Sunday, January 9, 2011

Psychoanalytic Therapy

Freud’s views continue to influence contemporary practice.Many of his basic concepts are still part of the foundation on which other theorists build and develop.Some extended the psychoanalytic model, others modified its concepts and procedures, and others emerged as a reaction against it.
Freud initially shaped psychotherapy by calling attention to psychodynamic factors that motivate behavior, by focusing on the role of the unconscious, and by developing the first therapeutic procedures for understanding and modifying the structure of one’s basic character.Freud’s theory is a benchmark against which many other theories are measured.This chapter focuses on basic psychoanalytic concepts and practices, and therapies that apply classical psychoanalytic concepts to practice less rigorously than Freud.
View of Human Nature:human nature is basically deterministic.According to Freud, our behavior is determined by irrational forces, unconscious motivations, and biological and instinctual drives.These evolve through key psychosexual stages in the first 6 years of life.
Instincts are central to the Freudian approach.Libido refers to the energy of all life instincts.Instincts serve the purpose of the survival of the individual and the human race.They are oriented toward growth, development, and creativity.Libido is a source of motivation that encompasses sexual energy but goes beyond it.Freud includes all pleasurable acts in his concept of life instincts.The goal of much of life is gaining pleasure and avoiding pain.
Death instincts are the aggressive drive in humankind.At times, people manifest through their behavior an unconscious wish to die or to hurt themselves or others.Managing this aggressive drive is a major challenge to the human race.
Structure of Personality:the personality consists of three systems – the id, the ego, and the superego.They operate together – one’s personality functions as a whole rather than as three discrete segments.From the orthodox Freudian perspective – humans are viewed as energy systems.The dynamics of personality consist of the ways in which psychic energy is distributed to the id, ego, and superego.The amount of energy one has is limited, therefore, one system gains control over available energy at the expense of the other two systems.Behavior is determined by this psychic energy.
The Id:The biological component of the personality structure – the id is the original system of personality; at birth a person is all id.The id is the primary source of psychic energy and the seat of the instincts.The id cannot tolerate tension and it functions to discharge tension immediately and return to a homeostatic condition.The id is ruled by the Pleasure Principle – the principle that we are ruled by seeking to reduce tension, avoid pain, and gain pleasure.The id is illogical, amoral, and driven to satisfy instinctual needs.The id never matures.It does not think but only wishes or acts.The id is largely unconscious, or out of awareness.
The Ego:The Ego is the psychological component of the personality structure.It is the executive that governs, controls and regulates the personality.It has contact with the external world of reality.It mediates between the instincts and the surrounding environment.The ego controls consciousness and exercises censorship.The Ego is ruled by the Reality Principle – The Ego does realistic and logical thinking and formulates plans of action for satisfying needs.The Ego is the seat of intelligence and rationality and it checks and controls the blind impulses of the id.The Ego distinguishes between mental images and things in the external world.
The Superego:The superego is the social component of the personality structure.It is the judicial branch of personality.It includes a person’s moral code, the main concern being whether an action is good or bad, right or wrong.It represents the ideal rather than the real and strives not for pleasure but for perfection.It represents the traditional values and ideals of society as they are handed down from parent to child.It functions to inhibit the id impulses, to persuade the ego to substitute moralistic goals for realistic ones, and to strive for perfection.The superego is related to psychological rewards and punishments.The rewards are feelings of pride and self-love; the punishments are feelings of guilt and inferiority.
Consciousness and Unconscious:are the keys to understanding behavior and the problems of personality.The unconscious cannot be studied directly but is inferred from behavior.This includes (1) dreams – symbolic representations of unconscious needs, wishes, and conflicts (2) slips of the tongue and forgetting, for example, a familiar name (3) posthypnotic suggestions (4) material derived from free-association techniques (5) material derived from projective techniques; and (6) the symbolic content of psychotic symptoms.
According to Freud, the larger part of the mind exists below the surface of awareness.The unconscious stores all experiences, memories, and repressed material.Needs and motivations that are inaccessible or out of our awareness, are also outside the sphere of conscious control.Most psychological functioning exists in the out-of-awareness realm.The aim of psychoanalytic therapy is to make unconscious motives conscious.
Unconscious processes are at the root of all forms of neurotic symptoms and behaviors.A “cure” is based on uncovering the meaning of symptoms, the causes of behavior, and the repressed materials that interfere with healthy functioning.
Anxiety:Anxiety is a state of tension that motivates us to do something.Anxiety develops out of a conflict among the id, ego, and superego over control of available psychic energy.The function of anxiety is to warn of impending danger.
3 kinds of anxiety:Reality anxiety is the fear of danger from the external world and the level of such anxiety is proportionate to the degree of real threat.
Neurotic anxiety is the fear that the instincts will get out of hand and cause one to do something for which one will be punished.
Moral anxiety is the fear of one’s own conscious.People with a well developed conscious tend to feel guilty when they do something contrary to their moral code.
Neurotic and moral anxieties are evoked by threats to the “balance of power” within the person.They signal to the ego that unless appropriate measures are taken, the danger may increase until the ego is overthrown.When the ego cannot control anxiety by rational and direct methods, it relies on indirect ones – ego-defense behavior.
Ego-Defense Mechanisms:Help the individual cope with anxiety and prevent the ego from being overwhelmed.Ego defenses are normal behaviors that can have adaptive value provided they do not become a style of life that enables the individual to avoid facing reality.
The specific ego-defenses employed depend on the individual’s level of development and degree of anxiety.Defense mechanisms have two characteristics in common:(1) they either deny or distort reality; and (2) they operate on an unconscious level.
Repression:One of the most important Freudian processes – the basis of many other ego defenses and neurotic disorders.Threatening or painful thoughts and feelings are excluded from awareness.Repression is an involuntary removal of something from consciousness.The assumption is that most of the painful events of the first 5-6 years of life are buried, yet these events do influence later behavior.
Denial:Denial generally operates at preconscious and conscious levels.Denial of reality is a way of distorting what the individual thinks, feels, or perceives in a traumatic situation.It consists of defending against anxiety by “closing one’s eyes” to the existence of threatening reality.
Reaction formation:A defense against a threatening impulse by actively expressing the opposite impulse.It involves developing conscious attitudes and behaviors that are diametrically opposed to disturbing desires.In this way people do not have to face the anxiety that would result if they were to recognize these dimensions of themselves.Examples include concealing hate with a fa├žade of love, being extremely nice when there are negative reactions, or masking cruelty with excessive kindness.
Projection:Attributing to others one’s own unacceptable desires and impulses.Lustful, aggressive, or other impulses are seen as being possessed by “those people out there, but not by me.”
Development of Personality:The delineation of the stages of psychosocial and psychosexual development from birth through adulthood.This provides the counselor with the conceptual tools for understanding key developmental tasks characteristic of the various stages of life.According to the Freudian psychoanalytic view, there are 3 areas of personal and social development:
(1) love and trust, (2) dealing with negative feelings, and (3) developing a positive acceptance of sexuality.Personal and social development occurs within the first 6 years of life.This is the foundation upon which later personality development is built.
Freud’s Psychosexual States of Development:
  • 1st Year: Oral stage – Infant needs basic nurturing or later feelings of greediness and acquisitiveness may develop. Oral fixations result from deprivation of oral gratification. Later personality problems can include mistrust of others, rejecting others; love, and fear of or inability to form intimate relationships.
  • 1-3 Years: Anal stage – Developmental tasks include learning independence, accepting personal power, and learning to express negative feelings such as rage and aggression. Parental discipline patterns and attitudes have significant consequences for child’s later personality development
  • 3-6 Years: Phallic stage – Basic conflict centers on unconscious incestuous desires that the child develops for parent of opposite sex. These desires are threatening and therefore repressed. Boys experience the Oedipus complex – mother is love object for boys. Girls experience the Electra complex – strive to win father’s love and approval. Both have impact on sexual attitudes and feelings that the child later develops.
  • 6-12 Years: Latency stage – Sexual interest are replaced by interests in school, playmates, sports, and a range of new activities. This is a time of socialization and forming relationships with others.
  • 12-18 Years: Genital stage – Themes of phallic stage are revived. This stage begins with puberty and lasts until senility sets in. Adolescents learn to deal with sexual energy by investing it in various socially acceptable activities such as friendships, engaging in art or sports, and preparing for a career.
  • 18-35 Years and beyond: Genital stage continues – Core characteristics of mature adult are the freedom to love and to work. Additionally, it involves freedom from parental influence and capacity to care for others.
Therapeutic Goals:(1) To make the unconscious conscious, (2) to strengthen the ego so that behavior is based more on reality and less on instinctual cravings or irrational guilt.Successful analysis is believed to result in significant modification of the individual’s personality and character structure.Therapeutic methods are used to bring out unconscious material; childhood experiences are reconstructed, discussed, interpreted and analyzed.It is essential that the feelings and memories associated with self-understanding be experienced.
Therapist’s Function and Role:Classical analysts typically assume an anonymous stance – called the “blank-screen” approach.They engage in very little self-disclosure and maintain a sense of neutrality in order to foster a transference relationship where clients will make projections onto them.The therapist believes whatever the client feels toward them will largely be the product of feelings associated with other significant figures from the past.The projections have their origins in unfinished and repressed situations.Their analysis is the very essence of therapeutic work.
One of the central functions of analysis is to help clients acquire the freedom to love, work, and play.Additional work includes assisting clients in achieving self-awareness, honesty, and more effective personal relationships, dealing with anxiety in a realistic way, and gaining control over impulsive and irrational behavior.
The analyst establishes a working relationship with the client and they do a lot of listening and interpreting.Particular attention is given to the client’s resistances.They make appropriate interpretations and listen for gaps and inconsistencies in the client’s story, infer the meaning of reported dreams and free associations, and remain sensitive to clues concerning the client’s feelings toward the analyst.Whether clients change depends considerably more on their readiness to change than on the accuracy of the therapist’s interpretations.
Client’s Experience in Therapy:Classical psychoanalysis - Clients must be willing to commit to an intensive and long-term therapy process.After some face-to-face sessions with the analyst, clients lie on a couch and free-associate (saying whatever comes to mind without self-censorship).Clients report their feelings, experiences, associations, memories and fantasies to the analyst.Lying on the couch encourages deep, uncensored reflections and reduces the stimuli that might interfere with getting in touch with internal conflicts.The client cannot read their analyst’s face for reactions and the analyst is freed from having to carefully monitor facial clues.
Many psychoanalytically oriented practitioners (as distinct from analysts) do not use all these techniques.They do remain alert to transference manifestations and work with dreams and with unconscious material.These highly verbal sessions are the heart of psychoanalytic therapy and clients are asked not to make any radical changes in their lifestyle during the period of analysis, such as getting a divorce or quitting their job.
Termination is mutually agreed upon by the client and the analyst when it is felt that symptoms and conflicts that were amenable to resolution have been clarified by understanding the historical roots of their difficulties, and integrating their awareness of past problems with the present relationships.
Relationship Between Therapist and Client:Transference is at the core of the psychoanalytic approach.Transference is the client’s unconscious shifting to the analyst of feelings and fantasies that are reactions to significant others in the client’s past.Transference allows clients to understand and resolve “unfinished business” from past relationships.As therapy progresses, childhood feelings and conflicts begin to surface from the depths of the unconscious.Clients regress emotionally.Some of their feelings arise from conflicts such as trust versus mistrust, love versus hate, dependence versus independence, and autonomy versus shame and guilt.Transference takes place when clients resurrect from their early years intense conflicts relating to love, sexuality, hostility, anxiety, and resentment, bring them into the present; re-experience them; and attach them to the analyst.In essence, the analyst becomes a current substitute for significant others.The transference relationship must be worked through which is a process where unconscious material and defenses primarily originating in early childhood are explored.Working through is achieved by repeating interpretations and by exploring forms of resistance.It results in a resolution of old patterns and allows clients to make new choices.If this phase of analysis is not properly worked through, clients simply transfer their infantile wishes for universal love and acceptance to other figures they deem powerful.All infantile conflicts may not be fully resolved, even though many aspects of transference are worked through with a therapist.We may need to struggle at times throughout our life with feelings that we project onto others as well as with unrealistic demands that we expect others to fulfill.In this sense, we experience transference with many people, and our past is always a vital part of the person we are presently becoming.
This intense therapeutic relationship is bound to ignite some of the unconscious conflicts within therapists.Counter transference is the phenomenon when there is inappropriate affect (emotion), when therapists respond in irrational ways, or when they lose their objectivity in relationships because their own conflicts are triggered.Counter transference also refers to the reactions therapist have toward their clients that may interfere with their objectivity.Counter transference can be seen as potentially useful if it is explored in analysis.What is of paramount importance is that therapists develop some level of objectivity and not react irrationally and subjectively in the face of anger, love, adulation, and other intense feelings expressed by clients.
PSYCHOANALYTICALLY ORIENTED THERAPISTS (as opposed to traditional psychoanalysis)
·Therapy is geared to more limited objectives than to restructuring one’s personality
·Therapist is less likely to use the couch
·Typically fewer sessions
·More frequent use of supportive interventions (reassurance, expressions of empathy and support, and suggestions)
·The focus is more on pressing practical issues than on working with fantasy material
Techniques are aimed at increasing awareness, fostering insights into the client’s behavior, and understanding the meanings of symptoms.Therapy moves through the client’s talk to catharsis to insight to working through unconscious material.
Six basic techniques:
(1)Maintaining the analytic framework – procedural and stylistic factors that include the analyst’s relative anonymity, the regularity and consistency of meetings and starting and ending the session time.The consistent framework is itself a therapeutic factor and analysts attempt to minimize departures from this consistent pattern.
(2)Free association – Part of the process of maintaining the analytic framework.In essence, clients flow with any feelings or thoughts by reporting them immediately without censorship.This is a basic tool used to open the doors to unconscious wishes, fantasies, conflicts, and motivations.The therapist hears not only the surface content but also the hidden meaning.This awareness of the language of the unconscious has been termed “listening with the third ear” (Reik, 1948).
(3)Interpretation – Interpretation consists of the analyst’s pointing out, explaining, and even teaching the client the meanings of behavior that is manifested in dreams, free association, resistances, and the therapeutic relationship itself.Under contemporary definition, interpretation includes identifying, clarifying, and translating the client’s material. Interpretation is presented when the phenomenon to be interpreted is close to the conscious awareness.The interpretation should start from the surface and go only as deep as the client is able to go and it is best to point out a resistance or defense before interpreting the emotion or conflict that lies beneath it.
(4)Dream Analysis – Dream analysis is an important procedure for uncovering unconscious material and giving the client insight into some areas of unresolved problems.Dreams have two levels:latent content and manifest content.Latent content consists of hidden, symbolic, and unconscious motives, wishes, and fears.The unconscious sexual and aggressive impulses that make up latent content are transformed into more acceptable manifest content.Manifest content is the dream as it appears to the dreamer.This process is called dream work.The therapist’s task is to uncover disguised meanings by studying the symbols in the manifest content of the dream.Dreams may serve as a pathway to repressed material, but they also provide an understanding of clients’ current functioning.
(5)Analysis and Interpretation of Resistance – Resistance refers to any idea, attitude, feeling, or action (conscious or unconscious) that fosters the status quo and gets in the way of change.Resistances are representative of usual defensive approaches in daily life.They serve as devices that defend against anxiety but that interfere with the ability to accept change that could lead to experiencing a more gratifying life.
(6)Analysis and Interpretation of Transference – Transference is valuable because its manifestations provide clients with the opportunity to re experience a variety of feelings that would otherwise be inaccessible.The analysis of transference is a central technique in psychoanalysis and psychoanalytically oriented therapy.
Freud emphasized intra-psychic conflicts pertaining to the gratification of basic needs.Later theorists have moved away from this orthodox position and have expanded the psychoanalytic movement by incorporating cultural and social influences on personality.
Ego psychology- stresses psychosocial development throughout the lifespan and was largely developed by Erik Erikson.His theory of development holds that psychosexual growth and psychosocial growth take place together.Additionally, at each stage of life we face the task of establishing equilibrium between ourselves and our social world.Ego psychology does not deny the role of intra-psychic conflict but emphasizes the striving of the ego for mastery and competence throughout the human life span.The stages of adolescence, mid-adulthood, and later adulthood all involve particular crises that must be addressed.Pages 62-64 compare Freud’s Psychosexual Stages and Erikson’s Psychosocial Stages of human development.
More recent approaches to psychoanalytic theory are classified under the labels of object-relations theory, self psychology, and relational psychoanalysis.The term object is used interchangeably with the term other to refer to an important person to whom the child, and later the adult, becomes attached.Rather than being individuals with separate identities, others are perceived by an infant as objects for gratifying needs. The relational model is based on the assumption that therapy is an interactive process between client and therapist.Contemporary approaches to analysis assume a more equal power relationship and describe the process of analysis as a mutual exploration of two subjectivities.A central influence on contemporary object-relations theory is Margaret Mahler who emphasizes separation and individuation.Her belief is that the individual begins in a state of psychological fusion with the mother and progresses gradually to separation.The unfinished crises and residues of the earlier state of fusion, as well as the process of separating and individuating, have a profound influence on later relationships.
A trend in contemporary psychoanalytic therapies includes time-limited therapy – brief psychodynamic therapy (BPT).This adaptation applies the principles of psychodynamic theory and therapy to treating selective disorders within a pre-established time limit of generally 10-25 sessions.BPT makes uses of key psychodynamic concepts. such as the enduring impact of psychosexual, psychosocial, and object-relational stages of development; the existence of unconscious processes and resistance; the usefulness of interpretation; the importance of the working alliance, and the re-enactment in the client’s past emotional issues in relationship to the therapist.Most forms of this time-limited approach call upon the therapist to assume an active and directive role in quickly formulating a therapeutic focus that goes beneath the surface of presenting problems and symptoms and treats underlying issues.
Positives:Erikson’s psychosocial approach, with its emphasis on critical issues in stages of development, has particular application to people of color.
Negatives:Traditional psychoanalytic approaches are costly, and psychoanalytic therapy is generally perceived as being based on upper and middle class values.Psychoanalytic approaches are inherently ambiguous and this can be problematic for clients from culture who expect direction from a professional.For example, Hispanic and Asian-American clients may prefer a more structured, problem-oriented approach to counseling and may not continue therapy if a nondirective approach is employed.Additionally, psychoanalytic therapy is more concerned with long-term personality reconstruction than with short term problem solving.The psychoanalytic approach can be criticized for failing to adequately address the social, cultural, and political factors that result in an individual’s problems.If there is no balance between the external and internal perspectives, clients may be blamed for their condition.
Limitations/Criticisms of the Psychoanalytic Approach:
Time, expense, and availability of trained psychoanalytic therapist, and the practical applications of many psychoanalytic techniques are limited.
Many severely disturbed clients lack the level of ego strength needed for this treatment.There is limited application to diverse client populations, and questionable benefits.
Dr. Rebecca Curtis


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