Test 2 Clinical & Counseling

Id

• Most basic, primitive component

• operates on an unconscious level

• guided by immediate gratification (Pleasure Principle)

• “I want to do that now!”

Ego

• The ‘reality principle’/ ‘mediator’

• balances pleasure-seeking drives

• “Maybe we can compromise”

Superego

• comprised of internalized values, beliefs, & morals

• acts as our conscience

• the ‘moral compass’

• “Its not right to do that”

DSM

The index of mental disorders & criteria for their diagnosis

• published by the APA

• currently on 5th edition

PDM

the psychodynamic diagnostic manual

• first published in 2006

• developed by the American Psychological Association

Unconscious

Level of consciousness that is completely submerged

Free Association

saying whatever thoughts come to mind without censoring to help the client uncover unconscious mental activity

Transference

projecting onto the THERAPIST characteristics that belong to other people

Countertransference

projecting onto the CLIENT characteristics that belong to other people

Psychodynamic Goals

• Fostering self-awareness

• Understanding thoughts, feelings, & beliefs in relation to ast (especially in childhood!)

• Make the unconscious, conscious

• Personality change

How do the conscious & unconscious relate to the Id, Ego & Superego

• The Id is fully unconscious, Ego & Superego are both unconscious & conscious

• think ‘ICEBERG’

Psychoanalysis

• Invented by Freud

• centered around free association, dream analysis, and transference to uncover repressed feelings

Psychodynamic Theory

a psychological framework that explores the interplay between the conscious and unconscious aspects of the mind, particularly in relation to personality development

Psychodynamic treatment techniques

• Probe the past

• interpret transference & countertransference

• interpret EVERYTHING

• Some statements to utilize:

  • “How old were you when you first noticed _____?”

  • “How far back does this go?”

  • DONT say: “How was the week?”

    • instead ask: “What do you want to talk about?” or say nothing

• intense, open-ended sessions (no specific agenda to follow!!)

How do we find out what is unconscious?

Helpful things:

• free association

• dream analysis

• freudian slips

• projective tests

  • Ex: TAT (Thematic Apperception Test) or Rorschach test

• MRI!!

Theoretical basis of the DSM

DSM 1&2 are heavily influenced by theories, DSM 3,4, & 5 are ATHEORETICAL

• only OBSERVABLE symptoms & categorization in newer DSM editions

Psychosexual Stages

1. Oral (from birth to age 1)

2. Anal (1-3)

3. Phallic (3-6)

   • Categorized by Oedipal complex (in boys) & Electra complex (in girls)

4. Latency ( age 6-puberty)

5. Genital (Puberty-?)

theory suggests that personality develops through a series of stages centered around different erogenous zones. These stages each represent a key period in a child's development!!

Any unsolved issues in these stages, according to Freud, could cause personality issues in later life stages.

Defense Mechanisms

unconscious protective behaviors designed to reduce ego anxiety

• Approximately 11 of these (Freudian)

Denial

Actively rejecting painful affect, refusing to accept something

• defense mechanism

Displacement

Shifting uncomfortable feelings toward someone who is less powerful & less threatening than the individual from whom the feelings originated

• defense mechanism

Identification

Emulating characteristics in others

• defense mechanism

Intellectualization

Avoiding painful feelings by focusing on ideas

• defense mechanism

Projection

Perceiving that others have characteristics that are unconsciously disliked in oneself

• defense mechanism

Rationalization

Making excuses for an anxiety-producing thought or behavior

• defense mechanism

Reaction Formation

Acting in a manner that is opposite to what one is feeling

• defense mechanism

Regression

Engaging in behaviors from an earlier stage of development at times when one is anxious

• defense mechanism

Repression

Not allowing painful material into one’s conscious thought

• defense mechanism

Sublimation

Changing unacceptable impulses into socially appropriate actions

• defense mechanism

Undoing

Behaving in a ritualistic manner to take away or make amends for unacceptable behavior

• defense mechanism

Hill Criticisms on Freud

• Too much emphasis on childhood

• Often forget about the action stage

Scientific criticisms on Freud

• unfalsifiable

• Based on case studies- not experiments

• Freud himself was the only researcher

• culturally bound- late 1800s Vienna

Positives of Psychodynamic

• rich

• interesting

• can be useful & can work

Types of Insight

• Intellectual

  • Centered around the objective explanation of a problem

• Emotional

  • Involves affect

• Integrative

  • involves both intellectual & emotional insight

Relational & Attachment Theories

Helped shift focus from humans as drive or pleasure seeking to relationship seeking

• Some theorists include:

  • Melanie Klein, W.R.D Fairbairn, Sandor Ferenczi, Harry Stack Sullivan, Karen Horney

    • The above aforementioned were heavily influenced by John Bowlby’ ATTACHMENT THEORY

Bowlby’s Attachment Theory

Theory claiming that humans are born with an instinctual behavioral system that drives them to regulate proximity to their primary caregiver(s) for the evolutionary purpose of survival.

• 3 types:

  • Secure

  • Insecure/Ambivalent

  • Insecure/Avoidant

Secure attachment

characterized by the child using the parent as a secure base from which to explore

Insecure/ Ambivalent Attachment

characterized by child showing distress when their caregiver leaves them but are then inconsolable on their return. These children fear abandonment but cannot trust their caregiver to be consistent

Insecure/ Avoidant Attachment

characterized by child’s unresponsiveness to parent, does not use the parent as a secure base, and does not care if parent leaves

Psychosocial Stages

1. Trust vs. mistrust (Birth-18 mos). Virtue - Hope

2. Autonomy vs. shame and doubt (18 mos-3 yrs). Virtue – Will

3. Initiative vs. guilt (3-5). Virtue – Purpose

4. Industry vs Inferiority (6-11). Virtue – Competence

5. Identity vs. role confusion (12-18). Virtue – Fidelity

6. Intimacy vs. isolation (19-40). Virtue – Love

7. Generativity vs. stagnation (40-65). Virtue – Care

8. Integrity vs. despair (65+). Virtue - Wisdom

Developed by Erik Erikson

Hans Kohut

• Started the self-psychology movement after noticing a fundamental problem in his patient’s self-regard and self-organization during his clinical work

• Developed concept of HEALTHY & PATHOLOGICAL (UNHEALTHY) NARCISSISM

  • meant to help clients work through feelings of emptiness, meaninglessness, lack of cohesion, and self-blame

Existential Psychotherapy

This form of therapy focuses on existential concerns rather than early experiences

• also believes in the principle that people are governed by conflicting forces and have varying levels of awareness

Four Major existential concerns

1. Death Anxiety

2. Freedom

3. Isolation

4. Meaning in life

• Developed by IRWIN YALOM

• Culture plays a BIG role in existential concerns, particularly in terms of religious/spiritual beliefs!!

Death Anxiety

anxiety that rises because we all die and thus have to come to terms with our mortality

• one of the major existential concerns, according to Yalom

Freedom

refers to the lack of external structure and the need to take responsibility for oneʼs destiny

• one of the major existential concerns, according to Yalom

Isolation

being apart from others & the world arises because each of us enters and exits the world alone and thus must come to terms with our separateness in tandem with our wish to be part of a larger whole, to be taken care of, and to be protected

• one of the major existential concerns, according to Yalom

Meaning in Life

We have to figure out what gives us a sense of purpose, why we want to wake up in the morning, what we want to do with our lives, and what legacy we want to leave.

• one of the major existential concerns, according to Yalom

Interpretation

assigning meaning or significance to a particular event, behavior, or experience

Open Questions for Insight

Examples:

• “What do you make of your feelings about the ending of the relationship?”

• “What connection do you make between your feelings and the event?”

• “What do you feel is getting in the way of you being able to . . .?”

• “How do you understand this?”

• “Where do you think your reactions come from?”

• “How might your current feelings about your friendʼs withdrawal be related to past experiences with close friends?”

It is best to ask one question at a time, give the client time to respond, focus on the client rather than others, & vary questions with other skills so that they do not sound repetitive

Insight

The ability to see things from a new perspective, make connections between things, or understand why things happen as they do

• Sort of an '“aha!” moment for clients

Accuracy Issues in Insight

• Accuracy can never be determined

• false memories

• whether clients agree or disagree with an interpretation is not a good indication of accuracy

• the client is the ultimate judge of the truth of the interpretation

• helpers can never really determine the accuracy of interpretations. The perceived helpfulness to clients, however, is probably a more important criterion for evaluating interpretations

What does it mean that insight is a ‘one way street’?

Once you learn something, you cannot unlearn it.

Freud’s Developmental Theory

that personality is shaped by psychosexual stages, each focused on a different erogenous zone, driven by libidinal energy

• Known as Psychosexual Stages

Differences between psychodynamic therapy & CBT

• CBT: focuses on solving present-day problems by identifying and changing negative thoughts and behaviors

  • Techniques: Cognitive restructuring, Exposure therapy, Behavioral Activation & even ‘homework’ asisgnments!!

  • Goal-oriented & typically SHORT-TERM

• Psychodynamic Therapy: insight-oriented- this approach focuses on helping you gain insight into how your early life experiences affect your present day

  • Techniques: Free Association, Dream Analysis, Transference & exploration of interpersonal relationships

  • LONG-TERM

Goals of Insight Stage

Overall goal: MOVE TO NEW DEPTHS OF SELF UNDERSTANDING

This is done by…

1. Fostering Awareness

   • Challenge Client

   • Confrontation!!

2. Facilitating Insight

   • Interpret & explain

3. Working on relationship

   • Be IMMEDIATE = here & now

   • Sharing thoughts & feelings

   • self disclosure (as appropriate)

Skills facilitating Insight goals

• Challenging client to foster AWARENESS. Some examples include:

  • challenging discrepancies, responsibility, & thoughts

  • chair work

  • humor

  • silence

  • nonverbal behaviors

  • ?’s!! (Open ?”s & probes for insight & immediacy)

• Interpretation!! & disclosing insight

• Immediacy

• Processing the Therapeutic relationship

Immediacy

the therapeutic technique of focusing on the present-moment interactions between therapist and client to deepen the connection, foster trust, and facilitate insight into behavioral and emotional patterns

Challenging

Awareness is often a precondition for insight. To facilitate awareness, the helper questions discrepancies and thoughts that a client may have

term used instead of CONFRONTATION (confrontation is more in your face)

Why challenge Clients? (Rationale)

• Helps get clients out of denial

• Points out ambivalent feelings

• Pushes clients to take responsibility for thoughts and feelings

• Helps clients dig deeper

• Clients become more aware of defenses

• Awareness comes before insight

Places to challenge

Occur between…

• two verbal statements (e.g., “You say you hate your brother because he is a goof-off, but you also say that you love him”)

• words and actions (e.g., “You say you want to get good grades, but you spend your time partying and sleeping”)

• two behaviors (e.g., “Youʼre smiling, but your teeth are clenched”)

• two feelings (e.g., “You feel angry at your sister, but you also feel regretful about shaming her in front of everyone”)

• values and behaviors (e.g., “You say you believe in respecting othersʼ choices, but you also try to convince them that abortion is wrong”)

• oneʼs perception of self and experience (e.g., “You say no one likes you, but earlier you described an instance in which someone invited you to have lunch”)

• oneʼs ideal and real self (e.g., “You want to meet your motherʼs high standards, but you feel like youʼre just average”)

• the helperʼs and the clientʼs opinions (e.g., “You say you are not working hard, but I think you are doing a great job”)

• values and feelings (e.g., “You would like to be a charitable person who volunteers for everything, but you feel angry when being asked to help out”)

How to challenge

• Is not a ‘GOTCHA!’ moment. Must be done empathically, thoughtfully, gently, & carefully

• Is COLLABORATIVE. Helper works with the client

• No judgement

• Done soon after a behavior occurs

• Ask client for reactions

• Tone is inquisitive & curious

• do NOT try and persuade client that you are correct (you could be wrong!)

Examples of challenging

• Search for discrepancies/ signs of cognitive dissonance

• This could look like:

  • “On the one hand_______ but on the other hand_____”

  • “You say_______ but you also say_______ “

  • “You say______ but nonverbally I am seeing______”

  • “I’m hearing____but I’m also hearing____”

Client Reactions

Client may experience…

• Denial

• No reaction

• Partial reaction

• Strong reaction

• Develop a new awareness

Other techniques for fostering awareness

Problems with challenges