psychodynamic therapy

Question 1

what is psychodynamic therapy

Answer 1

-Psychodynamic therapy is 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.
-Current theory and practice have moved far beyond Freud’s original formulation.
-Later generations of theorists and therapists developed a more social, relationship-oriented approach

Question 2

name and explain the origins of psychodynamic therapy

Answer 2

Origins: Sigmund Freud
>Born in the 19th century. His theory started to become popular in the 1900s.
>Originally trained in medicine.
>Learned about the technique of hypnosis from Charcot (in Paris).
Returned to Vienna and took in patients suffering from ‘hysteria’. Found some success in treating them.
>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.
>The expression of these appeared beneficial. In the case of Anna O, he called it ‘the talking cure’.
>Psychotherapy is still often called the talking cure today.

Question 3

what are the 3 critical tenets 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 in order 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 top of my mind. E.g. memories: not thinking of them in the moment, but can be accessed when prompted.
Unconscious: a hidden part of ourselves, a place where trauma or thoughts that feel threatening or taboo are repressed.

Question 5

explain the structural model of the mind according to Sigmund Freud

Answer 5

In response to criticism, he developed the structural model of the mind,
dividing it into 3 parts:
1. The id: uncontained, needs immediate gratification and avoids pain (operates on the pleasure principle). Entirely unconscious.
2. The superego: internalized values and morals, our sense of what’s right and wrong. E.g. don’t hurt people; work hard.
Creates our sense of guilt. Some are in the preconscious, some are in the conscious, and some are in the unconscious.
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. The self we present to the world. Some are in the preconscious, some in the conscious, and some in the unconscious

Question 6

explain drive theory

Answer 6

Proposes that we have two main drives/instincts. Suggests we’re always
being driven towards something:
1. Life/eros/libido: an unconscious drive towards anything life-giving. Vitality, procreation. E.g. eating, having sex.
2. Death/Thanatos/aggression: a destructive drive. Aimed towards self-destruction or
destructive impulses. Freud wrote of a tension between these two drives that takes place at an unconscious level. Believe we’re always trying to reconcile the two pulls.
Most psychotherapists have moved beyond this thinking. Freud neglected to recognize the importance of relationships in forming and meeting our drives.

Question 7

name and explain the psychosexual stages of development

Answer 7

4 conflicts that needed to be resolved in the process of development.
Organised around erogenous zones. Activity involved in that zone became the organising focus
of the child’s emotional life.
Believed that a child who experienced trauma during one of these phases experiences issues of
development related to that phase.
1. Oral phase (0-1 years) – sucking, biting, swallowing. Conflict = being weaned from
mother. Individuation, separation from mother.
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. This is why we still
describe overly-controlling people as ‘anal’.
3. Phallic (3-6): develop an awareness of their genitals. Start to negotiate their relationships
with their opposite-sex parents.
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.
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 8

what are the critical tenets Psychoanalytic Theory: Psychopathology and treatment

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.
Treatment thus 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.
- E.g. Carl Jung, Alfred Adler, Anna Freud, john Bowlby, Frantz Fanon etc

Question 9

what are the 7 common features of all psychodynamic therapy

Answer 9

The broad range of therapies that have derived from Freud’s psychoanalytic theory (which has
evolved greatly) tend to have 7 features in common:
1. Focus on affect (emotions).
2. Understanding and exploring defenses (reasons for avoiding things).
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

explain the feature of : Focus on affect + expression of emotion

Answer 10

-Emphasis on patients’ emotional worlds and emotional experiences.
-Recognising that affect helps us organise our experience.
-Having the patient explore and express their feelings.
-Emphasis on achievement of emotional insight (over intellectual). You can know something intellectually but not emotionally. Emotional insight resonates at a deep level and leads to change.
-Affect is the ‘gold’ of therapy: it’s where a lot of experience and meaning is made

Question 11

explain the feature of Understanding and exploring defenses

Answer 11

> various schools think of defences differently. Generally, they’re seen as unconscious attempts to protect self from painful, troubling or difficult
feelings or experiences. I.e. attempts to avoid distressing thoughts and feelings.
So defences become part of the way we organise our experience and relate to the world and other people.
Some schools interpret defences as part of the process.
Others see them as evidence of the patient feeling unsafe. Something is happening in the patient that is leading them to be defensive.
Either way, how and what is being avoided is important to the therapeutic process

Question 12

explain the feature of Identifying patterns

Answer 12

> Identifying themes and patterns within the person’s life is very important.
We look for things that will confirm our understanding/meaning and so maintain our sense of stability and predictability. >We’re wired to look for patterns.
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 helps 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.
“the patient may be unaware of the patterns until the therapist helps him or her recognize and understand them.”

Question 13

explain the feature of Understanding the influence of the past on the present

Answer 13

> Perhaps one of the most central and defining features of psychodynamic therapies, what sets it apart.
The idea that the present (patterns of relating, experiences of the self etc) is profoundly influenced and shaped by experiences in the past.
Especially experiences with early caregivers.
This is unconsciously ingrained in our way of being and relating.
“The focus is not on the past for its own sake, but rather on how the past sheds light on current psychological difficulties.
The goal is to help patients free themselves from the bonds of past experience in order to live more fully in the present.”

Question 14

explain the feature of “Focus on relationships”

Answer 14

> Relationships are seen as the primary site of injury and healing.
Emphasis is placed on interpersonal experiences and relationships (including patterns of relating e.g. consistent difficulties with people can tell us about how they’ve been hurt).
Problems are often seen as a result of unmet relational needs or difficulties establishing healthy
and satisfying relationships.

Question 15

explain the feature of Centrality of the therapeutic relationship to the therapy

Answer 15

Therapeutic relationship is seen as where relational patterns emerge. The way they and the therapist interact is seen as typical of how they interact with people.
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.
>Represents the emergence of unconscious expectations about how the patient will be perceived/ treated.
>Countertransference = therapist’s response to those feelings, behaviors, and expectations.
>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

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 emergence of fantasies and symbols that hold important information about hidden fears and wishes.
Exploring dreams is a good way to access unconscious materia

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. Hundreds or perhaps thousands of others have contributed to the field.He is the first source of the thinking, but many others developed it, filled in gaps, and showed
how certain of his concepts were unhelpful or erroneous.
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.
Patient’s don’t need to lie on a couch, and the therapist is a lot more interactive.
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

> Symptom reduction is not the primary goal, as is often the case with EBTs such as CBT.
The symptoms are seen as a manifestation of something problematic that needs to be
addressed. Getting rid of them won’t address the cause of the problem.
symptoms are seen as serving a purpose: they’re a means to re-establishing equilibrium / stable sense of self in the world.
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.
This leads to 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 motivators.
We’re social beings who seek out connection with others. We all have social needs, although they may be different: being seen, being cared for, caring for others etc.
- These needs all happen in the context of other people / relationships.
Psychodynamic therapies emphasise the relationship of therapy over the techniques.
More about a ‘posture’ and way of thinking and making meaning.
Therapists use whatever the patient brings to the space. The patient ‘sets the agenda’ and the therapist follows their lead.
It’s a collaborative meaning-making process.
->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
   other tools and techniques
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 24

explain the notion of interpreting defenses as a therapeutic tool

Answer 24

-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 25

name 3 criticisms of psychodynamic therapy

Answer 25

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

Question 26

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

Answer 26

> 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 27

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

Answer 27

> 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 28

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

Answer 28

> 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 29

what is some evidence in favour of psychodynamic theory and therapy

Answer 29

> 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 30

what is an incubator effect

Answer 30

> 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 31

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

Answer 31

> 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.