The Psychodynamic Perspective

Christine Valdez

PSY 321: Clinical PsychologyMarch 12, 2015California State University, Monterey BayThe Psychodynamic Perspective1The Psychodynamic ApproachPsychodynamic TherapyAn insight-oriented therapyFocus is on unconscious processes as they manifest in behaviorGoal is self-awareness and understanding of the influence of the past on present behaviorRooted in Psychoanalytic Theory

2Psychoanalysishttps://www.youtube.com/watch?v=AUB85lSj4pMAnno O. (Bertha Pappenheim)Patient of Josef BreuerDiagnosed with hysteriaInitially treated with hypnosisTalking Cure/Chimney SweepingSymptoms would improve after discussing them

3Psychoanalytic Theory: An OverviewPsychic determinism: everything we do has meaning and purpose and is goal-directedHealthy behavior represents known motivationsUnhealthy behavior represents unconscious motivations InstinctsLife instincts (Eros)Basis for all positive and constructive behavior Sex, hunger, thirst, creative cultural components (art, music, etc.)Death instincts (Thanatos)Basis for all compulsively self-destructive behaviorneurotic behavior (e.g., re-experiencing symptoms in trauma)

4Psychoanalytic Theory: An OverviewPersonality Structureshttps://www.youtube.com/watch?v=tMgpFnycZCgIdUncoordinated instinctual trendsDriven by pleasure principle EgoOrganized, rational system mediates desires of the id and super-egoDriven by reality principleSuperego Represents ideals and values of society conveyed during childhoodGenerates strivings toward perfection

5Psychoanalytic Theory: An OverviewTopographical ModelConscious level holds what youre aware ofPreconscious level can be accessedUnconscious levelnot directly accessible

6Psychoanalytic Theory: An Overview

7Psychoanalytic Theory: An Overview

8Psychoanalytic Theory: An Overview

9Psychoanalytic Theory: An Overview

10Psychodynamic Psychotherapy TechniquesFree association: client says whatever comes to mindPatterns of associations emerge that reveal unconscious thoughts/urgesEarly childhood memories and problems give clues to the structure of personality and development

11Psychodynamic Psychotherapy TechniquesAnalysis of dreamsSymbolic forms of unconscious wishes that are relaxed from defensesManifest content: what actually happens during the dreamLatent content: symbolic meaning

12Psychodynamic Psychotherapy TechniquesEveryday slip upsSlip of the tongue/Freudian slip http://www.mirror.co.uk/news/world-news/best-freudian-slips-linguistic-gaffes-3206919MishearingMisreadingTemporary forgettingResistance Any client action or behavior that prevents insight or prevents bringing unconscious material into consciousness Expect it! https://www.youtube.com/watch?v=QxGzkUOp-8cResistance in therapy mirrors what happens in real lifeIf analyzed for its true function, it will not be as likely to operate

13Psychodynamic Psychotherapy TechniquesTransferenceClient reacts to therapist as if the therapist represented an important figure form clients pastReactions do not reflect current realitiesCountertransference Redirection of a therapists feelings toward a clientInsight into what client is attempting to elicit in therapistInterpretationMethod by which unconscious meanings are revealed Limited to important life area problems therapist is trying to resolveMost common technique among all forms of psychotherapy14Psychodynamic Psychotherapy Techniques Reviewhttps://www.youtube.com/watch?v=OBUJX8fahTgFree associationAnalysis of dreamsEveryday slip upsResistanceTransferenceCountertransferenceInterpretation

15Psychoanalytic AlternativesPsychoanalytic theory underwent considerable modification

Symptoms rooted in fear of loneliness, insecurity of adulthoodInterpretation remained essential therapeutic techniquePsychoanalytic alternatives varied in the content Less emphasis on past and more of a focus on the futureFamily members consulted or a component of therapy

16Psychoanalytic Alternatives: Ego AnalysisClassic psychoanalysis overemphasized unconscious and instinctual determinants at expense of ego processesEgo performs conflict free functions (memory, learning, perception)Focus is on present problems of living rather than pastTherapist must also understand effective parts of personalityEmphasize building trust through reparenting

17Psychodynamic Alternatives: Object Relations Encouraged emphasis on how client relates to other peopleFamily experiences shape how one relates to others and subconscious assumptions maintain interpersonal patterns Need to form relationships is primary influence on behaviorLater experiences can reshape early patternsCorrective emotional experience Re-exposure under favorable circumstances to an emotional situation with which one could not cope in the past

18Psychodynamic Alternatives: Contemporary Psychodynamics Psychoanalytically oriented or psychodynamic psychotherapy is more flexible than classic psychoanalysis 1-2 sessions per week instead of fiveShort-term or open-ended instead of 3-5+ yearsTherapist sits with client seated in a facing chair instead of behind couchFree association no longer absolutely required Importance of dreams may be downplayed Medications and other therapeutic techniques used as adjunct

19Psychodynamic Alternatives: Interpersonal PsychotherapyBrief, empirically supported, insight-oriented approach applied primarily to depressive disorders12-16 weeksThorough assessment of depressive symptomsTargets a major problem life areaDelayed grief, role transitions or disputes, interpersonal deficitsImproves relationships to alleviate depressive symptomsTherapist is active, non-neutral, and supportiveUse realism and optimism to counter negative thinkingEmphasize hope and options that may effect positive change 20Psychodynamic Psychotherapy: The EvidenceEfficacious vs EffectiveFew studies published suggesting significant effects for youthModest support for effectiveness with adults and strength of evidence depends on specific disorder Clients who received PP were functioning better than 75% of those who received no treatment (Smith et al., 1980)Two separate meta-analyses of efficacy show conflicting results Selective review of studies over 40 years suggest it is efficacious and effective (McWilliams & Weinberger, 2003)Effect sizes for efficacy range from medium-large (Shedler, 2010)Longer term and longer periods of treatment = larger effect sizes21Psychodynamic Psychotherapy: The EvidenceStrength of efficacy also depends on research methodologyPoor quality of many studies used in reviews and meta-analyses Failure to specify effects for specific disorders

Interpersonal Psychodynamic Therapy (IPT) most studied38 studies (4,000 adults and teens) showed moderate-large effects over no treatment for depression (Cuijpers et al., 2011)IPT with medication showed advantage over tx with meds aloneIPT did not show advantage over other forms of tx (e.g., CBT)IPT showed less efficacy than meds alone (i.e., SSRIs)

22Psychodynamic Psychotherapy: Pros and ConsInterpretation and insightWhen does analysis end?Underemphasizes focus of current problems and solutionsDoes behavioral change really follow insight?Frequency and accuracy of interpretationsTransference interpretations and the therapeutic alliance

Effectiveness of transference interpretations depends onClient characteristicsClinician interpersonal styleTiming of interpretations Accuracy of interpretations

23Psychodynamic Psychotherapy: Pros and ConsCurative FactorsClinician-client relationshipQuality is related to treatment process and outcomePositive therapeutic alliance self-examination by client

24Psychodynamic Psychotherapy: Pros and ConsLack of Emphasis on Behavior Insight is not followed by active strategies for behavior changeEconomicsTherapy for the affluent ($, time)Poor, uneducated, minority groups, older populations, severely disturbed are not good candidatesIs it ethical to allow clients to remain so long in therapy with little evidence of improvement?

25Psychodynamic Psychotherapy: Who Benefits? Capacity for self reflection

Curiosity about oneself and ones internal life

Desire for honesty and truth

Willingness to tolerate vulnerable and painful feelings

Others?

26Psychodynamic Psychotherapy: Clinical VignetteA man comes to therapy stating among other issues that he has been late to several recent job interviews though not to other meetings or appointments. He is in the process of attempting to advance his career and being late to interviews is sabotaging his success.

27Psychodynamic Psychotherapy: Clinical VignetteA woman comes to therapy stating that she is chronically late and has done everything that she can to change this through a variety of organizational tools and methods but to not avail. Her tardiness is interfering with her work and relationships.

28Psychodynamic Psychotherapy: Clinical VignetteA man comes to couples therapy with his wife and among other issues reports that over the past few years he has developed a habit of being late specifically when meeting or going places with his wife.

29