PSYCHOANALYTIC PSYCHOANALYTIC ALTERNATIVESALTERNATIVES

Lecture 30Lecture 30

Psychoanalytic theory underwent considerable Psychoanalytic theory underwent considerable modification by the neo-Freudians, Alfred Adler, modification by the neo-Freudians, Alfred Adler, Carl Jung, Otto Rank, the ego analysts and Carl Jung, Otto Rank, the ego analysts and others.others.

The seminal contributions of Freud remained, The seminal contributions of Freud remained, but the emphases often changed.but the emphases often changed.

Jung made much more of dreams and symbolic Jung made much more of dreams and symbolic processes.processes.

Rank elevated the birth trauma to a pre eminent Rank elevated the birth trauma to a pre eminent positionposition

Adler and the neo-Freudians stressed the Adler and the neo-Freudians stressed the importance of culture, learning, and social importance of culture, learning, and social relationships instead of instinctual forces.relationships instead of instinctual forces.

These changes often did little to alter the critical These changes often did little to alter the critical roles of free association, dream analysis, roles of free association, dream analysis, interpretation, transference, and resistance.interpretation, transference, and resistance.

The supreme role of insight was little changed.The supreme role of insight was little changed.

In most of these early variants of In most of these early variants of psychoanalysis, interpretation remained the psychoanalysis, interpretation remained the essential therapeutic ingredient.essential therapeutic ingredient.

Those who no longer practice the strict Freudian Those who no longer practice the strict Freudian techniques are often said to be practicing techniques are often said to be practicing "psychoanalytically oriented" therapy."psychoanalytically oriented" therapy.

These changes involve many factors.These changes involve many factors. Duration of the therapy.Duration of the therapy. The location of the therapist.The location of the therapist. Although basic Freudian tenets are still observed, the Although basic Freudian tenets are still observed, the

over all context is not so rigid.over all context is not so rigid.

For many years, the therapy room was like an inner For many years, the therapy room was like an inner sanctum. Now, family members or a spouse are often sanctum. Now, family members or a spouse are often consulted, or sometimes therapy is conducted with the consulted, or sometimes therapy is conducted with the family as a unit.family as a unit.

There tends to be much less emphasis on the There tends to be much less emphasis on the past (childhood) and a more active past (childhood) and a more active confrontation with the present.confrontation with the present.

Clinics or institutes now provide some Clinics or institutes now provide some therapeutic services to aging clients, minority therapeutic services to aging clients, minority group clients, and others who have not group clients, and others who have not traditionally received psychoanalytic treatment.traditionally received psychoanalytic treatment.

It is a demonstration that traditional Freudian It is a demonstration that traditional Freudian treatments procedures are not the only treatments procedures are not the only therapeutic techniques that can be deduced therapeutic techniques that can be deduced from Freudian psychoanalytic theory.from Freudian psychoanalytic theory.

EGO ANALYSISEGO ANALYSIS The The ego ego analysis movement originating from analysis movement originating from

within the framework of traditional within the framework of traditional psychoanalysis.psychoanalysis.

This group of theorists accepted the role of the This group of theorists accepted the role of the ego in mediating the conflict between the id and ego in mediating the conflict between the id and the real world but believed that the ego also the real world but believed that the ego also performed other extremely important functions.performed other extremely important functions.

In a sense, the ego analysts seem to prefer In a sense, the ego analysts seem to prefer reeducative goals rather than the reconstructive reeducative goals rather than the reconstructive goals of orthodox psychoanalysis.goals of orthodox psychoanalysis.

Ego analytic therapy focuses more on contemporary Ego analytic therapy focuses more on contemporary problems in living than on a massive examination and problems in living than on a massive examination and reinstatement of the past. reinstatement of the past.

Also, the therapist must understand not only the Also, the therapist must understand not only the neurotic aspects of the patient's personality but also neurotic aspects of the patient's personality but also the effective parts and how they interact with those the effective parts and how they interact with those neurotic trends.neurotic trends.

The ego-analytic approach has also tended to The ego-analytic approach has also tended to emphasize the importance of building the patient's emphasize the importance of building the patient's trust through "reparenting" in the therapy relationship. trust through "reparenting" in the therapy relationship.

This approach sometimes even views transference as This approach sometimes even views transference as an impediment to therapy and works toward building an impediment to therapy and works toward building adaptive defenses in the patient adaptive defenses in the patient

OTHER CONTEMPORARY OTHER CONTEMPORARY DEVELOPMENTSDEVELOPMENTS

In particular, the work of Horney, Sullivan, and Adler In particular, the work of Horney, Sullivan, and Adler has been important in giving a new spin to has been important in giving a new spin to psychoanalysis.psychoanalysis.

Likewise, ego psychology and theories of object Likewise, ego psychology and theories of object relations have encouraged an emphasis on the relations have encouraged an emphasis on the manner in which the patient relates to other people, manner in which the patient relates to other people, rather than on conflicts among, instinctual forces.rather than on conflicts among, instinctual forces.

These theorists focus more on the role of love and These theorists focus more on the role of love and hate, as well as hate, as well as auautonomy and dependency, in the tonomy and dependency, in the development of the self.development of the self.

In the self psychology of Kohut (1977), the central task In the self psychology of Kohut (1977), the central task of maturation is not the successful negotiation of the of maturation is not the successful negotiation of the psychosexual stages but the development of an psychosexual stages but the development of an integrated self.integrated self.

Discussions of changes in psychoanalytic Discussions of changes in psychoanalytic therapies emphasize a shift in the therapeutic therapies emphasize a shift in the therapeutic focus to the "here and now" and to the focus to the "here and now" and to the interpersonal exchanges that occur within it.interpersonal exchanges that occur within it.

Strupp and Binder emphasize a movement Strupp and Binder emphasize a movement away from the recovery of childhood memories away from the recovery of childhood memories and their analysis toward a focus on the and their analysis toward a focus on the corrective emotional experiences that occur corrective emotional experiences that occur through through the the agency of the therapeutic agency of the therapeutic relationship. relationship.

BREIF PSYCHODYNAMIC PSYCHOTHERAPYBREIF PSYCHODYNAMIC PSYCHOTHERAPY Perhaps the chief practical thrust of recent years Perhaps the chief practical thrust of recent years

in psychodynamic therapy has been the in psychodynamic therapy has been the development of brief methods.development of brief methods.

Many of these brief therapies retain their Many of these brief therapies retain their psychodynamic identity even as they are psychodynamic identity even as they are employed in emergency, crisis-oriented employed in emergency, crisis-oriented situations.situations.

Although it would be nice to believe that theory Although it would be nice to believe that theory and/or research considerations have dictated the and/or research considerations have dictated the shift toward briefer psychotherapies, this is not shift toward briefer psychotherapies, this is not entirely the case.entirely the case.

An important driving force has been the increasing An important driving force has been the increasing focus on cost containment in health care systems.focus on cost containment in health care systems.

Cost containment has also provided indirect Cost containment has also provided indirect competition from psychiatrists, who frequently competition from psychiatrists, who frequently prescribe medications rather than psychotherapy.prescribe medications rather than psychotherapy.

There are now several hundred different brands of There are now several hundred different brands of brief therapy.brief therapy.

Not all of these briefer therapies could be labeled Not all of these briefer therapies could be labeled psychodynamic. Many forms of brief psychotherapy psychodynamic. Many forms of brief psychotherapy are quite eclectic in their approachare quite eclectic in their approach

Although some define 25 sessions as the upper Although some define 25 sessions as the upper limit of brief therapy others indicate that the limit of brief therapy others indicate that the range can be from onrange can be from one e session to 40 or 50 .session to 40 or 50 .

Events move rapidly in crisis-oriented therapy.Events move rapidly in crisis-oriented therapy.

The ultimate goal is not reconstruction of the The ultimate goal is not reconstruction of the personality, but the development of a benign personality, but the development of a benign cycle of functioning and the better handling of cycle of functioning and the better handling of day to day problems in living.day to day problems in living.

Transference is encouraged, but mainly as a Transference is encouraged, but mainly as a means of ensuring that the therapist will be means of ensuring that the therapist will be perceived as helpful, competent, and active.perceived as helpful, competent, and active.

The level of therapist activity is high, and both The level of therapist activity is high, and both therapist and patient are keenly aware of the element therapist and patient are keenly aware of the element of time.of time.

The therapist is likely to use homework assignments The therapist is likely to use homework assignments for the patient and to involve relatives or significant for the patient and to involve relatives or significant others in the treatment plan.others in the treatment plan.

Supportive activities outside therapy are likely to be Supportive activities outside therapy are likely to be used.used.

Research evidence attests to the efficacy of brief Research evidence attests to the efficacy of brief forms of psychotherapy across a number of clinical forms of psychotherapy across a number of clinical conditions.conditions.

Two recent Meta analyses are noteworthy.Two recent Meta analyses are noteworthy.

Svartberg and Stile (1991) found that brief Svartberg and Stile (1991) found that brief psychodynamic psychotherapy was su perior to no psychodynamic psychotherapy was su perior to no treatment.treatment.

Crits-Christoph (1992) also examined the effects of Crits-Christoph (1992) also examined the effects of brief psychodynamic psychotherapy.brief psychodynamic psychotherapy.

Crits-Christoph (1992) found that brief psychodynamic Crits-Christoph (1992) found that brief psychodynamic psychotherapy was clearly superior to no treatment psychotherapy was clearly superior to no treatment and, in contrast to Svartberg and Stiles (1991) that and, in contrast to Svartberg and Stiles (1991) that brief psychodynamic psychotherapy was brief psychodynamic psychotherapy was approximately equivalent in its effects to active approximately equivalent in its effects to active psychological treatments.psychological treatments.

INTERPERSONAL PSYCHOTHERAPYINTERPERSONAL PSYCHOTHERAPYAN EMPIRICALLY SUPPORTED TREATMENTAN EMPIRICALLY SUPPORTED TREATMENT

Interpersonal psychotherapy or IPTInterpersonal psychotherapy or IPT is a brief is a brief insight oriented approach that has been applied insight oriented approach that has been applied primarily to depressive disorders although it has primarily to depressive disorders although it has been modified for use in the treatment of other been modified for use in the treatment of other disorders (such as substance abuse and disorders (such as substance abuse and bulimia) as well.bulimia) as well.

IPT has been shown to be effective in treating IPT has been shown to be effective in treating acute depressive episodes and in preventing or acute depressive episodes and in preventing or delaying the recurrence of de pressive delaying the recurrence of de pressive episodes.episodes.

Features Of Interpersonal PsychotherapyFeatures Of Interpersonal Psychotherapy

FOCUS: FOCUS: IPT focuses on the connection between onset IPT focuses on the connection between onset of clinical problems and current interpersonal problems.of clinical problems and current interpersonal problems.

LENGTHLENGTH: : Typically 12-16 weeks.Typically 12-16 weeks.

ROLE OF THE IPT THERAPIST: ROLE OF THE IPT THERAPIST: IPT therapists are active, facilitator, and supportive.IPT therapists are active, facilitator, and supportive.

They use realism and optimism to counter patients' They use realism and optimism to counter patients' typically negative and pessimistic outlook. Therapists typically negative and pessimistic outlook. Therapists emphasize the possibility for change and highlight emphasize the possibility for change and highlight options that may effect positive changeoptions that may effect positive change

Phases Of TreatmentPhases Of Treatment

First phase (up First phase (up to 3 sessions):to 3 sessions): This includes This includes a diagnostic evaluation and psychiatric history, a diagnostic evaluation and psychiatric history, an interpersonal functioning assessment, and an interpersonal functioning assessment, and patient education about the nature of the clinical patient education about the nature of the clinical condition (such as depression).condition (such as depression).

Second phaseSecond phase: : Depending on which Depending on which interpersonal problem area has been chosen.interpersonal problem area has been chosen.

Third phase Third phase (last 2-3 sessions):(last 2-3 sessions): The patient's The patient's progress and mastery experiences are progress and mastery experiences are reinforced and consolidated.reinforced and consolidated.

Evaluation: does psychodynamic Evaluation: does psychodynamic psychotherapy works?psychotherapy works?

We know the widely known meta-analytic study We know the widely known meta-analytic study by Smith, Glass, and Miller (1980) that by Smith, Glass, and Miller (1980) that examined the effectiveness of psychotherapy.examined the effectiveness of psychotherapy.

In addition to examining the effects of In addition to examining the effects of psychotherapy in general, these authors also psychotherapy in general, these authors also reported effects separately for different types of reported effects separately for different types of psychological intervention.psychological intervention.

They found that the aver age patient who had They found that the aver age patient who had received psychodynamic psychotherapy was received psychodynamic psychotherapy was functioning better than 75%, of those who had functioning better than 75%, of those who had received no treatment.received no treatment.

Conflicting results--- one supporting the efficacy Conflicting results--- one supporting the efficacy of brief of brief psychodypsychodynamic treatment but the other namic treatment but the other not .not .

There appears to be at least modest support for There appears to be at least modest support for the effectiveness of psychodynamic the effectiveness of psychodynamic psychotherapy.psychotherapy.

INTERPRETATION AND INSIGHTINTERPRETATION AND INSIGHT A wide range of current psychotherapies depend to a A wide range of current psychotherapies depend to a

greater or lesser extent on the patient's achieving greater or lesser extent on the patient's achieving insight through therapist interpretation.insight through therapist interpretation.

When understanding is complete enough, it is When understanding is complete enough, it is believed that the patients' symptoms will be believed that the patients' symptoms will be ameliorated, or even disappear entirely.ameliorated, or even disappear entirely.

This emphasis on the pursuit of understanding has This emphasis on the pursuit of understanding has great appeal to many people.great appeal to many people.

The commitment of psychoanalysis and its The commitment of psychoanalysis and its psychotherapeutic heirs to insight and understanding psychotherapeutic heirs to insight and understanding is their greatest asset, but it also contains the seeds of is their greatest asset, but it also contains the seeds of their failurestheir failures

Although one can hardly fault psychoanalysis for Although one can hardly fault psychoanalysis for teaching the importance of the past in shaping the teaching the importance of the past in shaping the present, there can be too much of a good thing.present, there can be too much of a good thing.

The endless analysis of conflicts and motives and of The endless analysis of conflicts and motives and of their childhood origins can easily replace the need to their childhood origins can easily replace the need to find solutions and behavioral alternatives to problems find solutions and behavioral alternatives to problems in living.in living.

The failure to emphasize alternative ways of behaving The failure to emphasize alternative ways of behaving can be a major short coming of traditional can be a major short coming of traditional psychoanalysis.psychoanalysis.

Psychoanalysis often appears to involve a tacit Psychoanalysis often appears to involve a tacit assumption that more adaptive behavior will occur assumption that more adaptive behavior will occur automatically once insight is achieved by the working automatically once insight is achieved by the working through process that behavioral change will surely through process that behavioral change will surely follow insight.follow insight.

One of the chief methods used by psychodynamic One of the chief methods used by psychodynamic clinicians to facilitate patient insight is the clinicians to facilitate patient insight is the interpretation of transference.interpretation of transference.

(W. P. Henry et al., 1994) offer the following general (W. P. Henry et al., 1994) offer the following general conclusions:conclusions:

1. The frequency of interpretations made is not related to 1. The frequency of interpretations made is not related to better outcome. Indeed, some studies have found that better outcome. Indeed, some studies have found that a higher frequency of interpretation is related to poorer a higher frequency of interpretation is related to poorer outcome.outcome.

2. Transference interpretations do not result in a greater 2. Transference interpretations do not result in a greater degree of affective experience in the patient as degree of affective experience in the patient as compared with other types of interpretations or other compared with other types of interpretations or other types of interventions.types of interventions.

3. Interpretations by the therapist are more likely 3. Interpretations by the therapist are more likely to result in defensive responding on the part of to result in defensive responding on the part of the patient than are other types of interventions. the patient than are other types of interventions. Frequent transference interpretations may Frequent transference interpretations may damage the therapeutic relationship.damage the therapeutic relationship.

4. Clinicians' accuracy of interpretations may be 4. Clinicians' accuracy of interpretations may be lower than was previously believed.lower than was previously believed.

Transference interpretations do not seem Transference interpretations do not seem uniquely effective, may pose greater process uniquely effective, may pose greater process risks, and may be counter therapeutic under risks, and may be counter therapeutic under certain conditions“.certain conditions“.

CURATIVE FACTORSCURATIVE FACTORS

The empirical evidence points to the, strength of the The empirical evidence points to the, strength of the therapeutic alliance.therapeutic alliance.

It is interesting to note that the importance of the It is interesting to note that the importance of the clinician-patient relationship was recognized by Freud.clinician-patient relationship was recognized by Freud.

This term is generally used to refer to the patient's This term is generally used to refer to the patient's affective bond to the therapist.affective bond to the therapist.

Presumably, a strong therapeutic alliance makes it Presumably, a strong therapeutic alliance makes it less likely that a patient will react defensively to less likely that a patient will react defensively to interpretations by the clinician.interpretations by the clinician.

Research evidence suggests a direct link between Research evidence suggests a direct link between alliance and outcomealliance and outcome

THE LACK OF EMPHASIS ON BEHAVIORTHE LACK OF EMPHASIS ON BEHAVIOR The stereotypic practitioner of psychoanalytic The stereotypic practitioner of psychoanalytic

psychotherapy plays a relatively passive role except psychotherapy plays a relatively passive role except for interpretation.for interpretation.

The failure to deal with behavior to make suggestions The failure to deal with behavior to make suggestions or to adopt a generally more activist posture would or to adopt a generally more activist posture would seem to prolong psychotherapy unnecessarily.seem to prolong psychotherapy unnecessarily.

An active therapist who not only provides An active therapist who not only provides interpretations that will lead to insight but also guides interpretations that will lead to insight but also guides the patient into new learning situations seems more the patient into new learning situations seems more likely to achieve lasting solutions to the patient's likely to achieve lasting solutions to the patient's problems than does a therapist who relies solely on problems than does a therapist who relies solely on insight.insight.

It seems clear that a major reason for the rapid It seems clear that a major reason for the rapid rise of the behavioral therapies was the failure rise of the behavioral therapies was the failure of so many psychotherapists to deal directly of so many psychotherapists to deal directly with the specific problems of the patient.with the specific problems of the patient.

The approach inevitably seemed to be one of The approach inevitably seemed to be one of relegating the presenting problem to the status relegating the presenting problem to the status of a "symptom of something deeper." of a "symptom of something deeper."

The therapist then began working with that The therapist then began working with that "something deeper" while clinging to the abiding "something deeper" while clinging to the abiding belief that once the patient understood it, the belief that once the patient understood it, the symptom or deficit would disappear. symptom or deficit would disappear. Unfortunately, things did not work out that way Unfortunately, things did not work out that way often enough.often enough.

THE ECONOMICS OF PSYCHOTHERAPYTHE ECONOMICS OF PSYCHOTHERAPY

By its very nature (reconstruction of the By its very nature (reconstruction of the personality), psychoanalysis is a long and personality), psychoanalysis is a long and costly procedure.costly procedure.

Consequently, it has become a therapy for theConsequently, it has become a therapy for the affluent for those who have both the moneyaffluent for those who have both the money and and the time to pursue the resolution of theirthe time to pursue the resolution of their neuroses.neuroses.

Moreover, the procedures of psycho analysis Moreover, the procedures of psycho analysis are such that only relatively intelligent, are such that only relatively intelligent, sophisticated, and educated groups are likely tosophisticated, and educated groups are likely to be be able to accept the therapeutic demands it able to accept the therapeutic demands it makesmakes

For all these reasons, only a small portionFor all these reasons, only a small portion of of those in need of psychotherapy are likely tothose in need of psychotherapy are likely to be be reached by traditional psychoanalysis.reached by traditional psychoanalysis.

For these reasons alone, many regard For these reasons alone, many regard psychoanalysis as a failure.psychoanalysis as a failure.

For persons who have the necessary personal For persons who have the necessary personal qualities and financial re sources, qualities and financial re sources, psychoanalysis has been helpful, particu larly psychoanalysis has been helpful, particu larly for those whose problems can best be met for those whose problems can best be met through the development of understandingthrough the development of understanding

Psychoanalytic techniques seem to have Psychoanalytic techniques seem to have helped many patients, and as a theory of helped many patients, and as a theory of therapy, psychoanalysis undergirds many forms therapy, psychoanalysis undergirds many forms of psychotherapy.of psychotherapy.

Yet many clinicians still question whether, after Yet many clinicians still question whether, after all these years, there is really much in the way all these years, there is really much in the way of definitive research evidence for its of definitive research evidence for its effectiveness.effectiveness.

The case of 54.years old man.The case of 54.years old man.

An example of women who developed An example of women who developed agoraphobia.agoraphobia.

Admittedly, nearly every brand of therapy contains its Admittedly, nearly every brand of therapy contains its share of horror stories.share of horror stories.

It is encouraging, however, that brief forms of It is encouraging, however, that brief forms of psychodynamic psychotherapy have been developedpsychodynamic psychotherapy have been developed

Christoph’s (1992) meta-analysis indicates that brief Christoph’s (1992) meta-analysis indicates that brief psychodynamic treatments that incorporate the use of psychodynamic treatments that incorporate the use of manuals show stronger treatment effects.manuals show stronger treatment effects.

In addition to providing encouragement to psycho In addition to providing encouragement to psycho dynamically oriented clinicians, this finding should dynamically oriented clinicians, this finding should serve to impel them toward mastery and use of serve to impel them toward mastery and use of manual based, empirically supported brief manual based, empirically supported brief psychodynamic treatments, such as interpersonal psychodynamic treatments, such as interpersonal psychotherapypsychotherapy