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CH 2,3 Psychoanalytic & Psychodynamic Therapies.docx

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University of Toronto St. George
Neil Rector

CH 2 Psychoanalytic Therapies • Freud: the basis of neurosis was the conflict between the id’s instinctive desires and society’s retribution for the direct expression of those desires. • Freud insisted that as the founder he alone had the right to decide what should be called psychoanalysis. This led some of the best minds, includingAlfredAdler and Carl Jung, to leave the Psychoanalytic Society to develop their own systems • Freud viewed personality in 6 different perspectives: o the topographic, which involves conscious versus unconscious modes of functioning o the dynamic, which entails the interaction and conflict among psychic forces o the genetic, which concerns the origin and development of psychic phenomena through the oral, anal, phallic, latency, and genital stages o the economic, which involves the distribution, transformation, and expenditure of psychological energy o the structural, which revolves around the persistent functional units of the id, ego, and superego o the adaptive view, implied by Freud and developed by Hartmann (1958), which involves the inborn preparedness of the individual to interact with an evolving series of environments • Psychoanalysis is a conflict model leading to compromise formation. The mind is embroiled in constant conflict between conscious and unconscious forces, between what the individual immediately desires and what the society deems acceptable o Mature human behavior = compromise between conflicting factions o The id will demand instant gratification of food, sex, bodily relief, and adoration, but the superego will deny these earthly and immediate pleasures. So we invariably compromise—we wait until the acceptable time and place to eat, defecate, have sex, and secure undivided attention (ego) • Defence mechanism o The defenses serve to keep the individual out of danger of punishment for breaking social rules. Defenses also keep us from experiencing the anxiety and guilt that would be elicited by desires to break parental and social rules. For defenses to work, the person must remain unconscious of the very mechanisms being used to keep sexual and aggressive impulses from coming into awareness o Societal rules aimed at controlling those sexual & aggressive impulses, and the individual’s defense mechanisms controlling the impulses in such a way as to keep guilt and anxiety to a minimum while allowing some safe, indirect gratification Freud’s psychosexual developmental stages (SEE slides) • Oral stage o With deprivation, the child can remain fixated at the oral stage: Energies are directed primarily toward finding the oral gratification that was in short supply during childhood. With overindulgence, the child can 1 also become fixated at the oral stage but energies are directed toward trying to repeat and maintain the gratifying conditions. o Fixation due to either deprivation or overgratification leads to the development of an oral personality that includes the following bipolar traits: o Deprivation → pessimism, suspiciousness, self-belittlement, passivity, and envy o Overindulgence → optimism, gullibility, cockiness, manipulativeness, admiration • Fixation at the oral stage brings a tendency to rely on more primitive defenses when threatened or frustrated Defence mechanisms Definition Cognitive level Denial Having to finally close one’s eyes andClosing off one’s attention to go to sleep as a way of shutting out tthreatening aspects of the world or unmet oral needs self Projection Infant’s spitting up anything bad thatPerceiving in the environment taken in and making the bad things parthose aspects of oneself that are bad of the environment or threatening Incorporation Taking in food and liquids and making Making images of others part of these objects an actual part of oneselone’s own image • Oral personality: people are anxious that if their loved ones knew how selfish, demanding, and dependent they really are, their loved ones might leave or withdraw their love. o With experience, they learn that they had better control their intense desire to be cuddled, cared for, fed, and suckled, lest they be left alone. So they learn to deny or project such narcissistic wishes, although they continually crave to passively receive without giving or to aggressively take without deserving o Rarely judged to be pathological • Anal stage o Caretakers are too demanding → stinginess, constrictedness, stubbornness, orderliness, punctuality, precision o Caretakers are overindulgent → over-generosity, expansiveness, acquiescence, messiness, tardiness, vagueness o Fixation leads to “anal personality” – constricted, stubborn, over-controlling, stingy, & too focused on orderliness and tidiness Defence mechanisms Definition Reaction formation Behaving the opposite of what one truly desires, develops first as a reaction to being very clean and neat, as the parents demand, rather than expressing anal desires to be messy Undoing Atoning for unacceptable desires or actions 2 Intellectualization Process of neutralizing affect-laden experiences by talking in intellectual or logical terms, is partly related to such experiences as talking about the regularity of bowel movement as being soothing to one’s gastrointestinal system • Phallic stage o Oedipal conflict - The son will naturally direct his genital sexual desires initially toward his mother and would expect her to gratify him, BUT the father already has the rights and privileges of enjoying the mother. o The son’s fear is that the father might punish his rival by removing the source of the problem—the son’s penis. This castration anxiety eventually causes the son to repress his desire for his mother, repress his hostile rivalry toward his father o Over-rejection → self-hatred, humility, plainness, shyness, isolation, bashfulness o Over-indulgence → vanity, pride, stylishness, flirtatiousness, gregariousness, brashness o The child also has to defend against castration anxieties  Defence mechanism = repression • Latency stage o No new personality development o Ego development & learning the social rules of being a citizen. These gains enable the child to psychologically enter adolescence and to navigate the genital stage when it hits • Genital stage o An individual does not progress to the genital stage without at least some conflict between instinctual desires and social restraints. But no one becomes a fully mature, genital character without undergoing a successful psychoanalysis Theories of psychopathology • Stressful events—such as the death of a loved one, an offer of an affair, or a medical illness—stimulate the impulse that individuals have been controlling all their lives. • The person is highly motivated to spend whatever energy is necessary to keep impulses from coming into consciousness. → an exacerbation of previous defenses to the point which they become pathological • When symptoms serve both as defenses against unacceptable impulses and as indirect expressions of these wishes, then the symptoms are doubly resistant to change. Other benefits from symptoms, such as special attention from loved ones/ doctors, are secondary gains and make symptoms even more resistant to change. • Primary process-thinking o Not logical, unconscious in nature; secondary process-thinking = logical, conscious o Displacement – placing energies from highly charged emotional ideas onto more neutral ideas 3 o Manifest content - the content that is conscious, is only a minor portion of the hidden, or latent, meaning of events Therapeutic processes – consciousness raising • Patients’work o Free association → To help the patient work in the face of potential terror and resulting defensiveness, the analyst must form a working alliance with the part of the patient’s ego that wants relief from suffering and is rational enough to believe that the analyst’s directions can bring such relief. Through this alliance, patients also become willing to recall in detail dreams and childhood memories, even though such material brings them closer to threatening impulses • Therapists’work o 4 procedures: Confrontation, Clarification, Interpretation, Working through o Analyzing patients’resistance to free association & the transference that emerges as patient regress & express instinctual desires toward the analyst o Confrontation & Clarification: making sure patients are aware of the particular actions/exp being analyzed + detailed feedback regarding that particular phenomenon o Interpretation: assigning meaning & causality of patients’responses; it’s the patient’s response to verify the interpretation.  If patients gain insight—if they have a cognitive & affective awakening about aspects of themselves that were previously hidden—then analysts have some evidence for the validity of their interpretations.  The most critical response for verifying interpretations is whether the interpretations eventually lead to a change for the better in the patient. o As blind resistance is gradually reduced through insightful interpretations, the client begins to release hidden instincts toward the therapist. The patient satisfies frustrated sexual and aggressive impulses by displacing them onto the analyst, and gradually a neurotic transference develops in which the patient relives all of the significant human relationships from childhood. For weeks or months, the therapist may be experienced as the nongiving, miserly mother who does not care about the patient; o Painfully, through repeated interpretations, the patient must realize that these intense feelings and impulses come from within and represent the patient’s pregenital conflicts, not realistic feelings elicited by the relatively blank-screen analyst. o Working through = The slow, gradual process of working again and again with the insights that have come from interpretations of resistance and transference  Gradually the person becomes aware that there are indeed new and more mature ways of controlling instincts that allow some gratification without guilt or anxiety. Therapeutic content • Intrapersonal conflicts 4 o Anxieties shore up resistance & defences need to be replaced by more mature, realistic, & gratifying ones o Self-esteem: lack of genuine self-esteem results from personality problems. The best that can be done is to help patients consciously restructure their personalities into a more genital level of functioning. → stable sense of self-esteem o Responsibility • Interpersonal conflicts o Intimacy - The problem of intimacy is basically a transference problem. The pregenital personality cannot relate to another person as the other person really is, but distorts the other according to childhood images of what people are like. Rather, immature individuals distort their perceptions of other people to fit internalized images. o Sexuality - Sexual relationships for immature people also reflect transference relationships. Two immature people can only engage in object relationships in which the other is seen as perhaps finally being the one who will satisfy ungratified pregenital instincts. o Communication - Immature personalities are locked into their egocentric worlds, in which others are only objects for their gratification. They do not respond to what the other says, but rather to their own selfish desires. They do not talk to each other, but rather speak to their internal images of what the other is supposed to be. o Hostility - With overcontrolled neurotics, the best we can expect is to rechannel hostility into more socially acceptable outlets such as competition, assertiveness, or hunting o Control - Individuals also expect to control relationships when they experience the other person as nothing more than an object that exists to gratify their infantile desires. Each pregenital type of personality has its unique style of controlling others: Oral characters control by clinging, anal characters control through sheer stubbornness, and phallic characters control through seductiveness. The most intensely controlling people seem to be anal personalities who have come from overcontrolling families. They feel they were once forced to give in on the toilet and thereby lost control over their bodies. Now they act as if they are determined never to give in again. Therapists remain silent to countercontrol the patient. • Individuo-social conflicts o Adjustment vs transcendence - culture must be repressive to some degree. the most conscious individuals must compromise with the culture in which they live and leave fantasies of transcendence to the angels o Impulse control - Freud, however, was one of the earliest to recognize it is much easier for therapists to loosen the controls of neurotics than to produce controls for impulse-ridden personalities. The best hope for individuals and society was to replace the rigid but shaky infantile veneer with a more mature set of controls • Beyond conflict to fulfillment 5 o Meaning in life - Sublimation is a mature ego defense that allows us to channel the id’s energy into more acceptable substitute activities: Oral sucking can become cigar smoking, anal expression can become abstract art o Ideal individual - The ideal individual for Freud, and the ultimate goal of psychoanalysis, is a person who has analyzed pregenital fixations and conflicts sufficiently to attain, and maintain, genital functioning. → The genital personality loves sex without the urgent dependency of the oral character, is fully potent in work without the compulsivity of the anal character, and is satisfied with self without the vanity of the phallic character. This ideal individual is altruistic and generous without the saintliness of the anal character, and is fully socialized and adjusted without immeasurable suffering from civilization Therapeutic relationship • Working alliance based on the relatively nonneurotic, rational, realistic attitudes of the patient toward the analyst vs Transference represents the patient’s neurotic, unrealistic, and antiquated feelings toward the analyst • The analyst’s own reaction to the patient constitutes a delicate balance between being warm and human enough to allow a working alliance to develop, yet neutral and depriving enough to stimulate the patient’s transference reactions • Frequently, neutral responses such as silence are more likely to stimulate transference reactions, and thus an analyst’s reactions to the patient’s productions are best described as unconditional neutral regard Practicalities of psychoanalysis • Psychoanalysis completed in 3-5years; Patients are subtly encouraged to associate primarily to their past, their dreams, or their feelings toward the analyst. The analyst keeps self-disclosures to a minimum and never socializes with patients. Needless to say, the analyst becomes a central figure in the patient’s life, and during the neurotic transference, the analyst is the central figure Major alternatives: Psychoanalytic Psychotherapy & Relational Psychoanalysis • Anna Freud is rightfully known as one of the “mothers” of ego psychology (which is also considered in Chapter 3). Anna systematized and expanded our understanding of defense mechanisms • Briefer psychoanalytic therapy will frequently discourage a transference neurosis from developing; positive transference > more rapid therapy • If it has been decided that a transference neurosis is unnecessary/damaging, the interpretations will be restricted to the present situation, because interpretation of infantile conflicts encourages regression and dependency. • Regression to early stages of functioning → avoiding dealing with present conflicts. Attention to disturbing events in the past would be used only to illuminate the motives for irrational reactions in the present. • Acorrective emotional exp occurs when patients reexp the old, unsettled conflict but with a new, healthier ending within the therapeutic relationship 6 • Psychoanalysis has undergone a paradigm shift from drive reduction to the relational model. Relational psychoanalysis posits that the therapist is unavoidably embedded in the relational field of the treatment; the pulls and feelings of the therapist are regarded as related to the patient’s dynamics and as providing potentially useful information o Focuses upon desires, not sexual and aggressive drives.Amajor desire is for close, satisfying relationships. o The corresponding theory of mind: Freud’s structural perspective of id, ego, and superego → a mind socially constructed from interactions with others and the external world. Both the important content and the curative method of relational psychoanalysis are human relationships. o The relational model assumes that both insight and corrective emotional experiences are necessary to produce deep and enduring change. o Interpretation remaining one, but complemented by the power of the novel interaction within the therapy relationship o The locus of change: for Freud was inside the patient’s head; for relational psychoanalysts, the locus is between people. o The analyst’s role: from lofty, cerebral detachment → concerned, active involvement. o The importance assigned in classical psychoanalysis to abstinence, neutrality, and anonymity gives way in relational psychoanalysis to responsiveness, reciprocity, and mutuality. → the patient undergoes a corrective emotional experience and learns new skills within the context of an empathic relationship. Effectiveness of psychoanalysis • Knight (1941), who surveyed dispositions of patients who stayed in psychoanalysis for at least 6 months. • The data involved the analysts’judgments of whether patients were “apparently cured,” much improved, improved, unchanged, or worse when analysis was terminated. This survey study had the advantage of being cross-cultural. o Across patient diagnoses, approximately half of the patients completing classical psychoanalysis were apparently cured or much improved • Virtually all the researches are retrospective, uncontrolled, naturalistic studies in which treatments wasn’t standardized with duration/technique, etc • The efficacy of classical and relational psychoanalysis has not been adequately tested. We cannot safely conclude  that psychoanalysis has proved itself more effective than a credible placebo therapy 7 • Research on psychoanalytic psychotherapy o Sloane et al (1975): compared the effectiveness of short­term psychoanalytic psychotherapy with that of  short­term behavior therapy. At the end of 4 months of therapy, both treatment groups were significantly  more improved than the no­treatment group, and neither form of psychological treatment was more  effective than the other. On symptom ratings, 80% of the patients in each therapy group were considered  either improved or recovered, compared to 48% in the control group. On ratings of overall adjustment,  93% of the patients in behavior therapy were considered improved, compared with 77% of the  psychoanalytic psychotherapy group and 47% of the waiting list. o Kernberg (1973): no difference in improvement between those in psychoanalysis and those in  psychoanalytic psychotherapy;  o Intrapsychic conflict resolution is not always a necessary condition for change; the supportive  psychoanalytic therapy produced greater than expected success; and classical psychoanalysis produced  less than expected success Criticisms of psychoanalysis • From a cognitive­behavioral perspective o Psychoanalysis is much too subjective and unscientific. The psychoanalytic notions of unconscious  processes, ego, and defenses are mentalistic, and incapable of direct observation in a way that can be  objectively measured and scientifically validated • From an existential perspective o Too objective & too deterministic  • From a cultural perspective o The broader social context is practically ignored in psychoanalytic treatment. The exclusive focus on the  intrapsychic makeup of the individual neglects the family, the culture, and the society. Disorders and  fixations are attributed to internal conflicts rather than family dysfunction or social problems o Psychoanalytic theory is so clearly patriarchal and Eurocentric  • From an integrative perspective o Most integrationists will also use the concepts of resistance, defenses, and transference in their thinking  about the content of therapy & a psychoanalytic approach helps formulate clients’ problems 8 • Orthodox rather than effective, less flexible Future directions • Time­limited psychoanalytic therapy & briefer forms of relational psychoanalysis • Interpersonal & integration CH 3 Psychodynamic Therapies Asketch of Freud’s descendants Psychoanalytic Psychodynamic Id Ego Intrapsychic Interpersonal Defences Mastery, adaptation Biological Social • Carl Jung launched his own analytical psychology. Jung pursued a path different from Freud’s when he found himself unable to accept the exclusively sexual nature of Freud’s notion of libido. • Jung relied extensively on the interpretation of dreams and symbols to access the patient’s archetypes (inherited predispositions or models on which similar things are patterned). Jung was convinced of the existence of a collective unconscious, along with a personal unconscious. o The collective unconscious contains primordial archetypes inherited from our past that record common experiences repeated over countless generations. o Common archetypes include the hero, the shadow (or “dark side”), the Mother, and the trickster. These controversial propositions along with his word association test and the introvert-extravert distinction remain Jung’s original contributions to the field. Adlerian Therapy • Adler established individual psychology to underscore the importance of studying the total individual in therapy Theory of personality 9 • Striving for superiority is the core motive of the human personality. To be superior is to rise above what we currently are. To be superior does not necessarily mean to attain social distinction, dominance, or leadership. o Striving for superiority means striving to live a more perfect and complete life. It is the superordinate dynamic principle of life; striving for completion and improvement encompasses and gives power
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