Psychodynamic Psychotherapy

Psychodynamic Psychotherapy
• Why begin with the psychodynamic approach?
– Psychodynamic therapy came first historically
• For much of the first half of the 1900s, the psychodynamic
approach was practically synonymous with psychotherapy itself
– Many of the therapies that arose in later decades were
reactions against the psychodynamic approach
• These include humanistic, behavioral, and cognitive therapies
– Many of the pioneers of non-psychodynamic therapies
were initially trained in psychodynamic programs…
• … but later abandoned the approach to create something
different
 Psychodynamic Psychotherapy
• Psychodynamic psychotherapy does not enjoy the reputation or
popularity it once held
– “There can be little doubt that psychoanalysis and the psychodynamic
therapies that arise from it are currently in a beleaguered state. The
average educated reader today is likely to be confronted with a series of
statements in the popular press that are variations on the following
themes: Freud is dead; psychoanalysis is more religion than science;
psychodynamic psychotherapy has no research to support its efficacy;
cognitive-behavioral therapy has surpassed psychoanalytic therapy as
the most accepted form of psychotherapeutic treatment;
psychodynamic psychotherapy is too long and too expensive; and the
fundamental psychoanalytic concepts are too vague to be rigorously
studied. The common wisdom among psychoanalysts these days is that
if a patient asks you if you are ‘a Freudian,’ the correct answer is ‘no.’”
• Gabbard, 2009, p. vii
– Gabbard is a leading scholar in psychodynamic psychotherapy
 Psychodynamic Psychotherapy
• Despite its decline, it remains relevant and widely used
– Influences clinical psychology through adaptations of its
traditional methods into novel approaches that better suit
contemporary culture
• The quote on the previous slide
– Appears in the preface of a full book devoted to evidence-
based psychodynamic psychotherapy
– The mere existence of such a book shows the vitality of
psychodynamic psychotherapy in an era that emphasizes
empirical efficacy
 Psychodynamic Psychotherapy
• Sigmund Freud
– The pioneer of the
psychodynamic approach to
clinical psychology
• Psychodynamic psychotherapy
– An approach to psychotherapy
deriving from the theories of
Sigmund Freud
• Includes all subsequent efforts to
revise and expand on it
• Includes Freud’s original approach
to therapy
– Known in its classic form as
psychoanalysis
 Psychodynamic Psychotherapy
• Freud had many intellectual descendants
– Some were contemporaries
• Carl Jung, Alfred Adler, and Erik Erikson
– Others arrived in subsequent generations
• His daughter Anna Freud, Harry Stack Sullivan, Frieda Fromm-Reichmann,
Melanie Klein, Karen Horney, D. W. Winnicott, and Heinz Kohut
• Freud’s original term psychoanalysis was replaced by other
terms at various points in the evolution of his theory by others
– e.g., psychoanalytic psychotherapy, neo-Freudian therapy, and
psychodynamic psychotherapy
• Each of these has generated even more specific terms for its offshoots
• Here, we will use the term psychodynamic psychotherapy to
represent them all
 Goal of Psychodynamic Psychotherapy
• The primary goal is to make the
unconscious conscious
– Psychodynamic psychotherapists
help their clients to become aware
of thoughts, feelings, and other
mental activities they are not
aware of at the start of therapy
– Insight – looking inside oneself
and noticing something that had
previously gone unseen
– Once we become aware of
unconscious processes
• We can make efforts to control them
deliberately rather than them
controlling us
 The Unconscious
• The process of making the unconscious conscious assumes the existence
of an unconscious part of the mind
– Unconscious – mental activity occurring outside our awareness
• One of Freud’s most important and enduring contributions to clinical psychology
– Before Freud, there was little acknowledgement about any mental activity
occurring outside our awareness
• Freud changed the way we think about ourselves
– Proposed “mental processes that are outside the awareness of the individual and
that have important, powerful influences on conscious experiences” (Karon &
Widener, 1995, p. 26)
• According to Freud and his followers
– The unconscious exists and exerts a powerful influence on our day-to-day and
minute-to-minute lives
– Unconscious processes underlie depression, anxiety, personality disorders, eating
disorders, and all other forms of psychopathology that clinical psychologists treat
• Thus, gaining access to the unconscious is vital
 Accessing the Unconscious
• Psychodynamic psychotherapists access the
unconscious in many ways
– This is not done in an empirical and/or factual way
– This is done through inference, deduction, and conjecture
• Psychodynamic psychotherapists try to “read” their clients and
hypothesize about their unconscious activity using
– Free association
– Freudian “slips”
– Dreams
– Resistance
– Defense mechanisms
– Transference
 Free Association
• Free Association – a technique in which the psychodynamic
psychotherapists ask clients to say whatever comes to mind
without censoring themselves at all
– The client’s task is to verbalize any thought that occurs
• Not matter how nonsensical, inappropriate, illogical, or unimportant it may seem
– A bit like brainstorming works…
– Not an easy task
• It’s rare to speak with complete spontaneity without editing ourselves in some way
– Perhaps the only time are with very young children or intoxicated adults
– The idea is that the words of people in such states of mind can be
revealing of their innermost thoughts and feelings
– If clients can feel relaxed enough to engage in free association
• Their unconscious processes become more evident to the therapist and themselves
 Freudian “Slips”
• Freudian “slips” – verbal or behavioral mistakes
determined, according to the psychodynamic
psychotherapists, by unconscious motivations
– According to psychodynamic psychotherapists
• All our behavior is determined
• There is no such thing as a mistake, accident, or slip
– If a behavior can’t be explained by motivations
which we are aware of, unconscious motivations
must be the cause
Freudian “Slips”?
 Dreams
• Psychodynamic psychotherapists believe that our dreams
communicate unconscious material
– Freud theorized that when we sleep
• Our minds convert latent content (the raw thoughts and feelings of the unconscious)…
• … to manifest content (the actual plot of the dream as we remember it)
– Dream work – the process of converting the latent content of a dream to its
manifest content
– In psychodynamic psychotherapy
• The therapist analyzes dreams by attempting to uncover the unconscious meaning
behind them
– Essentially, undoing the dream work
• Therapist will often ask the client to help in the dream interpretation process by
explaining the personal meaning of the symbols appearing in the dream
– Even with the client’s help, dream interpretations (and other attempts to
understand the unconscious) are inferential rather than factual
 Resistance
• Sometimes, clients make it clear they “don’t want to go there”
– Can communicate their reluctance in many ways – some obvious, some subtle
• Might change the subject, may fill session with talk of unessential topics, etc.
– This is what psychodynamic therapists call…
• Resistance – client behavior that impedes discussion or conscious
awareness of selected topics or emotions
– According to psychodynamic psychotherapists, clients feel anxious when
thoughts and feelings are being laid bare too extensively or too quickly
– This anxiety motivates them to create distractions or obstacles that impede
the exploration or those thoughts and feelings
– Psychodynamic psychotherapists
• When they notice resistance, they assume that the therapy has “struck a nerve”
• Although the client might not be willing to delve into the issue, the resistance itself is an
important factor in the client’s daily life
– Could become a productive topic of discussion later in therapy
 Defense Mechanisms
• Psychodynamic
psychotherapists believe
that identifying clients’
unconscious defense
mechanisms and bringing
them into the clients’
awareness can improve the
quality of their clients’ lives
• First, we need to talk about
the personality components
(according to Freud), that
produce them…
 Freud’s Structural Model of the Mind
• Three forces… the interaction of which occurs largely outside
our awareness.
– The id – the part of the mind that generates all the pleasure-seeking,
selfish, indulgent, animalistic impulses
• Seeks immediate satisfaction of its wishes
• Oblivious of any consequences
• Freud believed the id was inborn
– The superego – the part of the mind that establishes rules, restrictions,
and prohibitions
• Tells us what we “should” do
• Often uses guilt to discourage us from overindulging in immediate pleasure
• Freud believed the superego became part of the mind through authority figures
• Stands
– As an internalization of the rules and morals taught to each of us
– In direct opposition to the id
 Freud’s Structural Model of the Mind
• According to Freud…
– Our unconscious mental processes involve a constant battle between
• An id demanding instant gratification
• A superego demanding constant restraint
– How does the mind manage these battles?
– What does it do with the conflicted impulses?
– This is the responsibility of…
– The ego – a mediator and compromise maker between the id and
superego
• Faces two challenges
– Partially satisfying both of these opposing forces
– Meeting the demands of reality
• The ego can be creative in the ways it handles id/superego conflict
– Over time it develops…
 Defense Mechanisms
• Defense mechanisms – techniques used by the ego to
manage conflict between the id and superego
• Freud offered descriptions of many. His followers,
including his daughter, Anna Freud, have added to the list
• Some commonly acknowledged defense mechanisms
– Repression
– Projection
– Reaction formation
– Displacement
– Sublimation
 Defense Mechanisms:
Repression
• Repression
– When the id has an impulse and the superego rejects
it the ego can repress conscious awareness of the
impulse and the id/superego conflict around it
• The ego can take the impulse and the internal conflict it
creates and “sweep them under the rug” so that we never
even become aware of them
– Denial is a similar defense mechanism
• Usually refers to events that happen to us rather than
impulses that come from within us
 Defense Mechanisms:
Projection
• Projection
– When the id has an impulse and the super ego rejects it,
the ego can project the id impulse onto other people
around us
– In this, we convince ourselves that the unacceptable
impulse belongs to someone else, not to ourselves
– In projection we
• Attribute our most objectionable qualities to others
• Cast ourselves as possible recipients of others’ unacceptable
behavior
– Rather than the ones with the impulse to carry it out ourselves
Defense Mechanisms:
Projection
 Defense Mechanisms:
Reaction Formation
• Reaction formation
– When the id has an impulse and the superego
rejects it, the ego can form a reaction against the
id impulse
• Essentially, do the exact opposite
– When the id urges us to do something selfish
• We don’t simply resist the temptation
• We do something selfless
– This is as if overcompensating for the original id impulse
 Defense Mechanisms:
Displacement
• Displacement
– When the id has an impulse and the superego
rejects it, the ego can displace the id impulse
toward a safer target
• Rather than aiming the id’s desired action to whom or
what it wants, we redirect the impulse towards another
person or object to minimize repercussions
– This way, the superego is somewhat satisfied as well
– The phrase “kicking the dog” has been used to
describe displacement
Defense Mechanisms:
Displacement
 Defense Mechanisms:
Sublimation
• Sublimation
– When the id has an impulse and the superego
rejects it, the ego can sublimate it
• This is to redirect it in such a way that the resulting
behavior actually benefits others
– Unlike “kicking the dog” in displacement, this
allows the id to do what it wants
• Others are helped in the process rather than harmed
 Defense Mechanisms
• Let’s take an id impulse of physical aggression…
– Repression
• The ego could repress the impulse so that you are never aware of it
– Projection
• You could become convinced that someone else, not you, had an impulse to attack
– Reaction Formation
• You could do the opposite of physical aggression
• You might be exceedingly gentle and kind towards others
– Displacement
• If you wanted to hit your boss, you could hit a friend, family member, dog, partner,
punching bag, or video game character
– Sublimation
• You could become a surgeon, whose incisions heal rather than harm
 Defense Mechanisms
• Psychodynamic psychotherapists believe that some defense
mechanisms are more mature/healthier than others
– Denial and repression are considered immature
• They don’t effectively satisfy the id
• Similar id demands end up resurfacing later
– Sublimation is considered mature
• Satisfies id impulses and societal needs simultaneously
• Goal of psychodynamic psychotherapy is to help clients
become aware of unconscious patterns
– With an awareness of one’s defense mechanisms
• One can exert control over them
• One can move toward more mature ways of managing internal conflicts
 Defense Mechanisms
• Alternate definitions of core Freudian terms
– Freud wrote in German. Some of his followers have argued that his terms were
mistranslated
• Id, Ego, and Superego are actually Latin terms uncommon to everyday English
• Id may be better translated to “it”
– That is, the part of you that is animalistic rather than human
• i.e., not “he” or “she”
• Superego may be better translated to “over-me”
– An internalization of the rules and demands that came from authority figures
(especially parents)
• Ego therefore refers to “me”
– The person negotiating between the demands for instant pleasure and the demands to
follow rules
• In this way, the defense mechanisms characterize the whole person
– Not just an abstract component of the mind (the “ego”)
 Transference
• Transference – clients’ tendency to form relationships with therapists in
which they unconsciously and unrealistically expect the therapist to behave
like important people from the clients’ past
– Without realizing it
• The client “transfers” feelings, expectations, and assumptions from early relationships onto the
relationship with the therapist
– Clients allow powerful previous relationships to distort their view of the therapist
• Subtly “prejudge” the therapist as a person whose responses will echo those of the mother,
father, or other important figure
• Transference may be the most essential means for the psychodynamic
therapist to access a client’s unconscious material
– It is “generally regarded s the most important focus” of psychodynamic
psychotherapy
• Galatzer et al., 200, p. 27
– It is seen as “the most powerful tool” of those who conduct psychodynamic
psychotherapy
• Karon and Widener, 1995, p. 27
 Countertransference
• Just as clients can transfer onto therapists, therapists can
transfer onto clients
• Countertransference
– Transference by therapists onto clients
– Psychodynamic psychotherapists generally strive to minimize it
• This is because it involves a reaction to the client that is unconsciously
distorted by the therapist’s own personal experiences
– This is one reason many psychodynamic training programs
require trainees to be clients in psychodynamic psychotherapy
• So they can become aware of their own unconscious issues
• So these issues won’t arise as countertransference towards their own
clients
 Psychosexual Stages: Clinical Implications
• Freud’s psychosexual stages
– Oral, anal, phallic, latency, and genital
– Among the most widely known aspects of his theory
• Fixation – unsuccessful resolution of the psychological
tasks of a particular developmental stage
– A child may become “stuck” at any stage to some extent
• If the child becomes “stuck,” they could struggle with issues related to
that stage for many years
– Often well into adulthood
– Fixation can happen for a variety of reasons
• Most often occurs when parents do “too much” or “too little” in
response to the child’s needs at a certain developmental point
 Psychosexual Stages:
The Oral Stage
• Oral stage – the first of the psychosexual stages and
the stage from which issues of dependency may
emerge
– Occurs during roughly the first year and a half of a child’s life
– During this time
• The child experiences all pleasurable sensations through the mouth
• Feeding (breast or bottle) is the focal issue
– Children whose parents mismanage this stage may display
blatantly “oral” behaviors later in life
• i.e., smoking, overeating, drinking, nail biting, etc.
 Psychosexual Stages:
The Oral Stage
• The primary issue at this stage is dependency
– If parents overindulge children in the oral stage
• Children may learn that
– Depending on others always works out wonderfully
– Other people exist solely to anticipate and meet their needs
• Children may become overly trusting, naïve, and unrealistically optimistic
personalities as adults
– And they’ll form relationships accordingly
– If parents are not responsive to children in the oral stage
• Children may learn that
– Depending on others never works out
– Other people have no interest in helping you at all
• Children may develop overly mistrusting, suspicious, and unrealistically
pessimistic personalities
– And they’ll form relationships accordingly
 Psychosexual Stages:
The Anal Stage
• Anal stage - the second of the psychosexual
developmental stages, and the stage from
which issues of control may emerge
– Occurs when the child is about 1.5 to 3 years old
– During this time
• Children are learning to control themselves in many
ways
• Toilet training is the central issue of this stage
• Adults (especially parents) place demands on children
regarding their speech and behavior
 Psychosexual Stages:
The Anal Stage
• The primary issue at this stage is control
– If parents are too demanding of children at this stage
• Children can become overly concerned about getting everything just
right
– In the bathroom, this may mean “no accidents”
– In general, this means having everything in exactly the right place at the right
time
• Children often grow to become adults who think obsessively or
behave compulsively in order to stay in control
– If parents are too lenient of children at this stage
• Children can become lax about organization
• Can continue into adulthood
– Messy desk piles, sloppy schedules, car oil gets changed “whenever”
 Psychosexual Stages:
The Phallic Stage
• Phallic stage – the third of the psychosexual stages,
and the stage from which issues of self-worth may
emerge
– Occurs from about age 3 to about age 6
– Of the most controversial of the Freudian stages, even
among contemporary psychoanalysts
– During this time
• Children wish to have a special, close relationship with parents
• The parent’s response to the child’s wish crucially shapes the
child’s view of themselves
 Psychosexual Stages:
The Phallic Stage
• The view of the self – self-worth – is the key consequence of the
phallic stage
– The ideal situation is for parent to respond positively to kids’ overtures
– When parents respond too positively
• They overinflate the child’s sense of self
• Such children may grow into adults whose opinions of themselves are
unrealistically high
– Strike others as egotistical
– When parents reject their child’s wishes for a special, close relationship
• Self-worth can be wounded
• Such children may grow into adults who devalue themselves and are overly
insecure and self-doubting