Introduction to the Psychotherapy Module Dr Lucy Buckley Aims • Know what to expect from the psychotherapy module • Know about the beginnings of psychotherapy • Have an understanding of some of Freud’s key theories • Know about Klein’s theories of the paranoid- schizoid and depressive positions • Be aware of Winnicott’s theories of early development Content • Introduction to the module • Freud and his theories ⚫ Topographical model ⚫ Structural model ⚫ Dreams and neurotic symptoms ⚫ Sexual development ⚫ Klein’s theory of the paranoid-schizoid and depressive positions ⚫ Winnicott’s concepts of primary maternal preoccupation and the ‘good enough’ mother Overview of module • Outline of different therapeutic models • Assessment • Psychotherapy evidence base • Formulation – applying psychodynamic principles in psychiatric practice Sigmund Freud, 1856-1939 ⚫ Born in Freiberg, Moravia ⚫ Moved to Vienna, studied Medicine ⚫ Studied under Charcot in Paris – use of hypnosis, interest in hysteria ⚫ Worked as neurologist, then saw more cases of psychiatric illness ⚫ Development of psychoanalysis ⚫ 1939, fled Nazi occupation of Austria, settling in London ⚫ Died soon after outbreak of Second World War Freudian theory is based on several assumptions 1) Mental life can be explained 2) The mind has a specific structure and follows intrinsic laws 3) Mental life is evolutionary and developmental 4) The mind holds unconscious forces of tremendous intensity, which, though they might not be experienced directly, hold great influence over us 5) The mind is an aspect of the body Topographical model, 1900 Freud divides the mind horizontally into 3 sections: Conscious Psychoanalysis Conscious – aware of Preconscious – can become aware of Preconscious Unconscious – no awareness Unconscious Topographical model Unconscious proper - never been conscious Repressed unconscious - once been conscious, but now pushed into unconsciousness - disowned impulses - accessible through dreams, free association, neurotic symptoms - active process of repression Topographical model Unconscious -primary process - no constraints of external reality, no logic, no sense of time -pleasure principle -immediate gratification Preconscious/conscious - secondary process - reality principle - awareness of external reality and its constraints - ego develops capacity for thought and delayed gratification - survival takes precedence over instant gratification Structural model, 1923 The id - reservoir of primitive impulses - unconscious - aim is gratification without compromise The ego - organised part of the mind that makes decisions - both conscious and unconscious - mediates between id and superego. Reconciles demands coming up from the id, down from superego, and from external reality Structural model The superego - last to develop - largely unconscious - internalisation of forbidding parental voice Aim of psychoanalysis - strengthen the ego - modify superego if too harsh or too weak - id is unchangeable, external reality is minimally changeable - help the ego to bear conflict, contain anxiety and think before acting - 'Where id was, ego shall be.' Dreams and neurotic symptoms • Evidence of the unconscious and primary process is seen in dreams and neurotic symptoms • Expression of repressed impulses • Dreams and neurotic symptoms can express a wish that is in conflict with the superego – an unconscious conflict - Unacceptable impulses are pushed down into the unconscious, but they press back up towards consciousness - Ego mediates between upwards pressure from the id, and downwards pressure from superego, causing anxiety - Ego distorts the impulse into something more acceptable to the superego, reducing anxiety Dreams and neurotic symptoms Dreams Neurotic symptoms • Manifest content • Symptom contains the - dream's story repressed wish trying to • Latent content emerge and the ego's - its underlying distortion of that wish meaning • Latent content is transformed to manifest content through dreamwork - symbolisation - condensation - displacement Psychosexual development Infantile sexuality • Important differences from adult sexuality • Bodily pleasure which precedes and leads towards adult sexuality • The importance of bodily experience in the development of the personality Psychosexual development Oral (Until 18 months) - Excitement around mouth and feeding Anal (18 months to 3 years) - Process and control of defecation Phallic (3 to 6 years) - Focus is genitals - Oedipus complex, formation of superego Latency (6 to 13 years) Psychosexual development Oedipus complex (classic male version) Mother is little boy's first love object Father seen as a rival, boy wants to get rid of him Through projection he fears father wants rid of him Threat is focussed on penis (castration anxiety) Resolved by identification with father – 'if you can't beat them, join them!' Introjection of paternal prohibition, forming basis of superego Desire, exclusion, ambivalence Melanie Klein, 1882-1960 • Focus on early pre-oedipal experiences • Proposed that the infant is born with innate destructive impulses • Two stages or positions in mental development – the paranoid schizoid position and the depressive position The paranoid schizoid position • Splitting of experience in very young infants into good and bad • The split off part can be unconsciously projected into the external world • Perceptions are coloured by whatever feeling has been projected • There may be an unwitting recipient of the projected feelings – the relationship with this person will be affected The depressive position • Gradual acceptance over first year of life that one can have good and bad feelings about the same person • Brings a feeling of sadness • Ambivalence can be tolerated.