COUN1003 Psychoanalytic & Psychodynamic Therapy

Psychoanalytic & Psychodynamic Therapy

Overview of Psychoanalytic Therapy

  • Founded by Sigmund Freud in the 1890s.
  • Other therapies developed later include:
    • Cognitive Therapy (Aaron Beck).
    • Rational Emotive Behavior Therapy (REBT) (Albert Ellis).
    • Behavior Therapy (Skinner & Bandura).
    • Gestalt Therapy (Fritz & Laura Perls).
    • Person-centered Therapy (Carl Rogers).
    • Existential Therapy (Frankl, May, Yalom).
    • Solution Focused Brief Therapy (SFBT) & Motivational Interviewing (MI).
    • Narrative Therapy.
  • Psychodynamic approaches were further developed by:
    • Adler, Jung, Klein & Anna Freud.
    • Mahler, Kohut.
    • Erik Erikson (Psychosocial Stages of Development).

Psychoanalytic Theory

  • Background:
    • Rooted in Freud's system.
    • Emphasizes a deterministic view of human nature.
    • Focuses on the role of instincts and the structure of personality.
    • Explores the unconscious mind.
  • Key Concepts:
    • Deterministic View: Behavior is determined by unconscious, irrational forces.
    • Instincts:
      • Life Instincts (Eros): Oriented towards growth, development, and creativity; includes the drive to survive, procreate, and libido.
      • Death Instincts (Thanatos): Oriented towards death, manifested as aggression outwards or self-harm/suicide inwards.
  • Structure of Personality:
    • Id: Untamed drives, impulsive, biological; present from birth; operates unconsciously; ruled by the pleasure principle (reduce tension, avoid pain, gain pleasure); illogical, amoral, and driven to satisfy instinctual needs; never matures.
      • The original system of personality that is the primary source of psychic energy and the seat of the instincts. It lacks organization, is blind, demanding, insistent, and a cauldron of seething excitement. The Id is driven to satisfy instinctual needs.
    • Ego: Realistic, rational, logical; organizes and mediates; both conscious and unconscious actions; ruled by the reality principle; formulates plans to satisfy needs; seat of intelligence and rationality; checks and controls the impulses of the id; distinguishes between mental images and things in reality.
      • Has contact with the external world and acts as an executive that governs controls and regulates the personality. The Ego mediates between the instincts and reality. It controls consciousness and exercises censorship.
    • Superego: Judicial function (good/bad, right/wrong); represents societal values and parental standards; moralistic, strives for ideals and perfection; related to reward and punishment, pride and guilt; inhibits id impulses and persuades the ego to substitute moralistic goals for realistic ones.
      • The judicial branch of personality and judges actions to be good or bad and right or wrong. It represents the ideal and moral rather than the real. The Superego strives for perfection and is related to psychological rewards or punishments, feelings of pride and self-love, guilt and inferiority.
  • The Unconscious:
    • Stores all experiences, memories, and repressed material; key to understanding behavior and personality problems; unconscious needs and motivations are inaccessible; consciousness is only a thin slice of the total mind.
  • Inferring the Unconscious:
    • Dreams: Symbolize unconscious needs, wishes, and conflicts.
      • Example: Dream of being lost in the woods symbolizes unconscious struggle with purposelessness.
    • Slips of the tongue and memory: Forgetting a familiar name indicates unconscious dislike (or attraction) to that person.
    • Posthypnotic suggestions: Reveal unconscious desires.
      • Example: "When you wake, you will remember seeing your mother naked" indicates unconscious desire.
    • Material from free-association: Uncovers unconscious memories of parental fighting.
      • Example: "Car, road, trip, pacifier, hot, shouting" is a free association.
    • Material from projective techniques: Reveals unconscious struggles with threats or dilemmas.
      • Example: Seeing demons in inkblots indicates unconscious struggles with some threat or dilemma.
    • Symbolic content of psychotic symptoms: Hearing voices commanding them to do things indicates unconscious fear of their own superego.
    • Transference, countertransference, and defenses reveal unconscious processes.
  • Neurotic Symptoms & Anxiety:
    • Unconscious processes lead to neurotic symptoms and behaviors like phobias, projections, and denials.
    • "Cure" involves uncovering meaning, causes, and repressed material (Id).
    • Confront repetition and process transference distortions.
    • Anxiety arises from the emergence of repressed feelings, memories, and desires, including:
      • Reality anxiety: Danger from the external world.
      • Neurotic anxiety: Fear of instincts (the Id) taking over.
      • Moral anxiety: Fear of violating own moral code (Superego).
  • Ego Defense Mechanisms:
    • Help cope with anxiety and prevent the ego from being overwhelmed.
    • Are normal behaviors with adaptive value but can deny or distort reality.
    • Operate mainly on an unconscious level.
    • Examples:
      • Repression: Painful thoughts/feelings are involuntarily excluded from awareness.
      • Denial: Consciously (or preconsciously) ignore threatening aspects of reality.
      • Reaction Formation: Actively express the opposite behavior of a threatening impulse.
      • Projection: Attribute one’s own unacceptable desires and impulses to others.
      • Displacement: Shift energy from threatening/unavailable target to safer one.
      • Rationalization: Make up “good” reasons to explain away a bruised ego.
      • Sublimation: Divert sexual/aggressive energy into other channels.
      • Regression: Return to an earlier, less demanding phase of development.
      • Introjection: Blindly swallow the values/standards of others (positive or negative).
      • Identification: Identify with successful causes/organizations/people to be perceived as worthwhile.
      • Compensation: Mask perceived weaknesses or develop positive traits to make up for limitations.

Staged Developmental Models

  • Freud’s Psychosexual Stages of Personality Development:
    • Oral Stage (first year): Pleasure from the mouth; fixation leads to inability to trust self/others.
    • Anal Stage (Ages 1-3): Pleasure from control; fixation leads to inability to recognize and express anger.
    • Phallic Stage (Ages 3-6): Pleasure from bodily awareness; fixation leads to inability to fully accept sexuality and sexual feelings; Oedipus/Electra complexes.
    • Later Genital and Latency stages.
  • Erikson’s Psychosocial Stages of Development:
    • Emphasizes social factors; tasks one must master in life by resolving crises.
    • Crises: Turning points; Can move forward or regress.
    • Includes:
      • Trust versus mistrust (infancy).
      • Autonomy versus shame & doubt (early childhood).
      • Initiative versus guilt (preschool age).
      • Industry versus inferiority (school age).
      • Identity versus role confusion (adolescence).
      • Intimacy versus isolation (young adulthood).
      • Generativity versus stagnation (middle age).
      • Integrity versus despair (later life).
  • Combined Perspective on Development (Freud & Erikson):
    • Outlines the parallel stages of psychosexual and psychosocial development, linking Freud's stages with Erikson's stages at various ages.
  • Limitations of Stage-based Theories:
    • Assume everyone follows the same sequence.
    • Do not account for individual differences, cultural differences, or other environmental factors.
    • Is a Western conceptualization.
    • Emphasize early childhood and unconscious influences (Freud).
    • Contemporary psychoanalytic/psychodynamic therapists focus on intrapsychic and interpsychic experiences.
      • Intrapsychic: Mental processes like thoughts, memories, dreams.
      • Interpsychic: Relational contacts and interpersonal/intersubjective dynamics.

The Work: Classical versus Contemporary Psychoanalysis

  • Classical Psychoanalysis:
    • Deterministic: Unconscious drives/instincts motivate human behavior.
    • Focus on psychosexual/psychosocial stages.
    • Id psychology: Intrapsychic conflict between id, ego, and superego.
    • Aims to make the unconscious conscious using techniques to surface/infer the unconscious.
    • Employs an anonymous blank-slate analyst.
    • Involves long-term intensive treatment focused on personality change, primarily with adults.
  • Contemporary Psychoanalysis:
    • Emphasizes interpersonal relationships, self-development, and the influence of the social environment on behavior.
    • Focuses on intrapsychic and interpsychic experiences.
    • Incorporates ego psychology, object relations, self-psychology, relational psychoanalysis, attachment, and affect.
    • Is more relational, using material from the intersubjective experience.
    • Involves a face-to-face collaborative therapeutic alliance.
    • Utilizes shorter-term treatments focusing on more practical matters with adults and children.

Therapy Goals

  • Make unconscious conscious: Repetitive explorations of unconscious material and defenses; recognize their past value.
  • Strengthen the Ego; make new conscious choices.
  • Enable more reality-based behaviors.
  • Reduce instinctual cravings and irrational guilt.
  • "Working through".

Reality-based Behaviors

  • Foster the capacity to cope with and solve own problems.
  • Increase adaptive functioning (reduce symptoms, resolve conflicts).
  • Significantly modify personality structure (rework old patterns).
  • Reconstruct, discuss, interpret, analyze childhood experiences.
  • Deeper probing into the past to develop self-understanding.
  • Achieve insight; experience feelings/memories from self-understanding.

Therapist Role

  • Classical Psychoanalysis:
    • Therapist is a blank screen.
    • Foster transference and client projection.
    • Analysis of transference and projection to build self-understanding.
  • Contemporary Psychoanalysis:
    • Rejects the blank screen approach.
    • A one-to-one therapeutic alliance; uses empathic attunement.
    • Analysis to build insight, better relationships, cope with anxiety.
    • Pays attention to what is said/unsaid, gaps/inconsistencies in stories.
    • Infers meanings of dreams and free associations.
    • Formulates the nature of the client’s problem.

Client Experience

  • Classical:
    • Intensive long-term work.
    • Lies on couch; engages in free association; free to express any idea/feeling.
    • Encouraged to loosen defense mechanisms and regress.
    • Change from working through old patterns in safety.
  • Contemporary:
    • Less intensive; face-to-face.
    • Therapist is supportive, less emphasis on regression.
    • Clients are not to make radical lifestyle changes during analysis.
    • Shortens and simplifies Classical Psychoanalysis.

Therapeutic Relationship

  • A present relationship that is a corrective and integrative experience.
  • Classical: Therapist is outside of the relationship.
  • Contemporary: Focuses equally on present transference and reenactments from the past.
  • Focus on mutual transference and countertransference.
  • Less likely to use the couch; fewer sessions.
  • Therapist is present, more actively supportive, may self-disclose, less neutral.
  • More focus on pressing practical concerns than fantasy material.

Transference

  • Transference reactions: Unconscious repetition of past patterns.
  • Client’s unconscious shifting to the analyst: Feelings, attitudes, fantasies (positive & negative); reactions to past significant figures.
  • React to the therapist as if they were a significant figure from the past.
  • Client regresses emotionally; therapist = substitute significant figure.
  • Not all feelings toward the therapist is transference.
  • Not all positive responses are positive transference.
  • Anger towards the therapist may not be negative transference.

Countertransference

  • Countertransference reactions are inevitable.
  • Therapist expresses inappropriate affect.
  • Therapist responds in irrational ways.
  • Therapist loses objectivity in a relationship.
  • Unconscious reactions to client transference & total behavior; based on therapist’s unresolved issues/triggers.
  • React to the client as if they were a significant figure from the past.
  • Distorts therapist’s perception of the client’s behavior; expression inevitably affects clients consciously or unconsciously.
  • Strong source of data to learn about the client and the therapist.

Six Basic Techniques

  1. Maintain the analytic framework.
  2. Free association.
  3. Interpretation.
  4. Dream analysis.
  5. Analysis of resistance.
  6. Analysis of transference.

Maintain the Analytic Framework

  • Analyst anonymity, neutrality, objectivity.
  • Session regularity, consistent start/ending times, clarity on fees.
  • Basic boundaries: Not advising or imposing values.
  • Consistent framework is itself therapeutic.
  • Any breaks in the consistency becomes the focus of interpretations (e.g., therapist vacation).

Free Association

  • Say whatever comes to mind.
  • Flow with any feelings or thoughts.
  • Report them immediately and without censorship.
  • Recall past experiences.
  • Catharsis of blocked feelings.
  • Therapist listens to surface content and hidden meanings; what is said/unsaid, described/avoided…
  • Access unconscious wishes, fantasies, conflicts, motivations.

Interpretation

  • Analyst identified, points out, clarifies, explains, translates, teaches; the meaning behind the client’s unconscious material.
  • Enable the Ego to assimilate new material.
  • Expedite uncovering of new material.
  • From assessment of personality, past causes, current challenges.
  • Contemporary practice: In the spirit of mutual discovery.

Dream Analysis

  • Freud: Dreams are the “royal road to the unconscious”.
  • Dream work: Transforms latent content; reduce threat.
  • Latent content: Hidden, symbolic, unconscious motives, wishes, fears.
  • Manifest content: The dream as it appears to the dreamer.
  • Analyst studies manifest content for symbols of hidden meanings.
  • Unacceptable motivations may appear in disguised/symbolic form.
  • Dreams also provide understanding of the client’s current functioning.

Analysis of Resistance

  • Anything that works against the progress of therapy; prevents the client from producing unconscious material; perpetuates the status quo to prevent change.
  • Reluctance to surface repressed unconscious material; to avoid anxiety and pain that comes from awareness; (not the client’s lack of cooperation with treatment).
  • Ambivalence: Wish to change and remain unchanged.
  • Must respect client resistances; help clients work therapeutically with their defenses.

Analysis of Transference

  • Transference is when the client distorts the present with the therapist.
  • Reexperience a variety of otherwise inaccessible feelings.
  • Help clients realize they are repeating same dynamic patterns:
    • In present relationship with the therapist.
    • In present relationships with significant others.
    • In past relationships with significant figures.
  • Through interpretations and working-through: Aware of patterns → Process old conflicts → Change behavior.

Trends: Psychoanalytic Theory

  • Classical perspective.
  • Ego Psychology.
  • Object-relations and interpersonal psychoanalysis.
  • Self Psychology.
  • Relational Psychoanalysis.
  • Freud: Intrapsychic conflicts from gratifying basic needs.
  • Neo-Freudian: Incorporate cultural/social influences on personality.

Trends: Object-relations Theory (1975)

  • Margaret Mahler: Child’s progression from symbiosis (psychological fusion) with mother to separation/individuation; internalized experiences of others.
  • Stages:
    • 3-4 weeks: Infantile Autism
      • Responds to physiological tension rather than psychological processes, undifferentiated from mother.
    • 3-8 months: Symbiosis
      • Pronounced dependency on mother.
    • 4-5 months: Separation-Individuation
      • Moves away from symbiotic, experiences separation, still turns to significant others for confirmation and comfort.
    • 36 months: Self and object constancy, others are separate from the self
  • Freud: Sexual and aggressive drives affect adult functioning.
  • Mahler: Early childhood experiences shape adult functioning/relating.

Trends: From Id Psychology to Ego Psychology

  • Classical Psychoanalysis: Id Psychology
    • Instincts & intrapsychic conflicts shape personality.
  • Contemporary psychoanalysis Ego Psychology
    • Ego strives for mastery.
    • Ego competence throughout life span.
    • The intersubjective experience (mutual understanding arising from the therapeutic interaction).

Trends: Ego Psychology

  • Gain awareness of defenses and develop better coping.
  • Deals with both early and later developmental stages; not just unconscious conflicts from early childhood.
  • Adolescence, mid-adulthood, later adulthood: particular crises in each stage that must be addressed.
  • The past has meaning for the future: There is continuity in development, reflected by stages of growth; each stage is related to the other stages.

Trends: Self Psychology

  • Heinz Kohut (1971)
  • Some level of narcissism may be healthy.
  • Self objects: Provide the self-worth and value to an individual.
  • Interpersonal relationships (self-objects) to develop sense of self.
  • Develop nonjudgment, acceptance, empathy, authenticity.
  • Freud: Sexual drives and narcissism (Id) are inherently harmful.
  • Kohut: Self-psychology Modern psychonalytic Theory.

Trends: Relational Psychodynamic Model

  • Therapeutic relationship is essential to change and directly healing.
  • Relational analysis: Explore client's life in a creative way, customized collaboration, contextual to particular culture and time.
  • More egalitarian style, values not-knowing; genuine curiosity.
  • Freud: Therapy is projecting unconscious material from the client’s self onto a blank slate therapist.
  • Relational Psychodynamic: Therapy is interactive/intersubjective between client and therapist.

Trends: Contemporary Psychodynamic Therapy

  • Chronic personality disorders, borderline and narcissistic personality disorders.
  • Devising specific treatments for specific disorders.
  • Collaborative; using a good therapeutic alliance.
  • Develop briefer forms of psychodynamic therapy for greater accountability and cost-effectiveness.
  • Freud: Attention on adult disturbances; Long term therapy.
  • Contemporary Psychodynamic: Attention on childhood and adolescence disturbances.

Multicultural Considerations

  • Strengths:
    • Appropriate if techniques are modified.
    • Erikson’s psychosocial approach applicable to diverse cultures.
    • Recognition of countertransference related to cultural biases.
  • Limitations:
    • More for long-term personality reconstruction; less for problems of living.
    • Expensive; based on upper-middle-class Western values.
    • Not suited to clients who want more active and structured work.
    • Intrapsychic analysis may not suit some social frameworks.

Contributions: Classical Psychoanalysis

  • Concept of resistances: Cancel appointments, flee from therapy prematurely, refuse to look at oneself.
  • Unfinished business can be worked through, to provide new endings to past events that have restricted clients emotionally.
  • The value and role of transference.
  • The overuse of ego defenses can impede functioning.

Contributions: Contemporary Psychoanalysis

  • Erikson’s psychosocial stages extended Freud’s psychosexual stages; clients discover significant connection across life stages.
  • Present behavior is largely a repetition of patterns set during one of the early development phases.
  • Object-relations theory: How we superimpose past experiences with significant others onto present relationships.
  • Psychosocial formulation can help with issues of individuation, intimacy, dependence versus independence, and identity.
  • Latitude to combine techniques from other approaches.

Limitations: Psychoanalytic Approaches

  • Practicality: Time, expense, trained analysts, nonpractical applications.
  • Clients can lack the necessary ego strength.
  • Restrictive anonymous/blank slate therapist.
  • Conceptually, the father is missing, the mother is blamed.
  • More for elite, highly educated clients; less relevant to the masses.