Clinical Applications of Psychoanalysis

• Psychoanalysis


  A theory, mode of investigation and treatment
• Psychoanalysis has been around for 120 years with frequent changes and development
• There are two main criticisms of Freud: not scientific (hard to test theories) and too scientific (materialist)
• Freud's practice

  • Developed out of hypnosis
  • Treating patients with Hysteria
  • Found that discussing trauma with appropriate emotional discharge reduced symptoms
  • 35 times a week
  • Length initially was short, then increased
  • Patient would lie on a couch with the analyst out of view - stop distraction
  • Free association
  • Aim was to look at Unconscious conflicts and defences against them
  • Giving the patient a sense of freedom and autonomy
• The Unconscious

  • Made up of drives, memories, emotions that are out of awareness
  • Dynamic – internally conflictual
  • No sense of space or time - can love and hate someone at the same time
• Defence mechanisms

  Responsible for keeping painful aspects of the Unconscious or external reality out of awareness
• Repression

  Initially saw repression as causing anxiety, later changed saw it as anxiety causes repression
• Early Experiences

  • Freud saw early childhood experiences as being key to adult development
  • Initially saw sexual trauma as the key factor in the development of Hysteria, later changed this but did not discount influence of trauma
  • Painful early experiences can be repressed but still affect behaviour
  • Repeating patterns of relationships
• Transference

  • Early relational patterns are played out in new relationships
  • Can be seen in everyday life
  • Plays out in the therapeutic relationship
  • Patient reacts to therapist based on past experiences
• Freud reflected on counter-transference, but saw it more as something that got in the way, rather than a tool in treatment
• Key features of psychoanalytic psychotherapy

  • Listen for recurring themes
  • Compulsion to repeat
  • Symptom based
  • Interpersonal
  • Reflexive thoughts
  • Verbal and non-verbal
  • Attachment and Development
• Affect

  • Contains emotions, feelings and mood
  • Emotions arise internally and are clusters of affect
  • Feelings are the conscious experience of emotion
  • Mood are longer lasting states of affect
• Awareness of Affect vs Expression of Affect

  • Defences can transform and disguise affect
  • Reaction Formation - feeling the opposite of what is going in
• Resistance, Avoidance and Defences

  • Due to the challenging nature of therapy resistances will emerge
  • These may reflect similar defences that emerge in real life
  • Defences that may have once been adaptive, become unsustainable
  • Important to look at what is not coming up in session
  • These can present behaviourally (E.g., coming late to session)
• Interpretation

  • The act of making sense of what is going on
  • Therapist as a professional and outsider in position to make sense of what's going on
  • Can be accurate without being useful (How can this be delivered without activating defences?)
  • More or less collaborative based on theoretical orientation
• Use of Transference and Countertransference

  • Displacement – 'I feel X about you, but really, I'm feeling X about someone else'
  • Projection - 'I don't feel X, you feel X'
  • Projective identification – 'I don't feel X, you feel X, and I'm going to make you believe you feel X'
  • Therapist uses countertransference to feel how others are interacted with by the patient
• Any mental phenomena is worth looking at in psychoanalytic psychotherapy, in contrast to other therapies that aim to be more prescriptive
• Mentalization-Based Therapy

  • Developed by Peter Fonagy and Anthony Bateman
  • Mentalisation is the ability to understand mental states
  • Mental states can be difficult to read
  • Lack of mentalising leads to problems
  • Developmental model - our parents help us understand our mental states as infants
  • Mentalising as central element of therapy
  • Mentalizing in the clinician encourages mentalizing in the patient
• Transference Focused Therapy

  • Based on the work of Otto Kernberg
  • Dominated by primitive defenses such as splitting and projective identification
  • Based on an object relations model
  • Internal images of self and others
  • Influenced by interactions between temperament, affect regulation, and environment
  • Transference is activated in session - activates internal images of self and others; work with conflicting transferences
  • Aim is identity integration
  • Therapeutic frame is contracted, safe, and contains affect
  • Explore and interpret contradictory self states