Psychodynamics

Central techniques of psychoanalytic treatment

1. Free Association

2. Transference Analysis

3. Resistance

4. Dream interpretation

Primary process

• “Pleasure–unpleasure” principle.

• We seek immediate release of tension by wish fulfillment.

• This energy is mobile and allows for displacement and condensation (emerging ideas).

• It’s dominant in dreams and symptoms

Secondary process

Dominant, rational, planned actions.

Psychic Determinism

Every mental process is not spontaneous but determined by unconscious or preexisting mental complexes. Nothing is without a reason.

Pleasure principle

based on the constancy principle which states the unconscious is governed by the need to immediately respond to excitatory stimulus, lowering tension.
Homeostasis= pleasure.
Heightened tension = unpleasantness/pain (anxiety)

Reality principle

the limitations and demands of reality.
Child – omnipotent. Neurotic patients wish for an object that does not exist/is not accessible.

Repetition Compulsion

There are many repetitions in life.
Things which are repressed come in dreams, symptoms, and in reliving past experiences.
We have a compulsion to repeat — not measurable or necessarily pleasurable.

Dream Formation

1. An event stirs up an unexpressed wish- Extra strong if similar to childhood wish.

2. The two sources for the wish push the mind.

3. Reality prevents wish fulfillment.

4. The energy goes to hallucinatory wish fulfillment.

5. The scenarios imagined need to be easy to digest.
   

This process uses condensation, displacement, etc.

Rules of Dream Interpretation

Rules of Dream Interpretation

1. You can’t interpret everything.

2. You can't see things “as they are” and interpret according to that.

3. The dreamer must interpret the dream.

4. You can’t deeply understand a dream early in analysis.

5. You gather the patient’s associations before/after.

6. Dream interpretation shouldn’t overshadow therapy.

7. Not every dream must be interpreted.

8. Reporting dreams can also be resistance.

9. The analyst appearing in dreams isnt a bad sign

10. Changes in dreams = progress in therapy; some dreams mark termination of therapy.

Dream Work- definition and what it consists of

The ego operations that turn the wishes+thoughts+ “day residue” into dream content.

Consists of:

1. condensation

2. Displacement

3. Symbolism

4. Secondary revision

Condensation

fusion of objects/concepts.
Happens in Dreams, Jokes, and parapraxes. In jokes and parapraxes, it is more of a compromise between censorship and fantasies.

Displacement’s four types of subconscious shifts

• Ideational displacement – changing ideas

• Relational displacement – changing object of feeling

• Affective displacement- changing the situation to which an emotion was regarded

• Temporal displacement – changing timing of the emotion

Secondary revision

Mental process that ”tidies up” a dream to turn it into a coherent story

Symbolism

The symbol is concrete; the symbolized is abstract.

Dreams in pairs

two dreams in one night are steps in wish fulfillment. They are interwined.

Dreams of convenience

Fulfill basic bodily needs.

Therapy Termination dreams

1. termination signal- appears before a decision to end the sessions has been made. The patient dreams of cleaning attic, finishing tasks, or assesing the patients progress

2. Termination phase dream - Appear after the decision to end the sessions. These dreams show the patient’s symptoms in a better state, and the analyst is involved. Also rebirth/ coming out of a tunnel

Parapraxes definition

Para- “beside”, Praxis- “action”

Parapraxes are unintentional actions (mistakes) that have hidden motives.
Freud: occurs when conflict exists between conscious intention and unconscious wish.

Types of Parapraxes

1. Slip of tongue

2. Slips of the pen

3. Slips in reading/hearing

4. Forgetting - protects from distressing memories

5. Losing/misplacing objects – unconscious wish to reject or punish oneself

6. Mistaken actions – there are no mistakes, everything is driven by forces.
   
   We express inner feelings or thoughts that contradict conscious intention

General information about Jokes

• Aesthetic pleasure from weakening repression and releasing energy

• The form of the story is more important than content

• Uses condensation, displacement, reversal, instinct fusion (fusion of sexual and destructive instincts, for example)

• Jokes disguise inner aims; we fulfill wishes through jokes

Types of jokes

• Fear of uncanny- black/morbid,

• Fear of otherness- racist

• Routine- knock knock jokes

• Sexual jokes

• Weakness - impotence, laziness, addictions

• Self-depreceting jokes

Defense Mechanisms

1. Regression

2. Isolation

3. Projection

4. Repression

5. Undoing

6. Sublimation

7. Turning against the self

8. Reaction formation

Rules of defense mechanisms

1. Aim to reduce anxiety

2. Operate unconsciously

3. Rooted in childhood

4. Some emerge at specific developmental stages

5. Some defenses are permanent, others situational

6. Important for structure formation and ego functioning

7. Any activity can be used as a defense

8. Some are specific to psychopathological symptoms (Conversion- hysteria, undoing- obsessional neurosis)

9. Some are more “ego”, others more “id”

10. Mature defenses are different from primitive ones.

Why are they called “primitive defences”?

1. Developmental context: They come early in the development, when there’s less ego organization.

2. Motivation context: They come to protect from more primal threats, like the threat of self-consistency.

3. Diagnostic context- Less “character organization”, like in psychoses, causes the use of more primitive defense mechanisms

Mature defense mechanisms

1. suppression

2. altruism

3. sublimation- לצייר במקום להרביץ

4. humor

5. anticipation- תכנון

Primary repression

something wasn’t allowed to enter consciousness

Repression proper

Something is pushed from consciousness to unconsciousness .

General facts about repression

• Its strength depends on the strength of desire and the power of suppression

• It requires constant mental energy

• It’s the base of all defenses

Conversion

The energy attached to a repressed idea is transformed into somatic symptoms

emotional energy → somatic symptoms.

Somatization

similar to conversion, but its not neurological and it’s with multiple body symptoms

Reaction formation - what it is and similar concepts

turning unacceptable wishes (feelings) into the opposite.

Similar concepts:

1. Undoing- short, momentary impulse that changes. a person tries to cancel out or remove an unhealthy, destructive or otherwise threatening thought or action by engaging in contrary behavior.

2. Displacement – object changes, not wish. Same feelings, different person

3. Sublimation - You change the outcome, not the emotion.

Polymorph perverse sexuality

The child is satisfied by different erotogenic zones in different stages. These zones serve as a source of pleasure.

Fixation

happens when a child is unsatisfied in one of the stages.

freud’s stages

1. Oral (0–1)-
   The mouth is the erogenous zone
   Passive/oral fixation → dependency, gullible
   Aggressive → nail biting, chewing, sarcasm
   

2. Anal (1–3)
   The butthole is the erogenous zone
   Retentive → organized, stingy
   Expulsive → messy, careless, wasteful
   

3. Phallic (3–6)
   The Genitals are the erogenous zones
   Oedipus/Electra complex
   Fixation → promiscuity, low self-esteem
   

4. Latency (6–puberty)
   Fixation →immaturity, unstable relationships
   

5. Genital
   Mature sexuality
   Fixation → frigidity, impotence, sexual perversion, difficulty in sexual relationships

Four Psychologies

1. Drive psychology- Freud. Focus is on instincts, tension reduction. This is no longer the central theory. What is the wish?

2. Ego psychology - Anna Freud, Hartman. Focus is on defense mechanisms, reality testing. What defense is at work?

3. Object relations psychology - Klein, Winnicott. Focus is on internalized relationships, primary caregiver, and early relational trauma. What relationship is being played out?

4. Self psychology - Kohut. Focus on self-esteem, empathy, needs, narcissistic vulnerability. How coherent is the sense of self? Is the self valued?

Psychosis definition

Severe disturbance of reality testing:
Delusions, hallucinations, disorganized thinking, disruption of identity and self-experience.

Psychiatric diagnoses that include psychosis

1. Schizophrenia

2. schizoaffective

3. acute psychosis

4. persistent delusions

5. Depression/mania with psychotic features

6. Organic or substance-induced psychosis

Structural Levels of Personality Organization:

• Neurotic – stable personality, anxiety disorders

• Perverse – sexual disorders, narcissism, antisocial traits

• Borderline – unstable self, intense emotions, primitive defenses

• Psychotic – loss of reality testing, fragmentation

Anxiety in psychosis vs. neurosis

• Neurosis → fear of loss, guilt, rejection

• Psychosis → annihilation, disintegration, persecution

Primitive defences in psychosis

• There’s massive denial of reality. “This does not exist.” “I’m not ill, you are”.

• There’s a need for omnipotent control or a sense of grandiosity.

• Their boundaries of external-internal are broken, causing inner fantasies to appear as external reality, and external events to be experienced as personal messages.

Freud’s take on psychosis

1. Neurotic conflict comes from id vs. ego vs. super ego

2. Psychotic conflict is more severe and primitive and comes from fusion vs. separation, good vs. bad internal objects, trust in society vs. hostility.

3. The psychotic conflict might be too unbearable, causing the ego to withdraw and reality to be replaced with delusions

4. Freud believed severe deprivation in the very early stages (especially oral) causes psychosis. Stress→regression to this level→psychosis

Klein’s take on psychosis

Paranoid schizoid position

• Early in life the world is split into good and bad objects

• Dominant defences: Splitting, projective identification

• Dominant anxiety : persecutory

• Psychosis causes a regression to this Paranoid schizoid level

• The next level is the depressive position, in which there is an understanding that the object can be both good and bad. This causes guilt, concern, and the development of empathy, symbolization, and an ability to tolerate ambivalence.

Winnicott’s take on psychosis

• Talked about the “good enough mother” and “holding”- the capacity of the environment to contain and support the infants experience.

• In psychosis there’s a failure of holding, which causes a development of a false self

• Under stress, the false self collapses

• Winnicott emphasized how therapy must provide holding and safety.

Bion’s take on psychosis

Containment and thinking

• The infant has raw, unprocessed emotional experiences- Beta elements

• The mother acts as a container - receives, processes, and transforms these experiences into a tolerable form, then returns them to the baby- Alpha elements.

• If the containment fails, the experiences remain unprocessed or unthinkable

• This creates an inability to think and symbolize emotional experiences

• Thoughts become indistinguishable from reality

• This causes projective identification

• psychotic parts of the personality control the individual’s thoughts, his link between self and others, and links between past, present and future.

Kohut’s take on psychosis

Self psychology and psychosis

Kohut said that for the development of the self we need Self-object (caregiver)

Actions needed from the caregiver:

1. mirroring- “ you see and value me” warm reflection on the childs experiences

2. idealization- A powerful, calm, reliable adult to deolize

3. twinship - Alter ego experience. “I am like you. I belong.” Part of a group, connected.

If the self-object fails → fragmentation of the self, and in sever cases→ psychosis.

Guidelines for Therapy With Psychotic Patients

• Provide stability, predictability

• Containment of anxiety

• Support reality testing

• Slow pace

• Minimal interpretation

• Strengthen self

• Focus on the here-and-now