Psychotherapy 2 Flashcards
Freud and development
Two layers in dream
manifest layer is what is remembered/recalled of dream; latent layer is the unconscious wish that is not recalled
manifest layer
portion of dream remembered
Latent layer
unconscoius portion of dream
Condensation
several unconscious impulses are attached to one manifest dream image. Example: a man with a face made of bread playing a trumpet may be the dreamer’s fear of men consuming creative instincts…or something like that
Displacement
intensity toward an object is redirected to a more neutral/acceptable object. Example: dreamer unconsciously wants to kill their mother; in the dream, they want to kill an unknown female stranger (more acceptable object)
Projection
dreamer’s unacceptable wishes are put onto another person in the dream. Example: dreamer wants to rob a bank; in dream they are concerned about their brother’s desire to rob a bank
Symbolic representation
innocent symbol represents a complex set of feelings. Example: dreamer sees a puppy, which actually represents their feelings of vulnerability and fear of being castrated/neutered…or something like that
Primary process
the above incoherent esoteric characteristics of the manifest layer (nonsensical dream aspects that are recalled)
Secondary revision
rational portions of dreams that resemble waking life (dreams acting out work/home scenarios, being on call, etc)
Topographical Model of the Mind
Based on principle that the mind is divided into layers. Freud used this theory to identify the workings of the conscious and unconscious mind
Instinct and Drive Theory
After developing the topographical model of the mind, Freud began to consider instinct theory. Instinct refers to a pattern of genetically derived behavior that is independent of learning. The instinct has 4 basic characteristics: the source (part of body from which instinct arises), the impetus (intensity of instinct), the aim (generally an action toward decreasing tension), and the object/target of the instinct.
Specific types of instinct
Libido: sexual/pleasure drives
Ego: non-sexual instincts/drives
Aggression: dual instinct theory refers to the balance between libido and aggression, where aggression aims to destroy
Pleasure principle
The Pleasure principle is that humans avoid pain and seek pleasure
Reality principle
The Reality principle is that which delays/postpones the pleasure principle when it is not appropriate. The Reality principle is generally learned.
Structural Theory of the Mind
Id: unorganized instinctual drives that are part of the primary process (see above). Occurs unconsciously x
Ego: spans all three areas of the mind (conscious, preconscious, and unconscious). It is responsible for logic/abstraction (conscious), defense mechanisms (unconscious), perception, contact with reality, and delay/modification of drives (to make them socially acceptable). The ego helps to modify the id, which sometimes leads to conflict
Superego: establishes and maintains the moral conscience, based on values internalized from parents. Proscribes what a person should not do
Functions of the Ego
Controls instinctual drives: mediates between the id and the external world and delays socially unacceptable drives
Judgment: anticipates the consequences of actions
Relation to reality: mediates between internal world and external world. Develops a sense of reality (distinguish inside body vs. outside body), reality testing (distinguish between fantasy and reality), and adaptation to reality (adapt to change)
Object relations: developing satisfying relationships stems from early interactions with parents and other early significant figures
What is the point of psychosexual development stages
The goal is to progress through these stages linearly, confronting pathology specific to each stage, leading to resolution of conflict/pathology and moving onto the next stage in life. Failing to resolve pathology leads to incomplete passage through each stage, and the person will continue to struggle with unresolved issues from previous stages.
List the psychosexual development stages
Oral (0-18 months) Anal (1-3 years old) Urethral Transition Stage (between anal and phallic stages) Phallic (3-5 years old) Latency (5/6-11/13 years old) Genital (11/13-Adulthood)
Oral Phase (0-18 months) general
Concepts of thirst, hunger, and satiation. Libido (oral eroticism) vs. Aggression (oral sadism, biting, devouring, and destroying)
Oral phase goal
develop trust and dependence and gratify libido without conflict with aggression
Oral phase pathology
narcissism, pessimism, dependence on objects/people for self-esteem, envy, jealousy
Oral phase resolution
learn to give and receive without excessive dependency/envy and build trust/self-reliance
Oral phase common defense mechanisms
projection and denial in early oral, displacement and “turn against self” in later oral
Anal phase (1-3 years old) general
Concepts of control (over anal sphincter), increasing aggressive drives, and the shift from a passive/dependent phase (oral) to an active phase
Anal phase goal
separation, individualization, maintaining a balance between overcontrol/undercontrol. Related to autonomy/independence with a good balance of control vs. shame/self-doubt due to lack of control
Anal phase pathology
overcontrol leads to being overly neat/orderly, stubborn, and willful. Loss of control leads to messiness, ambivalence, and defiance. Obsessive-compulsive neurosis pathology develops in this stage
Anal phase resolution
autonomy, initiative without guilt, self-determining behaviors without shame and doubt
Anal phase common defense mechanisms
undoing, reaction formation, regression, and isolation
Urethral Transition Stage (between anal and phallic stages) general
Release vs. retention. There is the potential for regression in this transition from anal stage (balance of control, autonomy) moving onto phallic stage. Regressive enuresis can occur here.
Urethral transition stage pathology
competitiveness/ambition, feminine shame due to lack of strong urine stream (seriously…)
Urethral transition stage resolution
pride and self-competence, sets the stage for gender identity
Phallic phase (3-5 years old) general
Sexual interest, stimulation, and excitement. Unconscious oedipal issues (boy’s competition with father for the mother’s love) and castration anxiety
Phallic phase goals
gender identity, overcome oedipal issues for organization of character
Phallic phase pathology
neurosis, castration anxiety in males, penis envy in females, abnormal development of human character
Phallic phase resolution
ability to maintain curiosity without embarrassment, initiation without guilt, sexual identity, regulation of drive impulses, generate superego based on identification with parent of the same sex
Phallic phase common defense mechanisms
Intellectualization vs. repression
Latency (5/6-11/13 years old) general
Development of the superego in the phallic stage leads to instinct control. In latency, the libido gets sublimated (directed into socially acceptable behaviors). Start to play and learn while fighting overcontrol and obsessions
Latency goals
finish the work started in the phallic stage by further integrating oedipal identification and consolidating sex roles. Develop Ego and begin to master skills
Latency pathology
Issues of control (like in anal stage), with problems with over-control/under-control. Overcontrol leads to closure/stunting of personality development. Under-control leads to not focusing on learning in this stage
Latency resolution
integrating psychosexual development, mastering tasks/objects, becoming autonomous, and learning to take initiative
Latency common defense mechanisms
sublimation
Genital (11/13-Adulthood) general
Physical maturity, hormonal development, increasing drives. There is a struggle against regression and this stage may reopen all conflicts in previous stages, leading to the need to re-resolve them
Genital phase goals
separate from dependence on parents, develop mature object relations, develop adult roles, and accept cultural values
Genital phase pathology
reopening/reworking previous development and potential for regression; previous unsuccessful resolution leads to pathology in adulthood
Genital phase resolution
reintegration and resolution of previously unresolved conflicts leads to maturation of personality and capacity for self-realization
Erik Erikson
Adapted some of Freud’s theories of development to formulate a theory of development that covers the entire span of the life cycle, from infancy and childhood through old age and senescence
Epigenetic principle
development occurs in sequential, clearly defined stages, and that each stage must be satisfactorily resolved for development to proceed smoothly. A virtue is associated with each stage. “If everything goes back to childhood, then everything is somebody else’s fault and taking responsibility for oneself is undermined.”
Eriksonian stages
Trust vs. Mistrust (0-18 months, correlates with Oral)
Autonomy vs. Shame and Doubt (18 months-3 years, correlates with Anal)
Initiative vs. Guilt (3-5 years old, correlates with phallic)
Industry vs. Inferiority (5-13 years old, correlates with latency)
Identity vs. Role Confusion (13-21 years old, correlates with genital)
Intimacy vs. Isolation (21-40 years old)
Generativity vs. Stagnation (40-60 years old)
Integrity vs. Despair (60 years old until death)
Trust vs. Mistrust
(0-18 months, correlates with Oral)
Starting to take in the world and learn trust based on quality maternal relationship. “Taking and holding onto things.”
Trust vs. Mistrust defense mechanisms
projection and introjection
Trust vs. Mistrust virtue
hope
Trust vs. Mistrust pathology
schizophrenia (aggravated crisis due to failing to develop hope), depression (feeling empty, no good), addictions issues
Autonomy vs. Shame and Doubt
(18 months-3 years, correlates with Anal)
Developing a sense of justice and maintaining a balance between goodwill/cooperativeness and willfulness. Self-certain vs. self-conscious. Regulate the will. Will to be oneself vs. self-doubt. “Holding on and letting go.”
Autonomy vs. Shame and Doubt virtue
Will
Autonomy vs. Shame and Doubt pathology
Persecutory paranoia (stuck between trust/autonomous will and mistrust/doubt), OCPD (conflict with hold on/let go, leading to doubt > autonomy and a harsh conscience), impulsivity
Initiative vs. Guilt
(3-5 years old, correlates with phallic)
Exploration, conquest, curiosity, competitive, aggressive, preoccupation with genitals. Compete with same sex parent, jealousy, and rivalry. Failure leads to guilt. Role anticipation vs. role inhibition. The superego is developed to regulate initiative. Oedipal impulse is overcome, and the child can then compete in the outside world and learn to lead an active adult life. “Being on the make.”
Initiative vs. Guilt virtue
purpose
Initiative vs. Guilt pathology
overcompensation for the conflict between initiative and guilt. This can cause conversion disorder, inhibition, paranoia, and psychosomatic illnesses
Industry vs. Inferiority
(5-13 years old, correlates with latency) Learning new skills, pride, work ethic, and diligence. Identify with teachers. Learn to find role in society. Task identification vs. sense of futility.
Industry vs. Inferiority virtue
competence
Industry vs. Inferiority pathology
failure to complete previous stages leads to mistrust/pessimism, imbalance between over-control/under-control, poor development of the superego and guilt. If there is no development of trust/balance of control/creation of superego, the child will not integrate well into society. In addition, they will not learn new skills or become competent. This all leads to creative inhibition and conformity
Identity vs. Role Confusion
(13-21 years old, correlates with genital) Puberty, comparing self with others and caring how others perceive them, cliques. Failure leads to identity diffusion and role confusion. Intolerance of individual differences is the way the youth wards off a sense of their own identity loss. Falling in love serves to clarify one’s sense of identity projecting your identity onto another person.
Identity vs. Role Confusion virtue
fidelity, sustaining loyalties to others despite contradiction of value systems (accepting people for who they are)
Identity vs. Role Confusion pathology
role confusion ensues when the person cannot formulate a sense of identity. This results in delinquency, gender-related identity disorders, and borderline psychotic episodes
Intimacy vs. Isolation
(21-40 years old)
Looks at the virtue of love within a balanced identity. Intimacy is tied to fidelity, to make compromise and to self-sacrifice. Ego loss occurs while becoming closer to others; the reaction may be to become detached and self-absorbed.
Intimacy vs. Isolation virtue
love
Intimacy vs. Isolation pathology
isolation and detached states, including schizoid personality disorder
Generativity vs. Stagnation
(40-60 years old)
Establishing and guiding the next generation, not just specifically your own offspring. Person has already learned to form intimate relationships, and this stage serves to broaden social scope to include groups, organizations and society. Importance of feeling needed. Failure of generativity leads to stagnation, escapisms (alcohol and other sexual infidelity), and mid-life crisis.
Generativity vs. Stagnation virtue
care
Generativity vs. Stagnation pathology
alcoholism, divorce, withering of leadership roles/destruction of companies, premature invalidism
Integrity vs. Despair
(60 years old until death) Accepting responsibility for one’s own life, holding onto integrity, and a “detached yet active concern with life.”
Integrity vs. Despair virtue
wisdom
Integrity vs. Despair pathology
failing to attain integrity leads to becoming deeply disgusted with the external world and contemptuous of persons and institutions. Disgusts masks the fear of death and a sense of despair that “time is now too short for the attempt to start another life and try out alternate routes to integrity.”
Pathological development
In both Freud and Erikson’s developmental theories one concept is central: failure to resolve conflict and mature through each stage leads to significant residual pathology. Plainly stated, if you don’t resolve the bad stuff in each stage, you will go on to the next stage with unresolved baggage and continue through life with that baggage. A person who does not resolve oral/trust/mistrust stages will have a lifelong struggle with dependence, trust, hopelessness and mental pathology. This section is not high-yield for PRITE, but it is very useful for providing good care for your patients, understanding the roots of pathology, and making a kickass bio-psycho-social-spiritual formulation for oral examinations in residency.
Birth to 18 months (pathological development)
Freud: Oral stage (feeding, nutrition, needs, narcissism, object relations), trust/give/receive.
Erikson: Trust vs. Mistrust (taking and holding onto things), hope, projection.
Pathology: Impaired trust leads to mistrust.
x Separation in infancy leads to depression, hopelessness, dysthymia x Projection (defense mechanism associated with this stage) leads to social mistrust, paranoia, delusional disorders, schizoid personality disorder, and paranoid schizophrenia
x Social mistrust leads to oral dependency and substance abuse due to the feelings of emptiness and hunger
x Feeling starved and empty also leads to thrill seeking behaviors
18 months to 3 years (pathological development)
Freud: Anal stage (control of sphincters), balance between over control/under control, individualization.
Erikson: Autonomy vs. Shame and Doubt (holding on vs. letting go), independence and the development of will.
Pathology: develops when shame and doubt dominate autonomy.
x Doubt > autonomy leads to obsessive personality
x Shame > autonomy leads to feeling dirty, delinquent behavior and paranoia about control
x Rigorous toilet training leads to excessive cleanliness and compulsions
x Over-control leads to obsessions/compulsions, willfulness and anal retention
x Under-control causes ambivalence, messiness, and sadomasochism x Mistrust (in earlier stage) plus shame and doubt leads to persecutory delusions
x Refusal to be controlled causes impulsivity
3 to 5 years (pathological development)
Freud: phallic stage (issues of oedipal conflict, gender identity, penis envy/castration anxiety), identification with parents leading to the development of superego to regulate drives.
Erikson: Initiative vs. Guilt (expedition, competition with parent), conscience, purpose, child learns values and recognizes the external world, guilt secondary to drives vs. initiative.
Pathology: guilt related to impulses and desires leads to symptom formation.
x Guilt leads to anxiety disorders, phobias, sexual inhibition (due to fear of punishment)
x Punishment for impulses leads to conversion disorder due to oedipal wishes, and sexual inhibition/impotence
x Fear of not fulfilling one’s purpose leads to psychosomatic disease
5 to 13 years (pathological development)
Freud: Latency stage (superego developed in phallic stage now controls/regulates desires and wishes), sexual identity, learning, mastery of skills.
Erikson: Industry vs. Inferiority (learn skills, begin to establish identity), competence, integration into society.
Pathology: development of inferiority due to problems completing goals.
x Work inhibition, feeling inadequate, compensatory drive for money/power/prestige later in adulthood at the expense of intimacy (later stages suffer due to incompletion of this stage)
13 years to 20s (Adolescence) (pathological development)
Freud: Genital stage (maturation, reworking conflict), separation/independence, emphasis is on reworking unresolved issues from the previous stages.
Erikson: Identity vs. Role Confusion (puberty, ego identity), roles, fidelity to oneself.
Pathology: identity confusion.
x Loss of identity through overidentification with others and formulation of cliques
x If unable to leave the home, there may be prolonged dependence
x Role confusion leads to conduct disorder, gender identity disorder, and disruptive behavior
20s to 40s (pathological development)
Freud’s last sage was the genital stage, which focused on continuing to work through previous conflict throughout adulthood. The remaining discussion on development of psychopathology will focus on Erikson.
Erikson: Intimacy vs. Isolation (maintaining identity while establishing intimacy), sacrifice/compromise, love.
Pathology: the inability to take risks, capacity to love and isolation leads to schizoid personality disorder.
40s to 60s (pathological development)
Erikson: Generativity vs. Stagnation (guiding the next generation), tribal leaders, caring, newly achieved personal intimacy with social groups, knowledge and skills.
Pathology: develops when a person cannot generate of skills and share knowledge with the next generation
x Stagnation leads to “escapism” into alcohol/substances, infidelity and mid-life crisis
x Society suffers, the patient suffers, leading to depression and disappointment
x Contemplation of past failures, current problems, and losing hope for the future
60s to End of Life (pathological development)
Erikson: Integrity vs. Despair (accept the life cycle and the proximity of death), healthy detachment and wisdom.
Pathology: the knowledge that time has run out, no generativity, and inability to accept life
x Declining physical health leads to anxiety, psychosomatic illness, hypochondria and depression.
x Lacking generativity and acceptance often leads to suicide
