Psychotherapy Developed from psychoanalysis Sigmund Freud (1856 - 1939) Basic Concepts 1) Unconsious 2) Psychic Energy 3) Repression 4) Transference 5)

PsychotherapyPsychotherapy

Developed from psychoanalysisDeveloped from psychoanalysis

Sigmund Freud (1856 - 1939)Sigmund Freud (1856 - 1939)

Basic ConceptsBasic Concepts

1)1) UnconsiousUnconsious

2)2) Psychic EnergyPsychic Energy

3)3) RepressionRepression

4)4) TransferenceTransference

5)5) DevelopmentalDevelopmental

UnconsciousUnconscious

Dynamic - system of wishes, impulses and memories Dynamic - system of wishes, impulses and memories which actively influence thoughts, actions, which actively influence thoughts, actions, symptoms, dreams, mistakes, accidents and symptoms, dreams, mistakes, accidents and emotionsemotions

Id, Ego and SuperegoId, Ego and Superego

Unconscious derived fromUnconscious derived from

-- innate drivesinnate drives

-- repressed materialrepressed material

Defies time and logicDefies time and logic

Not constrained by realityNot constrained by reality

Psychic energyPsychic energy

Mind fuelled by psychic energy (libido) derived Mind fuelled by psychic energy (libido) derived from the life preserving drives.from the life preserving drives.Later added life-destroying drives. Psychic Later added life-destroying drives. Psychic energy can never be created or destroyed but energy can never be created or destroyed but only changed in form. Severe psychological only changed in form. Severe psychological disorders e.g. anxiety, depression, result from disorders e.g. anxiety, depression, result from blocking of sexual energy.blocking of sexual energy.

RepressionRepression

Conscious or unconscious avoidance of painful Conscious or unconscious avoidance of painful or unwanted information.or unwanted information.Early work with Breuer - anxiety = consequence Early work with Breuer - anxiety = consequence of repressed energyof repressed energyLater proposed anxiety = a warning state of the Later proposed anxiety = a warning state of the ego that signals necessity for repression to ego that signals necessity for repression to defend the ego from internal danger arising from defend the ego from internal danger arising from forbidden impulses and wishes.forbidden impulses and wishes.Extended to include reaction formation, Extended to include reaction formation, sublimation and projection.sublimation and projection.

TransferenceTransference

Feelings of patient for therapist. Feelings of patient for therapist.

Initially seen as a nuisance, but later Initially seen as a nuisance, but later encouraged as a re-enactment of earlier encouraged as a re-enactment of earlier significant relationships.significant relationships.

Exploration of transference used as therapeutic Exploration of transference used as therapeutic tool.tool.

Counter transference = reactions of therapist to Counter transference = reactions of therapist to patient.patient.

Developmental stagesDevelopmental stages

OralOralAnalAnalPhallicPhallicLatencyLatencyGenitalGenital

Fixation can occur at any stage of Fixation can occur at any stage of development and is apparent as personality development and is apparent as personality traits or revealed at times of stress.traits or revealed at times of stress.Extended by Erikson (1963).Extended by Erikson (1963).

Mary - BackgroundMary - Background

50 year Irish Catholic Caucasian woman50 year Irish Catholic Caucasian womanLives with husbandLives with husbandMother of 3 adult childrenMother of 3 adult childrenNever worked outside homeNever worked outside homeSignificantly overweightSignificantly overweightFollowing death of father from a cardiac arrest Following death of father from a cardiac arrest

when she was 5 she was raised by a single when she was 5 she was raised by a single mothermother

Mother suffered from panic attacks.Mother suffered from panic attacks.Mother was eldest of 2 children having a brother 2 Mother was eldest of 2 children having a brother 2

years her junioryears her junior

Mary –Presenting ProblemMary –Presenting Problem

Frequent and severe panic attacks involving Frequent and severe panic attacks involving symptoms of rapid breathing, trembling, symptoms of rapid breathing, trembling, faintness and intense fearfaintness and intense fear

Episodes only occur outside her homeEpisodes only occur outside her homeFears she will die of a heart attackFears she will die of a heart attackSymptoms have confined her to home and othe Symptoms have confined her to home and othe

‘safe’ locations, such as church and her ‘safe’ locations, such as church and her daughter’s housedaughter’s house

Expressing marital conflict, centreing round her Expressing marital conflict, centreing round her perceived inability to work despite a recent perceived inability to work despite a recent financial setback in the home. financial setback in the home.

TechniquesTechniques

Free associationFree association InsightInsight Working throughWorking through Dream analysisDream analysis Analysis of transferenceAnalysis of transference

Mary - TechniquesMary - Techniques Free associationFree association

Mary encouraged to say whatever is on her mind no matter how silly or Mary encouraged to say whatever is on her mind no matter how silly or embarrassingembarrassing

InsightInsightMary learns she really hates her mother and her panic is partially a guilt Mary learns she really hates her mother and her panic is partially a guilt

reaction to her wish that her mother had died when she experienced reaction to her wish that her mother had died when she experienced episodes of panicepisodes of panic

Working throughWorking throughLearns to accept and cope with her insight concerning the hate she Learns to accept and cope with her insight concerning the hate she

experienced towards her motherexperienced towards her mother Dream analysisDream analysis

Reports dream that came to therapy session and the therapist was not Reports dream that came to therapy session and the therapist was not there to see her. In discussing dream reports fears of being there to see her. In discussing dream reports fears of being abandoned by her therapist as well as other important figures in her abandoned by her therapist as well as other important figures in her lifelife

Analysis of transferenceAnalysis of transferenceMary’s feelings of love and longing for her father are projected on to her Mary’s feelings of love and longing for her father are projected on to her

male therapistmale therapist

Ego Defense MechanismsEgo Defense Mechanisms

1)1) RepressionRepression2)2) DenialDenial3)3) Reaction formationReaction formation4)4) ProjectionProjection5)5) SublimationSublimation6)6) DisplacementDisplacement

Mary - Ego Defense MechanismsMary - Ego Defense Mechanisms

RepressionRepressionHate of her mother is so anxiety and guilt provoking that she does not allow Hate of her mother is so anxiety and guilt provoking that she does not allow these to become conscious, keeping them repressed in her unconscious these to become conscious, keeping them repressed in her unconscious DenialDenialDenies having hateful feelings towards her motherDenies having hateful feelings towards her motherReaction formationReaction formationHateful feelings are so powerful that she behaves in a very loving way. She Hateful feelings are so powerful that she behaves in a very loving way. She expresses a great deal of affection and has difficulty not being in close expresses a great deal of affection and has difficulty not being in close contact with hercontact with herProjectionProjectionDislike of mother is projected onto female therapist who she feels is cold, Dislike of mother is projected onto female therapist who she feels is cold, aloof and uncaringaloof and uncaringSublimationSublimationHate of mother has led her to channel her feelings into charities which Hate of mother has led her to channel her feelings into charities which prevent child abuseprevent child abuseDisplacementDisplacementHate toward mother cannot be channelled to her for fear of retaliation along Hate toward mother cannot be channelled to her for fear of retaliation along with anxiety and guilt. Instead she becomes very irritable and critical of her with anxiety and guilt. Instead she becomes very irritable and critical of her husband for no apparent reasonhusband for no apparent reason

NeofreudiansNeofreudians

Jung - 1875 - 1965 rejected emphasis Jung - 1875 - 1965 rejected emphasis on sexualityon sexuality

Erikson - 1909 - 1993 lifespan Erikson - 1909 - 1993 lifespan developmentdevelopment

Adler - 1870 - 1937 compensation for Adler - 1870 - 1937 compensation for feelings of inferiority = importantfeelings of inferiority = important

Contemporary ApproachesContemporary Approaches

Kleinke 1994 - Therapeutic goalsKleinke 1994 - Therapeutic goals

overcoming demoralisation and aging overcoming demoralisation and aging hopehope

enhancing mastery and self-efficiencyenhancing mastery and self-efficiencyovercoming avoidanceovercoming avoidancebecoming aware of one’s becoming aware of one’s misconceptionsmisconceptionsaccepting life’s realitiesaccepting life’s realitiesachieving insightachieving insight

DepressionDepression

DevelopsDevelops

Experience disappointment e.g. loss of Experience disappointment e.g. loss of loved oneloved oneLoved one cannot be abandoned and Loved one cannot be abandoned and affection transferred to someone elseaffection transferred to someone elsePerson identifies with the other and Person identifies with the other and internalises him/herinternalises him/herAttacks on self are seen as attacks Attacks on self are seen as attacks against loss or disappointing personagainst loss or disappointing person

Key FeaturesKey Features

Depressed individuals have difficulty giving up Depressed individuals have difficulty giving up what they have lostwhat they have lostRepressed hostilityRepressed hostilityInner conflictInner conflict

Depression = emotional expression of a state of Depression = emotional expression of a state of powerlessness of the self to achieve and live up powerlessness of the self to achieve and live up to strongly held wishes.to strongly held wishes.

AnxietyAnxiety

Anxious feelings arise from internal Anxious feelings arise from internal conflicts or impulses of which conflicts or impulses of which individual is not aware. Early loss individual is not aware. Early loss or separation may lead to anxiety in or separation may lead to anxiety in adult.adult.

Aim to trace feelings back to origins Aim to trace feelings back to origins in childhood by making in childhood by making interpretation.interpretation.

OCDOCD

Linked to anal-sadistic stage of developmentLinked to anal-sadistic stage of development

Toilet training = importantToilet training = important

Association = anger and aggressionAssociation = anger and aggression

Those who do not successfully negotiate this Those who do not successfully negotiate this stage of development = vulnerable to OCDstage of development = vulnerable to OCD

Humanistic ApproachesHumanistic ApproachesKey = self actualizingKey = self actualizing

Carl Rogers (1902-1987) Person centred Carl Rogers (1902-1987) Person centred therapytherapy

TherapistTherapist

-- passive rolepassive role

-- few interpretationsfew interpretations

-- give individual chance to developgive individual chance to develop

Unconditional positive regard. EmpathyUnconditional positive regard. Empathy

Relationships = single most positive Relationships = single most positive influence in facilitating human growthinfluence in facilitating human growth

Interpersonal TherapyInterpersonal TherapyKlerman et al 1994 Klerman et al 1994 IPT for depression based on model of IPT for depression based on model of Sullivan. Brief, time limited, individual therapy.Sullivan. Brief, time limited, individual therapy.

Therapists use:Therapists use:

Non-directive explorationNon-directive explorationencourage expression of affectencourage expression of affectteach more effective interpersonal teach more effective interpersonal communicationcommunicationalter behaviours through insight, information alter behaviours through insight, information and role playand role play

EvaluationEvaluation

Smith & Glass 1977 375 studiesSmith & Glass 1977 375 studies

Meta-analysis and effect-sizeMeta-analysis and effect-sizeTreated patients did better than untreatedTreated patients did better than untreatedNo difference between types of psychotherapy No difference between types of psychotherapy e.g. behavioural vs psychodynamice.g. behavioural vs psychodynamic

Follow up analyses support finding that treatment helps.Follow up analyses support finding that treatment helps.Psychodynamic vs cognitive behavioural treatmentsPsychodynamic vs cognitive behavioural treatments

use treatment manuals/protocolsuse treatment manuals/protocolstherapist confined to specific approachtherapist confined to specific approach

Norcross et al 1995Norcross et al 1995

Different types of therapy - Different types of therapy - different effectsdifferent effects

General cognitive/behavioural - General cognitive/behavioural - more positive outcomes than more positive outcomes than psychodynamic or verbal psychodynamic or verbal treatment orientationstreatment orientations

NIMH study - Depression NIMH study - Depression Elkin et al 1989Elkin et al 1989

Cognitive BehaviouralCognitive BehaviouralInterpersonal - psychodynamic and Interpersonal - psychodynamic and humanistichumanisticMedicationMedicationDrug placeboDrug placebo

– 250 patients250 patients– All treatments All treatments improvement improvement– Minimal differences between CBT and Minimal differences between CBT and

interpersonal therapyinterpersonal therapy– No one approach better for all disorders but No one approach better for all disorders but

differences according to specific problemsdifferences according to specific problems– Insight oriented dynamic therapy appropriate for Insight oriented dynamic therapy appropriate for

depression and mental discorddepression and mental discord

Frank et al 1990Frank et al 1990

Maintenance of gains following Maintenance of gains following medicationmedication

Monthly IPT vs Monthly IPT + Monthly IPT vs Monthly IPT + medication vs IPT + placebo vs placebo medication vs IPT + placebo vs placebo alonealone

Relapse rate lowest in IPT+ medicationRelapse rate lowest in IPT+ medication

Monthly IPT patients stayed well twice Monthly IPT patients stayed well twice as long as placeboas long as placebo

Factors associated with positive Factors associated with positive outcomeoutcome

Weinberger 1995Weinberger 1995

-- therapeutic relationshiptherapeutic relationship

-- expectation of successexpectation of success

-- providing experience of mastery or control providing experience of mastery or control over over problemproblem

-- confronting a problemconfronting a problem

-- an attribution of success or failurean attribution of success or failure

Change is difficultChange is difficult

Behaviour and thinking patterns = Behaviour and thinking patterns = difficult to changedifficult to change

Proshcaska 1984 - process of changeProshcaska 1984 - process of change

-- 5 stages5 stages

-- 5 levels5 levels

-- 10 processes10 processes

Poor OutcomePoor OutcomeCharacteristics of patientCharacteristics of patient

-Little motivation for change-Little motivation for change-Low tolerance of anxiety-Low tolerance of anxiety-History of inability to maintain satisfying -History of inability to maintain satisfying interpersonal relationshipsinterpersonal relationships

Characteristics of therapistCharacteristics of therapist-Lack of empathy-Lack of empathy-Impatient-Impatient-Authoritarian-Authoritarian

Interaction or fit between patient and therapistInteraction or fit between patient and therapist