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Lynette Chan
Lynette Chan

1. Freud developed psychoanalytic therapy to transform patients' misery into common unhappiness by helping them work through unconscious causes of their issues using techniques like free association and interpretation of transference. 2. Klein and subsequent theorists focused on transference and countertransference in the here-and-now. 3. Recent approaches like mentalization therapy aim to enhance patients' ability to think about mental states in relationships to improve symptoms like those seen in borderline personality disorder.

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SP639 23 Therapy 28 March 2013
Overview Freuds aim in therapy Freuds method of therapy Kleinian & Post-Kleinian therapy Evaluating psychoanalytic therapy Psychoanalytic therapy and cognitive behaviour therapy (CBT) Relational psychoanalysis Mentalization-based therapy
Freuds aim in therapy Freud (1895, SE2:305) Aims to transform the patients hysterical misery into common unhappiness so that they are better armed against that unhappiness Freud (1914, SE12:145-56) Aims to help patients remember and work through, rather than repeat, the otherwise more or less unconscious cause of their ills Case examples (a)Hysteria (Dora, SE7) (b)Phobia (Little Hans, SE10) (c)Obsessional neurosis (the rat man, SE10) (d)Melancholia (SE14)
Freuds method of therapy Freud (1912, SE12:111-20,115) Warns against the counter-transference recommends therapists, like surgeons, to adopt a stance of emotional coldness in their work with patients Freud (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 patients response to interpretations Freud (1915-1917, SE16:448-63) Contrasts his method with cosmetic cure provided by psychiatry Freud (1923, SE18:235-59,239) Recommends psychoanalysts to adopt an attitude of evenly suspended attention so as to catch the drift of the patients 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 patients response interpretations may 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 Isaacss (IJPA, 1952) Kleinian theory of phantasy Post-Kleinian attention to the counter-transference (e.g. Heimann, IJPA, 1950, 31:81-4; Bions 1967 book, Second Thoughts) See also Hinshelwood (1989) A Dictionary of Kleinian Thought Sayers (2007) Klein and Bion chapters in Freuds Art
Evaluating psychoanalytic therapy (1) Eysenck (1952) Eysenck (1952, J Consulting Psych, 16:319-24) Patients treated by means of psychoanalysis improve to the extent of 44%; patients treated eclectically improve to the extent of 64%; patients treated only custodially or by general practitioners improve to the extent of 72%. There thus appears to be an inverse correlation between recovery and psychotherapy; the more psychotherapy, the smaller the recovery rate. http://psychclassics.yorku.ca/Eysenck/psychotherapy.htm Livingstone Smith (Psychoanalysis in Focus 2003:60-4) criticises Eysencks 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 control trial (RCT) provide evidence for the efficacy of psychodynamic psychotherapy with 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 delivery of therapeutic techniques and to the development of a therapeutic alliance. Controlled quasi-experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy.
Psychoanalytic therapy and cognitive 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 than psychopharmacological 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, those with 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 of untreated 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 Freuds theory that what needs to be addressed in treating depression is enabling the patient to become conscious of its cause in unconsciouss 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 and psychoanalyst 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 and resolving clinical impasses and stalemates. (b) certain forms of self-disclosure are best understood as attempts to create a third point of reference, thus opening up psychic space for self-reflection and mentalization. (c) that a clinical case example plus several briefer examples suggest modifications to the psychoanalytic stance recommended by Freud so as to give the patient greater access to the inner workings of the psychoanalyst's mind. (d) this introduces a third that facilitates the gradual transformation from relations of complementarity to relations of mutuality. Note: this shifts the aim of psychoanalysis from treating symptoms to facilitating the patient's capacity 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 the psychoanalyst's approach to treatment (c) conflicting with the need for structure and discipline in conducting coherent and purposeful psychoanalytic treatment.
Mentalization-based therapy Fonagy & Bateman (1) Fonagy & Bateman (2006, J Clin Psych, 62:411-30) Note problematic early attachments in patients with borderline personality disorder (BPD) This causes BPD patients to be readily provoked by later intimate relationships into decoupling their mind from that of others 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 in entangled relationships (3) excessive idealization of the new intimate relationship (4) unstable emotion, including violent outbursts &/or suspiciousness (5) lack of emotion-laden memories causing chronic feelings of emptiness.
Mentalization-based therapy Fonagy & 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 client's/patients attachment to the therapist by creating a 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 confrontation of adverse/traumatic experiences (6) encouraging retrieval of emotion-laden episodic memories (7) focusing on the clients/patients mentalization about relationships that have relatively low levels of involvement (8) only gradually focusing on the clients/patients thinking about relationships closer to their core self Note Mentalization-based therapy (MBT) is similar to transference-focused psychoanalysis in focusing on mental states in an attachment situation. Evidence that attachment-related mentalization improves with transference-focused but not with supportive therapy. See also Sugarman (2006) Mentalization, insightfulness & therapeutic action, IJPA, 87:965-87; and 'Mentalization' entry on Wikipedia
Summary Freuds aim in therapy Freuds method of therapy Kleinian & Post-Kleinian therapy Evaluating psychoanalytic therapy Psychoanalytic therapy and cognitive behaviour therapy (CBT) Relational psychoanalysis Mentalization-based therapy
READ J. Shedler (2010) The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2):98-109 (available on Moodle) WRITE DOWN One essential ingredient, according to Shedler (2010), of effective psychoanalytic or non-psychoanalytic therapy ESSAY TITLE Evaluate 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 most common 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 in psychodynamic psychotherapy i.e. unstructured, open-ended dialogue; identifying recurring themes in the patients experience; linking the patients feelings and perceptions to past experiences; drawing attention to feelings regarded by the patient as unacceptable (e.g. anger, envy, excitement); pointing out defensive manoeuvres; interpreting warded-off or unconscious wishes, feelings, or ideas; focusing on the therapy relationship; drawing connections between the therapy & other relationships. Conclusion Value of psychodynamic psychotherapy lies in fostering inner capacities enabling people to live life with greater sense of freedom.
Group 1 Effective ingredients of therapy Actively exploring avoidances e.g. being late for therapy sessions; cf Freuds theory of unconsciously 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 on rather than sticking with blame of the past; BUT what about the argument against psychoanalysis (of e.g. Sartre) that we are morally responsible for the choices we make in the present Focus on feelings this links up with attachment theory approaches to psychoanalytic psychotherapy 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 psychopharmacological treatment 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-psychoanalytic therapy Therapeutic alliance & the problem of the transference & counter- transference Focus on feelings rather than on thoughts and this makes therapy quite difficult at times Identification of recurring themes and patterns in, for instance, the transference Long term follow up shows effectiveness of psychotherapy due, perhaps, to it helping them understand issues that come up for the patient through teaching the patient to think psychologically about himself or herself This is open to making mistakes about ones psychology; or quick- fix psychological formulae; or it can make one over self-centred and introspective Read Janet Malcolm, Psychoanalysis: The Impossible Profession or read one of Darian Leaders recent books

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Ahh

  • 2. Overview Freuds aim in therapy Freuds method of therapy Kleinian & Post-Kleinian therapy Evaluating psychoanalytic therapy Psychoanalytic therapy and cognitive behaviour therapy (CBT) Relational psychoanalysis Mentalization-based therapy
  • 3. Freuds aim in therapy Freud (1895, SE2:305) Aims to transform the patients hysterical misery into common unhappiness so that they are better armed against that unhappiness Freud (1914, SE12:145-56) Aims to help patients remember and work through, rather than repeat, the otherwise more or less unconscious cause of their ills Case examples (a)Hysteria (Dora, SE7) (b)Phobia (Little Hans, SE10) (c)Obsessional neurosis (the rat man, SE10) (d)Melancholia (SE14)
  • 4. Freuds method of therapy Freud (1912, SE12:111-20,115) Warns against the counter-transference recommends therapists, like surgeons, to adopt a stance of emotional coldness in their work with patients Freud (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 patients response to interpretations Freud (1915-1917, SE16:448-63) Contrasts his method with cosmetic cure provided by psychiatry Freud (1923, SE18:235-59,239) Recommends psychoanalysts to adopt an attitude of evenly suspended attention so as to catch the drift of the patients 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 patients response interpretations may be a suggestive effect of their positive transference to the psychoanalyst.
  • 5. 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 Isaacss (IJPA, 1952) Kleinian theory of phantasy Post-Kleinian attention to the counter-transference (e.g. Heimann, IJPA, 1950, 31:81-4; Bions 1967 book, Second Thoughts) See also Hinshelwood (1989) A Dictionary of Kleinian Thought Sayers (2007) Klein and Bion chapters in Freuds Art
  • 6. Evaluating psychoanalytic therapy (1) Eysenck (1952) Eysenck (1952, J Consulting Psych, 16:319-24) Patients treated by means of psychoanalysis improve to the extent of 44%; patients treated eclectically improve to the extent of 64%; patients treated only custodially or by general practitioners improve to the extent of 72%. There thus appears to be an inverse correlation between recovery and psychotherapy; the more psychotherapy, the smaller the recovery rate. http://psychclassics.yorku.ca/Eysenck/psychotherapy.htm Livingstone Smith (Psychoanalysis in Focus 2003:60-4) criticises Eysencks 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
  • 7. Evaluating psychoanalytic therapy (2) Leichsenring (2005) Leichsenring (2005, IJPA 86:841-68) Studies published between 1960 to 2004 with at least one randomised control trial (RCT) provide evidence for the efficacy of psychodynamic psychotherapy with 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 delivery of therapeutic techniques and to the development of a therapeutic alliance. Controlled quasi-experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy.
  • 8. Psychoanalytic therapy and cognitive 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 than psychopharmacological 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, those with 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 of untreated 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 Freuds theory that what needs to be addressed in treating depression is enabling the patient to become conscious of its cause in unconsciouss 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
  • 9. Relational psychoanalysis Ogden (1994, The analytic third, in Subjects of Analysis, BF704) emphasizes psychoanalytic attention to the transference-countertransference relation of patient and psychoanalyst 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 and resolving clinical impasses and stalemates. (b) certain forms of self-disclosure are best understood as attempts to create a third point of reference, thus opening up psychic space for self-reflection and mentalization. (c) that a clinical case example plus several briefer examples suggest modifications to the psychoanalytic stance recommended by Freud so as to give the patient greater access to the inner workings of the psychoanalyst's mind. (d) this introduces a third that facilitates the gradual transformation from relations of complementarity to relations of mutuality. Note: this shifts the aim of psychoanalysis from treating symptoms to facilitating the patient's capacity 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 the psychoanalyst's approach to treatment (c) conflicting with the need for structure and discipline in conducting coherent and purposeful psychoanalytic treatment.
  • 10. Mentalization-based therapy Fonagy & Bateman (1) Fonagy & Bateman (2006, J Clin Psych, 62:411-30) Note problematic early attachments in patients with borderline personality disorder (BPD) This causes BPD patients to be readily provoked by later intimate relationships into decoupling their mind from that of others 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 in entangled relationships (3) excessive idealization of the new intimate relationship (4) unstable emotion, including violent outbursts &/or suspiciousness (5) lack of emotion-laden memories causing chronic feelings of emptiness.
  • 11. Mentalization-based therapy Fonagy & 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 client's/patients attachment to the therapist by creating a 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 confrontation of adverse/traumatic experiences (6) encouraging retrieval of emotion-laden episodic memories (7) focusing on the clients/patients mentalization about relationships that have relatively low levels of involvement (8) only gradually focusing on the clients/patients thinking about relationships closer to their core self Note Mentalization-based therapy (MBT) is similar to transference-focused psychoanalysis in focusing on mental states in an attachment situation. Evidence that attachment-related mentalization improves with transference-focused but not with supportive therapy. See also Sugarman (2006) Mentalization, insightfulness & therapeutic action, IJPA, 87:965-87; and 'Mentalization' entry on Wikipedia
  • 12. Summary Freuds aim in therapy Freuds method of therapy Kleinian & Post-Kleinian therapy Evaluating psychoanalytic therapy Psychoanalytic therapy and cognitive behaviour therapy (CBT) Relational psychoanalysis Mentalization-based therapy
  • 13. READ J. Shedler (2010) The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2):98-109 (available on Moodle) WRITE DOWN One essential ingredient, according to Shedler (2010), of effective psychoanalytic or non-psychoanalytic therapy ESSAY TITLE Evaluate psychoanalytic approaches to therapy. Pre-Seminar Assignments
  • 14. 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 most common 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 in psychodynamic psychotherapy i.e. unstructured, open-ended dialogue; identifying recurring themes in the patients experience; linking the patients feelings and perceptions to past experiences; drawing attention to feelings regarded by the patient as unacceptable (e.g. anger, envy, excitement); pointing out defensive manoeuvres; interpreting warded-off or unconscious wishes, feelings, or ideas; focusing on the therapy relationship; drawing connections between the therapy & other relationships. Conclusion Value of psychodynamic psychotherapy lies in fostering inner capacities enabling people to live life with greater sense of freedom.
  • 15. Group 1 Effective ingredients of therapy Actively exploring avoidances e.g. being late for therapy sessions; cf Freuds theory of unconsciously 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 on rather than sticking with blame of the past; BUT what about the argument against psychoanalysis (of e.g. Sartre) that we are morally responsible for the choices we make in the present Focus on feelings this links up with attachment theory approaches to psychoanalytic psychotherapy 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 psychopharmacological treatment 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)
  • 16. Group 2 Effective ingredients in psychoanalytic and non-psychoanalytic therapy Therapeutic alliance & the problem of the transference & counter- transference Focus on feelings rather than on thoughts and this makes therapy quite difficult at times Identification of recurring themes and patterns in, for instance, the transference Long term follow up shows effectiveness of psychotherapy due, perhaps, to it helping them understand issues that come up for the patient through teaching the patient to think psychologically about himself or herself This is open to making mistakes about ones psychology; or quick- fix psychological formulae; or it can make one over self-centred and introspective Read Janet Malcolm, Psychoanalysis: The Impossible Profession or read one of Darian Leaders recent books