Lesson 4: Psychoanalytic Therapy

Freud’s psychoanalytic system

is a model of personality development and an approach to psychotherapy.

He gave psychotherapy a new look and new horizons, calling attention to psychodynamic factors that motivate behavior, focusing on the role of the unconscious, and developing the first therapeutic procedures for understanding and modifying the structure of one ’s basic character.

Freud’s theory is a benchmark against which many other theories are measured.

Deterministic

The Freudian view of human nature is basically ____. According to Freud, our behavior is determined by irrational forces, unconscious motivations, and biological and instinctual drives as these evolve through key psychosexual stages in the first six years of life.

Life instincts.

Instincts are central to the Freudian approach. Although he originally used the term libido to refer to sexual energy, he later broadened it to include the energy of all the ___.

Psychosexual stages

Importance of Early Development

A significant contribution of the psychoanalytic model is delineation of the stages of psychosexual and psychosocial stages of development from birth through adulthood. The _____ refer to the Freudian chronological phases of development, beginning in infancy.

Erikson’s Psychosocial Perspective

The developmental stages postulated by Freud have been expanded by other theorists. Erik Erikson’s (1963) psychosocial perspective on personality development is especially significant.

Erikson built on Freud’s ideas and extended his theory by stressing the psychosocial aspects of development beyond early childhood.

Psychosocial stages

refer to Erikson’s basic psychological and social tasks, which individuals need to master at intervals from infancy through old age.

Counseling Implications

By taking a combined psychosexual and psychosocial perspective, counselors have a helpful conceptual framework for understanding developmental issues as they appear in therapy.

The key needs and developmental tasks, along with the challenges inherent at each stage of life, provide a model for understanding some of the core conflicts clients explore in their therapy sessions.

Make the unconscious conscious and to strengthen the ego

The ultimate goal of psychoanalytic treatment is to increase adaptive functioning, which involves the reduction of symptoms and the resolution of conflicts Wolitzky, 2011a).

Two goals of Freudian psychoanalytic therapy are ____ and ___ so that behavior is based more on reality and less on instinctual cravings or irrational guilt.

“Blank-screen” approach.

In classical psychoanalysis, analysts typically assume an anonymous nonjudgmental stance, which is sometimes called the ____.

Transference relationship

They avoid self-disclosure and maintain a sense of neutrality to foster a transference relationship, in which their clients will make projections onto them.

This ____ is a cornerstone of psychoanalysis and “refers to the transfer of feelings originally experienced in an early relationship to other important people in a person’s present environment” (Luborsky, O’Reilly-Landry, & Arlow, 2011, p. 18).

Classical psychoanalysis

Clients interested in ____ must be willing to commit themselves to an intensive, long-term therapy process. After some face-to-face sessions with the analyst, clients lie on a couch and engage in free association; that is, they try to say whatever comes to mind without self-censorship.

Free association

This process of ____ is known as the “fundamental rule.” Clients report their feelings, experiences, associations, memories, and fantasies to the analyst.

Psychodynamic therapy

emerged as a way of shortening and simplifying the lengthy process of classical psychoanalysis (Luborsky et al., 2011). Many psychoanalytically oriented practitioners, or psychodynamic therapists (as distinct from analysts), do not use all the techniques associated with classical analysis.

Relational psychoanalysis

Relationship Between Therapist and Client

There are some differences between how the therapeutic relationship is conceptualized by classical analysis and contemporary relational analysis.

The classical analyst stands outside the relationship, comments on it, and offers insight-producing interpretations.

In contemporary ______, the therapist does not strive for an objective stance. Contemporary psychodynamic therapists focus as much on here-and-now transference as on earlier reenactment.

Transference

is the client’s unconscious shifting to the analyst of feelings, attitudes, and fantasies (both positive and negative) that are reactions to significant others in the client’s past.

involves the unconscious repetition of the past in the present. “It reflects the deep patterning of old experiences in relationships as they emerge in current life” (Luborsky et al., 2011, p. 47).

Working-through process

consists of repetitive and elaborate explorations of unconscious material and defenses, most of which originated in early childhood. Clients learn to accept their defensive structures and recognize how they may have served a purpose in the past (Rutan, Stone, & Shay, 2014). This results in a resolution of old patterns and enables clients to make new choices

Countertransference

From a traditional psychoanalytic perspective, _____ is viewed as a phenomenon that occurs when there is inappropriate affect, when therapists respond in irrational ways, or when they lose their objectivity in a relationship because their own conflicts are triggered.

____ consists of a therapist’s unconscious emotional responses to a client based on the therapist’s own past, resulting in a distorted perception of the client’s behavior (Rutan et al., 2014).

Psychoanalytic or psychodynamic therapy

differs from traditional psychoanalysis in these ways:

• The therapy has more to limited objectives than restructuring one’s personality.

• The therapist is less likely to use the couch.

• There are fewer sessions each week.

• There is more frequent use of supportive interventions such as reassurance, expressions of empathy and support, and suggestions.

• There is more emphasis on the here-and-now relationship between therapist and client.

• There is more latitude for therapist self-disclosure without “polluting the transference.”

• Less emphasis is given to the therapist’s neutrality.

• There is a focus on mutual transference and countertransference enactments.

• The focus is more on pressing practical concerns than on working with fantasy material.

Analytic Framework

The psychoanalytic process stresses maintaining a particular framework aimed at accomplishing the goals of this type of therapy.

Maintaining the _____ refers to a whole range of procedural and stylistic factors, such as the analyst’s relative anonymity, maintaining neutrality and objectivity, the regularity and consistency of meetings, starting and ending the sessions on time, clarity on fees, and basic boundary issues such as the avoidance of advice giving or imposition of the therapist’s values (Curtis & Hirsch, 2011).

Free Association

is a central technique in psychoanalytic therapy, and it plays a key role in the process of maintaining the analytic framework.

In ____, clients are encouraged to say whatever comes to mind, regardless of how painful, silly, trivial, illogical, or irrelevant it may seem. In essence, clients try to flow with any feelings or thoughts by reporting them immediately without censorship.

As the analytic work progresses, most clients will occasionally depart from this basic rule, and these resistances will be interpreted by the therapist when it is timely to do so.

Interpretation

consists of the analyst’s pointing out, explaining, and even teaching the client the meanings of behavior that is manifested in dreams, free association, resistances, defenses, and the therapeutic relationship itself.

The functions of ____ are to enable the ego to assimilate new material and to speed up the process of uncovering further unconscious material.

is grounded in the therapist’s assessment of the client’s personality and of the factors in the client’s past that contributed to his or her difficulties.

Dream Analysis

is an important procedure for uncovering unconscious material and giving the client insight into some areas of unresolved problems.

During sleep, defenses are lowered and repressed feelings surface. Freud sees dreams as the “royal road to the unconscious,” for in them one’s unconscious wishes, needs, and fears are expressed. Some motivations are so unacceptable to the person that they are expressed in disguised or symbolic form rather than being revealed directly.

Latent content

consists of hidden, symbolic, and unconscious motives, wishes, and fears. Because they are so painful and threatening, the unconscious sexual and aggressive impulses that make up ____ are transformed into the more acceptable manifest content,

Manifest content

latent content are transformed into the more acceptable ____, which is the dream as it appears to the dreamer.

Dream work.

The process by which the latent content of a dream is transformed into the less threatening manifest content is called

Resistance

a concept fundamental to the practice of psychoanalysis, is anything that works against the progress of therapy and prevents the client from producing previously unconscious material.

The client’s reluctance to bring to the surface of awareness unconscious material that has been repressed.

refers to any idea, attitude, feeling, or action (conscious or unconscious) that fosters the status quo and gets in the way of change.

Transference

As was mentioned earlier, ____ manifests itself in the therapeutic process when earlier relationships contribute to clients distorting the present with the therapist.

The ____ situation is considered valuable because its manifestations provide clients with the opportunity to re-experience a variety of feelings that would otherwise be inaccessible. Through the relationship with the therapist, clients express feelings, beliefs, and desires that they have buried in their unconscious.

Application to Group Counseling

The psychodynamic model offers a conceptual framework for understanding the history of the members of a group and a way of thinking about how their past is affecting them now in the group and in their everyday lives.

Group leaders can think psychoanalytically, even if they do not use many psychoanalytic techniques. Regardless of their theoretical orientation, it is well for group therapists to understand such psychoanalytic phenomena as transference, countertransference, resistance, and the use of ego-defense mechanisms as reactions to anxiety.

Jung’s analytical psychology

At one time Freud referred to Carl Jung as his spiritual heir, but Jung eventually developed a theory of personality that was markedly different from Freudian psychoanalysis.

____ is an elaborate explanation of human nature that combines ideas from history, mythology, anthropology, and religion (Schultz & Schultz, 2013).

Jung made monumental contributions to our deep understanding of the human personality and personal development, particularly during middle age.

Individuation

—the harmonious integration of the conscious and unconscious aspects of personality—is an innate and primary goal. For Jung, we have both constructive and destructive forces, and to become integrated, it is essential to accept our dark side, or shadow, with its primitive impulses such as selfishness and greed.

Shadow

Acceptance of our ____ does not imply being dominated by this dimension of our being, but simply recognizing that this is a part of our nature.

Collective unconscious

Jung taught that many dreams contain messages from the deepest layer of the unconscious, which he described as the source of creativity.

Jung referred to the ____ as “the deepest and least accessible level of the psyche,” which contains the accumulation of inherited experiences of human and pre-human species (as cited in Schultz & Schultz, 2013, p. 95).

Jung saw a connection between each person’s personality and the past, not only childhood events but also the history of the species.

Archetypes

The images of universal experiences contained in the collective unconscious are called ____. Among the most important archetypes are the persona, the anima and animus, and the shadow.

Persona

is a mask, or public face, that we wear to protect ourselves.

Animus and the anima

represent both the biological and psychological aspects of masculinity and femininity, which are thought to coexist in both sexes.

Shadow

has the deepest roots and is the most dangerous and powerful of the archetypes. It represents our dark side, the thoughts, feelings, and actions that we tend to disown by projecting them outward.

Ego psychology

Writers in the neo-Freudian school moved away from this orthodox position and contributed to the growth and expansion of the psychoanalytic movement by incorporating the cultural and social influences on personality.

____ is part of classical psychoanalysis with the emphasis placed on the vocabulary of id, ego, and superego, and on Anna Freud’s identification of defense mechanisms. She spent most of her professional life adapting psychoanalysis to children and adolescents. Erikson expanded this perspective by emphasizing psychosocial development throughout the lifespan.

Anna Freud

She spent most of her professional life adapting psychoanalysis to children and adolescents. Erikson expanded this perspective by emphasizing psychosocial development throughout the lifespan.

Object-relations theory

encompasses the work of a number of rather different psychoanalytic theorists who are especially concerned with investigating attachment and separation. Their emphasize is how our relationships with other people are affected by the way we have internalized our experiences of others and set up representations of others within ourselves.

____ are interpersonal relationships as these are represented intrapsychically, and as they influence our interactions with the people around us.

Object

was used by Freud to refer to that which satisfies a need, or to the significant person or thing that is the object, or target, of one’s feelings or drives.

Other

It is used interchangeably with the term ___ to refer to an important person to whom the child, and later the adult, becomes attached.

Self psychology

which grew out of the work of Heinz Kohut (1971), emphasizes how we use interpersonal relationships (self objects) to develop our own sense of self.

Kohut emphasized nonjudgmental acceptance, empathy, and authenticity.

Kohut and other self psychologists put empathy in the forefront of psychoanalytic healing and choose interventions based on them being genuinely empathically attuned to clients (McWilliams, 2016).

Relational model

is based on the assumption that therapy is an interactive process between client and therapist.

Whether called intersubjective, interpersonal, or relational, a number of contemporary psychoanalytic approaches are based on the exploration of the complex conscious and unconscious dynamics at play with respect to both therapist and client.

The relational movement ushered in a new emphasis on a more egalitarian therapeutic style (McWilliams, 2016). Relational analysts put value on not knowing and approach clients with genuine curiosity.

Margaret Mahler

had a central influence on contemporary object relations theory. A pediatrician who emphasized the observation of children, she viewed the resolution of the Oedipus complex during Freud’s proposed phallic stage as less critical than the child’s progression from a symbiotic relationship with a maternal figure toward separation and individuation.

Normal infantile autism.

Mahler calls the first three or four weeks of life ____. Here the infant is presumed to be responding more to states of physiological tension than to psychological processes. Mahler believes the infant is unable to differentiate itself from its mother in many respects at this age.

Symbiosis

Mahler’s next phase, called ____, is recognizable by the 3rd month and extends roughly through the 8th month. At this age the infant has a pronounced dependency on the mother. She (or the primary caregiver) is clearly a partner and not just an interchangeable part. The infant seems to expect a very high degree of emotional attunement with its mother.

Separation–individuation

process begins in the 4th or 5th month. During this time the child moves away from symbiotic forms of relating. The child experiences separation from significant others yet still turns to them for a sense of confirmation and comfort.

Narcissistic personality

Children who do not experience the opportunity to differentiate, and those who lack the opportunity to idealize others while also taking pride in themselves, may later suffer from ___ character disorders and problems of self-esteem.

The ____ is characterized by a grandiose and exaggerated sense of self-importance and an exploitive attitude toward others, which serve the function of masking a frail self-concept.

Borderline personality disorder

_____. conditions are also rooted in the period of separation–individuation.

People with a ____ have moved into the separation process but have been thwarted by parental rejection of their individuation.

In other words, a crisis ensues when the child does develop beyond the stage of symbiosis, but the parents are unable to tolerate this beginning individuation and withdraw emotional support.

are characterized by instability, irritability, self-destructive acts, impulsive anger, and extreme mood shifts.

Treating Borderline and Narcissistic Disorders

Some of the most powerful tools for understanding borderline and narcissistic personality disorders have emerged from the psychoanalytic models. Among the most significant theorists in this area are Kernberg (1975, 1976, 1997; Kernberg, Yeomans, Clarkin, & Levy, 2008), Kohut (1971, 1977, 1984), and Masterson (1976).

A great deal of psychoanalytic writing deals with the nature and treatment of borderline and narcissistic personality disorders and sheds new light on the understanding of these disorders.

Strupp

Some of the directions in psychodynamic theory and practice that ___ identifies are summarized here:

● Increased attention is being given to disturbances during childhood and adolescence.

● The emphasis on treatment has shifted to dealing therapeutically with chronic personality disorders, borderline conditions, and narcissistic personality disorders. There is also a movement toward devising specific treatments for specific disorders.

● Increased attention is being paid to establishing a good therapeutic alliance early in therapy. A collaborative working relationship is now viewed as a key factor in a positive therapeutic outcome.

● There is a renewed interest in the development of briefer forms of psychodynamic therapy, largely due to societal pressures for accountability and cost-effectiveness.

The Trend Toward Brief, Time-Limited Psychodynamic Therapy

Many psychoanalytically oriented therapists are adapting their work to a time-limited framework while retaining their original focus on depth and the inner life. These therapists support the use of briefer therapy when this is indicated by the client’s needs rather than by arbitrary limits set by a managed care system.

Although there are different approaches to brief psychodynamic therapy, Prochaska and Norcross (2014) believe they all share these common characteristics:

• Work within the framework of time-limited therapy.

• Target a specific interpersonal problem and goals during the initial session.

• Assume a less neutral therapeutic stance than is true of traditional analytic approaches.

• Establish a strong working alliance early in the therapy.

• Use interpretation relatively early in the therapy relationship.

Brief Psychodynamic Therapy (BPT)

Messer and Warren (2001) describe ____ as a promising approach. This adaptation applies the principles of psychodynamic theory and therapy to treating selective disorders within a pre-established time limit of, generally, 10 to 25 sessions.

uses key psychodynamic concepts such as the enduring impact of psychosexual, psychosocial, and object-relational stages of development; the existence of unconscious processes and resistance; the usefulness of interpretation; the importance of the working alliance; and reenactment of the client’s past emotional issues in relation to the therapist.

Strengths From a Diversity Perspective

Psychoanalytically oriented therapy can be made appropriate for culturally diverse populations if techniques are modified to fit the settings in which a therapist practices. All of us have a background of childhood experiences and have addressed developmental crises throughout our lives. Erikson’s psychosocial approach, with its emphasis on critical issues in stages of development, has particular application to clients from diverse cultures. Erikson has made significant contributions to how social and cultural factors affect people in many cultures over the lifespan (Sharf, 2016).

Shortcomings From a Diversity Perspective

Traditional psychoanalytic approaches are costly, and psychoanalytic therapy is generally perceived as being based on upper- and middle-class values. All clients do not share these values, and for many the cost of treatment is prohibitive.

Another shortcoming pertains to the ambiguity inherent in most psychoanalytic approaches. This can be problematic for clients from cultures who expect direction from a professional.

For example, many Asian American clients may prefer a more structured, directive, problem-oriented approach to counseling and may not continue therapy if a nondirective or unstructured approach is employed.

Contributions of Contemporary Psychoanalytic Approaches

If the psychoanalytic (or psychodynamic) approach is considered in a broader context than is true of classical psychoanalysis, it becomes a more powerful and useful model for understanding human behavior.

Although I find Freud’s psychosexual concepts of value, adding Erikson’s emphasis on psychosocial factors gives a more complete picture of the critical turning points at each stage of development.

Integrating these two perspectives is, in my view, most useful for understanding key themes in the development of personality. Erikson’s developmental schema does not avoid the psychosexual issues and stages postulated by Freud; rather, Erikson extends the stages of psychosexual development throughout life. His perspective integrates psychosexualand psychosocial concepts without diminishing the importance of either.

Limitations and Criticisms of Psychoanalytic Approaches

A major limitation of traditional psychoanalytic therapy is the relatively long time commitment required to accomplish analytic goals. Contemporary psychoanalytically oriented therapists are interested in their clients’ past, but they intertwine that understanding with the present and with future goals.

The emergence of brief, time-limited psychodynamic therapy is a partial response to the criticism of lengthy therapy. Psychodynamic psychotherapy evolved from traditional analysis to address the need for treatment that was not so lengthy and involved (Luborsky et al., 2011).