This summary discusses a symposium on psychodynamically-oriented psychotherapy presented by Drs. Katz, Hersh, and Plakun with Dr. Di Nicola as discussant. Dr. Katz presented on outpatient treatment focusing on facilitating deepened emotional experience and increased freedom through awareness of patterns. Dr. Hersh discussed transference-focused psychotherapy for BPD using detailed attention to communication channels to integrate split affects and cognitions. Dr. Plakun examined how psychodynamic therapy leads to change through epistemic trust developed in the therapeutic alliance to counter attachment trauma. Dr. Di Nicola emphasized asking what is missing with treatment-resistant cases and moving beyond loss to discovery through non-enact

1. Discussion
VINCENZO DI NICOLA
MPhil, MD, PhD, FRCPC, DFAPA
Symposium
Change During
Psychodynamically-Oriented
Treatment
APA On Demand – April 17, 2020

2. Vincenzo Di Nicola
Professor of Psychiatry
University of Montreal & The George Washington University
Chief, Child & Adolescent Psychiatry
Montreal University Institute of Mental Health
Founder & President
Canadian Association of Social Psychiatry
President-Elect World Association of Social Psychiatry

3. Declaration of Interests
I have no financial conflicts to declare.

4. Isolation vs.
connection

5. APA Symposium on Change
Jennifer Downey, MD: Chair
Debra A. Katz, MD:
Change During Psychodynamically-Oriented
Outpatient Treatment
Richard G. Hersh, MD:
Change During Transference-Focused Psychotherapy
for Borderline Personality Disorder (BPD)
Eric M. Plakun, MD:
Psychodynamic Change in Patients with
Treatment-Resistant Disorders
Vincenzo Di Nicola, MD: Discussant

6. Discussion
Rich and detailed, revealing deep engagements
with psychodynamic psychotherapy, close
readings of the literature, and carefully reflected
cases and commentaries
Each presentation is both an intense engagement
with a coherent model and an appeal to
interdisciplinarity
I will tease out some of these references
And offer an image for each presentation

7. Symposium – Dr. Katz
Debra A. Katz, MD:
Change During Psychodynamically-Oriented
Outpatient Treatment
Seeking understanding rather than attempting to
impose change
Facilitating deepened emotional experience
individually and with therapist
Increasing sense of freedom and the capacity to
choose

8. Symposium – Dr. Katz
Case of Ms. A: “I’m in free fall”*
Assessment vs. therapy
Multimodal plan – other elements, referrals
Characteristic patterns of thinking, feeling,
behaving
Therapeutic setting as a “safe space” –
“holding environment”
* A composite

9. Symposium – Dr. Katz
Case of Ms. A: “I’m in free fall”
Awareness of patterns and incongruities
Through the therapeutic relationship to arrive
at a deepened emotional experience –
transference therapy, as Kernberg frames it
Allowing repressed/dissociated traumatic
relational states to emerge, to be experienced

10. Discussion – Dr. Katz
Katz refers to DSM-5 Dx and other modalities
such as couple therapy and outcome
comparisons between PDT and CBT
Her language reflects our current social
preoccupations – eg, “safety” echoes the notion
of cultural safety in cultural psychiatry
The “incongruities” she looks for in therapy
mirrors cognitive therapy’s “cognitive distortions”

12. Discussion – Dr. Katz
An image for this presentation
In this cartoon, we see a Matryoshka doll on the
couch talking about other people being inside of
her
With the case of Ms. A, we have the therapist as
a kind of midwife
Recognizing that someone else is struggling to
emerge among the conflicts and incongruities of
her patient, she accompanies her patient in the
labor of giving birth to a new self

13. Symposium – Dr. Hersh
Richard G. Hersh, MD:
Change During Transference-Focused
Psychotherapy for Borderline Personality
Disorder (BPD)
Transference-focused psychotherapy
Empirically validated version of Kernberg’s
Structural Interview, adapted for female patients
with Borderline Personality Disorder (BPD)
A detailed, labor-intensive process

14. Symposium – Dr. Hersh
A detailed, labor-intensive process …
Elucidation, negotiation, permission
Attention to 3 channels of communication
in both the patient and the therapist
working on transference and countertransference

15. Symposium – Dr. Hersh
“Judicious use of interpretation”
Integration of cognitions and affects previously
split off and disorganized
Many approaches would not even recognize this
language
This is person-centered, attentive, respectful
The therapist is involved in “story repair” or
assembling a jigsaw puzzle where neither the
patient nor the therapist knows what will emerge

16. Discussion – Dr. Hersh
Dr. Hersh creates safety with the treatment frame
This rich concept keeps being rediscovered or
relabeled in the history of psychotherapy
From Winnicott’s “holding environment” to
experiments with the “parameters of therapy” to
Robert Langs’ “bipersonal field” – all forms of
therapy want to create a frame and a framework
None more so than transference-focused therapy

17. From: Vincenzo Di Nicola, Letters to a Young Therapist (2011)
Cartoon Credit: Thomas Zummer

18. Discussion – Dr. Hersh
An image for this presentation
With his gentle insistence on negotiation and
permission and minute attention to the
experiences of therapy, Dr. Hersh captures the
heart of Freud’s therapeutic innovations
In spite of the usual jokes, this cartoon captures
the goal of therapy which is a better reading of
reality
Here Freud affirms that sometimes a cigar really
is a symbol, a stand-in, a substitution

19. Symposium – Dr. Plakun
Eric M. Plakun, MD:
Psychodynamic Change in Patients with
Treatment-Resistant Disorders
How does psychodynamic psychotherapy lead to
change?
“Biomarkers” vs “enviro-markers”
Adverse Childhood Events Study
Trauma methylates DNA

20. Symposium – Dr. Plakun
“All psychopathology is loss; all psychotherapy is
mourning” (Martin Cooperman)
Against loss what do we have?
“Epistemic trust” (Peter Fonagy)
Vs. “epistemic hypervigilance”
Attachment trauma
Mis-attunement
Adversity
Therapeutic alliance

21. Discussion – Dr. Plakun
With a nuanced discussion of genetics effects
including the possibility that through epigenetics,
Lamarck was right after all – that acquired traits
may be inherited – Dr. Plakun in fact points us to
the profound impacts of adversity and trauma
As a child psychiatrist, I would be remiss not to
invoke the Adverse Childhood Events (ACE) Study
which shows a powerful association between
early adversity and lifelong negative health
outcomes that I call “the longest shadow"

23. Discussion – Dr. Plakun
An image for this presentation
With his wide-ranging discussion of the
possibilities of change via both neuroscience and
enviro-markers, Dr. Plakun does a
transdisciplinary “deconstruction” of Freud
This cartoon says it well, reminding us that Freud
was a neuropathologist who became an
archeologist (his preferred metaphor for his
method), revealing “skeletons in the closet”
Here, the Freudian mind also has a brain

24. What are we missing?

25. Discussion
With my training in several therapeutic
frameworks (behavioral, family therapy,
psychodynamic psychotherapy) –
When I am confronted with treatment-resistant
cases, I ask myself the question –
What am I missing?

26. Discussion – Dr. Plakun
Eric Plakun – The therapeutic alliance and the
vicissitudes that may occur through enactment
Comment: Can we move beyond loss and
mourning – avoiding enactment – to discovery
and growth?

27. Discussion – Dr. Katz
Debra Katz - Increasing sense of freedom and the
capacity to choose – a deepened emotional
experience
Comment: Therapy as a relationship – listening,
orienting the patient towards health
Can we help Ms. A to experience “free fall” as
freedom?

28. Discussion – Dr. Hersh
Richard Hersh – therapy as a labor-intensive
process
Comment: Therapy as a negotiation based on
elucidation, permission, attentiveness to the
transference relationship
Can the therapeutic relationship be a positive
model for growth and change in other
relationships?

29. Acknowledgments
Dr. Jennifer Downey,
Symposium Chair
Dr. Debra Katz
Dr. Richard Hersh
Dr. Eric Plakun
Turku, Finland