WEEK 7

Module 7: Psychodynamic Psychotherapy

Objectives

1. Define Psychodynamic therapy

2. What are procedures and goals in psychodynamic therapy.

3.
Learning Content

Traditional psychoanalysis stresses the role of unconscious conflict stemming from early childhood
relationships and of psychological defenses against anxiety. In therapy, it is assumed that clients will
exhibit signs of these conflicts and defenses, such as by reacting to the therapist in ways that reflect
relationships with parents and other significant figures from their pasts. By focusing on the transference
of old relationship patterns onto the therapeutic relationship, the therapist can interpret the client’s
maladaptive behaviors and the unconscious causes that motivate them. These interpretations, in turn,
help the client to develop insight into the historically grounded conflicts and patterns of behavior related
to their symptoms.

Theoretical Foundations

Freud described mental life as occurring partly at the level of conscious awareness; partly at a
preconscious level, which we can become aware of by shifting our attention; and partly at an unconscious
level, which we cannot experience without the use of special therapy techniques. This continuum from
unconscious, to preconscious, to conscious is called the topographical model of the mind, and it is
fundamental to understanding Freud’s views of personality.

Freud’s Personality Theory and View of Psychopathology

Psychodynamic approaches are based on the proposition that mental life is best understood as
an interaction among powerful competing forces within the person, some of which are conscious but most
of which are unconscious. Those forces are represented in Freud’s system as the id, ego, and superego.
The id is the primitive source of instinctual drives, especially sexual/sensual and aggressive drives.
Counterbalancing the id is the superego, the mental agency that incorporatesnorms from one’s parents,
family, and culture. The superego also contains the ego ideal, or how one would like to be. The id and the
superego are often in conflict—the id seeks to discharge tension by expressing sexual or aggressive
impulses, while the superego seeks to inhibit them or to prescribe more socially appropriate behavior.
The ego is the part of the personality that tries to mediate between the demands of the id and superego
while simultaneously recognizing and responding to external realities. Together, these three agencies—
id, ego, and superego—form a structural model of the mind; the topographical model refers to the level
of consciousness associated with these structures (see Figure 7.1).

Freud proposed that dynamic, tension-filled conflict occurs continuously, as seen in many examples of
conflicting urges. Imagine sitting through a boring class. One part of you wants to get up and leave,
perhaps to do something more exciting. Another part of you urges you to stay and try to pay closer
attention, reminding you that you need the class, need to be more mature, need to delay gratification,
and the like. While you might be consciously aware of this particular conflict, Freud said that the most
important and problematic psychic battles usually occur unconsciously, outside of awareness. To Freud,
then, most of mental life is a balancing act involving competing parts of the personality and an ever-
changing external reality.

Psychic Determinism

In psychoanalysis, slips of the tongue and other unexpected verbal associations

are presumed to be psychologically meaningful, as are mental images, failures of

memory, and a variety of other experiences. If a client suddenly remembers

something that seems trivial or unrelated to the topic of discussion during a therapy session (e.g., a family
vacation taken when he was 6 years old, or his mother’s blue dress), the therapist assumes that there is a
reason this material “popped into” the client’s head. By asking the client to elaborate, rather than ignoring
the material, the therapist looks for clues that might reveal the unconscious connection. The idea that
memories, impressions, or experiences that occur together in a client’s mind are necessarily related and
not random is called psychic determinism.

Resistance

As psychoanalytic therapy progresses, and the therapist and client get closer to a client’s core unconscious
conflicts, the client may begin to experience increasing anxiety. He or she may consequently begin to
“forget” appointments, experience panic, become overly intellectual and emotionally detached in
discussing topics, or engage in other activities that appear to take the focus away from his or her conflicts.
Psychoanalysts expect these or a variety of other resistance reactions as treatment focuses more intently
on the client’s core conflicts. As with transference, the manner in which the client resists is likely to be a
reenactment of earlier patterns and therefore may be subject to analysis and interpretation (Gabbard,
2010).

Interpretation, Working Through,and Insight

By offering both emotional support and judicious interpretations, the therapist helps the client
understand and work through transference reactions and resistance. In so doing, the client develops a
new understanding of his or her problems, psychological makeup, and ways of relating to others.
Interpretation involves the analyst suggesting connections between patients’ current experiences and
their historically based conflicts. In simpler terms, interpretation is a way of pointing out how the past
intrudes on the present. Interpretations can be based on material or reactions a client reveals in therapy
or on reports of the client’s experiences outside the therapy situation. Those that are based on in-session
material often involve transference—the client’s reactions to the therapist. Optimal psychoanalytic
interpretations are interpretations of transference reactions that can be related to the client’s current
difficulties outside of therapy (e.g., in a relationship) and also to historical forces in the client’s past.
Wolitzky (2003) describes it this way: The optimal interpretation, though not necessarily presented
comprehensively at one time, would take the form of “what you are doing (feeling, thinking, fantasizing,
etc.) with me now is what you also are doing with your current significant other (spouse, child, boss, etc.),
and what you did with your father (and/or mother) for such and such reasons and motives and with such
and such consequences.” (p. 41) If this explanation makes cognitive and emotional sense to the client (i.e.,
if it is accurate and the client is ready to process it), he or she may see a particular behavior pattern or
problem in a new way. When this happens, it is called insight. In psychoanalysis, insight is the basic
requirement for, and the beginning of, positive change.

Goals of Psychoanalysis

Freud originally proposed that the goal of psychoanalysis was to make the unconscious conscious, but he
later added another goal, namely to replace unconscious id processes with conscious ego processes
(Wolitzky, 2011). According to Freud, when patients understand the real, often unconscious, reasons they
act in maladaptive ways and see that those reasons are no longer valid, they will not have to continue
behaving in those ways.
The process of self-understanding includes intellectual recognition of one’s innermost wishes and
conflicts, emotional involvement in discoveries about oneself, and the systematic tracing of how
unconscious factors have determined past and present behaviors and affected relations with other
people.

Thus, the main goals of psychoanalytic treatment are (a) intellectual and emotional insight into the
underlying causes of the client’s problems, (b) working through or fully exploring the implications of those
insights, and (c) strengthening the ego’s control over the id and the superego. Freud saw working through
as particularly important because clients need to understand how pervasive their unconscious conflicts
and defenses are if they are to be prevented from returning. Thus, it would do little good for a patient to
know that she has unconscious feelings of anger toward her mother if she did not also see that she deals
with women in the present as if they were her mother and that her problems in relation to these women
are based on unconscious hostility and/or attempts to defend against it. Insight provides the outline of a
patient’s story; working through fills in the details.

Reaching the ambitious goals set by classical psychoanalysis involves dissecting and gradually
reconstructing the patient’s personality. This process requires a lot of time. In classical Freudian
psychoanalysis, three or four sessions each week are standard, and treatment can last for several years.
Psychoanalytic psychotherapy, a modified form of psychoanalysis, is often shorter in duration (Wolitzsky,
2011). With fees generally well in excess of $100 per hour, the process is expensive.

Suggested Exercises

1. What is your perception of psychotherapy?

2. What are the approaches in therapy you know?

Books

Geroge Kramer, Douglas Bernstein, Vicky Phares (2014) Introduction to Clinical Psychology.