Psychodynamic Psychotherapy

Question 1

What is the overarching aim of all schools of psychodynamic psychotherapy?

Answer 1

To achieve insight, make meaning, and transform experience of self in the world.

Question 2

What is the intended outcome of psychodynamic therapy?

Answer 2

To generalise experience in therapy to other relationships and experiences

Question 3

How have later generations of theorists and therapists departed from Freud’s classical model? (2 points)

Answer 3

• They have developed a more social, relationship-oriented approach.
• Therapy is a collaborative process of meaning-making.

Question 4

How was Freud involved in the origins of psychodynamic psychotherapy?

Answer 4

-All theories are derived from Freud’s approach.
- He learned about technique of hypnosis, but didn’t find it effect, and from this he developed free association.

Question 5

What is free association?

Answer 5

• This involves patients talking freely about whatever came to mind. It was believed to reveal hidden, unconscious concerns.
• Anna O called it “the talking cure”

Question 6

What are the three central tenets of Freudian Psychoanalytic theory?

Answer 6

1. Topographic/Structural model of the mind and discovery of the unconscious
2. Drive theory
3. Psychosexual stages of development.

Question 7

What is the topographic model of the mind?

Answer 7

• Conscious, preconscious, and unconscious.
• Conscious mind: where one’s current awareness exists
• Preconscious mind: contains memories, information and events of which one can easily become aware
• Unconscious: A part of the mind that remains hidden all the time, surfacing only in symbolic form in dreams or and in some of the behaviour people engage in without knowing why they have done so.

Question 8

Why are some things in the unconscious mind?

Answer 8

• Because they might threaten your sense of self.
• Freud believed that you can’t bring these things to mind.

Question 9

What is Freud’s structural model of the mind/personality?

Answer 9

• The id: pleasure principle
• The superego: conscience
• The ego: reality principle

Question 10

Define the 3 parts of the structural model of the mind/personality

Answer 10

• The Id: A completely unconscious, pleasure-seeking, amoral part of the personality that exists at birth. It contains all of the biological drives: hunger, thirst, self-preservation and sex.
• The Ego: mostly conscious and is more rational, logical, and cunning than the id. Reality testing. Manages the desires of the id in a socially appropriate way
• The Superego: The moral centre of personality. Contains the conscience.

Question 11

What is drive theory?

Answer 11

• Freud thought that behaviour was a result of trying to manage these two opposing drive. “life and death” and “libido and aggression”

Question 12

What are the different psychosexual stages?

Answer 12

• oral (0-1)
• anal (2-3)
• phallic (3-6)
  -latency (6-puberty)
• genital (puberty+)
• according to freud, the anal phase relates to self-control

Question 13

How did Freud define psychopathology?

Answer 13

According to freud, symptoms arose from repression of forbidden wishes and conflicts

Question 14

What was the treatment for psychopathology according to freud?

Answer 14

• making the unconscious conscious.

Question 15

How have we moved away from Freud’s understanding of psychopathology?

Answer 15

• We understand that insight isn’t everything. If you can understand why things are happening that’s great, but it isn’t a step on its own.

Question 16

What are the seven common features of psychodynamic therapy?

Answer 16

1. Focus on affect
2. Understanding and exploring defences
3. Identifying patterns.
4. Understanding the influence of the past on the present.
5. Focus on relationships
6. Centrality of the therapeutic relationship
7. Exploring symbols and fantasy life

Question 17

What is meant by “focus on affect”

Answer 17

• The emphasis is on patients’ emotional worlds and experiences
• Having patients explore and express their emotions
• Achieve emotional insight (over intellectual)
• Affect is considered the gold of therapy.

Question 18

What is meant by “understanding and exploring defences”?

Answer 18

• Generally defences are seen as unconscious attempts to protect self from painful, troubling, or difficult feelings or experiences.
• Some schools interpret defences as part of the process and others see them as evidence of the patient feeling unsafe.
• Either way, how and what is being avoided is important to the therapeutic process.
• Defences have a place, but when we overdo them they cut us off from our full emotional life.
• Freud thought our personalities were the sum of our defences.

Question 19

What is meant by “identifying patterns”

Answer 19

• We will look for things that confirm our understanding or meaning and so maintain our sense of stability. (this is what patterns are?)
• Ways in which these recur/repeat help us understand more about the patient’s fears and longings
  These are understood in the context of patient’s history and experiences.
• Essentially, the meaning we make of the things in our lives originate from somewhere.

Question 20

What is meant by “understanding the influence of the past?”

Answer 20

• This is one of the most defining features of psychodynamic therapies
• Early experiences, especially with caregivers, shape experiences of the present
• Patterns of relating, experiences of self, are formed in the past.
• Early experiences become the lens through which we make meaning of our lives.

Question 21

What is meant by “using the therapeutic relationship?

Answer 21

• The therapeutic relationship is where relational patterns emerge, this allows for new experiences.
• In the therapeutic setting, unconscious expectations about how patient will be perceived or treated emerge
• Transference is seen as fertile ground for processing, not just to bring to consciousness but to provide corrective emotional experience

Question 22

What is meant by “focus on relationships”

Answer 22

• Relations are seen as the primary site of injury and healing
• Emphasis is placed on interpersonal experiences and relationships (including patterns of relating)
• Problems are seen as the result of unmet relational needs or difficulties establishing healthy and satisfying relationships
• People could be suffering because of current relationships, not just childhood experiences.
• Deviate from freud, not repressed desires but due to relational issues.
• Psychodynamic therapy shows that you can heal relational wounds. This can be healed through the therapeutic relationship, or with other people who might’ve attuned to you better than your caregivers

Question 23

What is transference?

Answer 23

Emergence of patterns of interacting that are shaped by fears and hopes about relationships based on experience.

Question 24

What is countertransference?

Answer 24

Therapist’s response to the feelings, behaviours, and expectations that come up

Question 25

What is meant by “exploring symbols and fantasy life”?

Answer 25

• Therapy is unstructured and without agenda
• Patients are encouraged to talk freely
• This 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 26

What are four myths and misperceptions about psychodynamic therapies?

Answer 26

• Psychoanalysis is all the work of Freud
• Contemporary psychoanalysis is the same as it was in Freud’s time
• Psychoanalysis is esoteric and not grounded in evidence
• Psychoanalysis is no longer popular

Question 27

What is the central understanding of psychodynamic therapies? (3 points)

Answer 27

• Problems are usually the result of unmet relational needs or relational injuries
• Response to those repeated injuries, especially in childhood, lead to development of unconscious defences
• These become incorporated into patterns of relating that are evidenced in current relationships

Question 28

What is psychodynamic therapy focused on?

Answer 28

• Therapy is focused on developing emotional insight and corrective experiences that transform the way the patient sees themselves and therefore, their patterns of relating.

Question 29

What is the goal of psychodynamic therapies?

Answer 29

• Symptom reduction is not the primary goal
• Therapy aims to transform patient’s experience of themselves in context of their relationships
• **Improved psychological capacities and functioning, especially healthier ways of relating, are the main goals. **
• This lead to symptom remission

Question 30

How are symptoms seen in psychodynamic therapy?

Answer 30

• Symptoms are seen as serving a purpose
• Symptoms are seen as symbolic or real means of re-establishing equilibrium/ stable sense of self in the world.
• Symptoms can be seen as symbols of areas of “stuckness”

Question 31

What do contemporary psychodynamic therapies consider as our primary motivators?

Answer 31

• affect and relatedness (relationships)

Question 32

Do psychodynamic therapies emphasize relationship or technique?

Answer 32

relationship
- it is more about a posture and way of thinking and making meaning.

Question 33

What kind of process is psychodynamic therapy?

Answer 33

A collaborative meaning-making process.
- Use whatever the patient brings to the space.

Question 34

What are five main tools psychodynamic therapy?

Answer 34

1. Systematic use of the therapeutic relationship (transference)
2. Free association
3. Dreams and fantasies
4. Interpreting defences
5. Others. e.g. play therapy with children

Question 35

What do we know about systematic use of therapeutic relationships? (transference)

Answer 35

• Classical psychoanalysis: Therapist tends toward being neutral towards client. They become a blank screen on which the patient projects their fantasies
• As therapy progresses, feelings client has towards therapist will be similar to those towards significant others in past
• Transference feelings traditionally are seen as purely projection
• Powerful tool in therapy: allows therapist to observe early childhood relationships as they are re-enacted in consulting room
• Aim: Help client become aware of projections- first to therapist, then other relationships

Question 36

What to we know about free association as a therapeutic tool?

Answer 36

Aim: To have the person talk freely about themselves. In this state they are less likely to be influenced by defence mechanisms
- This is thought to facilitate the truth “slipping out”
- Patient sets the agenda, therapist follows patient’s lead

Question 37

What do we know about the use of dreams and fantasies as a therapeutic tool?

Answer 37

• Dreams are thought of as the royal road to the unconscious
• Purpose: to examine material that comes from deeper, less defended level of personality
• Events in dreams symbolically represent people, impulses, situations in waking life.
• Waking dreams, fantasies and images can be used in the same way
• Symbols aren’t universal

Question 38

What do we know about interpreting defences as a therapeutic tool?

Answer 38

• The other tools are used to generate material for interpretation of defences, resistance, symptoms and other patterns of behaviour
• Interpretation of meanings used to help clients understand origins of problems so they can gain more control over them and have more freedom to behave differently
• Interpreting defences is a difficult skill so therapists must keep timing and resonance for patient in mind.
• Resonance: allow the patient to confirm or deny your interpretation.

Question 39

What are other tools and techniques used as therapeutic tools?

Answer 39

1. Play therapy with children: externalisation of unconscious
2. Expressive techniques: art/writing
3. Projective tests
4. Diaries/journals or autobiographies

Question 40

What were Freud’s views on gender and sexuality?

Answer 40

• Freudian psychoanalytic model pathologized women.
• Memories of sexual abuse were interpreted as children’s fantasy (seduction theory)
• Original conceptualisations of pathology were considered “mother-blaming”
• Alternative sexuality also conceived of as pathological or deviant.
• Much of the developmental research in the 1950s and 60s was only done on boys (e.g. Erikson)

Question 41

How have feminists used Freudian theory?

Answer 41

• Feminists like Juliet Mitchell argue that Freudian theory offers an analysis of Freud’s socio-cultural context in the victorian era.

Question 42

What issues are there around Freudian theory and context?

Answer 42

• Classical psychoanalysis disregards context.
• Traditional models hold view of an isolated mind.
• It has essentialist ideas of what it means to be human.
• Very little attention was given to culture or social issues such as class.

Question 43

What are some critiques against contemporary psychodynamic therapy in terms of context?

Answer 43

• It is viewed as elitist as analysis sessions are 3-4 times a week, and therefore inaccessible to people who can’t afford it.
• It is a long term approach
• Need to consider applicability to other cultural contexts as it was not developed with those contexts in mind.
• Some models of contemporary psychodynamic therapy still position the analyst/therapist as the expert.
• BUT contemporary psychoanalytic models like intersubjectivity systems theory consider context central to understanding a person.

Question 44

What are the criticisms against psychodynamic therapy in terms of evidence?

Answer 44

• Most common criticism is that psychodynamic theories are considered “unscientific” and therefore not evidence-based.
• Concepts and constructs like the unconscious or affect are difficult to measure and so there is no proof that they exist.
• This criticism has been the most damaging and may be rooted in perception of psychoanalytic community as exclusionary and snobbish.
• However, this criticism is innacurate.

Question 45

What are the responses to criticisms against psychodynamic psychotherapy?

Answer 45

• Evidence for psychoanalytic constructs is rapidly accumulating (e.g. neuro-imaging studies that support claim for dynamic unconscious)
• Successful treatment not simply focused on resolution of symptoms but also development of positive psychological capacities.

Question 46

What is the evidence base to show that psychodynamic psychotherapy is effective?

Answer 46

A meta-analysis of 23 RCTs of 1432 patients receiving psychodynamic psychotherapy. Patients with CMDs who received short-term psychodynamic psychotherapy compared to controls found large effect sizes:
- General symptom improvement: 0.97 (increased to 1.51 at follow-up)
- Somatic symptoms: 0.81 (increased to 2.21 at follow up)
- Anxiety ratings: 1.08 (increased to 1.35 at follow-up)
- Depressive symptoms: 0.59 (increased to 0.98 at follow-up)
- This is known as the “incubator effect”

Question 47

What is the incubator effect?

Answer 47

In psychology, incubation refers to the unconscious processing of problems, when they are set aside for a period of time, that may lead to insights.

Question 48

What are some key things to note about contemporary practice?

Answer 48

• Much of Freudian theory has been transformed or left behind.
• Most contemporary schools of thought recognise the primacy of affect and relationships and not drives as motivators.
• Some reject drive theory altogether
• Therapists are no longer seen as blank slates
• Therapists are also responsible for what they bring to the process
• Each therapist-patient dyad creates their own unique intersubjective field.
• Unconscious is not “discovered” but meaning is co-created.