Paul Cammell
Consultant Psychiatrist, Flinders Medical Centre
Lecturer, Flinders University
Psychodynamically informed practice
1. Discussion of cultural context: Australian
psychotherapeutic culture (psychiatric and other)
2. Discussion of psychodynamic theories – relevance to
your training and practice in general
* Toolbox of concepts
*Recommended Readings
3. Three Lectures: Prof Kalucy, Dr Paul Cammell and Dr
Robin Chester
Psychoanalytic Psychotherapy:
-processes: transference, interpretation,
resistance, enactment, etc
-analytic triangles
Malan--of person/conflict
-models: classical, object relations, self psychology, ego
psychology, relational, interpersonal, intersubjective, attachment
orientation, mentalization, Lacanian, etc
-training (theoretical, clinical supervision, training analysis, infant
observation)
Ranges of modalities adopted by psychiatrists:
Formal psychoanalysis, psychoanalytic psychotherapy, psychodynamic
psychotherapy, insight-oriented psychotherapy, psychodynamicallyinformed psychiatric management
Conflicts with the era of managed care, health insurance funds, evidence
based medicine, health management, time-limited, cost efficient
approaches
Role of Psychotherapy Outcomes Research
Universal Techniques
• Focus on affect and expression of emotion
• Exploration of attempts to avoid distressing
thoughts and feelings
• Identification of recurring themes and
patterns
• Developmental focus – exploration of past
experiences
• Focus on interpersonal relations
• Focus on the therapeutic relationship
• Exploration of wishes and fantasies
Classical Freudian Technique
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•
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•
Transference Interpretation
Dreams, Parapraxes
Conflict and Defence
Remembering, repeating, working
through… Nachtraglichkeit
Transference
• Freud, S. (1912). The Dynamics of Transference. The Standard Edition
of the Complete Psychological Works of Sigmund Freud, Volume XII
(1911-1913): The Case of Schreber, Papers on Technique and Other
Works, 97-108.
• Freud, S. (1914). Remembering, Repeating and Working-Through
(Further Recommendations on the Technique of Psycho-Analysis II).
The Standard Edition of the Complete Psychological Works of Sigmund
Freud, Volume XII (1911-1913): The Case of Schreber, Papers on
Technique and Other Works, 145-156.
• Klein, M. (1952). The Origins of Transference. Int. J. Psycho-Anal.,
33:433-438.
• Strachey, J. (1969). The Nature of the Therapeutic Action of
Psychoanalysis. Int. J. Psycho-Anal., 50:275-292
• Winnicott, D.W. (1956). On Transference. Int. J. Psycho-Anal., 37:386388
Object Relations and British
Independent or Middle Tradition
• Klein: pre-Oedipal development, the
paranoid-schizoid and depressive
positions, envy, mourning
• Bion: containment and alpha-beta
function, psychotic personality
• Winnicott, holding, transitional
phenomena, false self
• Balint, Fairbairn etc
Ego Psychology, Neofreudian
approaches
• Ego defenses
• Countertransference
• Heimann, P. (1950). On Counter-Transference. Int.
J. Psycho-Anal., 31:81-84
• Bion, W. R. (1967b), Notes on memory and desire,
Psychoanalytic Forum, 2, 271-286
• Sandler, J. (1976). Countertransference and RoleResponsiveness. Int. R. Psycho-Anal., 3:43-47
ERIKSON’S EIGHT STAGES OF THE LIFE CYCLE
Trust versus Mistrust (Birth to Approximately 18 Months)
Autonomy versus Shame and Doubt (Approximately 18 Months
to Approximately 3 Years)
Initiative versus Guilt (Approximately 3 Years to Approximately 5
Years)
Industry versus Inferiority (Approximately 5 Years to
Approximately 13 Years)
Identity versus Role Confusion (Approximately 13 Years to
Approximately 21 Years)
Intimacy versus Isolation (Approximately 21 Years to
Approximately 40 Years)
Generativity versus Stagnation (Approximately 40 Years to
Approximately 60 Years)
Integrity versus Despair (Approximately 60 Years to Death)
Defense Mechanisms
Narcissistic-Psychotic Defenses
Projection
Denial
Distortion
Splitting
Immature Defenses
Acting out
Blocking
Hypochondriasis
Introjection
Passive-aggressive behavior
Projection
Regression
Schizoid fantasy
Somatization
Adapted from Vaillant GE. Adaptation
to Life. Boston: Little Brown; 1977;
Semrad E. The operation of ego
defenses in object loss. In: Moriarity
DM, ed. The Loss of Loved Ones.
Springfield, IL: Charles C Thomas;
1967; and Bibring GL, Dwyer TF,
Huntington DS, Valenstein AA. A
study of the psychological principles
in pregnancy and of the earliest
mother–child relationship:
Methodological considerations.
Psychoanal Stud Child. 1961;16:25.
Neurotic Defenses
Controlling
Displacement
Dissociation
Externalization
Inhibition
Intellectualization
Isolation
Rationalization
Reaction formation
Repression
Sexualization
Mature Defenses
Altruism
Anticipation
Asceticism
Humor
Sublimation
Suppression
Defense mechanisms
Adapted from Vaillant GE. Adaptation to Life.
Boston: Little Brown; 1977; Semrad E. The
operation of ego defenses in object loss. In:
Moriarity DM, ed. The Loss of Loved Ones.
Springfield, IL: Charles C Thomas; 1967; and
Bibring GL, Dwyer TF, Huntington DS, Valenstein
AA. A study of the psychological principles in
pregnancy and of the earliest mother–child
relationship: Methodological considerations.
Psychoanal Stud Child. 1961;16:25.
Attachment Theory
Bowlby: Attachment and Loss Trilogy
Evolutionary science, Ethology
Grief, Privation, Deprivation
(Maternal) attachment figure and security
Internal Working Models
Attachment (Proximity seeking)
Separation (Anxiety, Anger)
Loss (Sadness, Depression)
Questions ?
Recommended Readings
Self Psychology
• Heinz Kohut
• Narcissism, Self pathology
• Self cohesion, shame, mirror/twin and
other transferences
Kernberg
•Ego Psychology and Object Relations
•Borderline Personality
•Transference Focussed Psychotherapy and the
Evidence-Based Paradigm
Interpersonal, Relational
Approaches
• Ogden, Sullivan, Mitchell, Aron,
Stolorow, Orange, Bromberg
• The authority of the patient, coconstruction and the analytic third
• Context, prejudice, the return of
dissociation, focus on trauma,
existential, humanistic and
hermeneutic approaches
Lacan
• The French and Latin-American
psychotherapy cultures
• Theory, Philosophy and Psychotherapy
• The Three Orders, Linguistics,
Structuralism
Borderline Personality Disorder
“The Problem Patient
of Our Time”
Borderline Personality and
developmental neuroscience
Giovanni Liotti:
Disorganized Attachment and Borderline PD
Peter Fonagy et al.:
Mentalization as a core construct
Russell Meares:
Memory, frontal/pre-frontal function
Glen Gabbard:
Mind-body interactions
– HPA axis, hippocampal volume, hemispheric
lateralization
Allan Schore:
Right Brain Development and affective regulation
Borderline Syndromes – History
1.
Psychoanalysis
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–
2.
1930s-1950s Stern, Knight
1960s-1970s Kernberg, (Winnicott, Khan, Bergeret)
Psychiatry
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•
•
•
1940s-1960s Ambulatory Schizophrenia (Zilboorg),
“Preschizophrenia” (Rapaport), “latent schizophrenia” (Federn),
“pseudoneurotic schizophrenia” (Hoch and polatin), “schizotypal
disorder” (Rado)
Late 1960s “Borderline states” (Knight), “Borderline Syndrome”
(Grinker)
Mid 1970s “Borderline Personality” (Gunderson et al.)
1980 DSM III “Borderline Personality Disorder”
Modern “evidence-based” psychotherapy
3.
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1970s-1990s Object Relations BasedTransference Focussed
Psychotherapy (Kernberg, Clarkin)
1990s Dialectical behaviour Therapy (Linehan); “Mentalization-based
treatment” (Fonagy, Bateman, Target)
1990s-present Cognitive Analytic Therapy (Ryle), Conversational
Model (Meares), Supportive Psychoanalytic Psychotherapy
(Appelbaum), Schema-Focused Therapy and Systems Training for
Emotional Predictability and Problem Solving (or “STEPPS”, Blum)
Modern Therapeutic Approaches
• Pharmacotherapy
– HPA axis sensitization and anxiolytic medication (eg
atypical antipsychotic medications)
– Serotonergic agents
• Psychotherapy
– Dialectical Behaviour Therapy (Linehan)
– Psychodynamic psychotherapy
• Mentalization-based (Fonagy, Bateman, Target et al.),
• Object-Relations based (Kernberg)
• Self-Psychology based (Meares)
– Other
structured, crisis plans, patient responsive, limit setting,
team-based
Mentalization
• Theory of mind (Fonagy, Bateman,
Target et al.), social biofeedback
theory, “mentalized affectivity”
• Borderline Personality Disorder—
psychic equivalence and pretend
modes; splitting and dissociation;
disorganized trauma responses; affect
dysregulation
Giovanni Liotti and Attachment
Disorders
• Ethology/evolutionary research:
motivational systems (and IWM’s)
– eg care-seeking, care-giving, sexual—pair bonding, ranking—
dominance/submission, egalitarian/altruistic, intersubjective
• Attachment Disorganization and
psychopathology
– borderline and antisocial PD, conduct disorder, emotional
dysregulation and impulse control problems (HPA
Hyperresponsiveness)
• Transgenerational transmission
– The Adult Attachment Interview
Mentalization
• Theory of mind (Fonagy, Bateman,
Target et al.), social biofeedback
theory, “mentalized affectivity”
• Borderline Personality Disorder—
psychic equivalence and pretend
modes; splitting and dissociation;
disorganized trauma responses; affect
dysregulation
Borderline Personality and
“abuse” or “trauma”
Judith Herman:
Complex PTSD “sexual abuse”
ERS Nijenhuis, Onno van der Hart:
Psychotraumatology and
Dissociative Disorder
Questions ?
Case for Next Week
Recommended Readings
Recommended Readings:
General texts, including evidence based reviews:
New Oxford Textbook of Psychotherapy (Gabbard, Beck,
Holmes)
What works for whom, Roth & Fonagy
Standards and Guidelines for the Psychotherapies (Paul
Cameron, Jon Ennis & John Deadman Eds) eg Chapter 3
Basic Approaches to Psychodynamic Psychotherapy:
David Malan (Individual Psychotherapy and the Science of
Psychodynamics), Glen Gabbard (Psychodynamic
Psychiatry), Nancy McWilliams (Psychoanalytic
Psychotherapy: A Practitioner’s Guide), Psychodynamic
Diagnostic and Statistical Manual
Models and Theories:
Comprehensive Textbook of Psychiatry (Kaplan & Sadock),
Chapters 6 and 30