Exam 1 Essay Flashcards
The Dimensions of Psychological Wellness (McWilliams)
Work- feel generative, feel what you do is important, contribution to their environment
Play- take pleasure in life, symbolic activity, playing with others
Love- authentic intimate relationship with one person or capacity or devotion to raise a child w/ integrity
Secure attachment- attachment style where the child feels some distress when the parent leaves, but are able to compose themselves when the caretaker returns. Very hard to change attachment over the lifetime. Unless you have a marriage that lasts for over 5 years or have intensive psychotherapy for two years; do they feel adequately safe in the world
Sense of agency/self-efficacy/autonomy- you can go after what you want in life. You have some say in your life.
Self and object constancy/identity integration- Can feel ambivalent (bad and good qualities). People who lack this can’t talk about their dad as both good and bad, they’re either all bad or all good. They have no constancy. No continuity of who you were, who you are and who you want to be.
Ego strength/resilience- can you suffer some kind of stress and find a response to be adaptive? Be able to tolerate it & deal w/ it
Realistic and reliable self-esteem- Knowing what you’re good and bad at. This is why it’s bad in schools that kids are always told they’re perfect, have internal experience of being fraudulent. Praise feels empty.
Abiding values/conscious- ethics, morals, integrity.
Affect & thought tolerance and regulation- move fluidly from 1 emotion to another. Can regulate your emotions, if someone does something bad you don’t explode and crash their car.
Insight/ego alien/reality testing- understand themselves & other people, knowing they’re understood.
Capacity to mentalize about others/ theory of mind (mentalization)- other people are separate subjects of subjectivity. Think everything that happens to them is directed at them. “Baby knows how to push my buttons”
Flexibility of coping styles- people go to same defense if they don’t have this. Ability to have a different coping style in different scenarios. Character armor (rigid in 1 characteristic)
Balance between relatedness/separateness- can be close with people, but can also be alone.
Vitality, passion, pleasure in life, and meaning in life- People who don’t have this have never felt pleasure, passion.
Accepting what can’t be changed/capacity to mourn/surrender- Grieve and move on; stop spending useless energy on things that won’t change; not all problems are solveable
Shedler’s 7 features of psychodynamic technique
Focus on affect and emotional expression (versus thoughts and cognitions)- emotional insight versus intellectual insights accords for a more deeper sense of meaning.
Exploration of attempts to avoid distressing thoughts & feelings (defenses and resistance)- these explorations provide a window into the client’s unconscious feelings and emotions which may underlie the current problem.
Identification of recurring themes & patterns- work to identify recurring themes and patterns in client’s thoughts, feelings, self concepts, relationships and life experience
Patient may be aware of them but unable to escape them
Or may be unaware until therapist helps them recognize them
Discussion of past experience (developmental focus)- past experience may affect the conceptualization and approach towards the current situation and in some situations may even precipitate certain reactions in the given context. Psychodynamic psychotherapy therefore attempts to understand the relationship between past and present experiences.
. Goal: help patients free themselves from bonds of past experience- live more fully in the present
Focus on interpersonal relationships- Interpersonal relationships are considered to be the foundation of expression or restriction of emotions and feelings and their manifestations within these relationships are explored.
. Adaptive/non-adaptive aspects of personality & self-concept forged in attachment relationships
a. Psychological probs occur when problematic interpersonal patterns interfere w/ ability to meet emotional needs
Focus on the therapeutic relationship- the therapeutic relationship is central to the entire psychodynamic process and provides further insight into the client’s situation
. Deeply meaningful, emotionally charged
a. Repetition of interpersonal patterns occur in the therapy relationship too (transference & countertransference)
b. Goal: greater flexibility in interpersonal relationships & enhanced capacity to meet interpersonal needs
Exploration of fantasy life- repressed and unacceptable thoughts as perceived by the client are let out through symbolic and hidden expressions as seen in the client’s fantasy life and can be used to augment healing within therapy.
. Speak freely about whatever is on their mind
What are the active ingredients that predict successful therapy outcomes (see Shedler, McWilliams) and how effective is psychodynamic psychotherapy?
Ingredients
Working alliance/therapeutic relationship
Discussion of interpersonal relations & exploration of past experiences w/ early caregivers
Use therapeutic processes that have long been at the core of analytic theory & practice
The psychoanalytic sensibilities?
Efficacy
o Empirical evidence supports efficacy of psychodynamic therapy
large effect sizes
o Maintain gains after tx ends
o Can be just as effective as “legit” therapies
Which use things psychodynamic practitioners have used for yrs
What are the tasks of the first session of a dynamic treatment and why are these each important to do at the beginning?
(McWilliams)
Gaining informed consent
Addressing early obstacles to full participation in treatment
Encouraging Spontaneous, candid, emotionally expressive speech
Recommending the couch
Introducing work with the transference
Inviting the client’s reaction to the therapist
Conveying understanding
Assessing the patient’s reactions to a tentative formulation
Conveying Hope
Addressing Time and Length of Meetings
Addressing Payment
Reviewing your cancellation policy
Reviewing Diagnosis
Inviting Questions
Preparing clients to give a history
Sharing a dynamic formulation
Educating the client about the therapy process
Setting the frame for the whole thanggg
The psychoanalytic sensibility (McWilliams)
Curiosity and awe-
*Curiosity about an individual’s unconscious thoughts, feelings, images, and urges work together
*Willingness to feel small – open to being moved
*The receptivity to whatever presents itself and the curiosity about the magnitude of things it may mean
*Evenly hovering attention
*Not knowing
o Not difficult for observers to see others unconscious processes, but hard to see it in ourselves
· Most of our behaviors, thoughts, & feelings aren’t conscious
o Therapists don’t know what they’ll learn from a patient
o Have to be open to having your constructions disconfirmed
Be receptive to whatever presents itself & be curious to the multitude of things it may mean
Sentence form: therapist exhibits the genuine sense of interest and curiosity towards the client’s unconscious wishes, feelings and emotions. The therapist engages in an evenly hovering attention towards the client, with an open perception of receiving whatever may come out of therapy and dropping out any preconceived notions. Awe is characterized by the therapist’s willingness to feel small and to be moved by the patient’s experiences. Such curiosity and awe facilitates free flow of emotional expression.
- Complexity
*Paradox, ambiguity, dialectics, multiple self states, etc.
*Overdetermination: significant psychological problems or tendencies have more than one cause – often complex
*Anorexia example
*Temperament, emotionality, developmental history, social context, identifications, reinforcements received, values, stressors, etc.
*Also Multiple Functions: Any significant psychological tendency fulfills more than 1 unconscious function
May reduce anxiety, restore self-esteem, express an attitude, etc. – what this does for the individual
o Intrapsychic conflict = inevitable
o Freud saw humans as insatiable (b/c want mutually exclusive things)
Sentence form: Human psychology cannot be reduced to a single cause or effect. Psychoanalytical therapists view the individual as built up of a complex structure of psychological constructs which are influenced by a number of other factors and which influence several other factors as well (multiple functions). - Identification and empathy-
*Absorbing an aspect or attribute of the other
*Dipping into the client’s subjective experience
*“In order to find the patient, we must look for him within ourselves” Bollas, 1987
o View disturbance in any individual’s functioning as expressing an extreme or currently maladaptive version of a universal human tendency
o Constantly stress our common human developmental pathways, vulnerabilities, & strivings
o Can’t understand discrete probs in isolation from the person in which they exist
o Have to look to the psychopathologic parts of the self as the therapist to understand the patient
· ID deeper & deeper w/ client to get to emp
o Main “instrument” to understand ppl is our empathy
· Our person is our “delivery system” of that empathy
o Ability to “get” our patients rests on our intuitive & emotional abilities
o Better to be wrong but trying to ID w/ the client than being “right” but not being empathic
Sentence form: Human psychology shares common experiences (development, relationships etc.) which also underlie the therapeutic relationship. Most therapists themselves go into therpay and are therefore able to identify with the needs of the client. In an attempt to genuinely understand the client the therapist keeps dancing back and forth in and out of the patient’s world and deeply connecting and understanding the client from those perspectives. - Subjectivity and attunement to affect-
*There are many pre-verbally based communicative processes that are hard to observe – we feel them
*Scrutinized emotional experience can reveal a lot about what a client is trying to say
*Client is the one who can give free reign to feelings in session – you‘re at your best self
*Affect plays a determinative role in the process of growth and change
*Tuning into the affective world of the client (subjective immersion) remains one of the most important sources of information we have about what is “the matter”
o Learn from own affective reactions a lot about what the clients are trying to say
o Affects are contagious- induce complex emotional reactions in us
o Don’t let your subjectivity hang out, but pay attention to it
o Difference b/t intellectual & emotional insight
Can “know” something cognitively, but not know it at all
Sentence form: Psychodynamic psychotherapy derives from an appreciation of the subjective nature of human psychology which apply to both the therapist and client. Psychotherapy is usually characterized by the “right brain to right brain” dialogue between the client and therapist, wherein the therapist engages with the affective expressions of the client. - Faith
*Gut level confidence in a process, despite inevitable moments of skepticism, confusion, doubt, and even despair
*Trusting the analytic process
*It will take clients to honesty, agency, mastery, self-cohesion, self-esteem, affect tolerance, and the capacity for fulfilling relationships
*Believe symptoms will disappear or become significantly less severe
*The client must borrow your faith, lean on yours
*Not a faith in a particular outcome, only in the process
*Mutual search for what feels true
o Not in the religious sense
o Analysts have faith in process b/c had to be analyzed before could become analysts (have been thru the process b4)
o Practitioner must go w/ integrity so client trusts them to proceed too
o Have to be emotionally honest
Sentence form: The therapist conveys and asserts a sense of faith in the healing power of the therapy and the ability of the client to collaboratively and successfully engage in the healing process. This requires reliance on the therapist’s gut feelings. Such exhibition of faith gives the client the confidence and borrowed faith in the efficacy of the therapeutic process. - Attachment
*We are inherently social – developing in a relational matrix
*Individual psychology: determined by complex interactions between constitutional makeup, lived experience, and developmental challenges
*Treatment: the opportunity for a new person, the therapist, to facilitate a benign maturational process that naturally unfolds in an atmosphere of safety and honesty. Therapist and patient find a process to get the person to not be stuck because of the dangers that accompanied development exigencies in their history.
o Therapists will be experienced as “old objects” (internal voices similar to those of ppl by whom the client felt damaged)
Psychoanalytic not just about the past- about the here-&-now therapeutic relationship too
o “Cherishment”- sense of being affectionately & personally cared for by a devoted other
Creates possibility & will for change
Love can play a role in therapeutic healing (not necessarily romantic love)
More: By learning about the attachment process from Bowlby and the concept of separation from Mahler, we can actually begin to understand the therapeutic process. Relationship is the medium through which we work everyday. As we learn more about it, we begin to understand more about why the relationship between therapist and client is so healing and important. We require relationship in order to change.
How the self forms according to Object Relations Theory
Connection to the mother, initial connections, through being held, and connection through to separation and individuating. To be able to separate but connected. Internalizing the mother and remaining connected even in individuation. Having autonomy. Just being with the mother, having our needs without her needs intruding. We internalize some of mother, so we can be more on our own. The capacity to be alone. Psychological experience of another inside of us. To have a sense of presence of another.
Rather than feeling a void or vacuum or emptiness. This is what allows us to be human. Creativity and humanity and flow of thoughts and feelings – rather than being cut off, numbed, etc.
One Person Psychology and Two Person Psychology
one person - the traditional psychoanalytic stance conceived as the analyst as an observer in the session, and that the characteristics and dynamics that lie within the patient and are seen in session are bound to happen in almost any context
two person -strong emphasis on everything observed and experienced in the session is “co-constructed,” a product of the interaction between two people
you are observing”patient with me”
one is less likely to rule out any significant degree of therapist self-disclosure for fear of spoiling or muddying transference. the transference is a two person phenomenon in itself
the idea that one can see the transference in pure form, without the”distorting influence” of the therapist’s input is seen as an illusion
systems perspectives - believe that the two person perspective is just a conceptualization of the traditional clinical vantage point. the number two is an artifact of the structure of psychotherapy
Classical Theory and technique vs. Relational Theory and technique
in contrast to Freud’s emphasis on the organizing role of instinctual drives in the evolution and dynamics of personality, relationalists stress relationships between people as the most fundamental organizing theme of the evolving psyche
· the Freudian and later drive models were still concerned with relationships, and relational models don’t ignore the fact that relationships are always entered into and experienced by individuals who are not only “psyches” but biological organisms
· the new emphasis on relational thinking did shift the center of gravity in psychoanalytic discourse, away from metapsychology and more toward concrete and specific ways that humans actually experience and interact with each other
· rejection of drive theory - replace with relationships as the center of the theoretical system
· “two person” psychology - just like there is no mother without the baby
· deconstruction of dichotomies and polarizations
· emphasis on holding the tensions of extremes, ambiguity, dialogue and paradox
What are the basic changes as psychodynamic theory evolved from classical, to Ego, to Kleinian, to Winnicottian, and then to Relational Psychoanalysis?
A shift with regards to the focus of drives?
instinctual/sexual drives → drives there but ego more important → internal world/inner fantasy → external world/objective reality → relationships
A shift from lots of focus on the unconscious to less and less focus on it?
A shift from a more internal focus to a more external focus?
What are the important features of diagnosis using the PDM?
Questions:
1. Here is a list of the important issues to address in the initial interview. Please describe why this is important and how you would accomplish this.
Educating the client about the therapy process
Explain the procedures of the therapy process. Tell patient in ordinary language why the therapist is asking about dreams (looking into unconscious), free associations (the more freely you talk, the better I can understand you) , and memories (first step in resolving a problem is understanding where it came from). Create a safe and authentic environment to facilitate emotional expression. This creates a sense of trust towards the therapist. Explain confidentiality, routine, boundaries. Find out if the client has any expectations from the therapist, which may or may not be realistic. While educating the client on the therapeutic process, also discuss payment in a rational, straightforward manner/
Most patients are taken aback when they are asked how they feel about the practitioner. Then you explain that the way they are feeling towards you might be how they feel towards other people, so it may help the client to understand themselves and change.
Explain the importance of the couch- allows patient to relax, and take the therapist out of eye contact. Also, it makes the client come up with ideas about what the therapist may be thinking. People carry unconscious apprehensions about what people may be thinking about them, and learn to scan other people’s faces and disconfirm their fears before they even know they have them. The couch brings up these anxieties into conscious awareness. And another thing is that the couch allows therapist to sit back, and relax and think about how client’s words are bringing up the therapist’s associations.
3 benefits of the couch:
allows therapist to assume a relaxed position
allows client to relax and enter a different atmosphere of consciousness
reduces the effect of the therapist expressions and non-verbal gestures on the clients free association so that the client can express clearer images and feelings
some therapists dont use the couch bec they think the set up restricts their ability to fully engage with the client. some client’s feel the setup is unsafe. sometimes the client is uncomfortable with the couch and it hinders their emotional expression
This is all considered to be part of the therapeutic alliance where both parties know what is expected of them. Relationship without such an educational base is a caricature of a therapy.
Gaining informed consent
Addressing early obstacles to full participation in treatment
We cannot predict which patients will do well in therapy. Most therapists give a patient a try to see if they will do well in psychotherapy. Clients are good judges of what treatment will be helpful to them. Person who says tell me what to do or fix me is challenging, and they may be better off in CBT, but before a therapist will refer, they see if they can engage the client into a more introspective, reflective growth. Resistance is a key concept which is any lack of cooperation with the therapist. However, Freud thought of it more as an intrapsychic process- our psychic structures do not assimilate to change easily. One cannot decide to not be resistant, and resistance is a protective phenomenon. THE THERAPIST MUST ADDRESS AS EARLY AS POSSIBLE ANY RESISTANCES THAT MAY IMPEDE THE CLIENT’S TREATMENT. Sometimes patient is not resisting because he unconsciously doesn’t want to change, but because he has no idea what a therapeutic engagement looks like. By explaining what this interaction looks like you can go from resistance to willingness. Especially do this if cultures are from those that encourage deference from authority, or distrust ambiguity. To socialize a person into that of a patient, must elicit fears and expectations and give patient info that challenges those internal voices.
Example: artists fear that if they lose neurotic features they will also lose their inspired ones and have to tell them that it actually increases the inspired features.
Not expected to know all reservations but should ask about one’s apprehensions, talk to supervisor and then address them next session.
Encouraging Spontaneous, candid, emotionally expressive speech
Recommending the couch
It has utility & is best seating positioning for psychoanalysis
Allows patient & therapist to relax
Takes therapist out of eye contact
May notice they have ideas about what the therapist is thinking/feeling that never came to mind before
Takes away the anxiety of unconscious apprehensions about other people’s reactions to them
Usually scan faces & disconfirm their fears b4 they know they have them
Introducing work with the transference
Ask question about how the client feels about talking to the therapist – decides if they should work together as well as an understanding of how the patient experiences the relationship. It opens the door to any transference concerns that have not yet been obvious, and alerts client to the collaborative nature of therapy. Despite transference needs of the client, the therapy relationship is reciprocal. Client pays fee and the therapist tries to understand and help.
First session in psychodynamic treatment
Inviting the client’s reaction to the therapist
Show you’re interested in how patient experiences the relationship
Opens door to any underlying transference
Alerts them to collaborative nature of therapy
Shows they have a right to evaluate the therapist & give feedback
Reciprocal therapeutic relationship
They pay, you try & understand/help
Don’t expect emotional support from them in return (not a paid friendship)
Conveying understanding
Usually worried about being judged, misunderstood, or treated w/ contempt by therapist
Convey their probs aren’t incomprehensible
Don’t give elaborate interpretations in 1st session
If want to make interpretation, do it tentatively & not something elaborate
Try to figure out if on the right track
Very troubled people tend to say they have a chem imbalance or genetic defect
Show them it’s more than that & they can be helped
Assessing the patient’s reactions to a tentative formulation
How they respond to your 1st efforts to understand their probs indicates a great deal about how the patient will work in tx
Patients will vary in how much input they want, their reactions to you, etc.
Get a sense of how interpretations will be received so can adjust your style of interaction to their needs
Conveying Hope
Therapy is usually the last resort. Most patients are skeptical about what therapists can offer them, because they think they have their own psychological problems. But once they see they’re sane, It is beneficial to say “I think I can help you”.
Only a minority of clients confidently expect a therapist to help them
Most have come already trying lots of things to help themselves but nothing has worked
General public doesn’t have a high opinion of therapists- people very skeptical
Usually changes after they meet the therapist
Address contingencies: Ex: it’s going to take a long time, need to address your other probs (ex: addiction at AA), you may need to see a psychiatrist & get meds, etc.
Addressing Time and Length of Meetings
· Don’t leave anything unclear
· Stick to 45 min. sessions
· Pick a regular time to meet & not something you’ll regret (ex: too early/too late)
· Have a clock in their view so they can have a sense of the time
also discuss boundaries, physical safety, treating diagnosis, questions
Addressing Payment
· Be straightforward & reasonable
· Usually state your fee & ask if they have a prob w/ coming up w/ that
· May slide the fee if too much for them
Esp. if coming mult times/wk
· Can pay after each session or by the month
· May be hard to do therapy under managed care
Their confidentiality is compromised
Only cover short-term crisis intervention
Have strong financial incentives to deny tx
Termination of tx usually premature
Reviewing your cancellation policy
· Some have them, some don’t
· If do, usually have to pay part or all of hourly fee if cancel w/ insufficient notice
Ex: 24 hrs
· If don’t, feel like shouldn’t charge for services not rendered
Can actually use the time to do other imp things
· If develop a pattern of cancelling, that’s a diff issue
· Insurance comps usually don’t pay for missed sessions
· If strict psychopathy, need to have strict guidelines
· Should charge for no-shows though
Reviewing Diagnosis
No place for mystification in psychotherapy
Basic respect to share the diag w/ them (they can look it up on their insurance bills anyway)
Explain basis for it & discuss the recommended tx
Keeping it from them would reinforce that emotional probs are shameful
Can even show them the DSM & which categories they fit in
See if it’s an accurate description of their probs
May have them remember symptoms they forgot to tell you
Diagnostic process should be as consensual as the therapy process
People worried about this b/c think patient will be too upset, wouldn’t understand it, etc
Explain that no one fits exactly into 1 category- only rough approximations
May be reductionist but need to submit DSM diagnoses to insurance companies
Inviting Questions
Always ask if they have any questions at the end of the interview
Respond to their concerns directly & economically
Can say, “I’ll be glad to answer that question, but 1st, could you tell me why it’s important to you?”
They may be trying to test you
If too intrusive, can say “I appreciate why that would be important for you to know, but I feel that that is too private for me to be comfortable asking that question.”
“Are you afraid that if I have not experienced that that I can’t possibly understand you?”
Set boundaries
Preparing clients to give a history
Tell them ahead of time to reduce anxiety & show you have direction
Encourages them to start reflecting about how the past/personal history could be affecting the current prob
A lot of what happens in therapy goes on b/t the actual sessions
Sharing a dynamic formulation
Dynamic formulation goes way beyond a diagnostic label
Have a mutually ongoing process of revision & elaboration of the ways the 2 parties understand the person’s psychology
Mediate w/ timing & tact
Clients have the right to know the therapist’s working assumptions about the nature of their probs
Might become the cornerstone of the working alliance
Include some ideas about how the therapy will attempt to address their probs
Convey sense of hope & expectation of a gratifying collaboration
Educating the client about the therapy process
Explain the rationale for any procedures you recommend
Use ordinary, nontechnical language
Explain that you’re not asking what they think of you/for feedback out of vanity or b/c you feel insecure- explain it helps you do things that work better for them & help the relationship/process
Nothing mysterious about the couch- it has utility
Help develop the working alliance
