The Application of Psychodynamic Skills in Nontraditional Venues

Harvey Schwartz, MD, is a psychoanalyst and clinical professor of psychiatry at the Sidney Kimmel School of Medicine, Thomas Jefferson University in Philadelphia, Pennsylvania. He is the editor of 5 books and is the producer of the podcast, Psychoanalysis On and Off the Couch, which features interviews with psychoanalysts who apply their clinical skills in settings outside of the consulting room.

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The long road to learning psychodynamic skills can reward the clinician well beyond their work with individual patients in their offices.

One can apply these skills in settings as varied as oncology clinics, with children traumatized by violence, and in dialysis units. The basic attunement of the psychodynamically oriented clinician permits them access to deeper aspects of individuals’ minds regardless of where they are encountered. Over the years these skills have been variously called psychodynamic psychotherapy or applied psychoanalysis, and lately have taken on the moniker of “off the couch” work.

The dynamic therapist is attentive to both manifest and latent levels of meaning; we listen to what patients say on the surface and also attend to what may be operating at levels beneath their awareness that are contributing to their present difficulties. We also consider how a patient’s perceptions of the present may be influenced by experiences from their past, traumatic or otherwise. In addition, we are always alert to the meanings and attitudes that patients bring to their encounter with us – the unknowing transference of past attachments and aspects of themselves onto us and others in their life.

The technique of listening for these themes is similar both inside and outside of the office. The technique of intervening is different. In settings outside of the traditional frame, it can be said that one “thinks intrapsychically but acts interpersonally.”

When faced with a hospitalized, terminally ill patient, a dynamic ear might alert the clinician to the presence of repressed hostility toward a loved one. However, given the pressing circumstances, the clinician likely would not elect to bring the patient’s discomfort with their anger to their attention. Instead, the clinician might address the value of forgiveness. A dynamic ear – a supportive tongue.

In my conversations with a range of clinicians, including through podcast interviews with psychoanalysts, I have learned about the potential benefits of practicing psychodynamic skills in nontraditional venues.

For example, when confronting the isolation that many dialysis patients experience, a clinician intervened by asking the dialysis nurses to record a personal exchange they have had with each patient during every dialysis visit. This approach brought a personal quality to what was an otherwise alienating encounter, and the patients’ health outcomes improved.

The awareness that a young, multiply traumatized refugee mother is unable to meet the gaze of her infant daughter might lead the clinician to both hold the child in her own gaze, while also meeting the mother’s turned away eyes with her own.

As another example, a psychoanalyst who works with children overwhelmed by witnessed violence can intervene with a child by teaching them how to recognize that somatic pains are a manifestation of upsetness that the child is feeling but cannot yet put into words.

Additionally, a psychoanalyst who works with Native American children struggling at school meets with these children in the classroom. They have group sessions with the teachers in the presence of classmates. These interventions can yield empirically verified improvements in development and social functioning.

These clinicians are applying their psychodynamic skills in these and many other venues. These approaches, learned in training and throughout one’s career, can open many doors. They allow us to meet and impact large numbers of individuals who otherwise would never find their way to our offices. Through these “off the couch” efforts, the dynamic psychotherapist can uniquely and broadly contribute to our communities.