8.1 Psychoanalysis and dynamic psychotherapy

Psychoanalysis and psychodynamic psychotherapy

Both rest on a model of unconscious conflict, rooted in early experience and held out of awareness by defences. Psychodynamic psychotherapy applies psychoanalytic ideas in less intensive treatment that focuses on recurring emotional and relationship patterns.

• Both use analytic listening, neutrality, abstinence, interpretation and working through, and most National Health Service (NHS) treatment in this tradition is psychodynamic psychotherapy.

• Free association, saying whatever comes to mind without censorship, replaced hypnosis and abreaction in Freud's method.

• The techniques of classical psychoanalysis serve the interpretation of unconscious material, and behavioural reinforcement is not one of them.

Freud's models of the mind

Topographical model

• The topographical model has three systems: the unconscious, the preconscious and the conscious.

• "Subconscious" is a lay term that Freud rejected, and it is not one of the systems.

• The preconscious is the censoring system that keeps repressed material out of awareness.

• The unconscious system works, like the id, by primary process thinking under the pleasure principle.

Structural model

The structural model frames symptoms and interpersonal difficulties as unconscious conflict between the id, ego and superego. These agencies are defined by their function, not by their access to awareness.

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• The pleasure principle is the drive towards immediate gratification and avoidance of unpleasure, regardless of reality or consequence.

• Secondary process thinking is the ego's reality-oriented mode, which can delay discharge of a drive and reason about consequences.

• Reality testing is the ego function that separates what arises in the mind from what exists in the outside world, holding id impulse and superego demand against real circumstances.

• Defence mechanisms are operations of the ego, not of the id or superego.

• The superego forms by identification with the parents as the Oedipus complex resolves, and its punitive judgement of the ego produces guilt and an expectation of punishment.

• The ego ideal is the aspirational part of the superego, first described in Freud's paper on narcissism, and failing it is felt as shame and inferiority rather than guilt.

Drives and development

Catharsis has two senses:

• In Freud and Breuer's early work, catharsis was the relief felt when a forgotten memory and its emotion became conscious and were expressed.

• On Freud's hydraulic view of aggression, catharsis is the release of built-up aggressive energy through its expression.

Dreams and other routes to the unconscious

• Manifest content is the dream as remembered, and latent content is the hidden unconscious wish from which the dream is built and which interpretation uncovers.

• The dream work is the whole unconscious process that turns latent dream thoughts into the manifest dream, and dream interpretation runs the other way.

• Condensation is the dream-work mechanism by which one manifest image fuses several latent thoughts, wishes or people.

• Free association leads from the manifest content of a dream to its latent content.

• A parapraxis is a slip of the tongue, pen, memory or action, which Freud read as an unconscious wish breaking through.

• Dreams, free association, transference, parapraxes and symptom symbolism are all routes to the unconscious, so no single technique is the only way in.

• A dream with disturbing content, such as harming a relative, is explored through the patient's associations, not acted on as a literal disclosure.

Defence mechanisms

Defences are unconscious ways of managing anxiety and conflict. They are ranked by maturity into four tiers, and their usefulness also depends on context.

• Isolation of affect, undoing and reaction formation are the neurotic defences that classical psychodynamic theory ties to obsessive-compulsive disorder, in Vaillant's hierarchy.

• Undoing is the symbolic cancelling of a forbidden thought by a later act.

• Reaction formation shows as conspicuously excessive gentleness in someone troubled by intrusive violent thoughts.

• Sublimation channels an unacceptable impulse, including anger or erotic transference, into a socially valued activity that gives it partial, modified satisfaction, as when a surgeon puts aggression into technical skill.

• Suppression is the conscious, deliberate setting aside of a worry, which stays retrievable.

• Repression unconsciously bars an internal wish or memory from awareness while its feeling may stay conscious, so a trauma survivor may recall nothing yet stay anxious.

• Denial is the unconscious refusal of an external fact, which survives repeated presentation of the evidence.

• Displacement redirects an emotion from its real, threatening object onto a safer substitute, and the person keeps and owns the feeling, like a man who is shouted at by his manager and snaps at his children.

• Projection attributes one's own unacceptable feeling to another person, who need not feel anything, like a man tempted to stray who accuses his partner of infidelity.

• Projective identification lodges a disowned feeling in another person, such as the therapist, who comes to feel it and may act it out.

• Splitting holds the same person or object as wholly good or wholly bad, never both, so a figure may swing from idealised to denigrated, as when a patient calls the same nurse wonderful, then cruel.

• Idealisation alone is an all-good view in which no one is devalued.

• Acting out expresses unconscious conflict in behaviour instead of words, like an adolescent who self-harms rather than saying what upset her.

Repression and denial are unconscious while suppression is conscious, and repression bars an internal wish whereas denial refuses an external fact. In projection the other person need not feel anything, but in projective identification they come to feel it.

Displacement moves a feeling onto a safer person, whereas turning against the self moves it onto the self.

Staff teams can mirror a patient's split, with some seeing only manipulation and others only illness, and reflecting on these shared reactions stops the team enacting them.

Klein

Klein's positions are patterns of anxiety, defence and relating that begin in the first year and recur throughout life, rather than stages left behind.

• Splitting with projective identification are the primitive defences of the paranoid-schizoid position, and give the psychoanalytic account of borderline personality disorder.

• Object relations theory holds that the basic human motive is to seek relationships, not to discharge drives, as in Fairbairn's revision of Freud.

Bion and Winnicott

• Containment (Bion) is the receiving of projected, unbearable feeling by another mind, such as the mother or therapist, which processes it and returns it in a bearable form.

• Winnicott's account of early relationships came from his work as a paediatrician.

Jung, Adler and the neo-Freudians

• Jung proposed a personal unconscious and an inherited collective unconscious, shared by all humans, whose contents are archetypes.

• Archetypes are the inborn, universal patterns of the collective unconscious in Jung's analytical psychology, such as the shadow and the persona.

• Anima and animus are Jung's unconscious contrasexual archetypes.

• Jung replaced Freud's sexual libido with a broader life energy, and called the lifelong integration of conscious and unconscious parts of the self individuation.

• Adler's individual psychology holds that striving for superiority, the effort to overcome felt inferiority, is the main motive of personality.

• The neo-Freudians revised Freud, keeping unconscious conflict but stressing social and interpersonal forces, and theorists from a separate school are not counted among them.

Transference and countertransference

• The therapeutic alliance is the collaborative working relationship between patient and therapist.

• Transference is the patient's largely unconscious redirection onto the therapist of feelings and expectations from significant past relationships, usually with parents.

• Transference may be positive or negative, and either can support exploration or become resistance.

• Transference grows stronger when the therapist is little known as a real person and contact is frequent and prolonged.

• In borderline personality disorder transference is most intense and changeable, swinging between idealisation and devaluation, because of unstable attachments, fear of abandonment and splitting.

• Ending or handing on the therapy when transference appears is unhelpful, because it stops exploration and can re-enact the rejection the patient expects.

• Countertransference is the therapist's own emotional reaction to the patient, coloured by the therapist's earlier relationships, and it shows as boredom, sleepiness, and missed or late sessions.

Transference runs from patient to therapist, and countertransference runs from therapist to patient.

• Concordant countertransference is identifying with the patient's experience, and complementary countertransference is identifying with someone in the patient's internal world.

• Enactment is acting countertransference out, and reflection in supervision separates the therapist's own reactions from information about the relationship.

Resistance and the negative therapeutic reaction

• Resistance is the patient's conscious or unconscious interference with the aims of treatment, such as intellectualising, joking, silence, changing the subject, lateness or missing sessions.

• Resistance is explored for its meaning, because it may protect against the anxiety beneath the presenting problem.

• A negative therapeutic reaction is a worsening of symptoms after an accurate interpretation, acknowledged progress or partial gain, which Freud linked to unconscious guilt and a need to go on suffering.

• Because the negative therapeutic reaction is a theoretical formulation, deterioration still calls for reassessment of risk, treatment effects and other causes.

Formulation and technique

• A dynamic formulation links current symptoms to unconscious conflict between a wish, a prohibition and the anxiety or guilt they produce, so symptoms both express and defend against the wish.

• A pattern repeated across family, partners, work and therapy explains the current difficulty and the transference.

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• Hypothesising is also a technique of Milan systemic therapy, in a different sense.

• Intellectual insight is recognising a pattern, whereas emotional insight is experiencing its significance in a way that changes behaviour.

Selecting patients

• Psychological mindedness is the capacity to understand difficulties in emotional and relational terms, and it predicts a good response, is separate from intelligence and shows as a reflective response to a trial interpretation.

• The patient's own motivation to change is the best predictor of a favourable outcome in psychodynamic therapy.

• Acute psychosis is a contraindication, because exploratory work needs intact reality testing, reflective capacity and tolerance of arousal, while personality, mood and anxiety disorders are indications.

• Repeated, uncontrolled acting out or self-harm discharges distress in action rather than reflection, and predicts relapse and a poor response.

• Antisocial personality disorder, concrete thinking, absent psychological mindedness, poor impulse control and low motivation count against psychoanalytic psychotherapy.

• Florid mania, severe substance dependence, active suicidality and marked vulnerability to regression call for caution, stabilisation or substantial adaptation, and supportive work may protect coping better.

• Longer treatment may suit pervasive relationship or personality difficulties.

Brief psychodynamic psychotherapy

• Brief therapy depends on a single, well-defined, agreed psychodynamic focus, and absence of self-harm is not the suitability criterion.

• It keeps the core tools of interpreting unconscious conflict and transference, applied selectively to one focus within a time-limited frame.

• It takes up the early positive transference, fed by hopes of rapid change, because interpretation starts sooner than in full psychoanalysis.

• Motivation and psychological mindedness favour brief work, while poor ego strength, social instability and unreliable attendance count against it.

• Malan's brief focal psychotherapy (the Tavistock model) fixes the termination date at the outset, with one circumscribed focus and early transference interpretation.

• Dynamic interpersonal therapy is a 16-session model focused on recurring interpersonal and emotional patterns, used in NHS Talking Therapies for depression.

• The National Institute for Health and Care Excellence includes short-term psychodynamic psychotherapy among treatments for depression, not only after another therapy has failed.

• Research evidence is stronger for brief, focal, manualised therapies than for open-ended psychoanalysis.

Borderline personality disorder

• Psychodynamically, borderline personality disorder is marked by primitive defences, chiefly splitting with projection, which keep contradictory images of self and others apart.

• These differ from the neurotic defences of obsessional, phobic and hysterical states.

• Otto Kernberg described borderline personality organisation: identity diffusion, primitive defences and preserved reality testing.

• Working from object relations theory, Kernberg developed transference-focused psychotherapy.