attachment (Makransky, 2012). While it’s arguable that components of mindfulness are a cultural co-optation of Buddhism, the benefits of mindfulness in lives of both client and therapist are well documented.

Attention should be paid to the way both psychodynamic theory and mindfulness-based approaches encourage compassion and self-compassion. They are qualities encouraged for both client and therapist. However, as detailed by Germer (2012), while most psychotherapy is performed in a compassionate manner, all mindfulness-based approaches are geared specifically at cultivating compassion (as cited in Germer & Siegel, 2012). Germer (2012) asserts that if a therapeutic modality involves explicit teachings of meditations and exercises meant to foster compassion and self-compassion, it is compassion-based therapy: For example, Mindful Self-Compassion is an eight-week course designed specifically at fostering self-compassion within the client/group. Because the primary focus of psychodynamic therapy is attachment and relationships, it follows that the majority of modalities falling under the psychodynamic banner are compassion-informed psychotherapies (Germer, 2012), and thus do not provide the same, explicit compassion cultivation work. Interestingly, under both psychodynamic theory and mindfulness-based approaches, self-compassion is the most salient vehicle for change (Germer, 2012).

Both self and attachment are clinical concepts found within these two parallel and contrasting treatment modalities. The following section discusses self according to psychodynamic theory and non-self according to the mindfulness-based approach. In doing so, I want to acknowledge that this discussion is incomplete in nature and on the precipice of a philosophical debate much larger than this paper can address.

Clinical Concepts

Self vs. Non-Self

A fundamental difference between psychodynamic theory and a mindfulness-based approach is the view of the self. Both psychodynamic theory and mindfulness-based approaches encourage the client to pay attention to internal arising emotions. Additionally, within the context of a therapeutic session, both modalities will reference the client’s “self” when describing the person in which the emotions are arising. For example, both a psychodynamic therapist and a mindfulness-based therapist may ask a client, “What emotions are coming up inside of you?” Imagine how difficult a session would be if the therapist and client were to refrain from using “I,” “mine,” “You” or “Yours.” Yet Engler and Fulton (2012) cite that while humans universally experience a sense of self, the quality of the experience and construction of the self differs depending on one’s culture. It follows that Western Psychology and Buddhist Psychology will have fundamentally different views of the self, and that theories based upon each culture will experience, construct and heal the self differently as well.

A therapist who subscribes to psychodynamic theory will likely subscribe to the Western sense of self. According to psychodynamic theory, the therapist and client are different beings, which allow for and creates a self/other dyad. Furthermore, a sense of self is typical in the development of personal identity (Engler & Fulton, 2012). For example, if mentally healthy and not suffering from a personality disorder, a client’s sense of self is integrated and persistent (Hertz, 2008). If a client has narcissistic personality disorder, there is an idealized or de-idealized view of the self, and part of the pathology involves swings between these two extreme views of self (Engler & Fulton, 2012; Gellerson, 2015). The Western view of self promotes individualism, separation and ownership (Engler & Fulton, 2012). It’s likely that a therapist will suggest that it’s up to the client to change, that the client and therapist are separate entities, and that transference belongs to the client and countertransference belongs to the therapist.

A mindfulness-based practitioner is more likely to be working from a Buddhist framework and have a different view of the self. Engler and Fulton (2012) assert that Buddhist Psychology, upon which many mindfulness-based approaches are designed, rejects the social construction of the individual self and practices instead from the perspective of non-self. From a perspective of non-self, the human experience is interdependent and a series of sensations, impermanence is life’s one constant, and feelings cannot be owned. Olendzki (2012) details the Buddha’s definition of self as “an empirical description of experience” (p. 134). The idea of a self is seen as an illusion to help organize experiences, and the duality of “mine” and “not mine” ceases to exist. For example, if pain is arising within the client, and the client doesn’t take ownership of the pain (i.e. Suffering is a neutral experience. The pain is not good or bad, it’s not “mine” or “not mine”), the client can allow the hurt to arise and pass away. It’s likely that a mindfulness-based therapist will encourage the client to keep in mind the nature of impermanence, promote common and shared humanity, and remind the client that the feelings they may be experiencing do not belong to them anymore than a drop of water belongs to the ocean.

I write this section knowing that to devote two small paragraphs to such a complex topic is doing it an incredible disservice. However, as a mindfulness-based practitioner who intends to work in a Westernized therapeutic setting, it’s critical that I begin this dialogue, even in brief. This paper now touches on attachment as defined and discussed by both theories.

Attachment Theory vs. Attachment

Just as self means different things according to psychodynamic theory and mindfulness-based approaches, so does the concept of attachment. As mentioned above, psychodynamic theory relies heavily on attachment theory to predict and heal relational interaction patterns (Gerhardt, 2004; Watchel, 2011). Attachment, according to this theory, refers to the way in which an infant and their parent interact relationally, and is measured by the degree of safety the infant feels in exploring their surroundings (Watchel, 20110). These relational patterns form internal working models that guide interactions and relationships in adulthood (Levenson, 2010). An infant with a secure attachment comes to believe as an adult that all situations that the self experiences can be dealt with and seen, while an infant with an insecure attachment comes to believe as an adult that when threatened, others cannot keep them safe (Gerhardt, 2004; Levenson, 2010). Psychodynamic theory asserts that the therapists’ charge is to provide a new relational experience for the client, and it’s that new experience that will help the client form a new internal working model of relationships (Levenson, 2010). A healthy attachment style is a key to healthy interaction patterns.

According to mindfulness-based approaches, attachment has a different meaning. Attachment is defined as clinging to pleasant moments, and is seen as the root of suffering (Siegel & Germer, 2012). Siegel and Germer (2012) pair attachment with avoidance, an additional cause of distress and defined as the attempt to push away unpleasant moments. The mind creates suffering as a result of attachment and avoidance, and the purpose of mindfulness-based therapy is to create moments of awareness that allow the client to witness mechanisms of suffering as they unfold. To expand further on the concept of non-self, if a client is emotionally attached to a chronic physical pain, that pain will cause additional suffering than does the physical pain alone. One focus of mindfulness is use mediation to practice non-reaction to sensations that arise and pass away. Kabat-Zinn (2013) refers to this as the practice of “non-doing,” and details the holistic and transformative view that results from the mindfulness practice. It’s from this change in perspective that comes great healing: Primarily, the ability to experience and frame problems in a new way.

Both psychodynamic theory and mindfulness-based approaches to therapy are designed to promote healing by virtue of empirical research and personal growth. Interestingly, self and attachment have qualitatively different meanings according to each theory. This paper now turns to a discussion of my practice, a reflection on my experience in this course, and where I hope to use this exploration in the future.

Practice, Reflection, and Hopes

I’ve been interested in mindfulness practice since I entered Alcoholics Anonymous in 2009. I felt ostracized by the insistence on a higher power, and filled with shame after a “relapse” in 2011. The 11th step of Alcoholics Anonymous provided refuge, and many devout AAers insisted that this was the one step that mattered. When I came to UW, I participated in a Mindfulness-Based Relapse Prevention group that opened me to an entirely new way of experiencing my own recovery. Without judgment and with awareness, I could experience day-to-day life without having to react to cravings that came and quickly subsided (if I let them). I could let go of the trauma that kept insisting on being quieted: I didn’t have to own the experiences that inspired my substance abuse. And I was no longer tethered to my therapist.

Yet psychodynamic theory played a pivotal role in my life as well. I also entered therapy in 2009, and in developing a secure attachment with my therapist Jill, I was able to see clearly the unhealthy relationship with my mother. I then felt confident exploring the world around me, ready to form new healthy relationships, and willing to take risks to change my life. To say that my primary healing came from MBRP would be a half-truth, because my baseline started in one-on-one long-term therapy sessions with Jill. It’s this combination of experiences that inspires me to pursue mindfulness-based therapies, and to believe in the transformative power of the integration of these two modalities.

In March, I attended my first ten-day silent retreat. I spent 12 hours in seated meditation each day and confronted many of my own attachment and avoidant cognitive patterns. When I began to question the concept of a self, I felt as if the ground had slipped out from beneath me. That I was floating in space. Twelve hours of mediation was physically painful, and when I realized that I didn’t have to identify with the pain I was experiencing, I felt tremendous relief. I had the blessing of watching the sunrise each morning and realized with the changing sky that what I consider to be beautiful isn’t stagnancy or stability but instead the impermanence that comes with moment-to-moment life. I felt consumed with great sorrow and joy: I understood that impermanence isn’t bad or good, it’s simply a fact of life. It is, perhaps, the only fact of life.

Grounded in this experience, I am making strides to become a mindfulness-based therapist. I am attending a MBRP teacher training on Vashon Island this June. I am participating in a mindful-parenting teacher training this August. I plan on becoming certified in Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy within the next year, and Mindful Self-Compassion within the next two. I want to take these skills and build out a Mindfulness Clinic within the Polyclinic’s Behavioral Health Department, where I’ll be completing my Advanced Practicum. This Advanced Practice course has provided the tools that I’ll need to ensure that my practicum experience is well-rounded and that I am able to perform at multiple levels as a therapist and practitioner. Finally, writing this paper as provided an incredible theoretical foundation upon which my skills as a mindfulness-based therapist and a supporter of psychodynamic theory can grow and blossom.

 

 

 

 

 

References

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Gellersen, D. (2015). In-class communications. Advanced Practice I: Health and Integrative Mental Health, Spring. WA: University of Washington.

Gerhardt, S. (2004). Why Love Matters: How Affection Shapes a Baby’s Brain. New York: Routledge.

Germer, C.K. Cultivating compassion in psychotherapy. In Compassion and Wisdom in Psychotherapy, edited by Germer, C.K. & Siegel, R.D. (2012). New York: Guilford Press.

Hertz, P. Personality disorders with emphasis on borderline and narcissistic. In Berzoff, J., Flanagan, L, Hertz, P. (2008). Inside out and outside in: Psychodynamic clinical theory and practice in contemporary multicultural contexts Northvale, NJ: Jason Aronson Inc.

Kabat-Zinn, J. (2013). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. New York: Bantam Books Trade Paperback Edition.

Kornfield, J. (2009). The Wise Heart: A Guide to the Universal Teachings of Buddhist Psychology. New York: Bantam Books.

Levenson, H. (2010). Brief Dynamic Therapy. Washington, DC: American Psychological Association.

Makransky, J. Compassion in Buddhist psychology. In Compassion and Wisdom in Psychotherapy, edited by Germer, C.K. & Siegel, R.D. (2012). New York: Guilford Press.

Olendzki, A. Wisdom in Buddhist psychology. edited by Germer, C.K. & Siegel, R.D. (2012). New York: Guilford Press.

Siegel, R.D. & Germer, C.K. Wisdom and compassion: Two wings of a bird. In Compassion and Wisdom in Psychotherapy, edited by Germer, C.K. & Siegel, R.D. (2012). New York: Guilford Press.

Watchel, P.L. (2011). Therapeutic communication: Knowing what to say when. 2nd Ed. New York: The Guilford Press.