Psychodynamic Approaches to Behavioral Change

Psychoanalysts have generally avoided targeting behavioral change in psychoanalysis or psychoanalytic psychotherapies, believing such approaches can disrupt effective treatment. A central concern has been that these strategies constitute “suggestion,” an effort to influence or manipulate patients. A core focus of psychoanalysts has been on gaining insight, making the unconscious conscious; this increased understanding was considered the primary goal and paved the way for behavioral change. If behavioral change occurred without proper analysis, conflicts were believed to persist, leading to the substitution of different symptoms or problematic behaviors. Over the course of psychoanalytic history, there has been an increasing emphasis on the clinical impact of the therapeutic relationship independent of insight, but these theories and approaches still consider behavioral change to be a secondary outcome.

Rather than being at odds with or disrupting psychoanalytic treatments, efforts to change behavior can be used to enhance self-understanding. Considerable exploration takes place in identifying behaviors that are problematic. Targeting behavioral change provides an opportunity to determine what factors, including fantasies, emotions, and conflicts, inhibit these changes. Working with behavioral change allows for exploration of transferences that emerge in this effort, such as a need to please or defy the therapist or wishes to be taken care of. Additionally, changes in behavior allow for confrontation of specific fears and fantasies. For instance, successful assertive behavior can help patients reassess fears that expressing their needs or feelings directly will inherently lead to problems with others.

Psychoanalytic theory and techniques add several strategies for behavioral change to those employed in other treatments. Identifying developmental events contributing to these behaviors aids patients in recognizing their origins, helping to determine if they have overestimated risks of behavior based on early experiences. Additionally, the therapist explores unconscious dynamics that are interfering with behavioral change and uses the transference to observe conflicts and inhibitions as they emerge with the therapist. Furthermore, therapists assess countertransference reactions, which can lead them to be overly focused on behavioral change, expect that patients follow their advice more readily than they are capable of, or overlook patients’ concerns about the value of suggested actions.

From the psychoanalytic perspective, multiple factors contribute to specific behavioral problems. For example, patients with difficulties with assertiveness may struggle with conflicts regarding their aggression, a fear of disrupting close attachment relationships, and separation fears from increased autonomy. Adverse early experiences, such as harsh punishments of assertive behavior, may have added to the intensity of these fears. The psychodynamic therapist works to address these various contributors in targeting behavioral change,

Although psychoanalysts erred in believing that focusing on behavioral change would be inherently damaging to treatment, they identified specific difficulties to which to be alert in using these strategies. Patients, aware that the therapist wants them to make these changes, could develop a need to please the therapist and feel inadequate if they are unable to make the change. They may also feel pressured to submit to the therapist’s suggestions and view themselves as “bad” patients if they do not shift behaviors. Patients could also become dependent on the therapist, feeling that they need the therapist’s advice to make decisions. Alternatively, patients may wish to rebel against the therapist’s suggestions. These various reactions can be addressed with psychodynamic psychotherapeutic techniques, including interpretation of the transference.

A framework for understanding and addressing behavioral problems includes examining the context, emotions, and meanings of problematic behavior; formulating relevant intrapsychic conflicts, defenses, and developmental factors; identifying alternative behaviors; elaborating feelings and fantasies about performing alternative behaviors; addressing interfering factors; and monitoring the impact of behavioral change. Identifying alternative behaviors represents a significant departure from traditional psychodynamic psychotherapy. Therapists and patients discuss the employment of specific actions or “scripts” in addressing problems with others. They can then examine what factors interfere with implementing these changes. The therapist can ask patients to imagine performing these behaviors and identifying their concerns, including how they anticipate others will respond.

Homework, typically considered inimical to psychoanalytic treatments, can play a valuable role in behavioral change.  Patients can monitor emotions and contexts of problematic behaviors in diary form, helping identify thoughts, feelings, and symptoms that arise when attempting to enact particular behaviors. The therapist can work with patients in developing a written psychodynamic formulation that can be updated over the course of therapy. This process can help patients develop a growing understanding of how their minds work and affect their feelings and behaviors. Additionally, patients can make a written note of certain potential scripts, what they anticipate the response of others will be, what interferes with enacting these behaviors, and what their and others’ responses are to actual use of the script.  These approaches expand the therapist’s armamentarium for helping patients to obtain insight, relieve distress, change behaviors, and improve relationships. ■