Psychoanalytic and insight-oriented psychotherapy

1. Introduction

Version followed: Gabbard's Long-Term Psychodynamic Psychotherapy: A Basic Text (2nd ed., 2010) as the backbone: its expressive–supportive continuum of interventions, formulation, resistance, dreams, countertransference and termination chapters. Shedler's account of the seven distinctive features (Blagys & Hilsenroth, 2000) and his "That Was Then, This Is Now" are used for stance and the in-session process. McWilliams's Psychoanalytic Psychotherapy (2004) is used for preparing the client and for the frame. Freud's technique papers (1912, 1913, 1914) are the classical root. This is long-term (more than 6 months or 24 sessions), once- or twice-weekly, face-to-face psychotherapy, not 4–5×/week psychoanalysis on the couch. [source: Gabbard 2010; Shedler 2010; McWilliams 2004] Gabbard's book itself is not drawn on here. The continuum and chapter content below come from the book as cited in the secondary literature and from my knowledge of the text. Treat exact wording and ordering as [uncertain] where marked.

What it is. A talking treatment in which therapist and patient attend to whatever comes to mind: feelings, wishes, fears, fantasies, dreams, and reactions to the therapist. The aim is to find the unconscious conflicts, defences and relationship templates that produce symptoms and repeated life problems. [source: Shedler 2006; Shedler 2010]

How change happens. Many symptoms and character patterns are old solutions that have become costly. They are kept going by defences against painful feeling. They are also re-lived with the therapist (transference), which makes them observable as they happen. Change comes through two things together. First, emotionally felt insight: recognising the pattern, its function and its origins while feeling it, not only understanding it. Second, a new relational experience in which old expectations are tested and revised. Both are repeated over time (working through), so that automatic reactions become choices and disavowed parts of the self are reclaimed. [source: Shedler 2006; Gabbard 2010; Freud 1914]

2. Framework

Psychodynamic therapy is not manualised into fixed stages. The phases below follow Gabbard's chapter sequence (assessment → getting started → middle work with resistance, transference and dreams → termination), with McWilliams on preparing the client. [source: Gabbard 2010 contents; McWilliams 2004 contents] The session counts are typical ranges, not prescriptions. [synthesis]

Format. 45–50-minute sessions at a fixed time, 1–2×/week (more frequent sessions deepen the transference and the expressive work). Sitting face to face. Duration open-ended, usually 1 year to several years; Gabbard's working definition of "long-term" is longer than 24 sessions or 6 months. [source: Gabbard 2010] [uncertain: exact wording of the definition]

Phase 0: Assessment and formulation (≈1–4 sessions)

Goals: understand the presenting problem and why it is being brought now. Take a developmental, relational and psychiatric history. Assess ego strength, defences, object relations, psychological-mindedness, capacity for alliance and risk. Write a psychodynamic formulation. Decide where on the expressive–supportive continuum to start. [source: Gabbard 2010]
Indicators for a more expressive emphasis: strong motivation to understand oneself; psychological-mindedness; ability to tolerate frustration and painful affect without acting out; reasonably stable relationships; capacity to regress in the service of the ego and then reorganise; reasonable intelligence and impulse control. More supportive: severe ego deficits, poor impulse control, low frustration tolerance, little psychological-mindedness, acute crisis, or organic or cognitive impairment. [source: Gabbard 2010 (as commonly cited)] [uncertain: exact list]
Move on when the patient and you agree on a focus or goals and on the frame, and no acute risk needs another level of care first.

Phase 1: Opening (≈sessions 2–20)

Goals: prepare the client: explain how the therapy works, what the patient's job is, and the fees, cancellation and contact policies. Establish the frame and the working (therapeutic) alliance. Begin "free" talk. Notice initial transference expectations and the main defences. Start from the more supportive end of the continuum and test how the patient responds to clarification and confrontation. [source: McWilliams 2004; Gabbard 2010]
Move on when: the patient comes regularly and talks with growing spontaneity. They can reflect on their own experience when invited. Recurring themes are visible. The patient can use a trial observation or interpretation, by elaborating, feeling something or adding material, rather than complying or shutting down. [synthesis]

Phase 2: Middle phase / working through (bulk of treatment; months–years)

Goals: identify recurring patterns across three areas: current relationships, past relationships, and the relationship with the therapist. Address resistance as it appears. Interpret defences and the warded-off feelings, wishes and fears behind them. Use transference and countertransference. Explore dreams and fantasy. Work through: the same conflict is met again and again in new contexts until reactions change. [source: Gabbard 2010; Shedler 2010; Freud 1914]
Move on when the termination criteria start to be met (see Phase 3). Typically the patient recognises their patterns in the moment, sometimes before you name them. Signs of self-analytic capacity are taken as central. [source: Gabbard 2010] [uncertain: exact list]

Phase 3: Termination (≈1–6+ months; roughly proportional to treatment length) [uncertain: ratio is a common heuristic, not a fixed rule]

Goals: set an ending date by mutual agreement. Work through the feelings that the ending reactivates (loss, anger, abandonment, triumph, a return of symptoms). Review what has changed and what remains. Consolidate the patient's internalised capacity to reflect. [source: Gabbard 2010]
Typical criteria: symptoms have improved; relationships and work are more satisfying; defences are more flexible and mature; key transference patterns have been recognised and worked through; the patient can continue self-analysis. In practice termination is often driven by external events, and an agreed "good enough" ending is a legitimate goal. [source: Gabbard 2010 (as commonly cited)] [uncertain: exact list]
After: many clinicians leave the door open for a later return. Gabbard discusses post-termination contact cautiously. [uncertain]

3. Guiding principles

Psychic determinism / overdetermination: nothing the patient says or does in session is random, and symptoms usually serve several functions at once. Practically: ask "what is the function of this, now?" and hold more than one meaning open. [source: Shedler 2006]
The unconscious and conflict: people are divided against themselves, wanting and fearing the same thing. Practically: listen for the ambivalence and what is being kept out of awareness, not only the stated wish. [source: Shedler 2006; Gabbard 2010]
Focus on affect: emotion is the guide to what matters. Practically: follow and name feeling, including contradictory or unacknowledged feeling, before content. [source: Shedler 2010]
Explore avoidance: defence and resistance are the work, not obstacles to it. Practically: when the patient changes topic, goes blank, arrives late or intellectualises, get curious about what is being avoided and why. [source: Shedler 2010; Shedler 2006]
Recurring patterns: the same themes repeat across relationships and time. Practically: track and name repetitions once you have several examples. [source: Shedler 2010]
The past lives in the present: early experience shapes current templates. Practically: use history to illuminate present patterns, not as archaeology for its own sake. [source: Shedler 2010; Shedler 2006]
Interpersonal focus: problems are expressed in, and kept going through, relationships. Practically: bring vague complaints down to specific relational episodes. [source: Shedler 2010]
The therapy relationship is a central arena: transference is the activation of pre-existing expectations, templates, fears and desires with the therapist. Practically: treat reactions to you as data and explore them, rather than deflecting or reassuring them away. [source: Shedler 2006; Shedler 2010]
Fantasy life matters: dreams, daydreams and "random" thoughts reveal how the patient sees self and others. Practically: invite them and follow them. [source: Shedler 2010]
Free association / say what comes to mind: the patient's job is to speak as freely as possible. Practically: invite it explicitly, then help with what gets in the way. [source: Freud 1912/1913; Shedler 2006]
Evenly suspended attention: listen without fixing on one element or pursuing a theory too early. Practically: let themes emerge, and notice your own drifting thoughts and feelings as possible data. [source: Freud 1912 (via Wikipedia summary)]
Neutrality, properly understood: you do not take sides among the patient's conflicting wishes, prohibitions and reality. This is not coldness. Practically: explore both sides of an ambivalence rather than advising one. [source: classical; Gabbard 2010] [uncertain: wording]
Abstinence, modified: Gabbard rejects rigid abstinence and blankness. His maxim is "When in doubt, be human." Practically: be warm and real, while not gratifying wishes in ways that close down exploration. [source: Gabbard 2010 via AJP review]
Work with, not on, the patient: collaborative, tentative, humble about what can be known. Practically: offer interpretations as hypotheses ("Could it be…?") and see what the patient does with them. [source: Shedler 2006]
Expressive–supportive flexibility: every therapy mixes expressive and supportive interventions, and the balance moves with the patient's state, session by session. Practically: lean supportive when the patient is fragile or in crisis, and expressive when they can use it. [source: Gabbard 2010]
Surface before depth; defence before content: address what is nearest to awareness, and the defence before what it wards off. Practically: "interpret down" from the defence rather than "up" to deep content, except with some patients (e.g. schizoid) for whom naming the core can feel validating. [source: Busch 2000; McWilliams 1994/1998 as cited in Cerrone 2021] [uncertain: attribution detail]
Countertransference is information: your reactions can be induced by the patient's patterns, as well as come from your own history. Practically: notice and reflect, and use supervision; do not act on them unexamined. [source: Shedler 2006; Gabbard 2010]
Take responsibility for your contribution: do not interpret justified anger as transference when you caused the hurt. Shedler calls that misuse "a travesty of psychoanalytic technique." Practically: acknowledge real errors first. [source: Shedler 2006]
The frame protects the work: consistent time, place, fee and boundaries make deviations meaningful and the space safe. Practically: keep it steady, and explore requests to change it before deciding. [source: McWilliams 2004; Gabbard 2010]
Insight must be felt, and repeated: intellectual understanding alone does not change patterns. Practically: aim interventions at moments of live feeling, and expect to revisit the same theme many times. [source: Shedler 2006; Freud 1914]
Keep hope alive: therapy cannot work without it. Practically: convey realistic confidence that patterns can be understood and changed. [source: Shedler 2006]

4. Intervention inventory

This section has two parts. A sets up and maintains the frame and the listening. B is Gabbard's continuum of verbal interventions, from most expressive to most supportive: interpretation, observation, confrontation, clarification, encouragement to elaborate, empathic validation, psychoeducation, advice and praise, affirmation. [source: Gabbard 2010] [uncertain: exact order and definitions] C covers the core expressive process work: defences, resistance, transference, countertransference, dreams, fantasy, working through and termination. All example language is illustrative unless quoted.

A1. Preparing the client and setting the frame

Purpose / when: first sessions, and again whenever the frame is tested. It makes the treatment understandable and safe, and makes later deviations meaningful. [source: McWilliams 2004, chs. 4–5]
Steps: (1) Explain in plain words how the therapy works: talking freely, the feelings and patterns that emerge, including feelings about you. (2) State the practicalities: fixed time and length, frequency, fee, how payment works, the cancellation and missed-session policy, between-session contact, holidays, confidentiality and its limits. (3) Agree initial goals or focus. (4) Invite questions and reactions to the arrangement. (5) Keep the frame steady afterwards: start and end on time, and use the same room and fee.
Example (illustrative): "This works best when you tell me whatever is on your mind, including things that seem trivial, embarrassing, or about me. We'll meet at this time each week for 50 minutes. If you can't come, the session is still held for you and charged, so that the time is reliably yours."
Watch for / working: the patient's first reactions to the frame (haggling, over-compliance, "rules don't apply to me") are early transference data. It is working when the patient can talk about the arrangement rather than act against it.

A2. Inviting free association ("say what comes to mind")

Purpose / when: throughout. It gives access to material that ordinary purposeful conversation screens out. [source: Freud 1913; Shedler 2006]
Steps: (1) Give the invitation early (see A1). (2) Keep your structuring to a minimum. Let the patient begin each session. (3) When an image, slip, odd thought or shift appears, ask what comes to mind about it. (4) Follow the chain, because associations tend to lead toward what is emotionally charged. (5) When the patient censors ("this is stupid", "it's irrelevant"), treat the hesitation itself as material.
Example: Shedler gives open prompts like "What comes to mind?" and "Where do your thoughts go from there?" [source: Shedler 2006] Illustrative: "You paused and dismissed that thought. What was it?"
Watch for: blankness, scripted reports, "nothing comes": these are resistance (see C3). Working = associations get more spontaneous and more affect-laden, and they link in ways the patient didn't plan.

A3. Evenly suspended attention and listening

Purpose / when: the therapist's counterpart to free association, in every session. [source: Freud 1912 (via Wikipedia)]
Steps: (1) Listen without fixing on any one element or pursuing a preformed hypothesis. (2) Let attention rest on what is said, how it is said (tone, body, sequence, omissions) and your own reverie or feelings. (3) Alternate with active thinking: after a stretch of open listening, ask yourself what the theme of this hour is, what is avoided, and what is happening between us. [source: Reik 1948 as summarised on Wikipedia] (4) Notice sequence: what came just before a shift in topic or affect.
Example: mostly silent. Minimal facilitators ("Mm", "Go on").
Watch for: a premature closure on one theory, or drifting into boredom or sleepiness. Treat either as possible countertransference data (C5). Working = themes appear across the hour without your steering.

A4. Therapeutic silence [synthesis: standard practice; not a named entry in the sources]

Purpose / when: to give room for the patient's own associations and feelings, and to avoid pre-empting them. It suits expressive work with patients who can tolerate it.
Steps: (1) After the patient stops, wait several seconds before speaking. (2) Watch what emerges. (3) If the silence becomes persecutory (rising anxiety, dissociation, a fragile patient), break it supportively and explore the silence itself.
Example (illustrative): "It got quiet just now. What's it like sitting here in the silence?"
Watch for: silence experienced as cold withholding. That links to Gabbard's "be human" corrective. Reduce silence with more fragile patients.

B1. Interpretation (most expressive)

Purpose / when: to make something conscious that was not: a link between a feeling, wish or fear, the defence against it, and its origins or its appearance with the therapist. Use it when the material is near awareness, affect is live, and the alliance is good enough. [source: Gabbard 2010; Shedler 2006]
Steps: (1) Make sure groundwork has been done first, through clarification and confrontation, so the patient already sees the pieces. (2) Start with the defence, then what it protects ("interpret down"): "you do X in order not to feel Y because you fear Z." [source: Busch 2000; McWilliams 1998 as cited in Cerrone 2021] (3) Link where you can across current relationships, the relationship with you, and the past ("triangle of insight") [source: Menninger/Malan concept; secondary] [uncertain: not checked in Gabbard]. (4) Offer it tentatively, as a hypothesis. (5) Use simple, short, experience-near words. (6) Watch the response, and re-work rather than defend your interpretation.
Example (illustrative): "Could it be that when you start to feel close to someone, you find a fault in them, as if needing them is more dangerous than being disappointed?" Shedler's own framing is tentative: "Could it be…?" [source: Shedler 2006]
Watch for / working: signs it worked include new associations or memories, a shift in affect, a "yes, and…" that extends the idea, or a fresh confirming example over the next sessions. Signs it didn't include intellectual agreement with no affect, compliance, or feeling criticised or blamed. Frequent transference interpretation can worsen hostile interactions with some patients. [source: Schut et al. 2005; Høglend 2008 as cited in Cerrone 2021] Mistimed, it raises resistance.

B1a. Transference interpretation (here-and-now)

Purpose / when: to address the pattern as it lives with you. Use it when the transference is affectively alive and is either blocking the work or illustrating the core theme vividly. [source: Gabbard 2010; Shedler 2010]
Steps: (1) Notice a reaction to you: an expectation, fear, wish, or a change in behaviour after a break, a fee change or something you said. (2) First invite elaboration ("What did you imagine I was thinking?"). (3) Acknowledge any real basis in your behaviour. (4) Then link it to the template, and later to other relationships and the past.
Example (illustrative): "When I was a few minutes late, you went quiet and said it didn't matter. I wonder if you were expecting me not to care about this time, the way you've described expecting it from your father." Shedler's example: the patient seems to expect the therapist to hurt or disappoint them as others did. [source: Shedler 2006, paraphrase]
Watch for: do not use transference to dismiss justified grievances. [source: Shedler 2006] Working = the patient can observe the reaction while having it.

B1b. Extra-transference and genetic (developmental) interpretation

Purpose / when: to link present patterns in outside relationships (extra-transference), or to their developmental roots (genetic). Use it when the pattern is clear outside the room, or when the transference is not yet usable. [source: Gabbard 2010] [uncertain: terminology detail]
Steps: collect at least 2–3 concrete episodes. Name the shared pattern. Then ask about early experiences that resemble it, rather than asserting the cause. Check whether the patient recognises the link. [source: Shedler 2006]
Example (illustrative): "With your manager, your ex, and your sister, it's the same moment: they're preoccupied, and you decide you're a burden and withdraw. Does that feeling have a history?"
Watch for: history used to explain away responsibility, or as intellectual narrative. Working = the patient catches the pattern in vivo.

B2. Observation

Purpose / when: to point out something the patient does (behaviour, sequence, non-verbal sign) without explaining it. It prepares the ground for interpretation. [source: Gabbard 2010] [uncertain: definition]
Steps: state what you saw, neutrally and concretely, then stop and let the patient respond.
Example (illustrative): "I notice you smile when you talk about the breakup." · "Each time we get near your mother, the topic shifts to work."
Watch for: hearing it as criticism. Working = curiosity ("Huh, I hadn't noticed").

B3. Confrontation

Purpose / when: to address something the patient avoids or minimises, or does not want to accept, including behaviour that threatens the treatment or the patient's safety. [source: Gabbard 2010] [uncertain: definition]
Steps: (1) Pick an avoided topic that matters. (2) Name it directly and with care, not attack. (3) Link it to the patient's own stated goals. (4) Follow up on the reaction.
Example (illustrative): "You've mentioned the drinking three times now, and each time said it's not a problem. I'm not sure that's true, and I think part of you isn't either."
Watch for: shame, counter-attack, or compliance. Working = the patient engages with the avoided content rather than with you.

B4. Clarification

Purpose / when: to pull together, reformulate or sharpen what the patient is saying, so the picture becomes coherent. Use it constantly, especially early. [source: Gabbard 2010; Despland ESIL level cited in Di Riso 2011]
Steps: summarise or reflect the core of what was said, often with a question. Distinguish the feelings involved. Ask for specifics when the account is vague.
Example (illustrative): "So it sounds like you were both relieved and furious when she cancelled. Is that right?"
Watch for: you imposing your own frame. Working = the patient corrects or refines it, adding precision.

B5. Encouragement to elaborate

Purpose / when: to invite more about a topic, to deepen and widen the material. [source: Gabbard 2010]
Steps: use open, non-leading requests: "Tell me more", "What else comes to mind?" Ask for a specific example of a generality.
Example (illustrative): "Can you walk me through exactly what happened that evening?"
Watch for: over-questioning that becomes an interview. Working = richer detail and affect.

B6. Empathic validation

Purpose / when: to show that you understand the patient's internal state and that it makes sense from inside. Use it with fragile patients, in crisis, before confrontation, and as the base for all the other interventions. Associated with Kohut's self psychology. [source: Gabbard 2010] [uncertain: definition wording]
Steps: name the feeling, and why it is understandable given the patient's experience.
Example (illustrative): "Of course you felt humiliated. You'd told them how much it mattered, and they laughed."
Watch for: validation turning into collusion (agreeing that everyone else is to blame). Working = the patient feels understood, settles, and can then look further.

B7. Psychoeducational interventions

Purpose / when: to give information: about the therapy process, about symptoms or diagnosis, or about normal reactions. Use it early, and with patients unfamiliar with the work. [source: Gabbard 2010] [uncertain]
Steps: give brief, accurate, relevant information, then return to the patient's experience of hearing it.
Example (illustrative): "It's common for people to feel worse for a while when we start looking at painful things. It doesn't mean it isn't working. How is it for you?"
Watch for: lecturing as a defence against affect, yours or the patient's.

B8. Advice and praise

Purpose / when: to prescribe or reinforce specific behaviours. It belongs at the supportive end: use it in crises, with low-functioning patients, or when safety is at stake. [source: Gabbard 2010]
Steps: be specific and brief. Later, explore what it meant to the patient to receive advice or praise from you.
Example (illustrative): "I'd strongly encourage you not to make the decision to quit this week, while you're this upset. Let's look at it together next time."
Watch for: fostering dependency, or compliance to please you. Exploring the meaning restores the expressive balance.

B9. Affirmation (most supportive)

Purpose / when: a brief, simple endorsement of what the patient says or does. [source: Gabbard 2010] [uncertain: definition]
Steps: a short supportive comment, with no elaboration.
Example (illustrative): "Yes, I can see that." · "That was a good step."
Watch for: reflexive reassurance that cuts off exploration. Shedler warns against shallow reassurance as a therapist enactment. [source: Shedler 2006]

C1. Focusing on affect

Purpose / when: whenever affect shows (in the voice, face or body) or is conspicuously missing. Feeling is the guide to what matters. [source: Shedler 2010]
Steps: (1) Notice affect cues: tears welling, a laugh that doesn't fit, a flat tone with distressing content. (2) Slow down and name what you see. (3) Ask for the feeling in the body and in words. (4) Help the patient separate mixed or contradictory feelings. (5) Stay with the feeling rather than moving to explanation.
Example (illustrative): "Your voice changed just then. What are you feeling right now, as you talk about her?"
Watch for: flooding (shift supportive, see Section 5), or an intellectual retreat. Working = feeling deepens and new material follows it.

C2. Defence analysis

Purpose / when: to help the patient see how they keep painful experience away: avoiding, minimising, intellectualising, projecting, externalising, splitting, reaction formation, etc. Address it when the defence is visible in session and is costing the patient. [source: Shedler 2006; Shedler 2010]
Steps: (1) Notice a defence in action. (2) Observe it (B2) and invite curiosity. (3) Explore what it protects against: what would be felt without it. (4) Acknowledge its original adaptive value. (5) Interpret the triad of defence, feeling and fear (B1). Work from the surface down. [source: Busch 2000 via Cerrone 2021]
Example (illustrative): "Each time we get close to how lonely that was, you make a joke, and we both laugh. I wonder what it would be like not to make the joke." · "That way of shrugging it off probably protected you a lot growing up."
Watch for: stripping defences too quickly in fragile patients. In supportive mode, challenge defences only when they are maladaptive and strengthen the adaptive ones. [source: Di Riso et al. 2011, on supportive technique] Working = the patient notices the defence on their own ("I'm doing the joke thing again").

C3. Resistance work

Purpose / when: resistance is defence showing up in the therapy itself: lateness, missed sessions, silences, small talk, "nothing to say", forgetting the bill, intellectualising, flights into health. Treat it as conflict within the patient, not opposition to you. [source: Shedler 2006; Gabbard 2010]
Steps: (1) Notice the pattern without irritation. (2) Observe it neutrally. (3) Ally with the part of the patient that wants change, and get curious about the part that doesn't. (4) Explore what coming here, or talking about X, stirs up. (5) Interpret the resistance as protection ("in order not to…"). Address resistance before content. [source: Freud 1914; Gabbard 2010]
Example (illustrative): "We've had three late starts since we began talking about your brother. I'm not criticising, I'm curious. What's it like coming in now?"
Watch for: your own frustration (C5). Working = the resistance becomes something you discuss rather than something enacted, and new material emerges.

C4. Exploring the transference (non-interpretive phase)

Purpose / when: to bring reactions to the therapist into words before interpreting them. Do it at breaks, after frame events (fee, holidays, lateness), and when the patient avoids looking at you or asks about you. [source: Shedler 2006; Shedler 2010; Gabbard 2010]
Steps: (1) Listen for disguised references to you, e.g. stories about doctors, teachers or bosses who don't listen. (2) Ask directly about the patient's experience of you or of the session. (3) Invite the fantasy: what they imagine you think or feel. (4) Tolerate the patient's perception of you, even when it is distorted, rather than arguing them out of it. [source: Shedler 2006] (5) Only later link it (B1a).
Example (illustrative): "You've told me about two people this week who didn't really listen to you. I wonder if you've had any of that feeling here, with me." · "When you thought I'd be bored, what did you picture on my face?"
Watch for: idealisation or erotic transference that closes down exploration. Explore it like any other transference, and keep strict boundaries. [source: Gabbard 2010 (gender and transference discussion)] [uncertain: detail]

C5. Using countertransference

Purpose / when: your emotional reactions to the patient can show what the patient evokes in others, or what they cannot feel themselves. Use them always as information, and never act on them unreflectively. [source: Shedler 2006; Gabbard 2010]
Steps: (1) Notice unusual reactions: boredom, sleepiness, rescue urges, irritation, arousal, feeling deskilled, wanting to extend the session or waive the fee. (2) Sort them: how much is your own history, and how much is induced by the patient's pattern? (3) Hypothesise what the reaction tells you about the patient's inner world or relationships. (4) Usually, use it to inform an observation or interpretation about the patient. Disclose your reaction only selectively and briefly, when it serves the patient. [synthesis: Gabbard discusses judicious self-disclosure] [uncertain] (5) Take persistent reactions to supervision or consultation. Gabbard advises trainees to bring to supervision exactly what they'd prefer to avoid. [source: Gabbard 2010 via AJP review]
Example (illustrative, from countertransference to intervention): you notice you feel shut out → "I find myself wondering whether people sometimes feel kept at a distance from you, even when you're telling them important things."
Watch for: enactments (see Section 5), recreating your own pathology, e.g. rushing to label the patient a victim or offering shallow reassurance. [source: Shedler 2006] Working = the reaction becomes understood and stops driving your behaviour.

C6. Dream work

Purpose / when: dreams are a window onto wishes, fears, conflicts and the transference. Use them when the patient brings a dream; you can also invite dreams. [source: Gabbard 2010, ch. Dreams; Freud 1900]
Steps: (1) Ask the patient to tell the dream in detail, in the present tense if possible. (2) Ask for the feeling in the dream and on waking. (3) Take elements one at a time and ask what comes to mind about each (A2). (4) Ask about the day residue: what happened the day or two before. (5) Consider whether it is a commentary on the therapy or on you. (6) Build a tentative meaning with the patient. Do not decode symbols from a dictionary. (7) Note when in the session the dream is told, and how. [source: Gabbard 2010; classical technique] [uncertain: exact step order]
Example (illustrative): "What comes to mind about the locked room?" · "What was happening the day before?" · "You dreamed of a doctor who wasn't paying attention, the night after I cancelled. I wonder."
Watch for: dreams flooding the session as a defence, or intellectual dream-solving. Working = associations connect the dream to live current conflicts with feeling.

C7. Exploring fantasy life

Purpose / when: daydreams, wishes, imagined scenes and "what ifs" show how the patient sees self and others. Use them when the patient is stuck in concrete reportage, or a hint of fantasy appears. [source: Shedler 2010]
Steps: invite the fantasy in detail: who, what happens, how it ends, what the feeling is. Explore without judgment, including aggressive, sexual or grandiose content. Link it to wishes and fears.
Example (illustrative): "If you could have said anything to him without consequences, what would you have said? Let it play out."
Watch for: shame (normalise it) and acting on fantasies. Working = the patient can own wishes they had disavowed.

C8. Identifying recurring patterns and developmental exploration

Purpose / when: to link repeated themes across relationships and life events, and to their developmental history. It runs through the middle phase. [source: Shedler 2010]
Steps: (1) Collect specific relational episodes: what the patient wanted, how the other responded, how the patient reacted. (2) When an episode recurs, name the similarity. (3) Ask about earlier versions. (4) Formulate the template together. (5) Later, watch for it with you (B1a).
Example (illustrative): "This is the third time you've described giving more and more until you're exhausted and then exploding. When did you first learn that's how it has to go?"
Watch for: blaming parents as an endpoint. The aim is freedom from the past, not a verdict. [source: Shedler 2010] Working = the patient anticipates the pattern.

C9. Working through

Purpose / when: after insight. The same conflict must be recognised and re-experienced many times, in new contexts, before change becomes stable. [source: Freud 1914; Shedler 2006]
Steps: (1) Expect the theme to return in new guises. (2) Each time, help the patient recognise it, feel it, and notice what's different now. (3) Note small changes in behaviour outside sessions. (4) Expect resistance to returning to known ground, and expect relapses. Keep patient persistence.
Example (illustrative): "Here's that familiar moment again, and this time you noticed it before you withdrew. What happened then?"
Watch for: your own impatience ("we've covered this"). Working = shorter latency between the trigger and the patient's recognition, and new behaviour.

C10. Working with termination

Purpose / when: when the criteria are approaching (Phase 3), or when an external ending is imposed. [source: Gabbard 2010, ch. Termination]
Steps: (1) Raise the possibility, or respond to the patient raising it, and explore its meaning (is it readiness or flight?). (2) Agree a date well ahead. (3) Expect and interpret reactivated symptoms and old feelings about loss and separation. (4) Review the work together: what changed, how, and what remains. (5) Address the patient's plans for continuing self-reflection. (6) Discuss returning later if needed. Say goodbye with feeling: a human goodbye, not a cold one.
Example (illustrative): "Now that we've set the date, I notice the old headaches are back. I wonder if part of you is protesting our ending, or checking whether I'll still be here."
Watch for: avoidance of the ending (missed final sessions, a sudden new crisis). Working = sadness and gratitude can coexist with confidence.

C11. Managing frame deviations and boundary quandaries

Purpose / when: requests for extra sessions, gifts, touch, social contact, fee changes, out-of-hours contact. [source: McWilliams 2004, ch. 7; Gabbard 2010]
Steps: (1) Don't decide immediately unless it's an emergency. (2) Explore the request's meaning. (3) Decide on clinical and ethical grounds. Distinguish boundary crossings, which can be benign and should be discussed, from boundary violations, which exploit the patient (Gabbard's distinction, from his boundary-ethics writing). [source: Gabbard & Lester 1995] [uncertain: not verified in this session] (4) If you have already over-accommodated, re-establish limits in a way the patient can explore. [source: Shedler 2006]
Example (illustrative): "I'd like to understand what it would mean to you if we added a session, before we decide."
Watch for: a slippery slope of small concessions, and therapist depletion. Working = the request becomes material.

5. Handling problems

Stuck / circling (same content, no movement) [synthesis, drawing on Gabbard/Shedler principles]: (1) Check your formulation: is a different conflict being avoided? (2) Look at the process instead of the content: "We keep returning to this, as if something keeps us here." (3) Check the transference and countertransference. Am I part of the stalemate, for example by being too passive, colluding, or bored? (4) Move along the continuum: try a more confrontational or a more supportive intervention. (5) Take the case to supervision or consultation.
Resistance (lateness, silence, superficiality): treat it as meaningful conflict, not defiance. Observe, explore and interpret in that order (C3), and ally with the part that wants change. [source: Shedler 2006; Freud 1914]
Overwhelm / emotional flooding or dissociation: shift toward the supportive end. Use empathic validation, clarification and grounding in the here and now. Stop deepening. Slow the pace. Return to the material later once the patient can tolerate it. [source: Gabbard 2010 expressive–supportive flexibility] Specific grounding steps are [synthesis].
Non-adherence (missed sessions, not paying, "forgetting"): hold the frame consistently (charge per policy), and explore the meaning in the next session without punishing. If it persists, review the treatment agreement directly. [source: McWilliams 2004; synthesis]
Ruptures (patient angry, hurt, pulling away): (1) Name it. (2) Invite the patient's full account. (3) Acknowledge your real contribution first, without defensiveness. Shedler warns against interpreting justified anger as transference. [source: Shedler 2006] (4) Only later explore any transference amplification. (5) Treat the repair as an important new relational experience. [synthesis; cf. Safran & Muran's rupture–repair model, not a primary source of this modality]
Enactments (you find yourself in a role: rescuer, critic, seducer, withholder): (1) Notice it, often after the fact. (2) Stop the behaviour. (3) Reflect privately or in supervision on what was re-enacted. (4) Use it to understand the template, and when appropriate bring it into the conversation without blaming the patient. [source: Gabbard 2010 (countertransference chapter, enactment concept)] [uncertain: detail]
Negative therapeutic reaction (worse after progress or a good interpretation): consider guilt about improving, fear of separation or of envy, or a loyalty bind. Interpret the link between progress and danger. [source: classical concept (Freud 1923)] [uncertain]
Intellectualisation ("insight" with no feeling): stop offering interpretations. Return to affect (C1) and to the defence itself (C2). [source: Shedler 2006 on felt insight]
Erotic or idealising transference: explore it as you would any transference. Neither gratify nor shame it. Keep boundaries absolute, and use supervision. [source: Gabbard 2010] [uncertain: detail]
Hostile/negative transference: tolerate it, and do not retaliate or appease. Clarify the perception of you. Acknowledge any real basis. Interpret its protective function. [source: Shedler 2006; synthesis]
Crisis or acute risk (suicidality, self-harm, decompensation): shift supportive immediately. Do a risk assessment and safety planning, involve other services, and consider medication referral. Return to expressive work after stabilisation. [synthesis consistent with Gabbard's continuum] Risk-management specifics are outside the sources.
Patient wants advice and concrete techniques only: give limited advice where safety or practicality requires it (B8). Explore the wish for answers and what not receiving them stirs up. Re-evaluate whether a more structured or supportive therapy fits better. [synthesis]
Premature termination wish / flight into health: explore the timing (what was being approached just before?). Respect autonomy. Offer a planned ending, even a short one, rather than an abrupt one. [source: Gabbard 2010; synthesis]
Therapist fatigue, over-accommodation, burnout: re-establish limits. Seek supervision. Attend to self-care. [source: McWilliams 2004, chs. 11–12; Shedler 2006]
Online/video format: keep the frame explicit (privacy, the same time, no multitasking), and explore the meaning of the format. [synthesis; not addressed in the sources]

Sources

Sources:

Books and papers cited (further reading, not drawn on in full):

Gabbard, G. O. (2010). Long-Term Psychodynamic Psychotherapy: A Basic Text (2nd ed.). American Psychiatric Publishing.
McWilliams, N. (2004). Psychoanalytic Psychotherapy: A Practitioner's Guide. Guilford.
McWilliams, N. (1994/2011). Psychoanalytic Diagnosis. Guilford.
Freud, S. (1912). Recommendations to physicians practising psycho-analysis. SE 12. (1913) On beginning the treatment. SE 12. (1914) Remembering, repeating and working-through. SE 12.
Busch, F. (2000). What is a deep interpretation? JAPA, 48, 237–254.
Blagys, M., & Hilsenroth, M. (2000). Distinctive features of short-term psychodynamic-interpersonal psychotherapy. Clin Psychol Sci Pract, 7, 167–188.
Gabbard, G. O., & Lester, E. (1995). Boundaries and Boundary Violations in Psychoanalysis. Basic Books.

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