clinical psychology

1. PSYCHOANALYTICPSYCHOANALYTIC
ALTERNATIVESALTERNATIVES
Lecture 30Lecture 30

2.  Psychoanalytic theory underwent considerablePsychoanalytic theory underwent considerable
modification by the neo-Freudians, Alfred Adler,modification by the neo-Freudians, Alfred Adler,
Carl Jung, Otto Rank, the ego analysts andCarl Jung, Otto Rank, the ego analysts and
others.others.
 The seminal contributions of Freud remained,The seminal contributions of Freud remained,
but the emphases often changed.but the emphases often changed.
 Jung made much more of dreams and symbolicJung made much more of dreams and symbolic
processes.processes.
 Rank elevated the birth trauma to a pre-Rank elevated the birth trauma to a pre-
eminent positioneminent position

3.  Adler and the neo-Freudians stressed theAdler and the neo-Freudians stressed the
importance of culture, learning, and socialimportance of culture, learning, and social
relationships instead of instinctual forces.relationships instead of instinctual forces.
 These changes often did little to alter the criticalThese changes often did little to alter the critical
roles of free association, dream analysis,roles of free association, dream analysis,
interpretation, transference, and resistance.interpretation, transference, and resistance.
 The supreme role of insight was little changed.The supreme role of insight was little changed.
 In most of these early variants ofIn most of these early variants of
psychoanalysis, interpretation remained thepsychoanalysis, interpretation remained the
essential therapeutic ingredient.essential therapeutic ingredient.

4.  Those who no longer practice the strict FreudianThose who no longer practice the strict Freudian
techniques are often said to be practicingtechniques are often said to be practicing
"psychoanalytically oriented" therapy."psychoanalytically oriented" therapy.
These changes involve many factors.These changes involve many factors.
 Duration of the therapy.Duration of the therapy.
 The location of the therapist.The location of the therapist.
 Although basic Freudian tenets are still observed, theAlthough basic Freudian tenets are still observed, the
over all context is not so rigid.over all context is not so rigid.
 For many years, the therapy room was like an innerFor many years, the therapy room was like an inner
sanctum. Now, family members or a spouse are oftensanctum. Now, family members or a spouse are often
consulted, or sometimes therapy is conducted with theconsulted, or sometimes therapy is conducted with the
family as a unit.family as a unit.

5.  There tends to be much less emphasis on theThere tends to be much less emphasis on the
past (childhood) and a more activepast (childhood) and a more active
confrontation with the present.confrontation with the present.
 Clinics or institutes now provide someClinics or institutes now provide some
therapeutic services to aging clients, minoritytherapeutic services to aging clients, minority
group clients, and others who have notgroup clients, and others who have not
traditionally received psychoanalytic treatment.traditionally received psychoanalytic treatment.
 It is a demonstration that traditional FreudianIt is a demonstration that traditional Freudian
treatments procedures are not the onlytreatments procedures are not the only
therapeutic techniques that can be deducedtherapeutic techniques that can be deduced
from Freudian psychoanalytic theory.from Freudian psychoanalytic theory.

6. EGO ANALYSISEGO ANALYSIS
 TheThe egoego analysis movement originating fromanalysis movement originating from
within the framework of traditionalwithin the framework of traditional
psychoanalysis.psychoanalysis.
 This group of theorists accepted the role of theThis group of theorists accepted the role of the
ego in mediating the conflict between the id andego in mediating the conflict between the id and
the real world but believed that the ego alsothe real world but believed that the ego also
performed other extremely important functions.performed other extremely important functions.
 In a sense, the ego analysts seem to preferIn a sense, the ego analysts seem to prefer
reeducative goals rather than the reconstructivereeducative goals rather than the reconstructive
goals of orthodox psychoanalysis.goals of orthodox psychoanalysis.

7.  Ego analytic therapy focuses more on contemporaryEgo analytic therapy focuses more on contemporary
problems in living than on a massive examination andproblems in living than on a massive examination and
reinstatement of the past.reinstatement of the past.
 Also, the therapist must understand not only theAlso, the therapist must understand not only the
neurotic aspects of the patient's personality but alsoneurotic aspects of the patient's personality but also
the effective parts and how they interact with thosethe effective parts and how they interact with those
neurotic trends.neurotic trends.
 The ego-analytic approach has also tended toThe ego-analytic approach has also tended to
emphasize the importance of building the patient'semphasize the importance of building the patient's
trust through "reparenting" in the therapy relationship.trust through "reparenting" in the therapy relationship.
 This approach sometimes even views transference asThis approach sometimes even views transference as
an impediment to therapy and works toward buildingan impediment to therapy and works toward building
adaptive defenses in the patientadaptive defenses in the patient

8. OTHER CONTEMPORARYOTHER CONTEMPORARY
DEVELOPMENTSDEVELOPMENTS
 In particular, the work of Horney, Sullivan, and AdlerIn particular, the work of Horney, Sullivan, and Adler
has been important in giving a new spin tohas been important in giving a new spin to
psychoanalysis.psychoanalysis.
 Likewise, ego psychology and theories of objectLikewise, ego psychology and theories of object
relations have encouraged an emphasis on therelations have encouraged an emphasis on the
manner in which the patient relates to other people,manner in which the patient relates to other people,
rather than on conflicts among, instinctual forces.rather than on conflicts among, instinctual forces.
 These theorists focus more on the role of love andThese theorists focus more on the role of love and
hate, as well ashate, as well as auautonomy and dependency, in thetonomy and dependency, in the
development of the self.development of the self.
 In the self psychology of Kohut (1977), the central taskIn the self psychology of Kohut (1977), the central task
of maturation is not the successful negotiation of theof maturation is not the successful negotiation of the
psychosexual stages but the development of anpsychosexual stages but the development of an
integrated self.integrated self.

9.  Discussions of changes in psychoanalyticDiscussions of changes in psychoanalytic
therapies emphasize a shift in the therapeutictherapies emphasize a shift in the therapeutic
focus to the "here and now" and to thefocus to the "here and now" and to the
interpersonal exchanges that occur within it.interpersonal exchanges that occur within it.
 Strupp and Binder emphasize a movementStrupp and Binder emphasize a movement
away from the recovery of childhood memoriesaway from the recovery of childhood memories
and their analysis toward a focus on theand their analysis toward a focus on the
corrective emotional experiences that occurcorrective emotional experiences that occur
throughthrough thethe agency of the therapeuticagency of the therapeutic
relationship.relationship.

10.  BREIF PSYCHODYNAMIC PSYCHOTHERAPYBREIF PSYCHODYNAMIC PSYCHOTHERAPY
 Perhaps the chief practical thrust of recent yearsPerhaps the chief practical thrust of recent years
in psychodynamic therapy has been thein psychodynamic therapy has been the
development of brief methods.development of brief methods.
 Many of these brief therapies retain theirMany of these brief therapies retain their
psychodynamic identity even as they arepsychodynamic identity even as they are
employed in emergency, crisis-orientedemployed in emergency, crisis-oriented
situations.situations.
 Although it would be nice to believe that theoryAlthough it would be nice to believe that theory
and/or research considerations have dictated theand/or research considerations have dictated the
shift toward briefer psychotherapies, this is notshift toward briefer psychotherapies, this is not
entirely the case.entirely the case.

11.  An important driving force has been the increasingAn important driving force has been the increasing
focus on cost containment in health care systems.focus on cost containment in health care systems.
 Cost containment has also provided indirectCost containment has also provided indirect
competition from psychiatrists, who frequentlycompetition from psychiatrists, who frequently
prescribe medications rather than psychotherapy.prescribe medications rather than psychotherapy.
 There are now several hundred different brands ofThere are now several hundred different brands of
brief therapy.brief therapy.
 Not all of these briefer therapies could be labeledNot all of these briefer therapies could be labeled
psychodynamic. Many forms of brief psychotherapypsychodynamic. Many forms of brief psychotherapy
are quite eclectic in their approachare quite eclectic in their approach

12.  Although some define 25 sessions as the upperAlthough some define 25 sessions as the upper
limit of brief therapy others indicate that thelimit of brief therapy others indicate that the
range can be from onrange can be from onee session to 40 or 50 .session to 40 or 50 .
 Events move rapidly in crisis-oriented therapy.Events move rapidly in crisis-oriented therapy.
 The ultimate goal is not reconstruction of theThe ultimate goal is not reconstruction of the
personality, but the development of a benignpersonality, but the development of a benign
cycle of functioning and the better handling ofcycle of functioning and the better handling of
day to day problems in living.day to day problems in living.
 Transference is encouraged, but mainly as aTransference is encouraged, but mainly as a
means of ensuring that the therapist will bemeans of ensuring that the therapist will be
perceived as helpful, competent, and active.perceived as helpful, competent, and active.

13.  The level of therapist activity is high, and bothThe level of therapist activity is high, and both
therapist and patient are keenly aware of the elementtherapist and patient are keenly aware of the element
of time.of time.
 The therapist is likely to use homework assignmentsThe therapist is likely to use homework assignments
for the patient and to involve relatives or significantfor the patient and to involve relatives or significant
others in the treatment plan.others in the treatment plan.
 Supportive activities outside therapy are likely to beSupportive activities outside therapy are likely to be
used.used.
 Research evidence attests to the efficacy of briefResearch evidence attests to the efficacy of brief
forms of psychotherapy across a number of clinicalforms of psychotherapy across a number of clinical
conditions.conditions.

14.  Two recent Meta analyses are noteworthy.Two recent Meta analyses are noteworthy.
 Svartberg and Stile (1991) found that briefSvartberg and Stile (1991) found that brief
psychodynamic psychotherapy was su-perior to nopsychodynamic psychotherapy was su-perior to no
treatment.treatment.
 Crits-Christoph (1992) also examined the effects ofCrits-Christoph (1992) also examined the effects of
brief psychodynamic psychotherapy.brief psychodynamic psychotherapy.
 Crits-Christoph (1992) found that brief psychodynamicCrits-Christoph (1992) found that brief psychodynamic
psychotherapy was clearly superior to no treatmentpsychotherapy was clearly superior to no treatment
and, in contrast to Svartberg and Stiles (1991) thatand, in contrast to Svartberg and Stiles (1991) that
brief psychodynamic psychotherapy wasbrief psychodynamic psychotherapy was
approximately equivalent in its effects to activeapproximately equivalent in its effects to active
psychological treatments.psychological treatments.

15. INTERPERSONAL PSYCHOTHERAPYINTERPERSONAL PSYCHOTHERAPY
AN EMPIRICALLY SUPPORTED TREATMENTAN EMPIRICALLY SUPPORTED TREATMENT
 Interpersonal psychotherapy or IPTInterpersonal psychotherapy or IPT is a briefis a brief
insight oriented approach that has been appliedinsight oriented approach that has been applied
primarily to depressive disorders although itprimarily to depressive disorders although it
has been modified for use in the treatment ofhas been modified for use in the treatment of
other disorders (such as substance abuse andother disorders (such as substance abuse and
bulimia) as well.bulimia) as well.
 IPT has been shown to be effective in treatingIPT has been shown to be effective in treating
acute depressive episodes and in preventing oracute depressive episodes and in preventing or
delaying the recurrence of de-pressivedelaying the recurrence of de-pressive
episodes.episodes.

16. Features Of Interpersonal PsychotherapyFeatures Of Interpersonal Psychotherapy
 FOCUS:FOCUS: IPT focuses on the connection between onsetIPT focuses on the connection between onset
of clinical problems and current interpersonal problems.of clinical problems and current interpersonal problems.
 LENGTHLENGTH:: Typically 12-16 weeks.Typically 12-16 weeks.
 ROLE OF THE IPT THERAPIST:ROLE OF THE IPT THERAPIST:
 IPT therapists are active, facilitator, and supportive.IPT therapists are active, facilitator, and supportive.
 They use realism and optimism to counter patients'They use realism and optimism to counter patients'
typically negative and pessimistic outlook. Therapiststypically negative and pessimistic outlook. Therapists
emphasize the possibility for change and highlightemphasize the possibility for change and highlight
options that may effect positive changeoptions that may effect positive change

17. Phases Of TreatmentPhases Of Treatment
 First phase (upFirst phase (up to 3 sessions):to 3 sessions): This includesThis includes
a diagnostic evaluation and psychiatric history,a diagnostic evaluation and psychiatric history,
an interpersonal functioning assessment, andan interpersonal functioning assessment, and
patient education about the nature of thepatient education about the nature of the
clinical condition (such as depression).clinical condition (such as depression).
 Second phaseSecond phase:: Depending on whichDepending on which
interpersonal problem area has been chosen.interpersonal problem area has been chosen.
 Third phaseThird phase (last 2-3 sessions):(last 2-3 sessions): The patient'sThe patient's
progress and mastery experiences areprogress and mastery experiences are
reinforced and consolidated.reinforced and consolidated.

18. Evaluation: does psychodynamicEvaluation: does psychodynamic
psychotherapy works?psychotherapy works?
 We know the widely known meta-analytic studyWe know the widely known meta-analytic study
by Smith, Glass, and Miller (1980) thatby Smith, Glass, and Miller (1980) that
examined the effectiveness of psychotherapy.examined the effectiveness of psychotherapy.
 In addition to examining the effects ofIn addition to examining the effects of
psychotherapy in general, these authors alsopsychotherapy in general, these authors also
reported effects separately for different types ofreported effects separately for different types of
psychological intervention.psychological intervention.

19.  They found that the aver-age patient who hadThey found that the aver-age patient who had
received psychodynamic psychotherapy wasreceived psychodynamic psychotherapy was
functioning better than 75%, of those who hadfunctioning better than 75%, of those who had
received no treatment.received no treatment.
 Conflicting results--- one supporting the efficacyConflicting results--- one supporting the efficacy
of briefof brief psychodypsychodynamic treatment but the othernamic treatment but the other
not .not .
 There appears to be at least modest support forThere appears to be at least modest support for
the effectiveness of psychodynamicthe effectiveness of psychodynamic
psychotherapy.psychotherapy.

20. INTERPRETATION AND INSIGHTINTERPRETATION AND INSIGHT
 A wide range of current psychotherapies depend to aA wide range of current psychotherapies depend to a
greater or lesser extent on the patient's achievinggreater or lesser extent on the patient's achieving
insight through therapist interpretation.insight through therapist interpretation.
 When understanding is complete enough, it isWhen understanding is complete enough, it is
believed that the patients' symptoms will bebelieved that the patients' symptoms will be
ameliorated, or even disappear entirely.ameliorated, or even disappear entirely.
 This emphasis on the pursuit of understanding hasThis emphasis on the pursuit of understanding has
great appeal to many people.great appeal to many people.
 The commitment of psychoanalysis and itsThe commitment of psychoanalysis and its
psychotherapeutic heirs to insight and understandingpsychotherapeutic heirs to insight and understanding
is their greatest asset, but it also contains the seeds ofis their greatest asset, but it also contains the seeds of
their failurestheir failures

21.  Although one can hardly fault psychoanalysis forAlthough one can hardly fault psychoanalysis for
teaching the importance of the past in shaping theteaching the importance of the past in shaping the
present, there can be too much of a good thing.present, there can be too much of a good thing.
 The endless analysis of conflicts and motives and ofThe endless analysis of conflicts and motives and of
their childhood origins can easily replace the need totheir childhood origins can easily replace the need to
find solutions and behavioral alternatives to problemsfind solutions and behavioral alternatives to problems
in living.in living.
 The failure to emphasize alternative ways of behavingThe failure to emphasize alternative ways of behaving
can be a major short-coming of traditionalcan be a major short-coming of traditional
psychoanalysis.psychoanalysis.
 Psychoanalysis often appears to involve a tacitPsychoanalysis often appears to involve a tacit
assumption that more adaptive behavior will occurassumption that more adaptive behavior will occur
automatically once insight is achieved by the workingautomatically once insight is achieved by the working
through process that behavioral change will surelythrough process that behavioral change will surely
follow insight.follow insight.

22.  One of the chief methods used by psychodynamicOne of the chief methods used by psychodynamic
clinicians to facilitate patient insight is theclinicians to facilitate patient insight is the
interpretation of transference.interpretation of transference.
(W. P. Henry et al., 1994) offer the following general(W. P. Henry et al., 1994) offer the following general
conclusions:conclusions:
1. The frequency of interpretations made is not related to1. The frequency of interpretations made is not related to
better outcome. Indeed, some studies have found thatbetter outcome. Indeed, some studies have found that
a higher frequency of interpretation is related to poorera higher frequency of interpretation is related to poorer
outcome.outcome.
2. Transference interpretations do not result in a greater2. Transference interpretations do not result in a greater
degree of affective experience in the patient asdegree of affective experience in the patient as
compared with other types of interpretations or othercompared with other types of interpretations or other
types of interventions.types of interventions.

23. 3. Interpretations by the therapist are more likely3. Interpretations by the therapist are more likely
to result in defensive responding on the part ofto result in defensive responding on the part of
the patient than are other types ofthe patient than are other types of
interventions. Frequent transferenceinterventions. Frequent transference
interpretations may damage the therapeuticinterpretations may damage the therapeutic
relationship.relationship.
4. Clinicians' accuracy of interpretations may be4. Clinicians' accuracy of interpretations may be
lower than was previously believed.lower than was previously believed.
Transference interpretations do not seemTransference interpretations do not seem
uniquely effective, may pose greater processuniquely effective, may pose greater process
risks, and may be counter therapeutic underrisks, and may be counter therapeutic under

24. CURATIVE FACTORSCURATIVE FACTORS
 The empirical evidence points to the, strength of theThe empirical evidence points to the, strength of the
therapeutic alliance.therapeutic alliance.
 It is interesting to note that the importance of theIt is interesting to note that the importance of the
clinician-patient relationship was recognized by Freud.clinician-patient relationship was recognized by Freud.
 This term is generally used to refer to the patient'sThis term is generally used to refer to the patient's
affective bond to the therapist.affective bond to the therapist.
 Presumably, a strong therapeutic alliance makes itPresumably, a strong therapeutic alliance makes it
less likely that a patient will react defensively toless likely that a patient will react defensively to
interpretations by the clinician.interpretations by the clinician.
 Research evidence suggests a direct link betweenResearch evidence suggests a direct link between
alliance and outcomealliance and outcome

25. THE LACK OF EMPHASIS ON BEHAVIORTHE LACK OF EMPHASIS ON BEHAVIOR
 The stereotypic practitioner of psychoanalyticThe stereotypic practitioner of psychoanalytic
psychotherapy plays a relatively passive role exceptpsychotherapy plays a relatively passive role except
for interpretation.for interpretation.
 The failure to deal with behavior to make suggestionsThe failure to deal with behavior to make suggestions
or to adopt a generally more activist posture wouldor to adopt a generally more activist posture would
seem to prolong psychotherapy unnecessarily.seem to prolong psychotherapy unnecessarily.
 An active therapist who not only providesAn active therapist who not only provides
interpretations that will lead to insight but also guidesinterpretations that will lead to insight but also guides
the patient into new learning situations seems morethe patient into new learning situations seems more
likely to achieve lasting solutions to the patient'slikely to achieve lasting solutions to the patient's
problems than does a therapist who relies solely onproblems than does a therapist who relies solely on
insight.insight.

26.  It seems clear that a major reason for the rapidIt seems clear that a major reason for the rapid
rise of the behavioral therapies was the failurerise of the behavioral therapies was the failure
of so many psychotherapists to deal directlyof so many psychotherapists to deal directly
with the specific problems of the patient.with the specific problems of the patient.
 The approach inevitably seemed to be one ofThe approach inevitably seemed to be one of
relegating the presenting problem to the statusrelegating the presenting problem to the status
of a "symptom of something deeper."of a "symptom of something deeper."
 The therapist then began working with thatThe therapist then began working with that
"something deeper" while clinging to the"something deeper" while clinging to the
abiding belief that once the patient understoodabiding belief that once the patient understood
it, the symptom or deficit would disappear.it, the symptom or deficit would disappear.
Unfortunately, things did not work out that wayUnfortunately, things did not work out that way
often enough.often enough.

27. THE ECONOMICS OF PSYCHOTHERAPYTHE ECONOMICS OF PSYCHOTHERAPY
 By its very nature (reconstruction of theBy its very nature (reconstruction of the
personality), psychoanalysis is a long andpersonality), psychoanalysis is a long and
costly procedure.costly procedure.
 Consequently, it has become a therapy for theConsequently, it has become a therapy for the
affluent for those who have both the moneyaffluent for those who have both the money andand
the time to pursue the resolution of theirthe time to pursue the resolution of their
neuroses.neuroses.
 Moreover, the procedures of psycho­analysisMoreover, the procedures of psycho­analysis
are such that only relatively intelligent,are such that only relatively intelligent,
sophisticated, and educated groups are likely tosophisticated, and educated groups are likely to
bebe able to accept the therapeutic demands itable to accept the therapeutic demands it
makesmakes

28.  For all these reasons, only a small portionFor all these reasons, only a small portion ofof
those in need of psychotherapy are likely tothose in need of psychotherapy are likely to bebe
reached by traditional psychoanalysis.reached by traditional psychoanalysis.
 For these reasons alone, many regardFor these reasons alone, many regard
psychoanalysis as a failure.psychoanalysis as a failure.
 For persons who have the necessary personalFor persons who have the necessary personal
qualities and financial re­sources,qualities and financial re­sources,
psychoanalysis has been helpful, particu­larlypsychoanalysis has been helpful, particu­larly
for those whose problems can best be metfor those whose problems can best be met
through the development of understandingthrough the development of understanding

29.  Psychoanalytic techniques seem to havePsychoanalytic techniques seem to have
helped many patients, and as a theory ofhelped many patients, and as a theory of
therapy, psychoanalysis undergirds manytherapy, psychoanalysis undergirds many
forms of psychotherapy.forms of psychotherapy.
 Yet many clinicians still question whether, afterYet many clinicians still question whether, after
all these years, there is really much in the wayall these years, there is really much in the way
of definitive research evidence for itsof definitive research evidence for its
effectiveness.effectiveness.
 The case of 54.years old man.The case of 54.years old man.
 An example of women who developedAn example of women who developed
agoraphobia.agoraphobia.

30.  Admittedly, nearly every brand of therapy contains itsAdmittedly, nearly every brand of therapy contains its
share of horror stories.share of horror stories.
 It is encouraging, however, that brief forms ofIt is encouraging, however, that brief forms of
psychodynamic psychotherapy have been developedpsychodynamic psychotherapy have been developed
 Christoph’s (1992) meta­analysis indicates that briefChristoph’s (1992) meta­analysis indicates that brief
psychodynamic treatments that incorporate the use ofpsychodynamic treatments that incorporate the use of
manuals show stronger treatment effects.manuals show stronger treatment effects.
 In addition to providing encouragement to psychoIn addition to providing encouragement to psycho
dynamically oriented clinicians, this finding shoulddynamically oriented clinicians, this finding should
serve to impel them toward mastery and use ofserve to impel them toward mastery and use of
manual based, empirically supported briefmanual based, empirically supported brief
psychodynamic treatments, such as interpersonalpsychodynamic treatments, such as interpersonal
psychotherapypsychotherapy