Barber and Solomov - Psychodynamic Theories

Psych 401 Barber and Solomonov - Psychodynamic Theories 

DEFINITIONS 

• Five main themes of contemporary psychodynamic thinking 

1. Existence of unconscious contents and processes (including defense mechanisms) - MAIN

   1. Behaviour has meaning (sometimes it is obvious, sometimes it obvious only to an observer, and sometimes it lies deep within)

2. Conflicts in human life - central

   1. Can emerge among wishes, fears, desires, thoughts 

   2. Lead to feelings of ambivalence → lead to compromised formation 

3. Role of early childhood experiences 

   1. Particularly relationships with caretakers

4. Representations of self, others and interpersonal relationships in contrast to the wish to satisfy sexual and aggressive needs 

5. Personality → Capacity to regulate sexual and aggressive needs / impulses 

   1. Balancing needs, wishes for dependence and intimacy with independence and autonomy. 

THEORY OF PERSONALITY AND PSYCHOPATHOLOGY 

• All theories should define the key aspects of the individuals’ functioning 

• Psychodynamic theories and psychopathology also ensure to define the individual’s functioning

CLINICAL ASSESSMENT AND DIAGNOSIS

Depression 

• Klein and Freud: emphasis on loss of an object and the internalized toward it

• Kohut: role of low self-esteem and self-criticism (disturbances in early attachments)

• Phases 

  • One: educate on depression 

  • Two: explore the central themes (intense feelings of loss and abandonment and the internalization of anger + resentment caused by the experience of loss) 

  • Three:maintain self-awareness

• Common transference reactions: Abandonment + dependency, perceived rejection and disappointment

• Countertransference reactions: frustration, disappointment, anger, emotional exhaustion can lead to detachment

Obsessionality 

• Freud’s anal triad: {use of defenses in an effort to bind the id’s impulses}

  • Preoccupation with orderliness, bodily cleanliness, small details [allows them to feel morally clean and good]

  • parsimony/greed

  • Obstinacy (stubbornness, inflexibility) 

• Salzman: need for control → causing instability and loss of security 

• Common transference reactions: need to control the therapy and therapy, anger + autonomy from efforts to protect autonomy

• Countertransference reactions: anger, frustration, boredom

Fear of Abandonment 

• Margaret Mahler: infant’s failure to establish a bond with the primary caretaker

• Kernberg: constitutional predispositions to aggression that are exacerbated by trauma

• Common transference reactions: splitting and dependency

• Maintain calmness

  • One: form a contractual alliance

  • Two: development of a deeper relational alliance

  • Three: patient takes part in a supportive and stable relationship 

Low Self Esteem 

• Self love!!!

• Common transference reactions: need for an alternative parenting model 

• Countertransference reactions: resentment and anger towards the patient’s neediness

Panic 

• Common transference reactions: struggle over fear of separation and loss of the therapist and feelings of guilt and shame over their dependency, use defenses (repression, suppression, disavowal)

• Countertransference reactions: provide the patient with maternal caretaking and protection

Trauma 

• Common transference reactions: tendency to view the therapist as a potential abuser or bystander 

• Countertransference reactions: identification with the predator; underestimation of the severity of the trauma; overidentifica- tion with the patient; posttraumatic stress disorder (PTSD) as a result of recurrent exposure to the patient’s trauma; and confusion, forgetfulness, or anxiousness as a result of the patient’s overwhelm- ing trauma 

TREATMENT PROCESS

Insight / Self Understanding 

• “Aha” moment 

• Better self understanding and increased self-awareness, increase in insight

Defense Mechanisms

• Some are considered more mature (sublimation) and some are not (self harm, denial)

Quality of Object Relations 

• Object relations are based on one’s mental representations of the self and the others, develop in infancy on the basis of interactions with caretakers

• Disruptive → unhealthy and unstable representations of self and others and experience difficulties in interpersonal relationships

• Associated with symptom improvement

Relationship Rigidity and Transference 

• Rigidity appears in the form of transference. Rigidity is associated with a decreased response to psychodynamic therapy

Reflective Function 

• An operationalized construct for mentalization, the capacity to envision mental states in one’s self and others to understand how these mental states underlie behaviors

• More for bpd and panic disorders

Corrective Emotional Experience 

• Increase in the patient's openness, sense of closeness and strengthen the alliance

• Successful resolution of ruptures in the alliance is associated with better therapeutic outcomes

Therapeutic Relationship 

A Practical Formulation

1. Opening phase: develop a psychodynamic formulation 

2. Middle phase: all other factors, create a new narrative

3. Ending phase: improved self understanding and reflective capacity 

RESEARCH EVIDENCE AND CONTRIBUTION 

• Unconscious processes (other names): implicit knowledge, automatic processes, cognitive unconscious, implicit memory and perception, subliminal perception, implicit motivation 

• Evaluate efficacy of a treatment → use of meta analysis, aka, randomized controlled trials (RCTS),

EFFICACY OF PSYCHODYNAMIC PSYCHOTHERAPY 

Depression 

• Effectiveness: Significantly more effective than control conditions, and as effective as alternative treatments for mood disorders, combined with meds > only meds. 

• Maintenance: Maintained in short term and long term follow ups.

Obsessionality 

• Effectiveness: more effective than the control conditions for the cluster C personality disorders

• Maintenance: Patient symptoms were maintained in a 1.5 year follow up.

• Alternative: STPD was as effective as CBT and maintained at termination and long term follow up of 2 years.

Fear of abandonment 

• Effectiveness: Transference focused therapy is as effective as alternate treatments, mentalization therapy was superior to control conditions, psychodynamic therapy is as effective as DBT 

• Maintenance: mentalization - improvement in 5 year follow up (but included partial hospitalization), psychodynamic - improvement maintained in 2 year follow up.

• Alternate therapies: dbt, mentalization, transference-focused, interpersonal therapy

Low Self Esteem 

• Need more research for anything!!!.

Panic

• Effectiveness: Psychodynamic was significantly more effective than control conditions (didn’t differ from stuff like cbt), panic focused psychodynamic psychotherapy > relaxation training  

• Maintenance: psychodynamic - maintained at 1 year and later follow up, Panic focused - even greater for patients with a comorbid personality disorder 

Trauma 

• Need more research, there is only one single RCT 

• STPD, systematic desensitization and hypnotherapy were equally effective, improved significantly at termination and 2 year follow up  

MAJOR ACCOMPLISHMENTS 

• Current psychotherapy emerged from psychodynamic thinking , and is currently a huge part of the healthcare establishment (for example, implicit processes are studied in other fields as well, even though it is largely a part of scientific psychology).

• Psychoanalytic theory is nowadays more widespread in the humanities 

• Developers of the new psychotherapies were originally trained in psychodynamic, so that’s their base (but they emphasize new skills rather than old fashioned skills) 

FUTURE DIRECTIONS

• Need to focus more on researching its central assumptions. 

  • Assumption underlying CCRT - patients will express consistent themes across relationships, and across the same situation or similar situations in different relationships. 

    • Situational view of relationships 

    • Ecologically valid setting 

• Key challenges 

  • Decline in funding (difficult to conduct large clinical trials) 

  • Increase in medicalisation of mental health (decrease in the use of psychotherapy) 

  • Decline in psychodynamic research faculties and training opportunities 

Randomized Trials 

• Future studies will focus on which treatment are best suited for which disorders, who will benefit more from what

Process Research 

• Need for more empirical evidence supporting these mechanisms (mechanisms of change)

More than Symptoms 

• Essential to study psychodynamic constructs in therapy outcome

  • Erikson: improved ability to love and work 

  • Kohut: emphasis on a sense of wholeness and freedom from maladaptive relationship patterns 

  • Hartmann: focus on the healthy ego capacities

Brain Imaging 

• fMRI and other neural + metabolic measures 

• Incorporate all new technologies to collect data

Public Perceptions of Dynamic Psychotherapy 

• Present psychodynamic therapy in an accurate, accessible and convincing manner (realistic portrayals)