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PSYC3082 Psychotherapies & Counselling Psychoanalysis and Psychodynamic Therapies

Dr Shelley Viskovich (She/Her) PhD, Psychotherapist & Provisional Psychologist (Clinical Stream) School of Psychology University of Queensland

Acknowledgement of Country The University of Queensland (UQ) acknowledges the Traditional Owners and their custodianship of the lands on which we meet. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society.

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Freud and the context §Sigmund Freud was a Jew living in Austria (b. 1856). §Trained in medicine & experimental science. §Franz Mesmer identified hysterical disorders and treated them with hypnosis late 18th Century. §Freud visited Charcot in Paris (1886) influenced by his work on hysteria and the use of hypnosis. §Freud diverged from Charcot when he concluded that patients lost their hysteria symptoms during hypnosis because of psychological factors not bodily disease.

Freud and the context §Later Freud worked with Joseph Breuer who was treating patients with hypnosis. § Breuer discovered ‘hysterical’ patients recovered after talking about their problems under hypnosis. § called the cathartic method § Freud abandoned hypnosis, encouraging patients to talk freely. § Emotional conflicts at the root of patient's problems were revealed through free association. § "Studies in Hysteria" (1895) by Freud & Breuer initiated the psychoanalytic revolution.

“Anna O” Bertha Pappenheim •

Treated by Breuer for severe cough, paralysis of the extremities on the right side of her body, disturbances of vision, hearing and speech, hallucinations and loss of consciousness.

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Diagnosed with hysteria.

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Freud implied that her symptoms resulted from unconscious resentment over her father’s illness and death.

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She later decided to end her hypnosis sessions and just talk to Breuer about whatever came into her mind > free association.

Freud’s View of Human Nature In the early 1900s against the backdrop of two World Wars, psychiatry attempted to understand human nature at its worst.... •

Pessimistic

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Deterministic

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Humans have instinctual urges that are innate; resulting from our evolutionary heritage

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Unconscious motivations

Key Concepts 1.

Instinct theory

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Structural model of personality

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Topographic model: the iceberg

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Defense mechanisms

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Theory of psychosexual development

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Therapy process and techniques

Instinct Theory •

All instincts are innate and biological.

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“Libido” = sexual energy – later broadened to include the energy of all life instincts.

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Serves survival of the individual and human race.

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Growth, development and creativity.

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Death instincts = aggressive drive.

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Behaviour is largely determined by these drives.

Structure of Personality •

Personality consists of three systems: -

Id = “the demanding child”; biological component.

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Ego = “the traffic cop”; psychological component.

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Superego = “the judge”; social component.

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The Id • • • • • • •

At birth, we are all id. Driven by the pleasure principle. Id denotes the instinctual needs, drives and impulses. Gratification of id instincts is called wish fulfilment. People are primarily motivated by the id. Inability to tolerate tension or frustration. Out of awareness (unconscious).

The Ego • • • •

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The ego has contact with the external world of reality. Expresses and gratifies the desires of the id in accordance with the requirements of reality. Utilises the reality principle: realistic thinking and planning. Executive of the personality carrying out the demands of the id to minimise negative consequences. Develops basic strategies called ego defence mechanisms to control unacceptable id impulses and avoid or reduce the anxiety they arouse.

The Superego • • • • •

Ruled by the moral principle. Moral or judicial branch of personality. Idealistic and moralistic. Internalises societal standards. Has 2 components: • Conscience = behaviours, feelings or thoughts are good or bad. •

Ego ideal = the kind of person we believe we should strive to become.

Inner Conflict These three parts of the personality are often in conflict often seem impelled to act, think and feel in contradictory ways. A healthy personality is one in which an effective working relationship and acceptable compromise have been established among the three forces. ANXIETY develops out of conflict between the id, ego and superego: • Expression = Symptoms (vomiting, phobias, hysteria, mourning and melancholia). • Freud identified 3 kinds of anxiety: § Realistic anxiety - fear of things that could really harm the organism, e.g., falling from a height; snakes and spiders etc. § Neurotic anxiety - fear of libido; if the libidinal drives are expressed (e.g., seduce your married colleague and punch your boss) could result in harm. § Moral anxiety - fear of the punitive superego. § Anxiety is a motivating state of tension

Topographic Model of the Mind • • •

Only aware of conscious material. Preconscious material can be accessed e.g., through questioning. Unconscious material is outside of awareness & can be inferred from behaviour, including content of: •

Dreams

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Slips of the tongue & forgetting the familiar.

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Post-hypnotic suggestion.

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Free-association techniques.

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Material derived from projective techniques.

Defence Mechanisms •

Unacceptable wishes are prevented from entering conscious awareness by the Defense Mechanisms.

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Automatic forms of response.

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Help cope with anxiety.

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Prevent feelings from becoming overwhelming.

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Some of the more primitive Defense Mechanisms distort reality so that the actual wish does not enter consciousness.

Ego Defence Mechanisms Primitive: • Regression: revert to earlier form of behaviour. •

Denial: distortion of reality.

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Reaction formation: express opposite impulse.

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Projection: attribute unacceptable desires/impulses outside self.

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Dissociation: breaking off part of memory, consciousness or perception of self or the environment to avoid a problem situation and inner discomfort.

Ego Defence Mechanisms Less Primitive • Displacement: discharge impulse by shift to safer target. •

Repression: exclusion from awareness.

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Intellectualisation: justification.

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Rationalisation: assigning socially desirable motives to behaviour.

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Ego Defence Mechanisms Mature: • Sublimation: diverting impulses. •

Identification: become like the other.

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Affiliation: turning to others for help and support.

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Self-assertion: expressing one’s needs and opinion in a respectful and firm way.

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Altruism: dealing with stressors by dedicating oneself to meeting the needs of others.

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Self observation: dealing with stress by reflecting on one’s own thoughts, feelings, and motivations and then responding appropriately.

Theory of Psychosexual Development Personality forms in the first few years of life, rooted in unresolved conflicts of early childhood. Five overlapping stages of psychosexual development: • Oral (0 – 18 months) • Anal (18 – 36 months) • Phallic (3 – 6 years) • Latency (6 – puberty) • Genital (puberty on) The use of psychic energy changes over the five stages. Sexual energy is one important form of pleasurable psychic energy. Strong conflict can fixate an individual at Stages 1, 2 or 3.

Theory of Psychosexual Development Oral Stage • Birth to 18 months. • Sensual pleasure is located around the mouth. • Mouth and tongue are early pleasure centres - erogenous zones. • Gratification through swallowing and sucking. • Main threat = mother will disappear i.e. the risk of object loss. Oral fixation has 2 possible outcomes: • Oral receptive personality: - Preoccupied with eating/drinking - Reduce tension through oral activity " Eating, drinking, smoking, biting nails " Passive and needy; sensitive to rejection § Oral aggressive personality: - Hostile and verbally abusive to others.

Theory of Psychosexual Development Anal Stage •

18 months to 3 years.

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Erogenous zone is the anus.

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Anal fixation may result if parental toilet training techniques are too severe or is excessively rewarded.

Anal fixation has 2 possible outcomes: • Anal retentive personality. - Stubbornness, stingy, perfectionistic, compulsive orderliness, over-controlling. • Anal expulsive personality. - Lack of self control, messy, careless.

Theory of Psychosexual Development Phallic Stage •

3 - 6 yrs

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Erogenous zone is the genitals.

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At age 5 or 6 children experience the Oedipal complex (boys) or Electra complex (girls).

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A process through which they learn to identify with the same gender parent by acting as much like that parent as possible.

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For neo-Fruedians the term Oedipus complex refers to both male and female conflict re sexual attraction with parents.

Theory of Psychosexual Development Latency Stage •

6 - 12 yrs

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Sexual interest declines

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Sexuality is repressed

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Attention is directed towards mastering social and cognitive skills.

Theory of Psychosexual Development Genital Stage •

12-18 yrs

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During puberty sexual impulse reawakens in a more mature and socialised form.

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Sexual energy is channelled into work - sublimation.

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Adolescents begin searching for a mate to share intimacy.

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Adolescents learn the pleasures and perils of adult sexuality.

Erikson’s 8 stages of development Psychosocial stages: Erikson’s basic psychological and social tasks to be mastered from infancy through old age. Erikson’s theory of development holds that psychosexual and psychosocial growth take place together.

Trust vs mistrust (oral) Autonomy vs shame (anal) Initiative vs guilt (phallic) Industry vs inferiority (latency) Identity vs role confusion (adolescence)

During each psychosocial stage, we face a specific crisis that must be resolved in order to move forward.

Intimacy vs isolation (young adulthood) Generativity vs stagnation (adulthood) Ego integrity vs despair (older adulthood)

Therapy Processes & Techniques Symptom formation Traumatic childhood experiences

Defence mechanisms & forgetting

Symptoms

Symptom removal Free association & dreams

Recovery of forgotten material

https://youtu.be/i4tB8ziP5_M

Awareness & interpretation of forgotten material

Symptom removal

The Therapeutic Process Therapeutic goals: • Insight into behaviour and symptoms. • Strengthen ego. Therapist’s function and role: • Neutrality. • Listening and interpretation. Client’s experience: • Intensive, long-term commitment. • Verbalising. Relationship between therapist and client: • Working-through transference.

Techniques: Free Association “Fundamental rule” of psychoanalysis is for the client to reveal everything that comes into his head, even if it seems unimportant or nonsensical. Free association aims to uncover unconscious material that is typically blocked. Exercise: 1.

You have 30 seconds to write the first 3 words that come into your head.

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Don’t think about it, just write.

Techniques: Interpretation • • • • •

Pointing out, explaining, teaching meanings of behaviour. Sharing understanding of central themes. Allow ego to assimilate new material. Accelerate process of uncovering unconscious material. Timing is important

Techniques: Analysis & Interpretation of Resistance Resistance = anything that works against progress in therapy. Unconscious dynamic protecting against anxiety: • Missing sessions • Lateness • Not paying • Anger or withdrawal on counsellor’s absence

Techniques: Dream Analysis • • • •

Uncover unconscious material. Insight into areas of unresolved conflict. Manifest content: the dream as it appears to the dreamer. Latent content: hidden, symbolic, and unconscious motives, wishes & fears.

Techniques: Analysis of Transference The core of the psychoanalytic process. The client will unconsciously transfer onto the therapist qualities of significant other relationships, particularly with parental figures. Cautiously the analyst interprets the client’s behaviour and feelings to increase insight into the influence of past on present functioning. Repeated interpretation of transference is called “working through”.

Techniques: Countertransference Therapist’s reactions to client. E.g. therapist’s feelings of dislike toward a controlling obsessive client; reminds him of his own mother. Interfere with therapist objectivity. Therapist may be meeting own needs through the therapy relationship e.g. fostering dependency. Very important that the psychoanalytic therapist pays close attention to own process.

Projective Tests

Projective Tests

Major Theoretical Developments Ego Psychology • Anna Freud • Most closely associated with classical psychoanalysis. • More emphasis on adaptive functions of the ego. • i.e. ego function more central and less dependent on id/superego.

Major Theoretical Developments Jungian psychology • Differed from Freud re: - Function of dreams help to prepare a person for the future & reconcile opposites within a person. - Less emphasis on sexual drive. - Emphasis on spirituality and religion. Collective unconscious - accumulation of inherited experiences of human & prehuman species. Contain universal experiences called archetypes. • Persona – mask or public face we wear to protect ourselves. • Animus & anima – masculinity and femininity coexist in both sexes. • Shadow – represents our dark side – the parts of us we disown • To become integrated, it is essential to accept our dark side, or shadow. •Some similarities to person centred approaches (e.g. concepts around self-actualisation, unconditional positive regard).

Major Theoretical Developments Object relations (e.g., Melanie Klein, Otto Kernberg) •

Object relations = interpersonal relationships as they are represented intrapsychically.

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Object refers to an important other.

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Rejection of drive theory.

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Emphasizes attachment and separation.

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How we internalise our experiences of others.

Self-psychology (e.g., Heinz Kohut) •

Emphasizes how interpersonal relationships (self objects) develop our sense of self.

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Emphasised non-judgemental acceptance, empathy, and authenticity.

Major Theoretical Developments Relational psychology (Sandor Franzecki, Harry Stack Sullivan) •

Emphasizes the interactive process between client and therapist.

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Rejection of drive theory.

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Problems arise from lack of consistent experience of self and others.

Group Photo circa 1909

Common Themes in Psychodynamic Counselling •

Unconscious processes affect thinking & behaviour.

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Past experience can shed light on understanding current problems.

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Themes and patterns in life.

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Life as a series of stages.

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Relationships with significant others may be recreated with therapist.

Short Term Psychoanalytic Psychotherapy •

Applies the principles of psychodynamic theory and therapy to treating selective disorders within 10 to 25 sessions.

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Therapist is active: foster development of therapeutic alliance and positive transference.

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Focus on specific conflicts or themes.

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Recognition of patterns of interactions with others.

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Adherence to focus, achievable goals, termination issues.

Termination •

The way client deals with ending is reflection of previous separations à therapy needs to be sensitive to these issues: - Abandonment/rejection issues

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Ending is anticipated from the beginning of therapy.

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May form core focus.

Long Term vs Short Term Therapy

Long-term therapy Change in basic character

Short-term therapy Symptom relief

Presenting problems reflect Presenting problems are more basic pathology focus of treatment Therapy has timeless quality Therapy is finite; therapist is active Therapy is most important Being in world more important than being in part of client’s life therapy

Psychodynamic Therapy vs CBT Compared to CBT features more frequently observed in Psychodynamic Therapy are (Blagys & Hilsenroth, 2000): • Affect •

Resistance

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Identification of consistent patterns (relationships, feelings, behaviour)

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Past experiences

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Interpersonal experiences

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Therapeutic relationship

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Wishes, dreams, fantasies

Evidence Base • • • •

Limited evidence for efficacy for long term psychodynamic therapy. Uncontrolled case studies. Absence of manualised treatments (operationalistion of constructs). Personality disorders.

Previous meta-analyses have shown mixed results: • Leichsenring, Rabung & Leibing (2004) • 17 studies of STPP. • Mean number of sessions of STPP was 20.97. • STPP better than WL and TAU and comparable to other psychotherapies.

Evidence Base (Gibbons et al., 2008)

Contributions •

Importance of person’s past experience to understanding current symptoms.

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Understanding of resistance.

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Understanding transference & countertransference in therapeutic relationship.

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The impact of the unconscious on human behaviour.

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Defence mechanisms.

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Erikson made significant contributions to how social and cultural factors affect people in many cultures over the life span.

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This approach promotes intensive psychotherapy for therapists, which gives them insight into their countertransference, including biases and prejudices.

Limitations •

Limited practical application.

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Time commitment...