Psychodynamic

Psychotherapy
 ✔ Historical overview of the model

✔ Core psychodynamic theory (Internal Conflict, Defense

mechanism & Resistance)

✔ Projection, dynamics of transference and counter

Topics to be
transference
covered
✔ Goals for therapy

✔ Working with unconscious

✔ Working with transference

✔ Spectrum of psychodynamic techniques

Historical Overview
•Modern psychotherapy originated in the 18th century from two developments: moral

treatment in asylums and mesmerism.

•“Moral treatment” (or psychological treatment) emerged as a reaction against coercive

asylum practices like chains and physical punishment.

Origin of
•Late 18th c.: Franz Anton Mesmer develops “animal magnetism” (mesmerism)
Modern
•Mesmerism relies on powerful suggestion and doctor’s personality Psychotherapy
•Mesmerism- Implies mind harbors elements beyond conscious control

•Mid 19th c.: Jean‑Martin Charcot revives hypnotism and was treating patients of hysteria

using hypnosis.
 Born- Austria
Studied Medicine-
Vienna
 ▪ 1895: Freud and Josef Breuer publish Studies on Hysteria

▪ Propose that hysterics suffer from painful, unpleasant traumatic

memories

▪ These memories are unconsciously repressed

▪ Repressed memories manifest as physical hysteria symptoms

Hysteria
▪ 1896: Freud develops a therapeutic method called “psychoanalysis”

based on his clinical experiences with hysterical patients.

▪ Freud later abandoned hypnosis; introduces “free association” to

uncover repressed material hidden in the unconscious.

 • 1899: Publishes The Interpretation of Dreams- Dreams represented the

unconscious fulfilment of wishes that were otherwise disturbing and

sexual in nature.

• In The Interpretation of Dreams- topographical model of mind

Contribution • The Psychopathology of Everyday Life- method of interpretation to

s
human behaviour generally (Freudian Slips)

• 1905: Three Essays on the theory of Sexuality- stages of psychosexual

development

• 1920- Beyond the Pleasure Principle (Pleasure & Reality Principles)

 Neo-Freudians
▪ Followed many of Freud’s initial concepts but later left to form their
own views on personality.

▪ This includes Carl Jung, Alfred Adler, Eric Fromm and Karen Horney
etc.
Freud’s ▪ Jung- Rejected the idea of sexual drive being the sole determinant of
Legacy human behavior and gave his concept of collective unconscious.

▪ Adler- Objected emphasis on sexuality and posited the concept of

inferiority complex and striving for superiority.

▪ Fromm and Horney- maintained that it is important to consider the

importance of society in individual difficulties.
 ▪ Published The Ego and the Mechanism of Defence, which developed

her father’s concept of the ego and the role of defence mechanisms.

▪ Anna Freud, along with Melanie Klein, was a pioneer in establishing

Anna psychoanalytic psychotherapy for children but had different views.

Freud
▪ Melanie Klein was responsible for an approach to psychoanalysis that

came to be known as object relations theory.

 Object Relation Theory
▪ Focuses on formation of relationships; especially early relationships with caregivers

and how these shape our personality, inner world, and interactions with others.

▪ Investigated how individuals form mental images of others.

▪ Examined interactions between:

Melanie External objects – actual people in one’s life

Klein
Internal objects – mental/emotional images of those people

▪ She maintained that aspects of the internal world, such as feelings or images, could

be ‘projected’ externally.

▪ Aspects of the outer world could be ‘introjected’ into the inner world.
 ▪ Drawing on research in psychoanalysis, Bowlby fully developed his theory

of ‘attachment’ in his influential trilogy: Attachment (1969), Separation

(1973), and Loss, Grief and Mourning (1980).

▪ Caregiver must provide comfort & protection to the child, while

supporting autonomy.
John
Bowlby ▪ If Secure attachment → child sees self as valued and reliable

▪ Insecure attachment → child sees self as unworthy and incompetent

▪The focus in psychoanalytic thinking shifted
from the sex instinct to the mother and child
relationship.
“Mothers displaced castrating fathers as the crucial authority dominating
Turn to
both childhood and the inner life: it was on the base of that earliest and
fundamental relationship, not the paternal one, that all future relations, of
the Child
love and power, of attachment and dependence, would be placed.”
 CORE CONCEPTS

Psychoanalytical
theory
 Key Assumptions

▪ Structural theory of personality & topography of mind

▪ Theory of Psychosexual development

▪ Concept of Unconscious
 Topography of Mind
▪ Conscious Mind- All the thoughts, feelings, and sensations that

you are aware of at this particular moment represent the

conscious level.

▪ Preconscious Mind A region of the mind holding information that

is not conscious but is easily retrievable into conscious awareness

▪ Unconscious Mind A region of the mind that includes

unacceptable thoughts, wishes, feelings, and memories Not

aware of these thoughts, wishes, etc… but they exert great

influence over our conscious thoughts & behavior.

Structure of Personality
Basic Instincts
▪ Mind is energized by two instincts i.e.

positive & destructive (eros & thanatos).

▪ The positive (life giving force) has two

components i.e self preservation & sexuality.

▪ Thanatos- Instinct towards violence,

destruction and negativity

▪ The energy of the sexual part is derived from

the libido
ID
▪ Unconscious portion of personality

▪ Seeks immediate satisfaction

▪ Operates on “pleasure principle”

▪ Source of energy
 EGO
▪ Operates on Reality Principle

▪ Reality principle—ability to postpone gratification in accordance

with demands of reality

▪ Ego—rational, organized, logical, mediator to demands of reality

▪ Can repress desires that cannot be met in an acceptable manner

SUPEREG
O
▪ It is an ideal ego.

▪ internalization of society’s & parental moral standards

▪ One’s conscience; focuses on what the person “should”

do

▪ Id: “I want” Superego: “I should” Ego: “I will”

Integration
 DEFENCE
MECHANISM
▪ Unconscious tactics used by the ego to protect against anxiety &

guilt (from id & superego) by preventing material from surfacing or

disguising it when it does.

▪ Examples: repression, rationalization, projection, reaction formation,

sublimation, displacement, denial, compensation, regression, etc.

 Internal Conflict, Defense
Mechanism & Resistence

Psychodynamic
Theory
 ▪ Psychodynamic theory is interested in the underlying dynamics of

humans and their relationships.

▪ Adverse social circumstances including poverty, inequality, and social

injustice are hugely influential on human relationships and are linked

Core with adverse interpersonal experiences in childhood.
Concept
▪ This dimension is crucial for an understanding of human development,

as is awareness of the correlation between childhood experiences of

neglect, abuse, and family difficulties on a person’s subsequent

physical and mental health.

▪ Many kinds of conflicts might emerge.

▪ Common Internal Conflicts in Attachment and Relationships includes:

▪ Wanting care vs. resisting help

▪ Need to control others vs. desire to submit

▪ Feeling guilty vs. blaming others

▪ Conflicts may arise between core emotional needs (e.g., closeness vs. Internal
independence) Conflict
▪ These conflicts are often unconscious

▪ Maintained through defense mechanisms (e.g., projection, denial)

The notion of internal dynamic conflict is particularly associated with Freud’s

topographical model (1900) and structural model (1923)
▪ Defenses were thought of as being necessary to defend against painful
affects coming into consciousness (Freud)

“Defences are psychological configurations (or ‘strategies’) that operate

to help preserve ‘a sense of self-esteem in the face of shame and
narcissistic vulnerability, ensuring a sense of safety when one feels
dangerously threatened by abandonment or other perils, and insulating Defense
oneself from external dangers” Mechanism
▪ Defences may be internally directed, regulating impulses and affects as
an aspect of self regulation, and/or interpersonally directed ‘involving
others in psychosocial arrangements or collusions for regulating mental
balance
▪ Freud’s original use of the term resistance was used to describe
those dynamics in the patient which specifically oppose the
progress of therapy.

▪ Anna Freud emphasised the extent to which the resistances could

provide information about the patient’s mental functioning.

▪ Resistance became an object of analytic study in itself Resistanc

▪ Examples include: ending therapy prematurely; coming late or
e
missing sessions altogether; silences during sessions or
alternatively speaking a lot but with little affect; automatically
dismissing all the therapist’s interventions as useless or wrong.
There is a close link between resistance and
defences. Resistance refers to when, during
therapy, existing defences are activated and
old ways of being are held onto tightly to
defend the status quo, particularly when the
prospect of
change may be on the horizon.
▪ Projection is where impulses, feelings, or desires that are

intense, unacceptable, or particularly distressing to the

individual are unconsciously attributed to another person.

▪ In other words, what is inside is experienced as coming from

the outside. Projection

▪ For example, in an opening session of a therapy group, an

insecure group member kept on referring to the younger

and quieter of the two therapists as looking frightened.

“The experiencing of feelings, drives, attitudes, fantasies and defences towards
a person in the present which are inappropriate to that person and are a
repetition, a displacement of reactions originating in regard to a significant
person of early childhood”

▪ A person relates to another as if the other were somebody from the person’s
family of origin.

▪ Transference, like the majority of mental life, operates mostly unconsciously. Transference
▪ There is a unique opportunity for a patient to become more conscious of their
transference dynamics.

Transference refers to when the dynamics from a person’s inner object world are
unconsciously transferred to a present-day relationship.
Cont.

▪ The transference can be a vital window for understanding the

relational problems that have brought the patient into therapy.

▪ Transference is only useful insomuch as it promotes an understanding

of unconscious relational dynamics or offers the potential to work

these through
▪ Feelings aroused in the analyst (therapist) in the course

of clinical work were a resistance in the analyst towards

the therapeutic work, brought about by the analyst’s

own unconscious conflicts. Counter

Transference
▪ Therefore, to counteract this problem, Freud

recommended that the analyst undergo analysis in order

to reduce their resistance.

 Goals of
Psychodynamic
Therapy
Initial Phase Goals Middle Goals Final Phase Goals

▪ Promotion of Therapeutic ▪ Exploring Transference and ▪ Ending the therapy

Alliance Managing Counter Transference

Goals
 ▪ Common factors in therapy as follows:

- An emotionally charged bond between therapist and patient.

- A confiding, healing setting in which therapy takes place.

- A therapist who provides a psychologically derived and culturally

embedded explanation for emotional distress.

Initial
Goal - An explanation that is adaptive and is accepted by the patient.

- A set of procedures and rituals engaged by the patient and therapist that

leads the patient enact something that is positive, helpful or adaptive.

▪ Another goal of psychodynamic psychotherapy, and a more specific one, is

to foster the therapeutic alliance

 For the middle phase of therapy and include:

– Look out for and explore the transference.

– Monitor therapist countertransference.

– Use the emergence of transference and countertransference

Middle responses to inform formulation of the patient’s object relations.

Phase
– Link the patient’s object relations with external current relationships.
Goals
– Work with resistance and understand how the resistance

demonstrates the patient’s habitual defences.

– Promote capacity for self-analysis.

 ▪ The patient (and therapist) needs to be able to deal with the ending

of therapy and ideally the patient needs to learn how to mourn the

loss of the good object of the therapist.

▪ The goal here is to manage the ending in a good-enough way without

Final resorting to acting out on the part of the patient or the therapist.
Phase
Goals ▪ Examples of acting out might take the form of unthinkingly

extending the number of sessions or the patient dropping out of

therapy sooner than planned.

 Westenberger-Brueur (2006) describes another useful way to think
about goals in psychodynamic psychotherapy

▪ They are:

– Changes in symptoms and complaints

– Changes in life adjustment

Alternativ
e Goals – Changes in personality structure

– Realization of procedural goals.

 ▪ These are:

– Promotion of free association.

– Develop transference relationship and monitor

Procedura
l Goals countertransference.

– Manage boundaries and resistances.

 Free Association
▪ A key skill which therapists should try to adopt from the outset is in
encouraging the patient to ‘free associate’.

▪ So, at the beginning of a session, rather than introducing a topic for

discussion, a therapist might say ‘where would you like to start
today?’ and encourage the patient go on from there.

Techniques ▪ This technique is linked to Freud’s ‘fundamental rule’, where he

encourages patients to say ‘whatever comes into their heads, even if
they think it unimportant or irrelevant or nonsensical . . . or
embarrassing or distressing’

▪ The importance of encouraging free association is that it is a way of

accessing unconscious ideas, thoughts, wishes, feelings and so on.
 ▪ The analytic attitude as being, ‘a particular way of listening: the

therapist empathises with the client’s subjective experience while at

the same time being curious about its unconscious meaning, rather

Psychoanalytic than trying to solve problems or give advice’.

al Attitude
▪ There are three aspects to the analytic attitude: neutrality,

anonymity, and restraint.

Relative Neutrality

▪ Neutrality (sometimes referred to as being

non-judgmental) is not about being inactive or indeed

uncaring, but rather is an attempt not to influence the

patient in any particular direction.

Relative Anonymity

▪ The therapist tries to be ‘as unobtrusive as possible and

tries to retain a more neutral, relatively anonymous

stance towards the client’ – it is, after all, a space for the

patient.

▪ Such an approach ‘prioritises reflection and

interpretation over action

Relative Restraint

▪ Not excessively gratifying the patient’s conscious or unconscious wishes

for care beyond the limits of the therapeutic frame.

▪ Examples of what might be considered excessive gratification by the

therapist include:

- trying to show they are the longed-for figure a patient has been seeking

- buying the patient items or gifts

- trying to be overly reassuring and moving squarely into an advice-giving

mode rather than exploring anxieties.
 ▪ Unconscious processes revealed through dreams, slips,

symbols.
Working
with ▪ Key tools: Free association, dream analysis.
Unconsciou
s ▪ Encourage patients to speak freely.

▪ Look for recurring themes or symbols

 ▪ Redirection of feelings from significant others to the therapist.

▪ Types: Positive (affection), Negative (distrust, anger).

Transference ▪ Tool for exploring relational patterns.

▪ Interpret and work through these projections.

 ▪ Therapist's emotional reactions to the patient.

▪ Classical view: Manage and minimize.

Counter ▪ Modern view: Valuable insight into patient dynamics.

transference
▪ Monitor and reflect on emotional responses.
Supportive vs. Expressive Interventions

▪ Supportive: Reinforce functioning, manage anxiety.

▪ Expressive: Interpretation, insight development.

▪ Tailor interventions to patient’s ego strength.

▪ Use clinical judgment to choose approach.

Interpretation Techniques

▪ Linking: Connect current and past experiences.

▪ Clarification: Highlight contradictions.

▪ Confrontation: Address discrepancies in narrative.

▪ Timing: Intervene at the right moment.

 ▪ Unconscious defense against distressing material.

▪ Common forms: Silence, joking, intellectualization.

Resistanc
e ▪ Identify patterns and their function.

▪ Interpret gently to promote insight.

 ▪ Repeated interpretation of themes and resistance.

Working ▪ Deepens insight and facilitates change.

Through
▪ Key elements: Repetition, ambiguity tolerance.

▪ Encourages gradual internal transformation.

TASKS OF THE PSYCHODYNAMIC PSYCHOTHERAPIST?
 DIFFERENCE BETWEEN PSYCHOANALYSIS AND PSYCHODYNAMIC
PSYCHOTHERAPY

PSYCHOANALYSIS DYNAMIC PSYCHOTHERAPY

▪ Requires daily visits ▪ Once a week (twice/thrice for unstable or highly motivated
clients)
▪ Client lies on a couch with the analyst sitting out of
sight and behind ▪ Client and therapist sit face to face
▪ “Free-association” by client and a silent analyst. ▪ The psychotherapist usually talks quite a lot, compared to
Analyst breaks silence whenever “interpretation” the “silence” of the psychoanalyst.
required
▪ Highly interactive process
▪ Not a very interactive process
▪ No binding on the Client, flexible and Client pays therapist
▪ “Imposed” on the client– payment is required on each visit
whether they attend the session or not
▪ Treatment generally 1-12/20 sessions to more than 50
▪ Takes several years to be effective sessions/several years