Basic Psychological Treatments: Psychodynamic therapy
Dr Simon Reid Milligan Forensic Psychologist Roseberry Park Hospital Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust theory
Psyche – focus on psychological experience, primarily emotional pain. Mind is constructed in struggle to manage (conflicting) difficult and demanding processes
Dynamic – our mental life is in flux. Responding to constant conflict within ourselves based on changing world around us theory
No single articulated paradigm
Pre-theoretical: focus is on perception of human condition, not a concept
Includes all theories in psychology which regard human functioning as result of interaction of drives and forces within person, especially unconscious
Encompasses many theoretical approaches which remain connected to psychoanalytic roots
Object Relations Theory – internalised relation of self to self within world theory
Psychic determinism – unconscious motives. All behaviour has a cause
Developmental – role of childhood experiences and relationships as template for later life
Tripartite structure of personality History
Freud – psychoanalysis was the original psychodynamic theory
Adler (1927)
Anna Freud (1930s)
Erikson (1950)
Jung (1964)
History
Late 19th century – Dr Joseph Breuer; Anna O
1895 – Studies on Hysteria (Breuer & Freud). Emotional distress is product of trauma which cannot be integrated into one’s understanding of the world
1896 – psychoanalysis and ‘free association’
1900 – Interpretation of Dreams. Within two years, founded Vienna Psychoanalytic Society
International Psychoanalytic Association was founded – Freud named Jung as successor
Jung collaborated with Freud re dementia praecox History
1913 – Jung and Freud broke collaboration regarding disagreement about focus on sexual definition of libido and incest
Jung developed own theories of Analytical Psychology. Concepts included collective unconscious and archetypes
1930s – Anna Freud (daughter) became significant influential figure in British psychology and application of psychoanalysis to children
1950 – Erikson, ran with concept of stages of (psychosexual-) development
Melanie Klein (1882-1960), Wilfrid Bion (1897-1979)
1995 – Malan, Triangles of Conflict and Person, contemporary impact on practice and formulation Freud
Active between 1890s and 1930s developed collection of theories which have formed basis of psychodynamic approach Theories are clinically derived – based on small number of case studies of therapy (primarily depression or anxiety disorders) Psychoanalysis is both a theory and therapy Affect-Trauma model: Childhood trauma leads to painful affect. This leads to a physiological reaction Topographical model: Unconscious, preconscious and conscious ‘layers’. Primary and secondary processes of mental functioning
Freud
Case studies
Anna O
Dora
Little Hans
Rat Man
Wolf Man Anna O
Bertha Pappenheim – 21yrs
Healthy and intelligent, no signs of neurosis but feelings always exaggerated, moody, daydreamed
Developed illness: - incubation. Had to nurse unwell father until she was too unwell - manifest illness: paralysis of right arm, leg, squint and disturbed vision, hallucinated, abusive (threw things), false accusations against others, exclusively spoke in English - After father’s death – sleepwalking, could not understand german, refused food Anna O
Symptoms result of events buried in unconscious looking for expression
Lasted approx. 12 months
‘talking cure’
Discussed each symptom to identify cause. Each disappeared after describing its first episode
Although still spent time in sanatorium, addicted to morphine and lost German, became social worker and feminist figure Dora
Ida Bauer - 1900 (18yrs)
Contact from work with father. Attached to father (rich and intelligent), despised mother
Hysteria – depressed, suicidal, frequently lost consciousness, bouts of amnesia and migraines
11 weeks analysis. Predominantly dream analysis
Attributed to sexual abuse perpetrated by family friend. Guilt about masturbation and subsequent abstinence
Symptoms reduced. Attributed to conscious awareness of problems Little Hans
1909 (5yrs)
Presentation relayed by father
Phobia of horses; refused to go into street. Fear horse would enter house and bite him in revenge for wishing them dead
Attributed to ego defence mechanism of displaced fear of father onto horses. Wished father dead as competitor for mother’s love
Oedipus Complex – “foreshadowing of budding sexual wishes”
Rat Man
Ernst Lanzer - 1907 (late 20s) Compulsive irrational behaviours (opening apartment door at midnight to allow father’s ghost to enter); stared at penis: feared something bad would happen to young woman he was attracted to; feared his father would die (already dead); preoccupied by story of people being tortured by rats boring into their anus Compulsions and urges to cut own throat with razor Freud attributed neurosis to subject’s engagement in sexual foreplay with governess and fear his father would discover this and punish him Associated sexual pleasure with fear of punishment; manifested as fear father would be harmed Significant reduction in symptoms after 11 months Wolf Man
Sergei Pankeieff – 1910 (23yrs)
Depression and inability to open bowels without an enema
Attributed to childhood dream about six wolves sitting in walnut tree which he had been terrified by
Symbolic of fear reaction to seeing parents engaged in ‘violent’ intercourse. Long tails represented fear of castration; wolf represented father; stillness represented violent motion Structural perspective
Psychodynamic theory focuses on different levels of mental organisation Conscious – verbal syntax, logic, abstract conceptualisation, delineation
Unconscious – no contradiction, no ordered sequences, no delineation (concepts can be displaced, condensed), similar to dreams Structural perspective
Internal world is dominant force in structuring our perception of the world
All experiences are made to conform with expectations of world
Unconscious model used to interpret hidden meanings which are repressed, transformed or disguised by repression in our conscious mind Tripartite structure
Id Impulsive unconscious, responds directly and immediately to instincts. Personality of newborn is all id Remains infantile throughout life. Does not change because it has no contact with external world comprised of two instinctive drives – eros (sex drive and life) and thanatos (aggressive drive and death). Character of drives change with age, Stages of Development Pleasure principle – to be satisfied immediately; tension when not satisfied Primary process thinking – primitive, illogical, irrational and fantasy orientated Tripartite structure
Super-ego
Incorporates values and morals of society learned from environment
Develops between 3-5yrs, during phallic stage of psychosexual development
Internalisation of societal rules. Determined by childhood environment. To control forbidden impulses including sex and aggression; aims to achieve perfection and moralistic goals, not just realistic ones
Includes two systems: conscience and ideal self
Punishes self for giving in to id and drives aspiration. Also rewards self for acting in accordance with internalised norms Tripartite structure
Ego
Develops to mediate unrealistic id and external world
Reality principle – to find ways to satisfy id’s demands, inc compromise, postponing satisfaction. Considers social realities and norms
Secondary process thinking – decision-making component of personality; uses reason
Horse-rider analogy
If ego fails to use reality principle, and anxiety is experiences, unconscious defence mechanisms are used to ward off unpleasant feelings Tripartite structure
Id (exclusively) and super-ego (predominantly) are unconscious. They are often in conflict
Experience of conflict creates anxiety which can enter consciousness (ego)
Defence mechanisms are used to manage anxiety of conflict
Defences operate on continuum of more-less healthy, levels of primitiveness and behavioural control strength
Dynamic perspective
Psychic determinism – all behaviour is meaningful, purposeful, motivated and of potential significance, even maladaptive actions
Dynamic process of psychic pain and wish to avoid it
Conflict between parts of self – what we want and what we fear about its consequences Triangle of Conflict (Ezriel, 1952)
Defence Anxiety (A) mechanism (D) about consequences of feelings
Hidden feelings (F) Wishes and impulses Triangle of Conflict
Defence Anxiety (A) mechanism (D) about consequences of feelings
Hidden feelings (F) Wishes and impulses Triangle of Conflict
Defence Anxiety (A) mechanism (D) about consequences of feelings
Hidden feelings (F) “I am angry at you” Triangle of Conflict
Defence Anxiety (A) mechanism (D) about consequences of feelings
Hidden feelings (F) “I am angry at you” Triangle of Conflict
Defence Anxiety (A) mechanism (D) “if I show my anger, I fear it will destroy our relationship”
Hidden feelings (F) “I am angry at you” McCullough et al (2003)
Activating emotion (F) Function Adaptive expression Maladaptive expression Inhibiting anxieties
Anger Assert needs, protect Assertion boundaries Sexual desire Mate, reproduce Mutual consenting sex
Attachment Nurture others Closeness, care and trust
Positive feelings to self Nurture self Self-regard
Joy Soothe self Self-soothe
Excitement & interest Explore Exploration
Grief Relieve pain, elicit Resolve loss attachment McCullough et al (2003)
Activating emotion (F) Function Adaptive expression Maladaptive expression Inhibiting anxieties
Anger Assert needs, protect Assertion Aggression boundaries Sexual desire Mate, reproduce Mutual consenting sex Predatory, promiscuous sex
Attachment Nurture others Closeness, care and trust Relationship addiction
Positive feelings to self Nurture self Self-regard Grandiosity
Joy Soothe self Self-soothe Self-indulgence
Excitement & interest Explore Exploration Reckless risk-taking
Grief Relieve pain, elicit Resolve loss Despair attachment McCullough et al (2003)
Activating emotion (F) Function Adaptive expression Maladaptive expression Inhibiting anxieties
Anger Assert needs, protect Assertion Aggression I will destroy relationships boundaries Sexual desire Mate, reproduce Mutual consenting sex Predatory, promiscuous sex I will become perverted and dirty Attachment Nurture others Closeness, care and trust Relationship addiction I will become engulfed
Positive feelings to self Nurture self Self-regard Grandiosity I will become selfish
Joy Soothe self Self-soothe Self-indulgence I will be punished for feeling good Excitement & interest Explore Exploration Reckless risk-taking I will die from risk-taking
Grief Relieve pain, elicit Resolve loss Despair I will never be happy again attachment McCullough et al (2003)
Inhibiting emotion (A) Function Adaptive expression Maladaptive expression
Anxiety Inhibit behaviour which Careful avoidance of could threaten safety or danger security Guilt Inhibit behaviour which is Remorse unacceptable in society Shame Inhibit behaviour which is Atonement unacceptable to self
Taken from Carr & McNulty (2006) McCullough et al (2003)
Inhibiting emotion (A) Function Adaptive expression Maladaptive expression
Anxiety Inhibit behaviour which Careful avoidance of Paralysis or extreme could threaten safety or danger avoidance security Guilt Inhibit behaviour which is Remorse Self-attack unacceptable in society Shame Inhibit behaviour which is Atonement Self-hate unacceptable to self
Taken from Carr & McNulty (2006) Triangle of Conflict
Anxiety (A) in relation to the actual and expected responses of others to…
…our true inner Feelings (F), wishes and impulses. Consequently, we unconsciously implement…
…Defences (D) to keep our conscious pain at a manageable level
Defence Mechanisms
The conflict between true feelings and anxiety about their consequences creates painful unconscious dissonance and risks the disintegration of personality
Defence mechanisms are functional, used to avoid conscious acknowledgement of the conflict
Aim is to keep thoughts and feelings from our conscious mind which are too painful to address
Construct different internal object relations
Defence Anxiety (A) mechanism (D) about consequences of feelings
Hidden feelings (F) Wishes and impulses Defence Mechanisms
Comprise thoughts, feelings and behaviours developed to avoid pain
Occur out of awareness. Internal world constituted differently from external reality. Unconscious influences over the way we live
Defences often fail but we repeat them because they are unconscious
When defences do not work adequately, both elements of the conflict are expressed (A’s and F’s) to alleviate unconscious pain
Return of the Repressed, pathological symptoms Defence Mechanisms
Failing defences form and maintain patterns of psychological disorder. Extent to which defences are employed are built into our character structure. The pervasiveness, rigidity and severity of distortions distinguish personality styles from PDs
Seriousness of dysfunction depends on how early the developmental disruption occurred and its severity
Therapy aims to more adaptively manage painful thoughts and feelings – help client reformulate experiences in a more inclusive way and tolerate discomfort. Ability to cope is enhanced Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
High Optimal balance of F’s and Consider consequences before the conflict occurs, adaptation D’s to permit consciousness explore pros and cons of various solutions of conflict and maximise Seek social support, share problems whilst maintaining gratification personal responsibility Receive gratification from dedicating self to others, without excessive self-sacrifice Reframe situation which caused conflict in amusing way Express conflicting thoughts and feelings in direct but non-coercive way Monitor where conflict came from and use the understanding to modify dysphoria Channel dysphoria into prosocial activities, e.g. sport or work Intentionally avoid thinking about conflict
Taken from Carr & McNulty (2006) Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
High Optimal balance of F’s and Anticipation Consider consequences before the conflict occurs, adaptation D’s to permit consciousness explore pros and cons of various solutions of conflict and maximise Affiliation Seek social support, share problems whilst maintaining gratification personal responsibility Altruism Receive gratification from dedicating self to others, without excessive self-sacrifice Humour Reframe situation which caused conflict in amusing way Self-assertion Express conflicting thoughts and feelings in direct but non-coercive way Self-observation Monitor where conflict came from and use the understanding to modify dysphoria Sublimation Channel dysphoria into prosocial activities, e.g. sport or work Suppression Intentionally avoid thinking about conflict
Taken from Carr & McNulty (2006) Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
Mental Keep F’s out of awareness Transfer negative feelings about one person to inhibitions another less threatening one Compromise Breakdown in integrated functions of memory, formation perception or motor behaviour Excessive abstract thinking or generalising to minimise dysphoria Lose touch with feelings associated with the conflict
Engage in prosocial thoughts, feelings or behaviours opposite to those of F arising from conflict Expel unwanted thoughts or emotions from awareness
Ritualistic or magical words or actions to symbolically make amends or negate F’s Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
Mental Keep F’s out of awareness Displacement Transfer negative feelings about one person to inhibitions another less threatening one Compromise Dissociation Breakdown in integrated functions of memory, formation perception or motor behaviour Intellectualisation Excessive abstract thinking or generalising to minimise dysphoria Isolation of affect Lose touch with feelings associated with the conflict
Reaction formation Engage in prosocial thoughts, feelings or behaviours opposite to those of F arising from conflict Repression Expel unwanted thoughts or emotions from awareness
Undoing Ritualistic or magical words or actions to symbolically make amends or negate F’s Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
Minor image Distort image of self and Exaggerate negative characteristics of self or others distortion others to regulate self- esteem Exaggerate positive characteristics to others
Elevate position of self in relation to others by exaggerating positive characteristics, special abilities or powers of self Disavowal Keep F’s out of Refuse to acknowledge painful aspects of experience consciousness with or which are apparent to others without misattribution to Attribute own F’s to others external cues Self-serving or self-justifying explanation to conceal F’s
Major image Gross distortion or Excessive daydreaming or wishful thinking as substitute distortion misattribution of aspects of for problem-solving or social support self or others Attributing own F’s to others, then causing others to feel them by reacting aggressively to them. Then use other person’s aggressive reactions for acting out own aggression Failing to integrate own positives and negatives of self and others as either al good or bad Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
Minor image Distort image of self and Devaluation Exaggerate negative characteristics of self or others distortion others to regulate self- esteem Idealisation Exaggerate positive characteristics to others
Omnipotence Elevate position of self in relation to others by exaggerating positive characteristics, special abilities or powers of self Disavowal Keep F’s out of Denial Refuse to acknowledge painful aspects of experience consciousness with or which are apparent to others without misattribution to Projection Attribute own F’s to others external cues Rationalisation Self-serving or self-justifying explanation to conceal F’s
Major image Gross distortion or Autistic fantasy Excessive daydreaming or wishful thinking as substitute distortion misattribution of aspects of for problem-solving or social support self or others Projective identification Attributing own F’s to others, then causing others to feel them by reacting aggressively to them. Then use other person’s aggressive reactions for acting out own aggression Splitting image of self or Failing to integrate own positives and negatives of self others and others as either al good or bad Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
Action Action or withdrawal from Acting unacceptably to give expression to the action experience of emotional distress associated with conflict or stress Not engaging with others
Make repeated requests for help and then reject help when it’s offered as a way of expressing aggressive F’s Unassertively expressing unacceptable aggression to others in authority by overtly complying with their wishes whilst covertly resisting these Defensive Defences fail to regulate Attributing to others own F’s to an extreme degree dysregulation internal conflict leading to a breakdown in reality- Refuse to acknowledge the pain of the situation or testing experiences which are apparent to others in an extreme degree Viewing reality in an extremely distorted way Core Conflictual Relationship Theme (CCRT)
Level Features of defence Defence Involves…
Action Action or withdrawal from Acting out Acting unacceptably to give expression to the action experience of emotional distress associated with conflict or stress Apathetic withdrawal Not engaging with others
Help-rejecting Make repeated requests for help and then reject help complaining when it’s offered as a way of expressing aggressive F’s
Passive aggression Unassertively expressing unacceptable aggression to others in authority by overtly complying with their wishes whilst covertly resisting these Defensive Defences fail to regulate Delusional projection Attributing to others own F’s to an extreme degree dysregulation internal conflict leading to a breakdown in reality- Psychotic denial Refuse to acknowledge the pain of the situation or testing experiences which are apparent to others in an extreme degree Psychotic distortion Viewing reality in an extremely distorted way Developmental perspective
The significance of considering developmental experiences and relationships upon current functioning originated in psychodynamic theory
Early experiences are fundamental in forming dynamic and structural aspects of our mental life
Sequences of developmental phases characterise particular modes of relationships with care-givers
Progressive separation and differentiation from an early unity to individuation and integration into a coherent sense of self
Object relations Developmental perspective
Object Relations Theory highlights the role of the parents, especially mother in shaping our perceptions of the world. The focus is on child’s perception of all experiences, including unconscious meanings and fantasy elaborations
Interaction of external events and internal reactions is building platform for personality
Strategies to manage deficits and traumas are foundations for later distortions
Dysfunction at a developmental stage characterises nature of problems in later life associated with that stage Freud’s Stages of Psychosexual Development Erikson’s Stages of Psychosocial development (1959)
Ego develops by resolving eight stages of conflict
Self vs society
Lifespan
Epigenic – predetermined
Failure to successfully complete a stage causes problems with progression through subsequent stages Erikson’s Stages of Psychosocial development (1959)
Triangle of Person (Menninger, 1958)
Therapist (T) Current persons (C) Partner, spouse, children, friends, colleagues, boss, authority figures
Past persons (P) Parents, carers, teachers, siblings, significant relatives, close childhood friends Triangle of Person
Past relationships are replayed in client’s current relationships and with the therapist in the therapy room
How the client relates towards the therapist is a clue to how they experienced other relationships
Transference: the clients emotional and behavioural repetition of patterns from early relationships to the therapist in the therapy room
Sadomasochism transference is common. This can lead to a breakdown in therapy
Managing and interpreting the transference is essential to progress is therapy Triangle of Person (Malan, 1995)
Therapist (T) D A D A Current persons (C) Partner, spouse, children, friends, colleagues, boss, authority figures
F F D A
F
Past persons (P) Parents, carers, teachers, siblings, significant relatives, close childhood friends Transference & Counter- transference
Counter-transference: the therapist’s emotional and behavioural response to the client. It is an “unconscious resonance to the unconscious dimensions of an interpersonal situation in each relationship context” (Johnstone & Dallos)
Sandler – role-responsiveness
The client imposes a role on the therapist
Therapist responds to the imposed role and reflects on this
Useful in understanding the client’s internal object relations
Transference
Counter-transference: Transference:
How the therapist feels The client repeats a (e.g. annoyed) is the pattern of relating natural reaction elicited which they have by the style of relating learned from early life, which the client has unconscious repetition learned to repeat Treatment
Aims (Gamble, 2011)
Alleviating symptoms – clients may be resistant to ‘relinquishing’ symptoms because they are functional
Likely to be resistance whilst underlying conflict which led to symptoms is unresolved
Insight – psychotherapy aims to increase understanding of patterns of relationships and behaviours
Although some may ‘fake change’
Improved functioning
Improved tolerance, reduction in destructive behaviour Brief Psychodynamic Therapy
Contract
Specified limited number of regular, frequent therapy sessions of fixed duration. Usually once or twice per week for approx. 50mins. Limited to 12-30 sessions (3-6 months)
Client agrees to not make major life changes during the course of therapy, e.g. commit suicide, get married
Client must agree to talk without censorship, e.g. impression management
Therapist must listen attentively, offer interpretations and other interventions treatment
Therapist interprets material and helps client understand its meaning
Client begins to recognise their transference of early relationships
Client recognises the parallel between their relationship with the therapist and their intrapersonal relationship with self (Gamble, 2011)
Projection
Integration – process in which client withdraws projections. Client learns to recognise that problem relationships are parallels of conflicted internal relationships, which they gain capacity to work through BPT
Three stages of therapy Restructure defences, affects and self-other representations Therapeutic relationship is used to study and experience triangle of person, i.e. patterns of relating to others Client must experience and think about their emotions Free association – free narrative Typical pattern of changing relationship with therapist: 1. Regression – infantile wishes emerge. Client becomes angry at therapist (F) 2. Client experiences guilt and anxiety about angry feelings; feels sad and remorse (A) Defence restructuring
Defence recognition Point out defences against forbidden feelings Validate defences Point out existing exceptions to using defences Repeat until defences are routinely recognised
Defence restructuring Identify costs and benefits/secondary gains of defences Tracing origins of defences and how they are maintained Grieve losses due to defences Repeat relinquishing of defences to increase motivation to give them up Affect restructuring
Affect experiencing Facilitate gradual exposure to the feared adaptive feelings and impulses Prevent use of old defences Repeat until fear of forbidden feelings is desensitised
Affect expression Explore new ways to express feared adaptive feelings Explore ways to tolerate interpersonal conflict Repeat affect expression until new ways of expressing feared affect flow naturally Self-Other restructuring
Self-restructuring Desensitise to positive feelings towards self Facilitate viewing self from others’ perspective Integrate positive and negative feelings to self Facilitate self-parenting Repeat until positive self-feelings are no longer avoided and self-esteem improves
Other-restructuring Desensitise to nurturing feelings from others Train empathy skills to facilitate accurate and compassionate perception of others Integrate positive and negative views of others Identify and restructure addictive attachments Repeat until adaptive feelings in relationships are no longer avoided treatment
Client gains greater sense of resilience and self-determination by accepting parts of projected self
Whole object relations become possible based on acceptance of reality and love of the other (rather than love of the projected part of the self)