Introduction to Psychodynamic Psychiatry & Psychotherapy

1. Introduction to Psychodynamic Psychiatry & Psychotherapy RMO Training Programme, 2012 Paul Cammell Consultant Psychiatrist, Flinders Medical Centre Lecturer, Flinders University

2. Psychodynamically informed practice 1. Discussion of cultural context: Australian psychotherapeutic culture (psychiatric and other)2. Discussion of psychodynamic theories – relevance to your training and practice in general * Toolbox of concepts *Recommended Readings3. Three Lectures: Prof Kalucy, Dr Paul Cammell and Dr Robin Chester

3. Psychoanalytic Psychotherapy: -processes: transference, interpretation, resistance, enactment, etc -analytic triangles Malan--of person/conflict -models: classical, object relations, self psychology, ego psychology, relational, interpersonal, intersubjective, attachment orientation, mentalization, Lacanian, etc -training (theoretical, clinical supervision, training analysis, infant observation)Ranges of modalities adopted by psychiatrists:Formal psychoanalysis, psychoanalytic psychotherapy, psychodynamic psychotherapy, insight-oriented psychotherapy, psychodynamically-informed psychiatric managementConflicts with the era of managed care, health insurance funds, evidence based medicine, health management, time-limited, cost efficient approachesRole of Psychotherapy Outcomes Research

4. Universal Techniques • Focus on affect and expression of emotion • Exploration of attempts to avoid distressing thoughts and feelings • Identification of recurring themes and patterns • Developmental focus – exploration of past experiences • Focus on interpersonal relations • Focus on the therapeutic relationship • Exploration of wishes and fantasies

5. Classical Freudian Technique • Transference Interpretation • Dreams, Parapraxes • Conflict and Defence • Remembering, repeating, working through… Nachtraglichkeit

6. Transference • Freud, S. (1912). The Dynamics of Transference. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 97-108. • Freud, S. (1914). Remembering, Repeating and Working-Through (Further Recommendations on the Technique of Psycho-Analysis II). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 145-156. • Klein, M. (1952). The Origins of Transference. Int. J. Psycho-Anal., 33:433-438. • Strachey, J. (1969). The Nature of the Therapeutic Action of Psychoanalysis. Int. J. Psycho-Anal., 50:275-292 • Winnicott, D.W. (1956). On Transference. Int. J. Psycho-Anal., 37:386-388

7. Object Relations and British Independent or Middle Tradition • Klein: pre-Oedipal development, the paranoid-schizoid and depressive positions, envy, mourning • Bion: containment and alpha-beta function, psychotic personality • Winnicott, holding, transitional phenomena, false self • Balint, Fairbairn etc

8. Ego Psychology, Neofreudian approaches • Ego defenses • Countertransference • Heimann, P. (1950). On Counter-Transference. Int. J. Psycho-Anal., 31:81-84 • Bion, W. R. (1967b), Notes on memory and desire, Psychoanalytic Forum, 2, 271-286 • Sandler, J. (1976). Countertransference and Role-Responsiveness. Int. R. Psycho-Anal., 3:43-47

9. ERIKSON’S EIGHT STAGES OF THE LIFE CYCLETrust versus Mistrust (Birth to Approximately 18 Months)Autonomy versus Shame and Doubt (Approximately 18 Months to Approximately 3 Years)Initiative versus Guilt (Approximately 3 Years to Approximately 5 Years)Industry versus Inferiority (Approximately 5 Years to Approximately 13 Years)Identity versus Role Confusion (Approximately 13 Years to Approximately 21 Years)Intimacy versus Isolation (Approximately 21 Years to Approximately 40 Years)Generativity versus Stagnation (Approximately 40 Years to Approximately 60 Years)Integrity versus Despair (Approximately 60 Years to Death)

10. Defense Mechanisms Narcissistic-Psychotic DefensesProjectionDenialDistortionSplittingImmature DefensesActing outBlockingHypochondriasisIntrojectionPassive-aggressive behaviorProjectionRegressionSchizoid fantasySomatization Adapted from Vaillant GE. Adaptation to Life. Boston: Little Brown; 1977; Semrad E. The operation of ego defenses in object loss. In: Moriarity DM, ed. The Loss of Loved Ones. Springfield, IL: Charles C Thomas; 1967; and Bibring GL, Dwyer TF, Huntington DS, Valenstein AA. A study of the psychological principles in pregnancy and of the earliest mother–child relationship: Methodological considerations. Psychoanal Stud Child. 1961;16:25.

11. Defense mechanisms Neurotic DefensesControllingDisplacementDissociationExternalizationInhibitionIntellectualizationIsolationRationalizationReaction formationRepressionSexualizationMature DefensesAltruismAnticipationAsceticismHumorSublimationSuppression Adapted from Vaillant GE. Adaptation to Life. Boston: Little Brown; 1977; Semrad E. The operation of ego defenses in object loss. In: Moriarity DM, ed. The Loss of Loved Ones. Springfield, IL: Charles C Thomas; 1967; and Bibring GL, Dwyer TF, Huntington DS, Valenstein AA. A study of the psychological principles in pregnancy and of the earliest mother–child relationship: Methodological considerations. Psychoanal Stud Child. 1961;16:25.

12. Attachment TheoryBowlby: Attachment and Loss TrilogyEvolutionary science, EthologyGrief, Privation, Deprivation(Maternal) attachment figure and securityInternal Working ModelsAttachment (Proximity seeking)Separation (Anxiety, Anger)Loss (Sadness, Depression)

13. Questions ?Recommended Readings

15. Self Psychology • Heinz Kohut • Narcissism, Self pathology • Self cohesion, shame, mirror/twin and other transferences Kernberg • Ego Psychology and Object Relations • Borderline Personality • Transference Focussed Psychotherapy and the Evidence-Based Paradigm

16. Interpersonal, Relational Approaches • Ogden, Sullivan, Mitchell, Aron, Stolorow, Orange, Bromberg • The authority of the patient, co-construction and the analytic third • Context, prejudice, the return of dissociation, focus on trauma, existential, humanistic and hermeneutic approaches

17. Lacan • The French and Latin-American psychotherapy cultures • Theory, Philosophy and Psychotherapy • The Three Orders, Linguistics, Structuralism

18. Borderline Personality Disorder “The Problem Patient of Our Time”

19. Borderline Personality and developmental neuroscience Giovanni Liotti: Disorganized Attachment and Borderline PD Peter Fonagy et al.: Mentalization as a core construct Russell Meares: Memory, frontal/pre-frontal function Glen Gabbard: Mind-body interactions • HPA axis, hippocampal volume, hemispheric lateralization Allan Schore: Right Brain Development and affective regulation

20. Borderline Syndromes – History • Psychoanalysis • 1930s-1950s Stern, Knight • 1960s-1970s Kernberg, (Winnicott, Khan, Bergeret) • Psychiatry • 1940s-1960s Ambulatory Schizophrenia (Zilboorg), “Preschizophrenia” (Rapaport), “latent schizophrenia” (Federn), “pseudoneurotic schizophrenia” (Hoch and polatin), “schizotypal disorder” (Rado) • Late 1960s “Borderline states” (Knight), “Borderline Syndrome” (Grinker) • Mid 1970s “Borderline Personality” (Gunderson et al.) • 1980 DSM III “Borderline Personality Disorder” • Modern “evidence-based” psychotherapy • 1970s-1990s Object Relations BasedTransference Focussed Psychotherapy (Kernberg, Clarkin) • 1990s Dialectical behaviour Therapy (Linehan); “Mentalization-based treatment” (Fonagy, Bateman, Target) • 1990s-present Cognitive Analytic Therapy (Ryle), Conversational Model (Meares), Supportive Psychoanalytic Psychotherapy (Appelbaum), Schema-Focused Therapy and Systems Training for Emotional Predictability and Problem Solving (or “STEPPS”, Blum)

21. Modern Therapeutic Approaches • Pharmacotherapy • HPA axis sensitization and anxiolytic medication (eg atypical antipsychotic medications) • Serotonergic agents • Psychotherapy • Dialectical Behaviour Therapy (Linehan) • Psychodynamic psychotherapy • Mentalization-based (Fonagy, Bateman, Target et al.), • Object-Relations based (Kernberg) • Self-Psychology based (Meares) • Other structured, crisis plans, patient responsive, limit setting, team-based

22. Mentalization • Theory of mind (Fonagy, Bateman, Target et al.), social biofeedback theory, “mentalized affectivity” • Borderline Personality Disorder— psychic equivalence and pretend modes; splitting and dissociation; disorganized trauma responses; affect dysregulation

23. Giovanni Liotti and Attachment Disorders • Ethology/evolutionary research: motivational systems (and IWM’s) • eg care-seeking, care-giving, sexual—pair bonding, ranking—dominance/submission, egalitarian/altruistic, intersubjective • Attachment Disorganization and psychopathology • borderline and antisocial PD, conduct disorder, emotional dysregulation and impulse control problems (HPA Hyperresponsiveness) • Transgenerational transmission • The Adult Attachment Interview

24. Mentalization • Theory of mind (Fonagy, Bateman, Target et al.), social biofeedback theory, “mentalized affectivity” • Borderline Personality Disorder— psychic equivalence and pretend modes; splitting and dissociation; disorganized trauma responses; affect dysregulation

26. Borderline Personality and “abuse” or “trauma” Judith Herman: Complex PTSD “sexual abuse” ERS Nijenhuis, Onno van der Hart: Psychotraumatology and Dissociative Disorder

27. Questions ?Case for Next WeekRecommended Readings

28. Recommended Readings:General texts, including evidence based reviews:New Oxford Textbook of Psychotherapy (Gabbard, Beck, Holmes)What works for whom, Roth & FonagyStandards and Guidelines for the Psychotherapies (Paul Cameron, Jon Ennis & John Deadman Eds) eg Chapter 3Basic Approaches to Psychodynamic Psychotherapy:David Malan (Individual Psychotherapy and the Science of Psychodynamics), Glen Gabbard (Psychodynamic Psychiatry), Nancy McWilliams (Psychoanalytic Psychotherapy: A Practitioner’s Guide), Psychodynamic Diagnostic and Statistical ManualModels and Theories:Comprehensive Textbook of Psychiatry (Kaplan & Sadock), Chapters 6 and 30