PSY 245 CLINICAL PSYCHOLOGY II Assoc. Prof. Dr. Bahar BAŞTUĞ Clinical Psychologist Psychoanalytic Approaches Today we’ll be focusing on psychoanalytic and psychodynamic theory and practice, beginning with the work of Sigmund Freud. As an interesting starting place, say the first word that comes to mind when you hear: “Sigmund Freud.” Sigmund Freud (1856-1939) Sigmund Freud Freud was born in Freiberg, Moravia, in 1856, he died for larynx Ca in 1939 in London. His intellectual potential was obvious early on and Freud felt like a favored child. He obtained his medical degree from the University of Vienna with the goal of being a research scientist. He went into private practice of neurology because of financial needs. As a neurologist, Freud was exposed to the disorder “hysteria” . Sigmund Freud He became familiar with the work of Jean Charcot, who was using hypnosis to produce hysterical symptoms. Professor Charcot of Paris' Salpêtrière demonstrates hypnosis on a "hysterical" patient. For Freud, the same procedure might be used to treat hysteria. Sigmund Freud Freud began working with Viennese physician Josef Breuer. Breuer was treating hysteria symptoms by having patients talk about emotionally loaded childhood experiences. Breuer worked with Anna O., discussing her hysteria symptoms and treatment in great detail with Freud. They published Studies in Hysteria in 1895. Anna O., or Bertha Pappenheim, 1880 Hysteria was the main psychological disorder of Freud’s time. Psychological theories are a product of the dominant Zeitgeist and Ortgeist. He initially used hypnosis, but later became more enamored with the “talking cure.” Freud’s Early Fascinations: • Psychosexual Development • Unconscious Sexual Meaning of Many Behaviors Sigmund Freud Freud presented a paper titled “The Aetiology of Hysteria” in Vienna in 1896. He made a connection between childhood sexual abuse and later psychopathology. The Seduction Hypothesis suggested that childhood sexual abuse produces later psychopathology (Hy). « at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience” (Freud, 1896, cited in Masson, 1984, p. 263). Freud’s presentation of the Aetiology of Hysteria met with an “icy reception.” He abandoned the Seduction Hypothesis in favor of his theory concerning the Oedipal conflict. Theoretical Principles Freudian Theory • Is one of the “Giant theories” of developmental Psychology (Miller, 2010). • Is a one-person intrapsychic model. • Includes several different approaches to thinking about human behavior. Psychoanalytic Theoretical Principles Classical Freudian theory is a one-person intrapsychic model that treats the client as a separate, individual artifact to be systematically and objectively examined. X X X X X X X X Modern analytic theory treats the therapy encounter more as a two-person field, wherein the therapist’s and client’s intrapsychic and relationship interactions help shed light on patterns that may be troubling the client. The Dynamic Approach is known as drive theory or instinc theory. He believed humans are filled with mental or psychic energy. This energy comes from two essential sources: Eros energy associated with life and sex Libido Thanatos energy associated with death and aggression. Eros and thanatos are the two basic drives that energize behavior. According to drive (dynamic) theory, Psychic determinism underlies the dynamic approach (“. . . nothing happens by chance” [Brenner, 1973]). every impulse has an origin, aim, object, and intensity. An impulse always originates from some place in the body. Child – oral Their aim is to obtain oral pleasure. The pressure or intensity of pleasure need is building. The baby finds an object that will allow him or her to discharge tension and obtain pleasure. According to drive (dynamic) theory, if the internalized cycle does not flow smoothly due to parental withholding, there can be a fixation and later unconscious acting out of the pathological cycle during adulthood. Repeated patterns may result in an internal working model or repetition compulsion. The Topographic Approach Divides the mind into three interrelated regions: the unconscious, the preconscious, the conscious. The Topographic Approach There is much more going on at the unconscious level than at the conscious. Awareness of our basic, primitive sexual and aggressive impulses might disrupt our daily lives, our brain protects us from them. The main purpose of psychoanalytic therapy is to help us slowly become aware of unconscious impulses. By bringing unconscious impulses to awareness, we’re able to manage them, because even when they are outside awareness, primitive impulses can still act on us in an indirect and destructive manner. Oedipal conflict X Electra Complex Resolution of this conflict leads to development of the superego. The Developmental Stage Approach Explains how early childhood experiences influence later adult behaviors. Oral: birth to 1 year old Anal: 1 to 3 years old Phallic: 3 to 5 years old: Oedipus complex Latency: 5 to 12 years old Genital: adolescence to adulthood The Developmental Stage Approach Each stage is defined in terms of the part of the body around. Each stage presents new needs.The way in which these needs are met (or not met) determines not only how sexual satisfaction is achieved, but also how the child relates to other people and how he feels about himself. Unresolved conflicts in any stage may bother the person throughout his lifetime. The Developmental Stage Approach All children progress through all developmental stages. Progress through the stages is driven by biological maturation. At each stage, if parents are overly tolerant or withholding, the child can end up with fixations or complexes associated with the stage. A fixation or complex is an unresolved unconscious conflict. The Structural Approach involves the interrelationships of: • Id: Pleasure principle – primary process • Ego: Rational thought – secondary process • Superego: Conscience + ego ideal The id is the centre of biological desires. It functions on the pleasure principle and primaryprocess thought. Id impulses are unconscious. We can view id impulses within ourselves via dreams, fantasies toward pleasure-seeking behavior. The id is the mother of the ego. The Structural Approach Ego functions include memory, problem- solving ability, and rational or logical thought processes. These functions are defined as secondary thought processes. The superego develops around the time when children resolve their Oedipal issues and begin strongly identifying with parents and parental demands or expectations. The Structural Approach There are two parts of the superego: 1.the conscience develops as a function of parental prohibitions. When mom, dad, or another authority figure says, “No!” or “Stop that!”, these warnings are internalized within the child’s psyche and later used by the child to self-punish or prohibit unacceptable impulses. It becomes the inner source of punishment. 2. In contrast to the negative, punishing quality of the conscience, the ego-ideal is a positive desire. The conscience is a punishment as a motivator, while the ego-ideal is a reinforcement as a primary motivator. The Structural Approach The ego acts as a mediator between the id and the superego. This is no easy task, and therefore the ego often must use defense mechanisms. Defense mechanisms are designed to defend against unacceptable id impulses. They have four primary characteristics: • They are automatic: Individuals reflexively use defense mechanisms. • They are unconscious. • They defend against unacceptable impulses. • They distort reality. Defense mechanisms Repression involves forgetting an emotionally painful memory. Denial is usually expressed with more force. “Not me!” Projection occurs when clients push their unacceptable thoughts, feelings, or impulses outward, onto another person . Reaction Formation If it is too dangerous to directly express aggression toward someone, the individual may behave in an excessively loving way. Expressing the opposite Defense mechanisms (cont.) Displacement occurs when the individual shifts the aim of sexual or aggressive impulses from a more dangerous person or activity to a less dangerous person or activity. Rationalization occurs when clients use excessive explanations to account for their behavior. Regression involves going back to an old, less sophisticated method of doing things. Sublimation is one of the most productive defense mechanisms. Psychopathology and Human Change Psychopathology arises from early childhood experiences. Freud believed that psychopathology existed on a continuum. Normal-abnormal continuum. Psychopathology and Human Change There are several key issues: The therapy focuses on early childhood experiences as the origin of psychopathology. Pathological childhood experiences aren’t completely umderstood, recalled consciously. Human change involves an insightful or consciousness-raising experience. Human change isn’t an immediate process; it requires a working through process where consistent practicing of new ways of understanding inner impulses. Evolution and Development in Psychoanalytic Theory and Practice Ego Psychology (Psychoanalytic Ego Psychology)-Anna Freud, Eric Erickson Object Relations-Melanie Klein, Otto Kernberg Self Psychology- Hans Kohut Anna Freud Anna Freud studied children directly, through psychoanalysis. She studied their dreams and fantasies. She observed children’s unconscious mental processes through play. She changed the psychoanalytic focus from the instinctual drives to the ego development. She is best known for her work with children and her writing on ego defense mechanisms. Psychoanalytic Ego Psychology began in about the 1930s. Following Anna Freud, they emphasized that certain ego functions were inborn and autonomous of biological drives. These ego functions are memory, thinking, intelligence, and motor control. In Erik Erikson’s eightstage theory of development, Erikson deviated from Freudian developmental theory in two ways: – psychosocial development instead of psychosexual development. – the continuous nature of development into old age, rather than ending his stages, like Freud, in early adulthood. Object Relations In the 1950s, object relations theorists began reformulating traditional psychoanalytic theory. Traditional Freudian theory focuses primarily on parent-child dynamics during the Oedipal crisis. Object relations theory focused on pre-Oedipal dynamics. Dynamics and motivation: earlier parentchild relationships Object Relations Objects are not things. Objects are internalized versions of people. Fairbairn states that “libido is object seeking, not pleasure seeking”. Fairbairn’s psychic world is consisted of internalized objects and internalized object relations. Object relations theorists believe humans mentally internalize both a representation of self and a representation of early caregiver figures. Object Relations (cont.) These internalized self and other representations are then carried within the individual into adulthood. If during early childhood an object relationship was characterized by trauma or destructive interpersonal patterns, remains of these early self-other relationship patterns can adversely affect a client’s relationships. Object relations therapy attempts to “replace the ‘bad object’ with a ‘good object’. Self Psychology Formulated by Heinz Kohut. Focused on the development of healthy narcissism within individuals. Mirroring is an important therapy concept. Retraumatization is the central client fear that leads to resistance and the therapist’s interpretation of resistance. Heinz Kohut Therapists are imperfect, and clients retreat from intimacy. Making “optimal failures” and then working toward empathy is seen as the basic therapeutic unit leading to new self structure. Continuing Theoretical Developments There are many different psychoanalytic or psychodynamic approaches. Karen Horney’s work focused on how social and cultural factors can affect personality development. Horney criticized Freud’s ideas in a feminist way. Horney’s work has been labeled “neo-Freudian.” Margaret Mahler includes components of drive, ego, object relations, and self psychology. She emphasized mother-child interactions. The Relational Psychoanalytic Movement Jacques Lacan Relational psychoanalysis is also referred to as: – Intersubjectivity or Two-person psychology – It emphasizes that the psychoanalyst is always subjective. The analyst is viewed as participantobserver. – Emotional involvement and countertransference reactions are used to facilitate therapy. The Relational Psychoanalytic Movement The therapist and client are referred to as the psychoanalytic couple. This means the analyst no longer has the unquestionable authority to make “interpretations” of his client’s unconscious derivatives, but instead is a partner in exploring the client’s personal and interpersonal unconscious and conscious dynamics. Attachment-Informed Psychotherapy Attachment theory is a psychoanalytically oriented approach. John Bowlby focused on: – Internal working models based on – Real child-caretaker interactions (not fantasies!). Actual child-caretaker interactions are foundational to personality formation. Attachment-Informed Psychotherapy II • Mary Ainsworth (1970) elaborated on attachment dynamics or styles in her strange situation experiments in the lab. – She studied children as they were separated from mothers, reacting to strangers, and were then reunified with mother. – She identified three attachment styles: 1. 2. 3. Secure attachment Anxious-resistant insecure attachment Anxious-avoidant insecure attachment – Disorganized/disoriented attachment style was added by Mary Main. Practical Modifications: Short-Term and TimeLimited Psychoanalytic Psychotherapy There have been efforts to shorten the treatment duration. Sandor Ferenczi (1920, 1950) • Therapy is more or less suggestive. • Be more active to shorten treatment duration. Alexander and French (1946) wrote about the corrective emotional experience where therapists adopted a compensatory role. If the client suffered from critical parent and due to the transference, expected criticism from the analyst, then the analyst would adopt a very positive and supportive role. THE PRACTICE OF PSYCHOANALYTIC THERAPY Goals include: To make the unconscious conscious or increase client awareness To help clients develop greater ego-control or selfcontrol over maladaptive impulses To help clients rid themselves of maladaptive or unhealthy internalized objects and replace them with more adaptive internalized objects To repair self-defects through mirroring, presenting a potentially idealized object, and expressing empathy. Assessment Issues and Procedures • Psychoanalysts use: – Clinical interviewing – Projective testing • Rorschach Inkblot Test • Thematic Apperception Test • Free association to specific words • Human figure drawings These approaches have been criticized by some. Unless you’ve received adequate training and supervision, you should avoid using projective assessment strategies. THE PRACTICE OF PSYCHOANALYTIC THERAPY The Basic Rule: Psychoanalysts begin each session the same way. They tell the client, “Say whatever comes to mind.” This is the basic rule in psychoanalysis. Through free association, unconscious impulses can rise more closely toward consciousness. The Basic Rule All external stimuli are minimized. To let unconscious impulses and conflicts rise to consciousness, distractions must be minimized. This is one reason why Freud used a sofa. If the client lies on a sofa and then the analyst sits behind it, the client cannot see him; the distracting stimulus of the analyst’s facial expressions is eliminated. The Basic Rule The client’s internal stimuli are minimized. When free associating, it’s best not to be too hungry or thirsty or physically uncomfortable. If clients come to analysis hungry, thoughts about food will flood into their free associations. If the client is physically uncomfortable, it will distract from the free association process. The Basic Rule Cognitive selection or conscious planning is reduced. Free association is designed to deal with intentional or planned thought processes. If a client comes to therapy with a list of things to talk about, psychoanalytic practitioners might interpret this behavior as resistance. • Psychoanalytic approaches include the following concepts and procedures: – – – – – – – – Interpretation Developing a therapeutic alliance Role induction Timing Transference Countertransference Triangles of insight Dream interpretation Interpretation The Freudian analyst’s job is to listen for and interpret unconscious derivatives. Fenichel is saying that analysts must prepare clients before using interpretation. Proper client preparation involves these steps: Developing a Therapeutic Alliance Role Induction Timing What to Interpret Role Induction Role induction is a procedure through which therapists tell clients about how therapy works. To use interpretation more collaboratively, you might say something like this: “As I do therapy with you, I may notice some patterns. These patterns may be linked to your early childhood relationships, your relationship with me, or your descriptions of your relationships outside therapy. Is it okay with you if I occasionally mention these patterns so we can explore them together and a better understanding about how they might affect your life?” THE PRACTICE OF PSYCHOANALYTIC THERAPY Transference is a distortion that involves re-experiencing Oedipal issues in the therapeutic relationship. The client’s experience of the therapist that is shaped by the client’s own psychological structures and past and involves displacement, onto the therapist, of feelings, attitudes and behaviors belonging in earlier significant relationships. Your client treates you like someone you aren’t. THE PRACTICE OF PSYCHOANALYTIC THERAPY Countertransference: defined as the therapist’s tendency to see the client in terms of his or her own previous relationships. It’s the same as transference, but it occurs only when the transference is directed from the therapist toward the client. For Freud, countertransference is a negative factor in therapy. When working with clients, it’s helpful to pay attention to your own emotions, thoughts, impulses, and behaviors. During a session, you may notice that you feel irritated or annoyed with a client. Transference X Countertransference Because clients bring developmental baggage into therapy with them, they will project their parent relationship dynamics onto the therapist. It is called transference. Because therapists bring developmental baggage into therapy with them, the same projection process can occur in the opposite direction. When therapists project their childhood relationship patterns onto the client, it is called countertransference. THE PRACTICE OF PSYCHOANALYTIC THERAPY Triangles of Insight Beyond resistance, psychoanalytic therapists often focus their interpretations on triangles of insight. These insight triangles are conflict-based or transference- based. The conflict-based triangle of insight includes: (1) the client’s wish, aim, or drive; (2) the threat or imagined threat that makes the direct pleasure of the wish impossible; (3) the defensive compromise. THE PRACTICE OF PSYCHOANALYTIC THERAPY (cont.) The transference-based triangle of insight includes: (1) observations based on the transference relationship, (2) the client’s reports of his early childhood relationship dynamics, (3) the client’s reports of his current, outsideof-therapy relationships. THE PRACTICE OF PSYCHOANALYTIC THERAPY (cont.) Dream Interpretation Freud considered dreams to be the royal road to the unconscious. Dreams consist of unconscious derivatives and require interpretation to produce insight. Psychoanalytic dream analysis is an interactive. It emphasizes client’s reactions to and impressions of the dream’s meaning. Although the analyst’s perspective and interpretations are important, the method involves asking clients to free associate to their dreams, and then a collaborative exploration of responses follows. Freud’s Theory in Action: Implications for Psychotherapy Traditional psychoanalysis interprets psychological defenses before conflict. If you interpret underlying conflict first, client will use preexisting mechanisms to deny, repress or defend themselves from your insightful interpretation. If you tell the client that the reason for her silence is fear of rejection, she’s likely to withdraw from you by more silence. But if you interpret defense first, discussing how she uses silence to protect herself, she may use less distorting defenses. Interpretation works best when nested in an empathic therapy alliance. Timing is critical for interpretation. Wait until the interpretetive material comes to surface. Problem formulation Psychoanalytic case formulations have interpersonal foundations. These foundations are built from repeated childcaretaker interactions and later manifest themselves clients’ daily lives. Outcome measures Contemporaray psychodynamic outcome researchers use a combination of symptomoriented measures (BDI) and interpersonal process measures. Cultural and Gender Considerations Psychoanalytic approaches have historically not been friendly to women and feminist perspectives. – There is often blaming of mothers. – There is often insensitivity or lack of focus on social explanations for behavior. – Psychoanalytic treatment can also be very sensitive to individual differences. Evidence-Based Status Research on psychoanalytic approaches is very challenging. – Evidence is accumulating to support psychoanalytic approaches. – Some studies have weak or defective methodologies. – CBTs are sometimes found to be more effective. – Controlled research and meta-analyses have indicated that psychoanalytic therapies are at least slightly more effective than no treatment. Preparing Yourself to Do Psychoanalytically Informed Therapy Getting psychoanalysis for yourself. When in doubt, don’t forget the basic rule “What’s passing through your mind right now?” Use noncritical, mutual exploration as a general technique. Pay attention to your client’s childhood baggage and possible transference. Pay attention to your own childhood, interpersonal baggage, and possible countertransference. Allegiance effect: A term used to describe the research finding that a researcher’s therapy choice or allegiance is a strong predictor of outcome study results.