Overview• Freud’s aim in therapy• Freud’s method of therapy• Kleinian & Post-Kleinian therapy• Evaluating psychoanalytic therapy• Psychoanalytic therapy and cognitivebehaviour therapy (CBT)• Relational psychoanalysis• Mentalization-based therapy
Freud’s aim in therapyFreud (1895, SE2:305)Aims to transform the patient’s ‘hysterical misery into commonunhappiness’ so that they are ‘better armed against thatunhappiness’Freud (1914, SE12:145-56)Aims to help patients remember and work through, rather thanrepeat, the otherwise more or less unconscious cause of their illsCase examples(a)Hysteria (Dora, SE7)(b)Phobia (Little Hans, SE10)(c)Obsessional neurosis (the ‘rat man’, SE10)(d)Melancholia (SE14)
Freud’s method of therapyFreud (1912, SE12:111-20,115)Warns against the counter-transference – recommends ‘therapists, like surgeons, to adopt a stance ofemotional coldness’ in their work with patientsFreud (1913, SE12:121-44 in Gay 1995:363-78)Psychoanalytic treatment includes• Trial period• Time & money• Analyst sitting behind the patient lying on a couch• Fundamental rule of free association• Attention to the transference (negative & positive)• Timing of interpretations• Attention to the patient’s response to interpretationsFreud (1915-1917, SE16:448-63)Contrasts his method with ‘cosmetic cure’ provided by psychiatryFreud (1923, SE18:235-59,239)Recommends psychoanalysts to adopt an attitude of ‘evenly suspended attention’ so as ‘to catchthe drift of the patient’s unconscious with [their] own unconscious’.Freud (1937, SE:255-69)Emphasizes timing and testing interpretations in terms of what the patient subsequently says and does.BUT Livingstone Smith (Psychoanalysis in Focus 2003:34) objects that the patient’s response interpretationsmay be a suggestive effect of their positive transference to the psychoanalyst.
Kleinian & Post-Kleinian therapy• Focus on the here-and-now transference (see e.g. Strachey,IJPA, 1934/1969, 50:275-92)• Justification of this focus in terms of Isaacs’s (IJPA, 1952)Kleinian theory of ‘phantasy’• Post-Kleinian attention to the counter-transference (e.g.Heimann, IJPA, 1950, 31:81-4; Bion’s 1967 book, SecondThoughts)• See also• Hinshelwood (1989) A Dictionary of Kleinian Thought• Sayers (2007) Klein and Bion chapters in Freud’s Art
Evaluating psychoanalytic therapy(1) Eysenck (1952)• Eysenck (1952, J Consulting Psych, 16:319-24)• ‘Patients treated by means of psychoanalysis improve to the extentof 44%; patients treated eclectically improve to the extent of 64%;patients treated only custodially or by general practitioners improveto the extent of 72%. There thus appears to be an inversecorrelation between recovery and psychotherapy; the morepsychotherapy, the smaller the recovery rate.’• http://psychclassics.yorku.ca/Eysenck/psychotherapy.htm• Livingstone Smith (Psychoanalysis in Focus 2003:60-4)• criticises Eysenck‘s lack of control for• (1) criteria of recovery;• (2) therapist personality characteristics;• (3) therapist-patient fit;• (4) sufficient application of treatment method studied;• (5) external and internal reliability;• (6) averaging over positive together with negative effects
Evaluating psychoanalytic therapy(2) Leichsenring (2005)• Leichsenring (2005, IJPA 86:841-68)• Studies published between 1960 to 2004 with at least one randomised controltrial (RCT) provide evidence for the efficacy of psychodynamic psychotherapywith• depressive disorders (4 RCTs)• anxiety disorders (1 RCT)• post-traumatic stress disorder (1 RCT)• somatoform disorder (4 RCTs)• bulimia nervosa (3 RCTs)• anorexia nervosa (2 RCTs)• borderline personality disorder (2 RCTs)• Cluster C personality disorder (1 RCT)• substance-related disorders (4 RCTs)• Outcome of psychodynamic psychotherapy is related to the competent deliveryof therapeutic techniques and to the development of a therapeutic alliance.• Controlled quasi-experimental effectiveness studies provide evidence thatpsychoanalytic therapy is• (1) more effective than no treatment or treatment as usual, and• (2) more effective than shorter forms of psychodynamic therapy.
Psychoanalytic therapy andcognitive behaviour therapy (CBT)• Westbrook & Kirk (2005 Behaviour Research & Therapy 43:1243-61)• find 50% of sample treated with cognitive behaviour therapy (CBT) in routine clinical NHS practice improved• Depression Report (2006 http://cep.lse.ac.uk/research/mentalhealth )• find 1 in 6 people are diagnosable as having depression or chronic anxiety disorder. CBT provides a cost-effective treatment which is equally effective short term and more effective long term thanpsychopharmacological treatment. 50% more patients (than untreated controls) with 16 once weekly hour-long CBT sessions will have lost their psychiatric symptoms; those with anxiety are unlikely to relapse, thosewith depression & CBT are less likely to relapse than those with only psychopharmacological treatment.• Layard et al (2007 Nat. Inst. Economic Review 2002:908)• advocate increase in availability of CBT trained therapists as relatively cheap compared to the cost ofuntreated psychological disorders• Improving Access to Psychological Therapies (IAPT)• Programme launched in May 2007; favours CBT over other psychotherapies• Leader (2008, The New Black)• argues against antidepressants and CBT and in favour of treatment returning to Freud’s theory that whatneeds to be addressed in treating depression is enabling the patient to become conscious of its cause inunconsciouss loss• See also http://www.guardian.co.uk/science/2008/sep/09/psychology.humanbehaviour/print• J. Milton (2001) Psychoanalysis and cognitive behaviour therapy. IJPA, 81:431-47
Relational psychoanalysis• Ogden (1994, The analytic third, in Subjects of Analysis, BF704)• emphasizes psychoanalytic attention to the transference-countertransference relation of patient andpsychoanalyst in treatment as the analytic third• Aron (2006, IJPA, 87(2):349-88) argues• (a) attention to the counter-transference and the analytic third is useful in understanding andresolving clinical impasses and stalemates.• (b) certain forms of self-disclosure are best understood as attempts to create a third point ofreference, thus opening up psychic space for self-reflection and mentalization.• (c) that a clinical case example plus several briefer examples suggest modifications to thepsychoanalytic stance recommended by Freud so as to give the patient greater access to the innerworkings of the psychoanalysts mind.• (d) this introduces a third that facilitates the gradual transformation from relations ofcomplementarity to relations of mutuality.• Note: this shifts the aim of psychoanalysis from treating symptoms to facilitating the patientscapacity for thinking about and mentalizing feelings• Tublin (2011, Contemporary Psychoanalysis, 47(4):519-46)• criticizes relational psychoanalysis for• (a) lack of codification of its technical principles• (b) advocating a broad menu of sanctioned interventions and excessive freedom in thepsychoanalysts approach to treatment• (c) conflicting with the need for structure and discipline in conducting coherent and purposefulpsychoanalytic treatment.
Mentalization-based therapyFonagy & Bateman (1)• Fonagy & Bateman (2006, J Clin Psych, 62:411-30)• Note problematic early attachments in patients with borderlinepersonality disorder (BPD)• This causes BPD patients to be readily provoked by laterintimate relationships into decoupling their mind from that ofothers• This contributes to the following symptoms in BPD patients:• (1) rapid shift from first meeting to great intimacy• (2) lack of the usual barrier between self and other resulting inentangled relationships• (3) excessive idealization of the new intimate relationship• (4) unstable emotion, including violent outbursts &/orsuspiciousness• (5) lack of emotion-laden memories causing chronic feelingsof emptiness.
Mentalization-based therapyFonagy & Bateman (2)• Fonagy & Bateman (2006, J Clin Psych, 62:411-30)• recommend enhancing mentalization by activating the attachment system through• (1) discussing current attachment relationships• (2) discussing past attachment relationships• (3) encouraging and regulating the clients/patient’s attachment to the therapist by creatinga setting which helps them regulate their feelings• (4) engendering attachment links between clients/patients in group therapy• (5) gradually activating negative emotions through the therapist encouraging confrontationof adverse/traumatic experiences• (6) encouraging retrieval of emotion-laden episodic memories• (7) focusing on the client’s/patient’s mentalization about relationships that have relativelylow levels of involvement• (8) only gradually focusing on the client’s/patient’s thinking about relationships closer totheir core self• Note Mentalization-based therapy (MBT) is similar to transference-focusedpsychoanalysis in focusing on mental states in an attachment situation. Evidence thatattachment-related mentalization improves with transference-focused but not withsupportive therapy.• See also Sugarman (2006) Mentalization, insightfulness & therapeutic action, IJPA,87:965-87; and Mentalization entry on Wikipedia
Summary• Freud’s aim in therapy• Freud’s method of therapy• Kleinian & Post-Kleinian therapy• Evaluating psychoanalytic therapy• Psychoanalytic therapy and cognitivebehaviour therapy (CBT)• Relational psychoanalysis• Mentalization-based therapy
READJ. Shedler (2010) The efficacy of psychodynamic psychotherapy.American Psychologist, 65(2):98-109 (available on Moodle)WRITE DOWNOne essential ingredient, according to Shedler (2010), of effectivepsychoanalytic or non-psychoanalytic therapyESSAY TITLEEvaluate psychoanalytic approaches to therapy.Pre-Seminar Assignments
Shedler summarised• Shedler (2010) American Psychologist 65(2):98-109• Distinctive features of psychodynamic psychotherapy• Focus on feelings rather than cognitions• Attention to attempts to avoid upsetting feelings• Identification of recurring themes & patterns• Discussion of past experience (developmental focus)• Focus on interpersonal relations• Focus on the therapy relationship• Exploration of fantasy life• Findings re benefits of psychodynamic psychotherapy• Benefits increase with time while the benefits of non-psychodynamic therapies tend to decay for the mostcommon disorders• Benefits of psychodynamic psychotherapy with depression, anxiety, panic, somatoform, eating,substance-related, and personality disorders• Effective active ingredients in cognitive therapy (CBT) are the same as those emphasized inpsychodynamic psychotherapy i.e. unstructured, open-ended dialogue; identifying recurring themes in thepatient’s experience; linking the patient’s feelings and perceptions to past experiences; drawing attentionto feelings regarded by the patient as unacceptable (e.g. anger, envy, excitement); pointing out defensivemanoeuvres; interpreting warded-off or unconscious wishes, feelings, or ideas; focusing on the therapyrelationship; drawing connections between the therapy & other relationships.• Conclusion• Value of psychodynamic psychotherapy lies in fostering inner capacities enabling people to live life withgreater sense of freedom.
Group 1• Effective ingredients of therapy• Actively exploring avoidances e.g. being late for therapy sessions; cf Freud’s theory ofunconsciously intended forgetting; e.g. shifting the topic of conversation• Exploring patterns within the individual e.g. recurring dreams;• Talking about past experiences e.g. with early attachment figures as a way of moving onrather than sticking with blame of the past; BUT what about the argument againstpsychoanalysis (of e.g. Sartre) that we are morally responsible for the choices we make inthe present• Focus on feelings – this links up with attachment theory approaches to psychoanalyticpsychotherapy – other factors also affect the ability of people to reflect on their feelings –• Focus on inter-personal relationships – as means of relating the past and the present –and as means of assessing change as effect of therapy – unlike psychopharmacologicaltreatment• Problems and advantages of psychoanalytic therapy• Focus on the past might not be relevant to patients with e.g. PTSD, still birth victim,psychotic conditions (e.g. schizophrenia, manic-depressive psychosis)
Group 2• Effective ingredients in psychoanalytic and non-psychoanalytictherapy• Therapeutic alliance & the problem of the transference & counter-transference• Focus on feelings rather than on thoughts – and this makes therapyquite difficult at times• Identification of recurring themes and patterns in, for instance, thetransference• Long term follow up shows effectiveness of psychotherapy due,perhaps, to it helping them understand issues that come up for thepatient through teaching the patient to think psychologically abouthimself or herself• This is open to making mistakes about one’s psychology; or quick-fix psychological formulae; or it can make one over self-centred andintrospective• Read Janet Malcolm, Psychoanalysis: The Impossible Profession orread one of Darian Leader’s recent books