Psychodynamic psychotherapy

Question 1

what is psychodynamic therapy?

Answer 1

-an umbrella term for many different types of therapy.
- All are derived/evolved from Freudian psychoanalytic theory.
-All place emphasis on the therapeutic relationship.
-The overarching aim of all schools is to: achieve insight, make meaning, and transform the experience of self in the world.
-Their goal is to generalize the experience in therapy to other relationships and experiences in the outside world.

Question 2

who is the founder of psychodynamic therapy.

Answer 2

Sigmund Freud

Question 3

what are the 3 critical apsects of psychoanalytic theory

Answer 3

1. The topographic/structural model of the mind and the discovery of the Unconscious.
2. Drive theory (that human behaviour is motivated by drives/instincts).
   3.Psychosexual stages of development (we progress through a series of stages, each with different challenges that need to be overcome to develop into healthy, happy people.

Question 4

explain the topographic model of the mind

Answer 4

> Thought of the mind as an iceberg: we only see some of it (the conscious), but the majority isn’t entirely seen (the
preconscious and unconscious).
Preconscious: just ‘below the surface’. Not fully hidden but not immediately at the top of my mind.
Unconscious: a hidden part of ourselves, a place where trauma or thoughts that feel threatening or taboo are repressed.

Question 5

what are the 3 parts to the structural model of the mind according to Sigmund Freud

Answer 5

1. The id: uncontained, needs immediate gratification and avoids pain
2. The superego: internalized values and morals, our sense of what’s right and wrong.
3. The ego: the I, or the self. Regulates the relationships between the id and superego. Operates on the reality principle: meeting
   the needs of the id while also satisfying the superego.

Question 6

explain the two drives to drive theory

Answer 6

1. Life/eros/libido: an unconscious drive towards anything life-giving.
2. Death/Thanatos/aggression: a destructive drive. Aimed towards self-destruction or
   destructive impulses.

Question 7

name and the 5 psychosexual stages of development

Answer 7

1. Oral phase (0-1 years)
2. Anal (2-3)
3. Phallic (3-6)
4. Latencwhaty (6-puberty)
5. Genital (puberty onwards)

Question 8

what are the 3critical tenets of Psychoanalytic Theory in terms of psychopathology?

Answer 8

> Saw pathology as repressed forbidden wishes and conflicts. Too painful, taboo or threatening to hold in the conscious.
Continued repression leads to symptom expression.
Symptoms thus become symbols of what is repressed.

Question 9

what are the 7 common features of all psychodynamic therapy

Answer 9

1. Focus on affect .
2. Understanding and exploring defenses
3. Identifying patterns.
4. Understanding the influence of the past on the present.
5. Focus on relationships.
6. Centrality of the therapeutic relationship to the therapy.
7. Exploring symbols and fantasy life to the patient’s world.

Question 10

What is affect?

What is the benefit to focusing on Affect

Answer 10

-Emphasis on patients’ emotional worlds and emotional experiences.
-Recognizing that effect helps us organize our experience.
-Having the patient explore and express their feelings.
-Emphasis on achievement of emotional insight (over intellectual).
-Affect is the ‘gold’ of therapy: it’s where a lot of experience and meaning is made

Question 11

what does it mean to Understand and explore defences

Answer 11

> defences is seen as unconscious attempts to protect self from painful, troubling or difficult feelings or experiences.
So defences become part of the way we organise our experience and relate to the world and other people.

Question 12

what does it mean to Identify patterns in terms of psychodynamic therapy

Answer 12

> We look for things that will confirm our understanding/meaning and so maintain our sense of stability and predictability.
We can feel quite threatened by things that disrupt that pattern and suggest that the way we’ve made sense of something may not be correct.
Ways in which patterns recur / repeat help the therapist understand more about the patient’s fears and longings.
These are understood in the context of a patient’s history and experiences, which serve as the backdrop to the patterns.

Question 13

what is the influence of the past on the present in terms of psychodynami

Answer 13

> The idea that the present is profoundly influenced and shaped by experiences in the past. Especially experiences with early caregivers.
ingrained in our way of being and relating.

Question 14

explain the feature of “Focus on relationships” in terms of psychodynamic therapy

Answer 14

> Relationships are seen as the primary site of injury and healing.
Emphasis is placed on interpersonal experiences and relationships
Problems are often seen as a result of unmet relational needs or difficulties establishing healthy and satisfying relationships.

Question 15

explain the feature of the Centrality of the therapeutic relationship to the therapy in terms of psychodynamic therapy

Answer 15

> Therapeutic relationship is seen as where relational patterns emerge.
transference
Represents the emergence of unconscious expectations about how the patient will be perceived/ treated.
involves transference and counter transference
These transferences are seen as fertile ground for processing, not just to bring to
consciousness but to provide corrective emotional experience – experiencing yourself in a relationship in a different way. Will hopefully be taken into your broader life

Question 16

Explain the feature of symbols and fantasy life to the patient’s world in terms of psychodynamic therapy

Answer 16

-Therapy sessions are unstructured and without agenda.
-The patient brings whatever they want to the session.
- Patients are encouraged to talk freely.
-Allows for the emergence of fantasies and symbols that hold important information about hidden fears and wishes.
-Exploring dreams is a good way to access unconscious material

Question 17

what are the 4 common myths and misperceptions about psychodynamic theory

Answer 17

1: Psychoanalysis is all the work of Freud.
There have been many derivatives of psychoanalytic theory. .
2. Contemporary psychoanalysis is the same as it was in Freud’s time.-For the most part, the conventions of Freud’s original therapy has changed.
3. Psychoanalysis is esoteric and not grounded in evidence. But overall, this is false. There is a considerable amount of evidence for psychodynamic
therapies.
4. Psychoanalysis is no longer fashionable.
It’s features are still relevant today. It has value and a place in our society.

Question 18

what is the goal of psychodynamic therapies

Answer 18

-Therapy aims to transform patient’s experience of themselves in the context of their relationships
-Improved psychological capacities and functioning, especially healthier ways of relating, are the main goals.
-Not just dealing with symptoms: developing the person as a whole.
-symptom remission: Getting to the root of the problem can in turn reduce the symptoms

Question 19

Freud understood human behaviour as motivated by drives and instincts, what does contemporary theory say

Answer 19

> Relatedness are primary motivator.
We’re social beings who seek out connection with others.
- These needs all happen in the context of other people/relationships.
Psychodynamic therapies emphasise the relationship of therapy over the techniques.
->Working together to make sense of something. Therapy isn’t “done” by the therapist. The therapist and patient work together

Question 20

name 5 main therapeutic tools

Answer 20

1. Systematic use of the therapeutic relationship i.e. transference
2. free association
3. dreams and fantasies
4. interpreting dreams
5. other tools and techniques

Question 21

explain “ Systematic use of the therapeutic relationship i.e. transference”

Answer 21

> In classical psychoanalysis, the therapist tends toward being neutral towards the client. They don’t really react, they’re an objective, neutral ‘blank screen’ on which the patient projects fantasies and fears.
- As therapy progresses, the feelings the client has towards the therapist will be similar to those towards significant others in the past.
- They’re effectively repeating their patterns and expectations in the context of the
therapeutic relationship.
-Transference feelings thus traditionally seen as purely projection, the therapist hasn’t had a role in it.
- But this takes the therapist out of the relationship, which isn’t accurate.
There are few contemporary schools of thought which still see the therapist as a blank slate, and transference to be purely projection.
- They tend to recognize that the relationship is two-way.
- The therapists come into it with their own histories and issues.
-The relationship is still considered a powerful tool in therapy. It allows the therapist to observe early childhood relationships as they are re-enacted in the consulting room.
- How they organize their sense of self in relation to others, what patterns they’ve
developed etc.
-Aim: to help clients become aware of projections – first to the therapist, then other relationships in the world.
-This thinking has developed dramatically in some schools. There is a considerable amount of variation.

Question 22

explain free association

Answer 22

> Aim: the person talks freely about themselves so they’re less likely to be influenced by defense mechanisms.
Thought to facilitate the truth ‘slipping out’. Their defenses would be down, allowing thoughts, feelings, fantasies etc. to be revealed.
Remember, free association isn’t practiced the same way as it used to be. The therapist is more active in the discussion.
Patient sets the agenda, the therapist follows the patient’s lead.

Question 23

explain the tool of “dreams and fantacies” within therapy

Answer 23

-Many psychoanalysists are interested in dreams. Freud saw dreams as the ‘royal road to the unconscious’.
-Purpose: to examine material that comes from deeper, less defended levels of personality.
-Events in dreams symbolically represent people, impulses, situations in waking life.
-Waking dreams, fantasies, images can be used in the same way.But we don’t usually associate certain symbols with certain fixed meanings (as Freud or Jung thought).
i.e. There’s no 1-to-1 translation. Different things have different meanings for everyone

Question 24

what are some alternative tools and techniques used in therapeutic spaces

Answer 24

-Play therapy with children meant to lead to the externalisation of the unconscious.
-Expressive techniques like art or writing.
-Some people may prefer this to verbal expression, so may be useful as part of the therapeutic process.
-Projective tests e.g. Rorschach / inkblot test. Aren’t used much nowadays.
Diaries/journals or autobiographies.

Question 25

explain the notion of interpreting defenses as a therapeutic tool

Answer 25

-Depends on what the therapist views defences as (as ways to resist/avoid things, as indicators of pathology, or as means of protection).
-The above techniques are used to generate material for interpretation of defences, resistance, symptoms and other patterns of behaviour.
-Interpretation of the defences and their meanings are used to help clients understand origins of their problems
-They can thus gain more control over them and more freedom to behave differently.
Interpreting defences is a difficult skill, and it can be threatening for the patient, so the therapist must keep some issues in mind:
- Timing: a good relationship must already be in place.
- Resonance for patient: must feel truthful and meaningful.

Question 26

name 3 criticisms of psychodynamic therapy

Answer 26

1. gender+ sexuality
2. ignoring context
   3.lack of evidence

Question 27

explain how gender and sexuality can be used as a criticism to psychodynamic therapy

Answer 27

> Original Freudian psychoanalytic model pathologised women. It favoured men and saw women as second-class citizens.
E.g. hysteria; the concept of ‘penis envy’.
This was also emblematic of the time Freud lived in.
Memories of sexual abuse were eventually interpreted as children’s symbolic, repressed fantasies (seduction theory).
Original conceptualisations of pathology were often considered ‘mother-blaming’. Children’s problems seen as the responsibility of the other e.g. over-controlling mother leads to anorexia in
her daughter.
Alternative sexuality was also conceived of as pathological or deviant. Much of the developmental research in the 1950s and ‘60s was only done with boys (e.g.
Erikson’s stages of development).
- Therefore ideas of normal development were based on male standards.
But, feminists like Juliet Mitchell argue that Freudian theory offers an analysis of Freud’s sociocultural context, in the Victorian era.
- Argues that Freud was attempting to make sense of the problematic values of his time,
although many of his ideas ended up being problematic themselves.
- E.g. penis envy represents the desire of women to hold the power that men have in
society

Question 28

explain how ignoring context can be used as a criticism for psychodynamic therapy

Answer 28

> One of the biggest criticisms of classical psychoanalysis is that it disregards context.
Traditional models hold views of the ‘isolated mind’, independent of social values, relationships, culture etc.
Very little attention was thus given to culture or social issues such as class.
Promotes essentialist ideas of what it means to be ‘human’ – that there’s a prototypical human and one type of development we should all follow. But what it means to be human, how we think about others and the world etc differs around the world.
We are also products of our contexts.
Another big problem is that it was viewed as elitist and inaccessible to people who can’t afford it (analysis sessions can be 3-4 times/week, and are very expensive).
- This is still true to a certain extent.
Also criticised for its long-term approach. Another reason why it’s more expensive.
Applicability to other cultural contexts has been questioned.
Ideas are based in Western/Eurocentric thought.
Some models still position the analyst/therapist as an expert – they know exactly what’s happening with the patient and what to do. Their ideas take prominence in the therapy.
BUT contemporary psychoanalytic models like Intersubjectivity Systems Theory consider context central to understanding a person.
Also insists on the therapists being reflexive.“ Psychoanalysis has changed this traditional doctor-patient relationship from one of authority to one of partnership (Rayner, 1991).
- It is generally accepted that the doctor knows as much or as little as the patient and thus both patient and therapist are involved in an exploration of what is going on for the patient.” (Berg, 2014)
But this uneven power dynamic is particularly evident in a context such as SA, where Western ideas and techniques are put on a pedestal and there are entrenched relationships of domination as a result of colonial and apartheid ideologies (Berg, 2014).

Question 29

explain how lack of evidence can be used as a criticism for psychodynamic therapies

Answer 29

> Most common criticism is that psychodynamic theories are considered ‘unscientific’ i.e. not
‘evidence-based’.
This is driven by some of the EB movement.
If we were to use the APA’s definition of evidence-based we’d see that psychodynamic therapies
are supported.
Even RCTs provide evidence for psychodynamic therapies. However, they’re ill-suited to RCTs
as they don’t use a manualised approach.
“the (often unacknowledged) “active ingredients” of other therapies include techniques and
processes that have long been core, centrally defining features of psychodynamic treatment.”
Concepts and constructs like the Unconscious or affect are difficult to measure and so there’s
no proof that they exist.
This criticism has been the most damaging to the perception of psychotherapies.
It may be rooted in the perception of psychoanalytic community as elitist, exclusionary and
snobbish.
It is in fact an inaccurate criticism…

Question 30

what is some evidence in favour of psychodynamic theory and therapy

Answer 30

> Evidence for psychoanalytic constructs is rapidly accumulating (e.g. neuro-imaging studies that support claims for dynamic unconscious).
Important to remember that successful treatment is not simply focused on the resolution of symptoms but also development of positive psychological capacities. So when studies are set
up to compare therapies on degree of symptom-reduction only it will be an unfair comparison.
general psychotherapy is effective, and has large effect sizes. CBT and related therapies are also effective but the effect sizes are generally smaller. Antidepressant medicationis significantly less effective than any type of therapy.
- Lastly, Psychodynamic therapy has a wide
body of evidence showing large effect sizes.
-“Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.”
-“In addition, patients who receive psychodynamic therapy maintain therapeutic gains and
appear to continue to improve after treatment ends”.
- “In contrast, the benefits of other (nonpsychodynamic) empirically supportedtherapies tend to decay over time for the most common disorders”.
Abbass, Hancock, et al. (2006): meta-analysis of 23 RCTs of 1431 patients receiving psychodynamic psychotherapy.

Question 31

what is an incubator effect

Answer 31

> The patient’s improved general
psychological/intrapsychic abilities may lead to increased positive outcomes even after therapy has ceased.
Thus, there is in fact considerable evidence to show that psychodynamic psychotherapy is effective

Question 32

explain what contemporary practice is and looks like in terms of psychodynamic therapy

Answer 32

> Much of Freudian psychoanalysis has been transformed or left behind.
Most contemporary schools of thought recognise the primacy of relationships and not drives as motivators.
- We organise our experiences and understanding around affect, and our strong feelings are often in relation to other people.
Some schools of thought reject drive theory altogether.
Therapists are no longer seen as objective ‘blank slates’.
- Important to recognise the role of the therapist within the relationship. The
therapist is also responsible for what they bring to the process.
-Each therapist-patient dyad creates its own unique intersubjective field between
them. Each person creates a unique interaction with someone else.
-“What takes place in the clinical consulting room reflects the qualities and style of
the individual therapist, the individual patient, and the unique patterns of
interaction that develops between them.”
-The Unconscious is not out there to be ‘discovered’, but rather meaning is co-created.
- The meaning constructed varies according to context and to the people involved.
- Releases us from the idea of an ‘objective and essential truth’ which must be discovered.

Question 33

how did Freuds free association come about

Answer 33

> But he didn’t find hypnosis effective for him as a treatment technique.
Developed ‘free association‘ (a technique that evolved from hypnosis) – letting patients talk freely without interruption.
Found that the material that often emerged included strong emotions, deeply buried memories and childhood sexual experiences.
Psychotherapy is still often called the talking cure today.

Question 34

explain the oral phase of psychosexual development

Answer 34

1. Oral phase (0-1 years) – sucking, biting, swallowing. Conflict = being weaned from
   mother. Individuation, separation from mother.

Question 35

explain the anal phase of psychosexual development

Answer 35

2. Anal (2-3) – learning to use a toilet. Resolution of the challenge leads to the ability to control themselves. Symbolic of other forms of control in adulthood.

Question 36

explain the phallic phase of psychosexual development

Answer 36

3. Phallic (3-6): develop an awareness of their genitals. Start to negotiate their relationships
   with their opposite-sex parents.

Question 37

explain the latencwhaty phase of psychosexual development

Answer 37

4. Latencwhaty (6-puberty): energy is sublimated into working and developing. Not much is happening, there is no conflict to be resolved. A time of consolidation, learning,
   developing friendships etc.

Question 38

explain the genital phase of psychosexual development

Answer 38

5. Genital (puberty onwards): when teenagers have a sexual awakening, and become
   sexually attracted to others. People learned to love, and developed an understanding of
   social rules.

Question 39

what are the critical tenets of Psychoanalytic Theory in terms of treatment

Answer 39

-Treatment involves making the unconscious conscious – becoming more and more aware.
-A lot of this has been retained, but a lot has also been transformed.
-There have been many other psychotherapists who have been influential. —Each developed Freud’s theories in different ways.

Question 40

define what transference is

Answer 40

Transference = the emergence of patterns of interacting that are shaped by fears and hopes about relationships. The therapist then uses those patterns to help you understand them better (emotional insight), and to have a different experience of oneself in relation to the therapist.

Question 41

what is countertransference

Answer 41

> Countertransference = therapist’s response to those feelings, behaviors, and expectations.