How I Talk with My Patients (Ogden, 2018)

I’ve often thought if I were put in charge of a clinical or counseling psychology program’s curriculum, I would make major changes to the outdated way we teach theory. Instead of the typical historical survey method of teaching specific theories/theorists of the past 130 years, I would group all psychotherapies into two categories: (1) relationally-focused or process-focused psychotherapies (which include psychoanalytic therapy, humanistic, existential, and other similarly unstructured, relationally-focused and depth-oriented therapies), and (2) skills-focused or content-focused psychotherapies (which include the various cognitive-behavioral therapies and other structured therapies). In my view, the major distinctions between therapies are best understood by this dichotomy and therapists should be trained to work effectively in both paradigms (for more details, see these slides).

Relationally-focused therapies such as psychoanalysis focus less on the content or what a person communicates, and instead focus on the process or how a person communicates. In How I Talk with My Patients, Thomas Ogden illustrates this way of thinking from the therapist’s subjective experience with patients in session. He offers detailed clinical vignettes to give you an appreciation for this way of listening and interacting within sessions.

A few brief notes to assist with your reading:

• Thomas Ogden is one of the most celebrated contemporary psychoanalytic writers. Ogden is influenced by object relations and relational thinking. He’s written quite a lot on the work of Melanie Klein, DW Winnicott, and Wilfred Bion (all prominent British object relational theorists). His somewhat unique therapeutic style relies heavily on making use of his countertransference and what he describes as “dreaming the session” with patients.

• Ogden makes several references to secondary process in this paper. In case this is an unfamiliar term to you, Freud wrote about primary process and secondary process thinking. If you're familiar with the work of Nobel Prize laureate and psychologist Daniel Kahneman's work on Type I and Type II thinking, it's roughly analogous to this idea. Basically, primary process thinking occurs outside of consciousness. It happens very fast and can co-occur with multiple thoughts simultaneously. Secondary process is slower, conscious, more deliberate, and occurs one thought at a time. In psychoanalysis, we want to encourage patients to speak more from primary process - when truly free associating, a patient is speaking without conscious deliberation, giving us more of a glimpse into their primary process/unconscious mental life.

• Ogden writes: “I had in mind the idea (or perhaps more accurately, I felt) that just as the patient is all of the figures in his dreams, he is also all of the figures in his accounts of his daily life” (Ogden, 2018, p. 405). Ogden is referring to a commonly held idea of analytic dream interpretation. One important way of looking at dreams is to consider that all elements of the dream - the characters, the setting, the actions, words, etc. - are all parts of the dreamer. So if I have a dream about my nephew, I might consider what aspect of myself is represented by my nephew. Ogden listens to patients the way he listens to dreams: he assumes that the content is representative of a deeper, unconscious latent meaning, and he sets out to listen for those meanings so he can tailor his responses accordingly.

Ogden 2018 - How I talk with my patients.pdf

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