Developing Insight in Intensive-Extensive Psychodynamic Psychotherapy: A Case Study
Don Yutzler, Ph.D.
Although a voluminous, if not tedious, literature exists on the theoretical construct of insight and its conceptual and dynamic underpinnings, as well as its cognitive and affective precursors and concomitants, little in the way of hard clinical data, drawn from actual real-life therapy cases, has been cited as a means of illustrating the dynamics of insight and “the working through process.” The author presents, here, an annotated transcript of therapy sessions with one of his more successful therapy patients in order to vividly illustrate the development of therapeutic insight.
This is the case of a 34-year-old Caucasian male, who sought psychodynamic psychotherapy in order to gain insight into why he had left his ex-wife several years earlier. After a great deal of self-exploration, as well as another marriage and two children, the patient now wanted to embark on a formal journey of self-understanding.
The treatment began with 8 sessions of therapy, during which rapport and a strong “working alliance” were established. The following crucial interchange occurs in the 9th session:
Therapist: So, tell me about your ex-wife.
Patient: She was a short woman.
As is evident, this purely descriptive reply reflects no true insight. Note also the therapist’s technique which, although highly directive, remains remarkably free of any countertransferential cathexes.
By the 14th visit the therapist assessed that the patient was ready to tolerate more intensive, affectively charged material and so begins to probe more daringly:
Therapist: So, tell me about your ex-wife.
Patient: As I told you, she was a short woman.
Therapist: Um-hmm. Tell me more.
Patient: Well, she weighed about 180 pounds.
In this lively interchange, we immediately note the gains in self-understanding. Although to the naïve observer this patients seems rather superficial, the therapist begins to speculate that perhaps the patient is only superficial on the surface.
Again, to the casual listener, the juxtaposition of these descriptive concepts could immediately bring to mind an interpretative intervention, i.e., the woman was obese. But this patient clearly is not yet ready to draw such a conclusion himself and it would be a serious error if the therapist were to precipitously and wantonly blurt out such an anatomical observation. A premature insight could be extremely detrimental to the course of therapy, perhaps shortening it a great deal, perhaps even rendering any further sessions altogether unnecessary. Wisely, the therapist waits.
The next stage of therapy is focused on strengthening the patient’s defenses to prepare him to handle the truth. Although the therapist thinks the patient is ready, he has erred, as the following dialogue in the 26th meeting reveals:
Therapist: 12 sessions ago, you described your ex-wife as a short woman weighing 180 pounds. Have you given any further thought to these two ideas?
Therapist: Why not?
Patient: I don’t know.
Therapist: Would you like to know?
Patient: I don’t know. Do you think it’s important?
Therapist: Important? I didn’t say it was important. Do you think it is?
Patient: I asked you first.
Here, it is evident that the therapist has pushed too hard, and the patient is decompensating. The patient shows this by missing the next 2 appointments, thus requiring 4 more to explore resistance and billing issues.
A breakthrough occurs in the 33rd session when the patient refers to his ex-wife as a “tubster.” The therapist, unfamiliar with this slang expression, asks for clarification.
Therapist: No, I mean what do you mean?
Patient: She was fat.
Here, the patient is obviously in touch with deeper levels of emotion, for he could have chosen a less pejorative term, e.g., “pleasingly pump,” “rotund,” or “the wide ride.” In “fat,” we have hit a nerve. But it was still too early to press for further insight. What remained, of course, was a fuller understanding of the many rolls of the ex-wife’s fat in their marriage and its demise.
Finally, in the 40th session, the patient arrives at a marvelous insight:
Therapist: So, why did you leave your wife?
Patient: I just couldn’t stand that short, stupid, fat woman any longer!
So, that was it. He had left her because she lacked height and depth, while being overly wide. Notice the exclamation point at the end of the patient’s statement, clearly signifying his angry yet liberated tone. Here, we have full simultaneous cognitive and affective insight.
The author is please to report that the treatment was successfully concluded in only 12 more sessions, as termination issues were worked through to satisfy the therapist’s needs for closure and further income to cover malpractice insurance.
© Copyright 1986 Wry-Bred Press, Inc./Glenn Ellenbogen. All rights reserved.
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