Psychoanalysis & Psychodynamically Oriented Psychotherapy

1. Psychoanalysis & Psychodynamically Oriented Psychotherapy

2. Psychodynamic Psychotherapy • Deterministic world view • Origins in the medical model • Early proponents were physicians concerned with treatment-resistant physical symptoms (e.g., conversion reaction) • Focus on symptom resolution through identifying and working through remote causes • Initially, the psychoanalytic model was embraced as scientific and revolutionary; clinical practice evolved slowly over time

3. Characteristics of Psychodynamic Psychotherapy • Unconscious motivation is emphasized • Focus on manifest (surface) and latent content of symptoms, dreams, and parapraxes • Depth-oriented approach • Initial emphasis on biological instincts and drives; later concerns with social contexts • Therapy based on therapeutic relationship in which roles are defined by the expert therapist

4. Psychoanalysis and Psychodynamic Psychotherapy • PSYCHOANALYSIS • Joseph Breuer (Breuer & Freud, 1895/1955) • Sigmund Freud (1900/1953,1920/1955, 1933/1964) • Karl Abraham (1927) • Wilhelm Reich (1933) • Anna Freud (1937) • Ernst Kris (1950) • Theodore Reik (1948) • Robert Stoller (1975)

5. Psychoanalysis and Psychodynamic Psychotherapy • NEOFREUDIAN • Carl Jung (1913/1973, 1921/1971, 1945/1960) • Alfred Adler (1963)

6. Psychoanalysis and Psychodynamic Psychotherapy • OBJECT RELATIONS/SELF PSYCHOLOGY • Melanie Klein (1948) • Karen Horney (1951) • Helene Deutsch (1965) • W.R.D. Fairbairn (1952) • D.W. Winnicott (1953, 1965, 1971) • Heinz Kohut (1971) • Otto Kernberg (1968) • J.F. Masterson (1976) • Althea Horner (1979)

7. Psychoanalysis and Psychodynamic Psychotherapy • DEVELOPMENTAL/ATTACHMENT THEORY • Erik Erikson (1950) • Harry Stack Sullivan (1953) • John Bolwby (1969) • Margaret Mahler (1968, Mahler et al, 1975) • Mary Ainsworth (Ainsworth et al, 1978)

8. Psychoanalysis and Psychodynamic Psychotherapy • RECENT REVISIONISTS • Alice Miller (1983, 1986, 1990) • Louise Kaplan (1991) • Judith Herman (1992) • Paul Wachtel (1997) • J.J. Magnavita (1997)

9. Sigmund Freud • Sigmund Freud was born May 6, 1856, in Freiberg in the Austro-Hungarian Empire.  He was given a Christian name (“Sigismund,” which he hated and shortened to “Sigmund” at age 19). His Jewish name was “Shlomo” in memory of his paternal grandfather. He was born to a non-believing Jewish father, who had previous children, and a vivacious woman twenty years younger than her husband. • His father, who was initially successful in business, failed when they moved to Freiberg. The family was dependent on “gifts” from the mother’s family. Freud’s father had two previous wives, who had died. • Young Sigmund enjoyed the pastoral life in Frieberg, recalling a “green meadow with yellow flowers.” At age two, he had a younger brother, who died at the age of six months. His paternal grandfather also died during his early childhood. His mother then had a series of daughters. • After age three in 1859, the family moved to the urban center, Vienna. Freud was a prodigy as a child, reading early and learning several languages. He was treated as a very special child. Although the family was not religious, he was drawn to Bible study. He studied the classics, did moderately well in the sciences, and progressed in the gymnasium. • Freud was disgusted by the urban sprawl, poverty (in which he developed), and promiscuity of the times. He, like his father, was ashamed of being a Jew in the liberal, intellectual, but anti-Semitic climate of the times. • As a student, Freud would eat alone and read. He did not describe any friendships. He remained rather introverted, formal, and aloof.

10. Sigmund Freud • When writing The Interpretation of Dreams, Freud recalled an incident when he was seven years old. He urinated in his parents’ bedroom right in front of them. While he was his mother’s “golden child,” his father declared him a misfit who would never amount to anything. Subsequently, he was driven to succeed. • He entered the University of Vienna, initially studying law, then changing to medicine because of an increasing interest in neurology. He learned that mental illnesses were biological in origin. • Freud’s academic interests led him to the famous Salpetriere Hospital in Paris. This was an asylum, where poor women with “hysteria” were isolated/insulated from the society at large. Jean Martin Charcot was practicing hypnosis to relieve the women of physical symptoms and “insanity.” Freud was attracted to hypnosis, but apparently lacked skill in the technique. He came to view psychopathology as “mental” rather than strictly organic. • During his time in Paris, Freud was to see in the morgue evidence of man’s inhumanity to man, especially sexually motivated attacks on women and children. This exposure to victimization contributed substantially to Freud’s early views that hysteria and other neuroses were the results of sexual abuse trauma.

11. Sigmund Freud • From adolescence throughout adulthood, Freud developed intense relationships with male mentors or friends. He idealized his teachers and demanded that friends and colleagues agree with him. There were some homoerotic undercurrents, manifested in his curious relationship with Willhelm Fliess. • Freud returned to Vienna and married Martha Bernays, “a sweet girl,” after a lengthy courtship of four years. He was shy and communicated his feelings through nearly 900 letters. They married and his dutiful wife had six children in nine years. Freud was an attentive, but demanding father. • During the courtship, Freud experimented with cocaine, which he continued to use for several years. Some remark that his incredible productivity may have been fueled by cocaine. • Beginning in 1895, Freud devoted himself to his magnum opus, which he entitled Project for a Scientific Psychology. The “Project” was his personal quest to reconcile his desire to be accepted as a great neuroscientist while exploring the uncharted territory of the mind. Ultimately, he abandoned his quest and the “project” was published 11 years after his death. • Freud initially developed the “talking cure” and his understanding of “transference” in the therapeutic relationship by reviewing the case of “Anna O.” who was really Bertha Pappenheim, a 21-year-old patient of Breuer, who suffered from hysteria (with panic and phobic anxiety). Through “chimney sweeping,” as she called it she overcame much of neurosis.

12. Sigmund Freud • Freud had an obsessive preoccupation with smoking cigars. He told his nephew, “…smoking is one of the greatest and cheapest enjoyments in life, and if you decide in advance not to smoke, I can only feel sorry for you.” He said smoking was a great substitute for the “primal addiction” of masturbation. He was diagnosed in 1923 with cancer of the mouth, yet continued smoking for seven more years. • He fled the Nazis in 1938 and lived for nearly a year in London. His mouth cancer rendered him in constant pain. He persuaded a physician friend to administer large doses of morphine and he died on September 21, 1939.

13. Key Concepts • Unconscious: the realm of mental activity that produces drives and wishes, motivating a person outside of ordinary awareness. The unconscious is accessible only through dreams, parapraxes (“slips”), and analysis • Defense mechanisms: the differentiated part of the unconscious called the “ego” defends against overwhelming sexual and aggressive urges by means of repression and other mechanisms • Transference: the patient “works through” the unfinished business of childhood by projecting distortions onto the “blank screen” of the psychoanalyst, who interprets patterns of behavior and uses “countertransference” to understand the dynamic relationship

14. Oral: Birth to 18 months Anal: 18 months to three years Phallic: Three to seven years, culminating in the Oedipus complex Latency: Seven years old to puberty; revisiting the Oedipal conflicts at puberty Genital: Puberty through adulthood Psychosexual Development

15. Clients in Psychoanalytic Therapy • Adults • Children • Celebrities • Artists and creative persons • YAVIS • Young • Affluent • Verbal • Intelligent • Socially Mobile • “The Worried Well” • “Neurotics” • Couples

16. Characteristics of Psychoanalysis and Psychodynamically Oriented Therapy • Symptoms represent unconscious conflicts, repressed memories, and repetition compulsion • Individuals can develop the maturity to use rational thought processes in order to love and work • Adults mature by regressing to “stuck points” from earlier development (typically childhood), withdrawing libido invested in defenses, and “working through” dysfunctional patterns by remembering and sharing with the therapist • Mature persons present “ego strength” needed for hierarchal and executive thought processes (e.g., planning)

17. Process in Psychoanalysis • Analytic Neutrality • “The Blank Screen” • Analysis of countertransference • Opening Phase • Free association (“The Passive Method”) • Transference reaction/neurosis • Resistance • Importance of structure • Interpretation (Resistances, defenses) • Working Alliance • Recollection (Reliving, revising, revisiting) • Working through • Resolution • Insight (repetitive patterns, transference) • Termination

18. Freud’s Views on Psychopathology • Unresolved childhood trauma • Overexcitation of a vulnerable nervous system • Betrayal by a caregiver or trusted other • Neglect or overindulgence leading to fixation or regression • Failure of higher-order defenses (e.g., rationalization) to contain instinctual impulses • Symptom as code, symptom as solution

19. Jungian Dream Analysis (Jung, 1945) • “Royal road to the unconscious” • While Freud tended to assign fixed meanings to dream symbols, derived from literature and art, Jung encouraged patients to develop their own meanings • Dream-ego directs or facilitates complexes and part-personalities to tell a dynamic story • Dreams are interpreted in sequence: initial dreams may be prophetic or point the direction of the therapy

20. Jungian Dream Analysis (Hall, 1984) • Securing the dream; • Recording the dream report in some modality • Disclosing the dream to the analyst • Placing the dream in context • Sequence and current life experience • Personal, cultural and archetypal amplifications (e.g., in “big dreams”) • Processing the dream • Active imagination • Interpretation (especially with regard to compensation)

21. Assessment Methods • Freud studied the individual case, especially in terms of history-taking or disclosure of the life-story • Jung used a word-association test and measured latency of response • Physiological measures of anxiety have been used to assess psychodynamics • Adler conducted lifestyle assessment

22. Research on Psychoanalysis • Traditionally, the major unit of research was the case study • Psychoanalytic studies excluded from meta-analytic outcome studies due to lack of controls or other methodological concerns • Recently, there has been more empirically-oriented research: Menninger Foundation Psychotherapy Research Project; Columbia Psychoanalytic Center Research Project; Fonagy’s (2002) Open Door Review of Outcome Studies in Psychoanalysis • Generally, among those selected as having sufficient ego-strength for psychoanalytic treatment 60-90 percent of patients improve

23. Trends in Psychoanalysis and Psychodynamically Oriented Therapy • Resurgence of interest in psychoanalysis (perhaps stimulated by the attention to sexual abuse trauma initiated in the 1980s) • Movement toward more empathic and interactive roles for the analyst • Object relations and attachment theory have contributed to a lot of work on intimacy, addressing the issues of couples

24. References • Abraham, K. (1927). Selected papers on psychoanalysis. London: Hogarth Press. • Adler, A. (1963). The practice and theory of individual psychology. Paterson, NJ: Littlefield. • Ainsworth, M.D.S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Analytic Press. • Anzieu, D. (1986). Freud’s self-analysis (peter Grahan, Trans.). Madison, CT: International Universities Press. • Bowlby, J. (1969). Attachment and loss, Vol. 1. New York: Basic Books. • Breuer, J., & Freud, S. (1955). Studies on hysteria. Standard Edition, 2, 1-305. London: Hogarth (Original work published 1995). • Deutsch, H. (1965). Neuroses and character types. New York: International Universities Press. • Erdelyi, M.H. (1985). Psychoanalysis: Freud’s cognitive psychology. New York: W.H. Freeman.

25. References • Eriksen, E. (1950). Childhood and society. New York: Norton. • Fairbairn, W.R.D. (1952). Psychoanalytic studies of the personality. London: Routledge. • Fonagy, P. (2002). An open door review of outcome studies in psychoanalysis (Online). Available: www.ipa.org.uk/research/complete.htm • Freud, A. (1937). The ego and the mechanisms of defense. New York: International Universities Press. • Freud, S. (1900). The interpretation of dreams. Standard Edition, 4, 1-338; 5, 339-627. London: Hogarth 1953. • Freud, S. (1920). A note on the prehistory of the technique of analysis. Standard Edition, 18, London: Hogarth, 1955. • Freud, S. (1923). The ego and the id. Standard Edition, 18, 12-66. London: Hogarth, 1961. • Freud, S. (1933). New introductory lectures on psychoanalysis. Standard Edition, 20, London: Hogarth, 1964.

26. References • Hall, J.A. (1984). The use of dreams and dream interpretation in analysis. (pp. 123-156). In M. Stein (Ed.), Jungian analysis. Boulder, CO: Shambhala. • Herman, J. (1992). Trauma and recovery. New York: Basic Books. • Horner, A. (1979). Object relations and the developing ego in therapy. New York: Jason Aronson. • Horney, K. (1951). Neurosis and human growth. London: Routledge & Kegan Paul. • Jung, C.G. (1913). On the doctrine of complexes. Collected works, Vol. 2. Princeton, NJ: Princeton University Press, 1973. • Jung, C.G. (1921). Psychological types. Collected works, Vol. 6. Princeton, NJ: Princeton University Press, 1971. • Jung, C.G. (1945). On the nature of dreams. Collected works, Vol. 8. Princeton, NJ: Princeton University Press, 1960.

27. References • Kaplan, L.J. (1991). Female perversions: The temptations of Emma Bovary. New York: Doubleday. • Kernberg, O. (1968). The therapy of patients with borderline personality organization. International Journal of Psychoanalysis, 49, 600-619. • Klein, M. (1948). Mourning and its relation to manic-depresive states. Contributions to psychoanalysis, 1921-1945. London: Hogarth. • Kohut, H. (1971). The analysis of the self. Monograph Series of the Psychoanalytic Study of the Child, Vol. 4. New York: International Universities Press. • Kris, E. (1950). Preconscious mental processes. Psychoanalytic Quarterly, 19, 540-560. • Magnavita, J.J. (1997). Restructuring personality disorders: A short-term dynamic approach. New York: Guilford. • Mahler, M. (1968). On human symbiosis and the vicissitudes of individuation: Vol. 1. Infantile psychosis. New York: International Universities Press.

28. References • Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York: Basic Books. • Masterson, J.F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel. • Miller, A. (1983). For your own good: Hidden cruelty in child rearing and the roots of violence. New York: Farrar, Straus & Giroux. • Miller, A. (1986). Pictures of a childhood: Sixty-six watercolors and an essay. New York: Farrar, Straus & Giroux. • Miller, A. (1990). The untouched key: Tracing childhood trauma in creativity and destructiveness. New York: Doubleday. • Reich, W. (1933). Character analysis: Principles and techniques for psychoanalysis in practice and training. New York: Orgone Institute Press.

29. References • Reik, T. (1948). The inner experience of the psychoanalyst. London: George Allen & Unwin. • Stoller, R. (1975). Perversion: The erotic form of hatred. New York: Pantheon. • Sullivan, H.S. (1953). The interpersonal theory of psychiatry. New York: Norton. • Wachtel, P. (1997). Psychoanalysis, behavior therapy, and the relational world. Washington, DC: American Psychological Association. • Winnicott, D.W. (1953). Transitional objects and transitional phenomena: A study of the first not-me possession. International Journal of Psychoanalysis, 34, 89-97. • Winnicott, D.W. (1965). The maturational process and the facilitating environment. New York: International Universities Press. • Winnicott, D.W. (1971). Playing and reality. New York: Basic Books.