Psychiatry · Year 3 · from Psychiatry
Case 3: Psychodynamic Psychotherapy
Patient Demographics
- Age: 42 years old
- Sex: Female
- Occupation: Attorney
Chief Complaint
"I keep choosing the wrong partners. I want to understand why I keep repeating the same mistakes."
History of Present Illness
The patient is a 42-year-old woman presenting for therapy after her third failed long-term relationship. She describes a pattern of choosing partners who are emotionally unavailable or critical. Despite being highly successful professionally, she describes chronic low self-esteem in relationships and fears of abandonment that lead her to tolerate mistreatment.
She describes her childhood as "fine on the surface" but on exploration reveals a distant father who prioritized work and was emotionally unavailable, and a mother who was critical and demanding of perfection. She learned to earn love through achievement and has difficulty believing she is worthy of unconditional affection.
Mental Status Examination
Appearance: Professional, polished
Behavior: Intellectualizing, controlled
Mood: "Fine... actually, not fine. Sad, I suppose."
Affect: Constricted initially, softens when discussing childhood
Thought Process: Articulate, intellectualized, avoids emotion initially
Insight: Developing
Psychodynamic Formulation
Core Conflicts:
- Desire for love and connection vs. expectation of rejection
- Need for autonomy vs. fear of abandonment
- Wish to be valued for self vs. learned pattern of earning love through achievement
Object Relations:
- Internalized critical mother object → harsh internal critic
- Internalized absent father → expectation that love figures will be unavailable
- Seeks relationships that confirm these internal expectations (repetition compulsion)
Defense Mechanisms:
- Intellectualization: Uses logic to avoid painful emotions
- Rationalization: Justifies staying in poor relationships
- Reaction formation: Presents as strong and independent to hide vulnerability
Attachment Style: Anxious-preoccupied
Psychodynamic Treatment Plan
Goals:
- Develop insight into unconscious patterns
- Understand how past relationships influence present choices
- Work through feelings about early relationships
- Develop healthier internal object relations
- Make different choices in relationships
Treatment Frame:
- Weekly sessions, 45-50 minutes
- Open-ended duration (typically 1-3 years for personality-focused work)
- Consistent time, place
- Use of couch optional (this patient prefers face-to-face)
Key Psychodynamic Concepts Illustrated
1. Transference: The patient begins to experience the therapist in ways that mirror early relationships.
Example: After therapist takes a vacation, patient is distant in the following session.
Therapist: "You seem a bit withdrawn today. I wonder if my absence last week stirred up some feelings."
Patient: "I'm fine. You're entitled to a vacation."
Therapist: "Of course. But I notice you looked away when you said that. Sometimes when important people aren't available, even for good reasons, it can bring up old feelings."
Patient: (tearful) "I just... I felt like you forgot about me. Like I don't matter when you're not in the room."
This opens exploration of how father's emotional absence created feelings of being forgettable.
2. Interpretation: Linking present patterns to past experiences.
Patient: "I don't understand why I stayed with Mark for so long. He was clearly never going to commit."
Therapist: "I wonder if something felt familiar about waiting for someone who couldn't fully show up for you."
Patient: (pause) "Like my father. I was always waiting for him to notice me."
3. Working Through: Repeated exploration of themes from multiple angles.
Over many months, the patient comes to understand:
- She chose unavailable partners because it was familiar
- She stayed because she believed she could "earn" their love through being perfect
- Her self-worth was contingent on external validation
- She deserved love not based on achievement
4. Defense Analysis:
Patient: "I don't know why you keep asking about my feelings. This is a waste of time. I need practical advice."
Therapist: "I notice when we get close to feelings about your father, you often shift to wanting practical solutions. That makes sense - feelings about him might be quite painful."
Session Example (Late in Treatment)
Patient: "I met someone new. He's actually emotionally available. It's strange - it makes me uncomfortable."
Therapist: "Tell me more about the discomfort."
Patient: "It feels too easy. Like I'm waiting for the other shoe to drop. I keep looking for signs he's going to disappoint me."
Therapist: "Does that remind you of anything?"
Patient: "That's what I always did with my father. Scanning for signs he'd let me down. At least then it didn't hurt as much when he did."
Therapist: "And now you're bringing that same scanning into a new relationship."
Patient: "I don't want to. This man is different. I'm different now. I don't have to protect myself in the same way."
This represents therapeutic progress - the patient now has insight and can make different choices.
Outcome Measures
- Structured psychodynamic outcome measures less common
- Quality of relationships
- Self-esteem
- Reduced anxiety in relationships
- Ability to form secure attachment
Image Attribution
Image: Diagram comparing cognitive-behavioral, psychodynamic, and interpersonal therapy approaches including theoretical foundations, techniques, and typical treatment durations. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.