Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship (Book Review)

Author:  Maroda, Karen J. 
Publisher: Guilford, 2009
Reviewed By: Andrea Celenza, PhD, January 2011, pp. 274

Written at a time when training in psychodynamic psychotherapy is nearly nonexistent, Karen Maroda's book Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship is a profoundly needed corrective for a wide range of clinicians and academics. Maroda has integrated current findings in psychological, psychosocial, attachment/developmental and neurophysiological research with the emerging empirical literature on the efficacy of long-term psychodynamic psychotherapy. Her timing is impeccable! Psychodynamic psychotherapy is almost impossible to find in graduate school curricula; derived as it is from psychoanalytic principles, it can be argued that until psychodynamic clinicians submit to the gods of empiricism, the craft will continue to be viewed as an antiquated (albeit charming) piece of literature. Maroda's book is destined to play a crucial role in grounding psychodynamic theory in empirical demonstrability and practical utility, serving as the basis for any thorough-going clinical technique. This book serves as one of the few linchpins that just may resituate psychodynamic theory as the cornerstone of sound clinical theory and technique.

Pitched to new trainees, this book offers much to those who teach psychodynamic psychotherapy to the neophyte as well as the more experienced. Most of the beginners' texts from the past were written from an ego-psychological perspective and did not have the benefit of current attachment and neurophysiological research to substantiate the claims of dynamic processes. Maroda's text provides this bridge and is written from a relational perspective, clearly at the contemporary cutting edge. But she doesn't simply state the basic premises of relational psychoanalysis (e.g. the reformulation of the therapist's stance in relation to power, participation, neutrality, mutual influence and regression), she presents relational precepts in conjunction with empirical literature that substantiates them. In this way, she pitches her message high—to graduate students who are trained to appreciate empiricism yet are resistant to indoctrination. She is persuasive because she respects academia and is willing to fight one of the most important battles we face—the increasing marginalization of psychodynamic orientations in academic and clinical settings.

Basic premises of relational theory are identified, such as 'We are all emoting constantly,' 'Therapy is a relationship', and the ubiquity of 'ongoing conscious and unconscious communication.' Beyond stating these fundamental principles as received wisdom, however, Maroda documents the substantiating evidence that validates such claims and translates these precepts into "teachable interactive skills." The volume is suffused with clinical knowledge that provides the basis for its practical utility. For example, beginning with Freud's concept of the repetition compulsion, she addresses the ubiquitous problem of repeating old relationships from the vantage point of relational theory, citing Greenberg and Mitchell's (1983) elaboration on relational patterns. Maroda then adds Griffith's (1997) studies on 'triggered affect programs in the brain' to elucidate the neurophysiological substrates of this relational process. She then adds an example from her own practice that puts this knowledge into use, including her own emotional and visceral reactions when interacting with the client.

As if this sweeping integrative effort was not enough, Maroda illustrates all of the basic principles with honest and explicitly detailed case examples from her own practice. She has an engaging writing style, revealing personal reactions and recalling the felt-sensations when she was a beginning therapist. The "sweaty palms" and "queasy stomach" we all experienced is part of her charm; any writer willing to open herself up in this way plants a treasure trove of seasoning throughout. She could not be more generous with explicit examples from her clinical experience, including word for word reproductions of her interventions, thought processes, doubts and feelings.

Maroda takes multiple vantage points as she reveals her own thought processes in both typical and difficult clinical moments. She provides examples from the surface and the depth, from the inside out as well as the outside in, and provides suggestions based as much on what the therapist knows about the client as what she feels. Comprehensive as these orientations are, and each are well-represented in this book, Maroda goes one step further by offering practical and explicit guidelines on how to put these tenets into practice… What does the therapist say? What does she actually do? What is he likely to feel? What might de-stabilize and how does one find an equilibrium? The reader is offered a wide range of everyday therapeutic events and interactions that are bound to resonate, but Maroda goes above and beyond for the more difficult-to-manage interactions where she provides explicit guidance, a list of common phrases, feelings or interactions that may serve as signposts for the moments where clinicians can easily feel lost.

Much like Maroda's description of the therapist's job to know the client from the inside out and the outside in, she makes herself available so that we can know her both ways as well. Thus, she demonstrates in this book what she is advocating—she gives numerous examples of how she herself reacted as a beginning therapist, often examples that do not flatter but display the therapist's quandary as she goes about an honest day of work.

One of the most important sections of the book deals with the budding clinician's demands on him/herself and the impossibly high expectations we tend to set for ourselves. Maroda gives permission to therapists not to accept every client that comes through the door. She notes, correctly, that many, if not most clinicians have the idea that they should be able to treat anyone, anywhere at all times. It is as if disliking a potential client is simply not allowed. This is a dangerous value to hold because it leads some therapists to persist in trying to establish a connection with a client for whom they are actually a bad match. Such is the fodder for some transference/countertransference misalliances, and in the worst case scenario, can lead to disastrous results. Maroda's permissive grant and plea to factor in the therapist's desires and proclivities are crucial aspects of self-care, the teaching of which has been dangerously lacking.

The last third of the book is devoted to the intricacies of difficult moments, impasses and problematic emotional interactions. Problems such as lateness (in paying bills or tardiness), managing anger or hatred of a client, confrontation, and the inevitability of erotic feelings are all given careful consideration. Most importantly, she describes the typical therapist's personality foibles: the guilt-ridden, conflict avoidant tendency to martyr oneself, masquerading as 'putting others' needs before one's own.' Maroda's direct style debunks the stereotypic and self-congratulatory language we often use to describe ourselves…her stance on our own ethic as therapists is not only refreshing, I believe it goes some distance in potentially preventing boundary violations of all sorts. This is one reason I believe all clinicians should have her book readily available on their personal library shelf.

This book is an empirically substantiated, practical guide to the therapeutic landscape. I know a young woman about to enter graduate school in clinical psychology for whom I have already bought this book as a gift to celebrate her budding career. More importantly, I will use this text in my teaching of both trainees and more experienced clinicians. Maroda firmly believes that good therapeutic technique is a "teachable skill." Presumably true for the neophyte therapist who is inexperienced but nonetheless talented and devoted, this book is an important addition to any therapist's library.

Greenberg, J. R. and Mitchell, S.A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press.

Griffiths, P. (1997). What emotions really are: The problem of psychological categories. Chicago:
Chicago University Press.

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