PSY 245 CLINICAL PSYCHOLOGY II

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PSY 245CLINICAL PSYCHOLOGY II

• Assoc. Prof. Dr. Bahar BASTUG
• Clinical Psychologist

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Psychoanalytic Approaches
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• Today well be focusing on psychoanalytic and
  psychodynamic theory and practice, beginning with
  the work of Sigmund Freud.
• As an interesting starting place, say the first
  word that comes to mind when you hear Sigmund
  Freud.

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Sigmund Freud (1856-1939)
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Sigmund Freud

• Freud was born in Freiberg, Moravia, in 1856, he
  died for larynx Ca in 1939 in London.
• His intellectual potential was obvious early on
  and Freud felt like a favored child.
• He obtained his medical degree from the
  University of Vienna with the goal of being a
  research scientist.
• He went into private practice of neurology
  because of financial needs.
• As a neurologist, Freud was exposed to the
  disorder hysteria .

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Sigmund Freud

• He became familiar with the work of Jean Charcot,
  who was using hypnosis to produce hysterical
  symptoms. Professor Charcot of Paris' Salpêtrière
  demonstrates hypnosis on a "hysterical" patient.
• For Freud, the same procedure
• might be used to treat hysteria.

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Sigmund Freud

• Freud began working with Viennese physician Josef
  Breuer. Breuer was treating hysteria symptoms by
  having patients talk about emotionally loaded
  childhood experiences. Breuer worked with Anna
  O., discussing her hysteria symptoms and
  treatment in great detail with Freud. They
  published Studies in Hysteria in 1895.

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• Anna O.,or Bertha Pappenheim,1880

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• Hysteria was the main psychological disorder of
  Freuds time.
• Psychological theories are a product of the
  dominant Zeitgeist and Ortgeist.
• He initially used hypnosis, but later became more
  enamored with the talking cure.

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• Freuds Early Fascinations
• Psychosexual Development
• Unconscious Sexual Meaning of Many Behaviors

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Sigmund Freud

• Freud presented a paper titled The Aetiology of
  Hysteria in Vienna in 1896. He made a connection
  between childhood sexual abuse and later
  psychopathology.
• The Seduction Hypothesis suggested that childhood
  sexual abuse produces later psychopathology (Hy).
  
• at the bottom of every case of hysteria there
  are one or more occurrences of premature sexual
  experience (Freud, 1896, cited in Masson, 1984,
  p. 263).

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• Freuds presentation of the Aetiology of Hysteria
  met with an icy reception.
• He abandoned the Seduction Hypothesis in favor of
  his theory concerning the Oedipal conflict.

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Theoretical Principles

• Freudian Theory
• Is one of the Giant theories of developmental
  Psychology (Miller, 2010).
• Is a one-person intrapsychic model.
• Includes several different approaches to thinking
  about human behavior.

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Psychoanalytic Theoretical Principles

• Classical Freudian theory is a one-person
  intrapsychic model that treats the client as a
  separate, individual artifact to be
  systematically and objectively examined.
• X X X X X X X X
• Modern analytic theory treats the therapy
  encounter more as a two-person field, wherein the
  therapists and clients intrapsychic and
  relationship interactions help shed light on
  patterns that may be troubling the client.

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The Dynamic Approach

• is known as drive theory or instinc theory. He
  believed humans are filled with mental or psychic
  energy.
• This energy comes from two essential sources

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Eros

• energy associated with life and sex
• Libido

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Thanatos

• energy associated with death and aggression.
• Eros and thanatos are the two basic drives that
  energize behavior.

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According to drive (dynamic) theory,

• Psychic determinism underlies the dynamic
  approach (. . . nothing happens by chance
  Brenner, 1973).
• every impulse has an origin, aim, object, and
  intensity.
• An impulse always originates from some place in
  the body. Child oral
• Their aim is to obtain oral pleasure.

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• The pressure or intensity of pleasure need is
  building.
• The baby finds an object that will allow him or
  her to discharge tension and obtain pleasure.

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According to drive (dynamic) theory,

• if the internalized cycle does not flow smoothly
  due to parental withholding, there can be a
  fixation and later unconscious acting out of the
  pathological cycle during adulthood.
• Repeated patterns may result in an internal
  working model or repetition compulsion.

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The Topographic Approach

• Divides the mind into three interrelated regions
• the unconscious,
• the preconscious,
• the conscious.

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The Topographic Approach

• There is much more going on at the unconscious
  level than at the conscious.
• Awareness of our basic, primitive sexual and
  aggressive impulses might disrupt our daily
  lives, our brain protects us from them. The main
  purpose of psychoanalytic therapy is to help us
  slowly become aware of unconscious impulses. By
  bringing unconscious impulses to awareness, were
  able to manage them, because even when they are
  outside awareness, primitive impulses can still
  act on us in an indirect and destructive manner.

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• Oedipal conflict X Electra Complex
• Resolution of this conflict leads to development
  of the superego.

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The Developmental Stage Approach

• Explains how early childhood experiences
  influence later adult behaviors.
• Oral birth to 1 year old
• Anal 1 to 3 years old
• Phallic 3 to 5 years old Oedipus complex
• Latency 5 to 12 years old
• Genital adolescence to adulthood

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The Developmental Stage Approach

• Each stage is defined in terms of the part of the
  body around. Each stage presents new needs.The
  way in which these needs are met (or not met)
  determines not only how sexual satisfaction is
  achieved, but also how the child relates to other
  people and how he feels about himself. Unresolved
  conflicts in any stage may bother the person
  throughout his lifetime.

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The Developmental Stage Approach

• All children progress through all developmental
  stages. Progress through the stages is driven by
  biological maturation. At each stage, if parents
  are overly tolerant or withholding, the child can
  end up with fixations or complexes associated
  with the stage. A fixation or complex is an
  unresolved unconscious conflict.

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The Structural Approach

• involves the interrelationships of
• Id Pleasure principle primary process
• Ego Rational thought secondary process
• Superego Conscience ego ideal
• The id is the centre of biological desires. It
  functions on the pleasure principle and
  primary-process thought. Id impulses are
  unconscious. We can view id impulses within
  ourselves via dreams, fantasies toward
  pleasure-seeking behavior. The id is the mother
  of the ego.

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The Structural Approach

• Ego functions include memory, problem- solving
  ability, and rational or logical thought
  processes. These functions are defined as
  secondary thought processes.
• The superego develops around the time when
  children resolve their Oedipal issues and begin
  strongly identifying with parents and parental
  demands or expectations.

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The Structural Approach

• There are two parts of the superego
• 1.the conscience develops as a function of
  parental prohibitions. When mom, dad, or another
  authority figure says, No! or Stop that!,
  these warnings are internalized within the
  childs psyche and later used by the child to
  self-punish or prohibit unacceptable impulses. It
  becomes the inner source of punishment.
• 2. In contrast to the negative, punishing quality
  of the conscience, the ego-ideal is a positive
  desire.
• The conscience is a punishment as a motivator,
  while the ego-ideal is a reinforcement as a
  primary motivator.

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The Structural Approach

• The ego acts as a mediator between the id and the
  superego.
• This is no easy task, and therefore the ego often
  must use defense mechanisms.

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Defense mechanisms

• are designed to defend against unacceptable id
  impulses. They have four primary characteristics
• They are automatic Individuals reflexively use
  defense mechanisms.
• They are unconscious.
• They defend against unacceptable impulses.
• They distort reality.

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Defense mechanisms

• Repression involves forgetting an emotionally
  painful memory.
• Denial is usually expressed with more force. Not
  me!
• Projection occurs when clients push their
  unacceptable thoughts, feelings, or impulses
  outward, onto another person .
• Reaction Formation If it is too dangerous to
  directly express aggression toward someone, the
  individual may behave in an excessively loving
  way. Expressing the opposite

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Defense mechanisms (cont.)

• Displacement occurs when the individual shifts
  the aim of sexual or aggressive impulses from a
  more dangerous person or activity to a less
  dangerous person or activity.
• Rationalization occurs when clients use excessive
  explanations to account for their behavior.
• Regression involves going back to an old, less
  sophisticated method of doing things.
• Sublimation is one of the most productive defense
  mechanisms.

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Psychopathology and Human Change

• Psychopathology arises from early childhood
  experiences.
• Freud believed that psychopathology existed on a
  continuum. Normal-abnormal continuum.

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Psychopathology and Human Change

• There are several key issues
• The therapy focuses on early childhood
  experiences as the origin of psychopathology.
• Pathological childhood experiences arent
  completely umderstood, recalled consciously.
• Human change involves an insightful or
  consciousness-raising experience.
• Human change isnt an immediate process it
  requires a working through process where
  consistent practicing of new ways of
  understanding inner impulses.

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Evolution and Development in Psychoanalytic
Theory and Practice

• Ego Psychology (Psychoanalytic Ego
  Psychology)-Anna Freud, Eric Erickson
• Object Relations-Melanie Klein, Otto Kernberg
• Self Psychology- Hans Kohut

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Anna Freud
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Anna Freud

• studied children directly, through
  psychoanalysis. She studied their dreams and
  fantasies. She observed childrens unconscious
  mental processes through play.
• She changed the psychoanalytic focus from the
  instinctual drives to the ego development.
• She is best known for her work with children and
  her writing on ego defense mechanisms.

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Psychoanalytic Ego Psychology

• began in about the 1930s. Following Anna Freud,
  they emphasized that certain ego functions were
  inborn and autonomous of biological drives. These
  ego functions are memory, thinking, intelligence,
  and motor control.
• In Erik Eriksons eightstage theory of
  development, Erikson deviated from Freudian
  developmental theory in two ways
• psychosocial development instead of psychosexual
  development.
• the continuous nature of development into old
  age, rather than ending his stages, like Freud,
  in early adulthood.

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Object Relations

• In the 1950s, object relations theorists began
  reformulating traditional psychoanalytic theory.
• Traditional Freudian theory focuses primarily on
  parent-child dynamics during the Oedipal crisis.
  Object relations theory focused on pre-Oedipal
  dynamics. Dynamics and motivation earlier
  parent-child relationships

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Object Relations

• Objects are not things. Objects are internalized
  versions of people.
• Fairbairn states that libido is object seeking,
  not pleasure seeking.
• Fairbairns psychic world is consisted of
  internalized objects and internalized object
  relations.
• Object relations theorists believe humans
  mentally internalize both a representation of
  self and a representation of early caregiver
  figures.

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Object Relations (cont.)

• These internalized self and other representations
  are then carried within the individual into
  adulthood. If during early childhood an object
  relationship was characterized by trauma or
  destructive interpersonal patterns, remains of
  these early self-other relationship patterns can
  adversely affect a clients relationships.
• Object relations therapy attempts to replace the
  bad object with a good object.

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Self Psychology

• Formulated by Heinz Kohut.
• Focused on the development of healthy narcissism
  within individuals.
• Mirroring is an important therapy concept.
• Retraumatization is the central client fear that
  leads to resistance and the therapists
  interpretation of resistance.

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Heinz Kohut

• Therapists are imperfect, and clients retreat
  from intimacy.
• Making optimal failures and then working toward
  empathy is seen as the basic therapeutic unit
  leading to new self structure.

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Continuing Theoretical Developments

• There are many different psychoanalytic or
  psychodynamic approaches.
• Karen Horneys work focused on how social and
  cultural factors can affect personality
  development. Horney criticized Freuds ideas in a
  feminist way. Horneys work has been labeled
  neo-Freudian.
• Margaret Mahler includes components of drive,
  ego, object relations, and self psychology. She
  emphasized mother-child interactions.

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The Relational Psychoanalytic Movement

• Jacques Lacan
• Relational psychoanalysis is also referred to as
• Intersubjectivity or Two-person psychology
• It emphasizes that the psychoanalyst is always
  subjective. The analyst is viewed as
  participant-observer.
• Emotional involvement and countertransference
  reactions are used to facilitate therapy.

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The Relational Psychoanalytic Movement

• The therapist and client are referred to as the
  psychoanalytic couple. This means the analyst no
  longer has the unquestionable authority to make
  interpretations of his clients unconscious
  derivatives, but instead is a partner in
  exploring the clients personal and interpersonal
  unconscious and conscious dynamics.

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Attachment-Informed Psychotherapy

• Attachment theory is a psychoanalytically
  oriented approach.
• John Bowlby focused on
• Internal working models based on
• Real child-caretaker interactions (not
  fantasies!). Actual child-caretaker interactions
  are foundational to personality formation.

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Attachment-Informed Psychotherapy II

• Mary Ainsworth (1970) elaborated on attachment
  dynamics or styles in her strange situation
  experiments in the lab.
• She studied children as they were separated from
  mothers, reacting to strangers, and were then
  reunified with mother.
• She identified three attachment styles
• Secure attachment
• Anxious-resistant insecure attachment
• Anxious-avoidant insecure attachment
• Disorganized/disoriented attachment style was
  added by Mary Main.

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Practical Modifications Short-Term and
Time-Limited Psychoanalytic Psychotherapy

• There have been efforts to shorten the treatment
  duration.
• Sandor Ferenczi (1920, 1950)
• Therapy is more or less suggestive.
• Be more active to shorten treatment duration.
• Alexander and French (1946) wrote about the
  corrective emotional experience where therapists
  adopted a compensatory role. If the client
  suffered from critical parent and due to the
  transference, expected criticism from the
  analyst, then the analyst would adopt a very
  positive and supportive role.

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THE PRACTICE OF PSYCHOANALYTIC THERAPY

• Goals include
• To make the unconscious conscious or increase
  client awareness
• To help clients develop greater ego-control or
  self-control over maladaptive impulses
• To help clients rid themselves of maladaptive or
  unhealthy internalized objects and replace them
  with more adaptive internalized objects
• To repair self-defects through mirroring,
  presenting a potentially idealized object, and
  expressing empathy.

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Assessment Issues and Procedures

• Psychoanalysts use
• Clinical interviewing
• Projective testing
• Rorschach Inkblot Test
• Thematic Apperception Test
• Free association to specific words
• Human figure drawings
• These approaches have been criticized by some.
  Unless youve received adequate training and
  supervision, you should avoid using projective
  assessment strategies.

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THE PRACTICE OF PSYCHOANALYTIC THERAPY

• The Basic Rule
• Psychoanalysts begin each session the same
• way. They tell the client, Say whatever comes
  to mind. This is the basic rule in
  psychoanalysis.
• Through free association, unconscious impulses
  can rise more closely toward consciousness.

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The Basic Rule

• All external stimuli are minimized. To let
  unconscious impulses and conflicts rise to
  consciousness, distractions must be minimized.
  This is one reason why Freud used a sofa. If the
  client lies on a sofa and then the analyst sits
  behind it, the client cannot see him the
  distracting stimulus of the analysts facial
  expressions is eliminated.

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The Basic Rule

• The clients internal stimuli are minimized. When
  free associating, its best not to be too hungry
  or thirsty or physically uncomfortable. If
  clients come to analysis hungry, thoughts about
  food will flood into their free associations. If
  the client is physically uncomfortable, it will
  distract from the free association process.

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The Basic Rule

• Cognitive selection or conscious planning is
  reduced. Free association is designed to deal
  with intentional or planned thought processes. If
  a client comes to therapy with a list of things
  to talk about, psychoanalytic practitioners might
  interpret this behavior as resistance.

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• Psychoanalytic approaches include the following
  concepts and procedures
• Interpretation
• Developing a therapeutic alliance
• Role induction
• Timing
• Transference
• Countertransference
• Triangles of insight
• Dream interpretation

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Interpretation

• The Freudian analysts job is to listen for and
  interpret unconscious derivatives. Fenichel is
  saying that analysts must prepare clients before
  using interpretation. Proper client preparation
  involves these steps
• Developing a Therapeutic Alliance
• Role Induction
• Timing
• What to Interpret

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Role Induction

• Role induction is a procedure through which
  therapists tell clients about how therapy works.
• To use interpretation more collaboratively, you
  might say something like this
• As I do therapy with you, I may notice some
  patterns. These patterns may be linked to your
  early childhood relationships, your relationship
  with me, or your descriptions of your
  relationships outside therapy. Is it okay with
  you if I occasionally mention these patterns so
  we can explore them together and a better
  understanding about how they might affect your
  life?

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THE PRACTICE OF PSYCHOANALYTIC THERAPY

• Transference is a distortion that involves
  re-experiencing Oedipal issues in the therapeutic
  relationship.
• The clients experience of the therapist that is
  shaped by the clients own psychological
  structures and past and involves displacement,
  onto the therapist, of feelings, attitudes and
  behaviors belonging in earlier significant
  relationships.
• Your client treates you like someone you arent.

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THE PRACTICE OF PSYCHOANALYTIC THERAPY

• Countertransference
• defined as the therapists tendency to see
  the client in terms of his or her own previous
  relationships. Its the same as transference, but
  it occurs only when the transference is directed
  from the therapist toward the client. For Freud,
  countertransference is a negative factor in
  therapy. When working with clients, its helpful
  to pay attention to your own emotions, thoughts,
  impulses, and behaviors.
• During a session, you may notice that you feel
  irritated or annoyed with a client.

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Transference X Countertransference

• Because clients bring developmental baggage into
  therapy with them, they will project their parent
  relationship dynamics onto the therapist. It is
  called transference.
• Because therapists bring developmental baggage
  into therapy with them, the same projection
  process can occur in the opposite direction. When
  therapists project their childhood relationship
  patterns onto the client, it is called
  countertransference.

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THE PRACTICE OF PSYCHOANALYTIC THERAPY

• Triangles of Insight
• Beyond resistance, psychoanalytic therapists
  often focus their interpretations on triangles of
  insight. These insight triangles are
  conflict-based or transference- based.
• The conflict-based triangle of insight includes
• (1) the clients wish, aim, or drive
• (2) the threat or imagined threat that makes the
  direct pleasure of the wish impossible
• (3) the defensive compromise.

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THE PRACTICE OF PSYCHOANALYTIC THERAPY (cont.)

• The transference-based triangle of insight
  includes
• (1) observations based on the transference
  relationship,
• (2) the clients reports of his early childhood
  relationship dynamics,
• (3) the clients reports of his current,
  outside-of-therapy relationships.

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THE PRACTICE OF PSYCHOANALYTIC THERAPY (cont.)

• Dream Interpretation
• Freud considered dreams to be the royal road to
  the unconscious. Dreams consist of unconscious
  derivatives and require interpretation to produce
  insight.
• Psychoanalytic dream analysis is an interactive.
  It emphasizes clients reactions to and
  impressions of the dreams meaning. Although the
  analysts perspective and interpretations are
  important, the method involves asking clients to
  free associate to their dreams, and then a
  collaborative exploration of responses follows.

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Freuds Theory in Action Implications for
Psychotherapy

• Traditional psychoanalysis interprets
  psychological defenses before conflict. If you
  interpret underlying conflict first, client will
  use preexisting mechanisms to deny, repress or
  defend themselves from your insightful
  interpretation. If you tell the client that the
  reason for her silence is fear of rejection,
  shes likely to withdraw from you by more
  silence. But if you interpret defense first,
  discussing how she uses silence to protect
  herself, she may use less distorting defenses.

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• Interpretation works best when nested in an
  empathic therapy alliance.
• Timing is critical for interpretation.
• Wait until the interpretetive material comes to
  surface.

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Problem formulation

• Psychoanalytic case formulations have
  interpersonal foundations. These foundations are
  built from repeated child-caretaker interactions
  and later manifest themselves clients daily
  lives.

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Outcome measures

• Contemporaray psychodynamic outcome researchers
  use a combination of symptom-oriented measures
  (BDI) and interpersonal process measures.

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Cultural and Gender Considerations

• Psychoanalytic approaches have historically not
  been friendly to women and feminist perspectives.
• There is often blaming of mothers.
• There is often insensitivity or lack of focus on
  social explanations for behavior.
• Psychoanalytic treatment can also be very
  sensitive to individual differences.

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Evidence-Based Status

• Research on psychoanalytic approaches is very
  challenging.
• Evidence is accumulating to support
  psychoanalytic approaches.
• Some studies have weak or defective
  methodologies.
• CBTs are sometimes found to be more effective.
• Controlled research and meta-analyses have
  indicated that psychoanalytic therapies are at
  least slightly more effective than no treatment.

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Preparing Yourself to Do Psychoanalytically
Informed Therapy

• Getting psychoanalysis for yourself.
• When in doubt, dont forget the basic rule
  Whats passing through your mind right now?
• Use noncritical, mutual exploration as a general
  technique.
• Pay attention to your clients childhood baggage
  and possible transference.
• Pay attention to your own childhood,
  interpersonal baggage, and possible
  countertransference.

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• Allegiance effect A term used to describe the
  research finding that a researchers therapy
  choice or allegiance is a strong predictor of
  outcome study results.