Lesson 11 Sublimation

Psychodynamic Psychotherapy  Channeling the expression of unacceptable impulses into more

socially acceptable activities
Psychoanalysis
THEORETICAL FOUNDATIONS Transference and Countertransference
a) searching--relationships between a person’s developmental history Transference
and current problems.  client unconsciously brings a maladaptive pattern of relating--
b) blockages or dissociations--self-awareness as causes of therapy −
psychological problems countertransference
c) talking as an approach--treatment  therapists’ reactions toward clients--based on the therapist’s
d) therapeutic relationship as a curative factor personal history and conflicts

topographical model of the mind Psychic Determinism

Freud’s Personality Theory and View of Psychopathology
 Psychodynamic approaches--based on the proposition--mental life
is best understood--interaction among powerful competing forces
within the person, some of which--conscious but most of which--
unconscious.
Id
 primitive source of instinctual drives, especially sexual/sensual
and aggressive drives.
 seeks--discharge tension by expressing sexual or aggressive
impulses
Superego
 mental agency--incorporates norms from one’s parents, family,
and culture.
 seeks--inhibit them or to prescribe more socially appropriate
behavior.
Ego
 tries to mediate between--demands of the id and superego while
simultaneously recognizing and responding--external realities
 dynamic, tension-filled conflict occurs continuously
 psychoanalysis, slips of the tongue and other unexpected verbal
associations--presumed--psychologically meaningful, as are
mental images, failures of memory, and a variety of other
experiences.
 idea--memories, impressions, or experiences--occur together in a
client’s mind--necessarily related and not random − psychic
determinism
Resistance
 manner in which the client resists--likely to be a reenactment of
earlier patterns and therefore may be subject--analysis and
interpretation
Interpretation, Working Through, and Insight
 Interpretation involves--analyst suggesting connections between
patients’ current experiences and their historically based conflicts.
 Interpretation--way of pointing out how--past intrudes--present.
 Interpretations--based on material or reactions a client reveals--
therapy or on reports--client’s experiences outside--therapy
situation.
Optimal Interpretation
 explanation makes cognitive and emotional sense--client (i.e., if it
is accurate and the client--ready to process it), he or she may see a
particular behavior pattern or problem-+new way − insight
 Insight--beginning of positive change.

Defense Mechanisms Goals of Psychoanalysis

 Imagine a child who feels strong anger toward a parent but fears--
expressing it would result--punishment
 Anna fully developed--idea of defense mechanism.
 Ego and the Mechanisms of Defense (Freud, 1936/1966),--
categorized and described defense mechanisms, stressing--role in
everyday life and in psychoanalytic treatment.
Denial
 Simply refusing--recognize or acknowledge threatening
experiences
Repression
 Pushing anxiety provoking thoughts and memories out of
consciousness and into--unconscious; “motivated forgetting”
Regression
 Retreating--coping strategies characteristic of earlier stages of
development
Projection
 Attributing one’s unacceptable motives and impulses to others
Reaction Formation
 Adopting thoughts and behaviors--opposite of those prompted by
one’s unacceptable, impulses
Displacement
 Directing pent-up impulses toward--safer substitute rather than the
target--aroused the feelings
Rationalization
 Providing socially appropriate, but fundamentally untrue,
explanations--one’s unacceptable behavior
Compensation
 Coping with feelings of inferiority in one area by working to
become superior in another area
1. Intellectual and emotional insight into--underlying causes--client’s
problems
2. Working through or fully exploring--implications of those insights
3. Strengthening--ego’s control over the id and the superego
 Reaching--ambitious goals set by classical psychoanalysis
involves dissecting and gradually reconstructing--patient’s
personality.
 classical Freudian psychoanalysis, three or four sessions each
week--standard, and treatment can last--several years.
CASE OF ELEN
Ellen, a 33-year-old female, sought psychotherapy after
having a series of panic attacks over the last year and a half. She also
stated that each day was a struggle and she felt little enjoyment of her
life, so she had become concerned about depression. Finally, she said
that she had questions about her marriage and herself.
At the time of referral, Ellen was employed as a sales
representative for a large paper manufacturer, a position she had held for
4 years. She was married to Rick, a radiologist at the local hospital.
They had no children but were contemplating them. This too was a
source of discomfort, as she reported that she was more in favor of
having children than Rick, who said that he was not ready.
 Ellen reported having had one panic attack in college—at least
she believes that is what it was—but no more until about a year and a
half ago. At the time of that more recent incident, she had been
attending an industry-related convention in a distant city. After mingling
for a while at an evening social hour sponsored by her company, she
returned to her room and lay on her hotel bed. While there she noticed
her heart racing. It quickly escalated to a rapid, uncontrollable pounding.
She had difficulty breathing and was sweating. At one point, she tried
getting out of bed but had to lay back down for fear she would faint and
fall, possibly injuring herself.
By rolling sideways, she was able to reach the phone and call
the front desk, and personnel there summoned an ambulance. By the
time Ellen arrived at the hospital, her symptoms had subsided, but she
still felt shaky and very anxious. After history taking and a number of
tests at the hospital, she was given a provisional diagnosis of panic
attack. Since that initial attack, she has had others: “some at home, two
at work, one while shopping, and one while driving.” She said, “They
hit me out of the blue. They’re terrible, terrifying . . . and embarrassing.”
She worried frequently about when the next attack might come.
Ellen’s concerns about depression had arisen more gradually.
During the last year or two, she reported, she had occasionally felt lost
and unsure about what she was doing with her life. Despite the fact that
she was apparently valued at work—she had been promoted and given a
raise twice in the last 2 years— Ellen often felt that there was no point
to her daily activities there. These episodes of feeling down and
unfulfilled had increased prior to her seeking treatment.
She was also not sure if she loved her husband or if he loved
her. She regarded him as a good man, committed to his work, and
reasonably pleasant to be around. But she feared that his interest in her
had waned because he spent more time in activities with his friends
(racquetball, cycling, poker) than ever before. Her satisfaction with their
sexual relationship had diminished too. She found herself more inclined
to avoid situations that might lead to sex.
Clinical Applications
History and Case Formulation
 Traditional psychoanalysts--not stress--use of structured
assessment instruments.
 use them, especially--make differential diagnostic classifications,
but psychoanalysts--more Likely--rely on interview data and
sometimes--projective tests--develop an understanding of the
client.
a) historical data such as family and developmental history (to
identify information related--early conflicts or trauma)
b) mental status, level of distress, ego strengths and deficits, and
“psychological mindedness” (to assess--client’s intellectual and
emotional ability--engage in psychoanalytic treatment)
c) defense mechanisms, themes, or patterns of attachment
difficulties--interpersonal relationships (to identify transference
patterns).
Case Formulation
Ellen is the older of two children. When she was 12 years old,
her father, a physician in a small town, divorced her mother and
essentially abandoned the family. This was partly a relief, as there had
been numerous fights in which Ellen’s mother accused her husband of
having affairs. But it also brought difficulties. Ellen’s mother
maintained a series of serviceindustry jobs and was barely able to keep
the family out of poverty. The mother did not remarry but had a series of
boyfriends, none of whom left any lasting impression on Ellen (or,
apparently, her mother).
Ellen’s father was a particularly important figure in her
childhood. A man she described as “dashing,” he was outgoing and free-
spirited at home. Particularly significant were Ellen’s memories of him
walking around the house in his underwear, pinching her, and teasing
her about being ugly. This behavior continued as Ellen approached early
adolescence. His pinching her on the buttocks or on her developing
breasts brought her great embarrassment. She denied other forms of
sexual abuse but reported strong anger about how his callous behaviors
had hurt her self-esteem.
In high school and college, Ellen had a few boyfriends. She
said that she was attracted to the rebellious type, but these were often
young men she felt to be her intellectual inferiors and the relationships
typically did not last more than a few months. She met Rick when she
was 27 (he was the same age) and felt that he was an interesting person
and a more stable partner. His clear interest in her impressed her, and
she agreed to marry him the following year
Free Association
 Psychoanalysis proper begins with--analyst explaining to the
client--therapy requires following a single fundamental rule:
a. client should say everything--comes--mind without editing
or censorship
Ellen related her reaction to a man she met at a company
convention. “He was a jerk. I guess he thought he was hot stuff. I
wondered if he was coming on to me, but I think he was like that with
several women. Shameless. Greasy. I don’t know why he bothered me
so, I didn’t even really get to know him.” After a few moments of
silence, Ellen reported, “I don’t know why I just thought of this, but I
remembered standing in our bathroom when I was growing up, holding
my father’s comb.
 It could mean--characteristics--man she met reminded her of her
father (e.g., greasy black hair, inappropriately flirtatious with
women).
 In therapy, the analyst may engage Ellen in a discussion--possible
connections. One way of doing so would be--encourage more free
association around the man, the comb, and her father.
 He assessed her depression--secondary symptom arising gradually
as she attempted, unsuccessfully, to cope with conflicts--affected
her relationships.
 analyst believed--panic attacks were also related--concerns about
intimacy, sexuality, and abandonment.
 After determining--Ellen was not suicidal, that she was motivated-
-treatment, and that she had sound intellect and adequate ego
strength, the analyst and Ellen began a course of psychoanalysis
The Role of the Therapist
 therapy sessions, traditional psychoanalysts maintain--analytic
incognition−revealing little about themselves during--course of
psychotherapy
 This arrangement makes it easier--clients--focus their attention
inward rather than on Facial expressions or other visual cues from
the therapist.
 If clients ask personal questions, therapist usually reminds them
that--session is for their benefit and that while--exchange of
personal information--appropriate in other circumstances, it does
not benefit psychoanalysis.
 therapist may also explore with the client, and perhaps interpret,
motives behind--client’s desire--know more about the therapist.
 Psychoanalysts understand--importance of creating emotional
safety--therapeutic relationship, and frequently empathic,
supportive, and reflective in their comments.
 may use direct questions or encouraging phrases--help the client
more deeply explore perceptions, emotions, motivations, and the
like.
 therapist’s use of interpretation, when it occurs, can range from
the suggestive (e.g., “I wonder if that seems familiar to you?”)--
more direct statements--summarize patterns--current and historical
conflicts.
Analysis of Everyday Behavior
 analyst tries--maintain an “evenly divided” or “freefloating”
attention--trivial as well as momentous events, to purposeful acts
and accidental happenings, to body language as well as spoken
language.
 Mistakes--speaking or writing (so-called “Freudian slips”),
accidents, memory losses, and humor--seen as especially
important sources of unconscious material.

Analysis of Dreams
 client’s description--dream reveals its manifest content
 Manifest content often contains features associated with the
dreamer’s recent activities (called “day residue”).
 Latent content − unconscious ideas and impulses--appear in
disguised form.
 process of transforming unacceptable material into acceptable
manifest content −dream work (viewed as being symbolic of
something else)
 common analytic procedure--ask the client to free associate--
dream’s manifest content.
Analysis of Transference
patient–therapist
relationship miniature
version--causes of the
client’s problems − transference neurosis
 Transference and transference neuroses must be handled with
care--analysts try to decode--meaning of their clients’ feelings
toward them
 goal--understand--meaning of the client’s feelings--therapist.
 If this can be done, transference neurosis will be resolved and,
with it, the client’s main unconscious conflicts.
Analysis of Resistance
 Client behaviors--interfere with analytic process--considered signs
of resistance against achieving insight.
 Psychoanalysts try--help clients overcome resistance by pointing
out--presence in obstructed free associations, avoidance or sudden
changes of topics, feelings of distress upon approaching certain
topics, distorted dream reports, missed appointments, lateness for
treatment sessions, failure to pay the therapist’s bill, or a variety of
other behaviors
As Ellen’s analysis progressed, she explored her feelings
about her childhood, especially her ambivalent feelings about her father
and mother. On the one hand, she admired her father and longed to win
his affection, but he seemed interested only in himself. On the other
hand, Ellen felt rage
at her father’s selfishness and cruelty
Being a “psychologically minded” person, Ellen was aware
that her father’s behavior toward her during her childhood had affected
her self-concept and self-esteem. In adulthood, she therefore worked to
convince herself that she was attractive and special. She reported that
she did this partly by going through some “wild years” during and just
after college. During this time, she exerted considerable effort to attract
men, and she was typically successful, though with men that she was not
that interested in or who were not that interested in her as a person.
Ellen and her therapist considered the possibility that her
relationship patterns with men may have multiple causes and meanings
(Freud called such situations “overdetermined”). Those patterns were a
way to prove her father wrong (she was not ugly), but also they were a
symbolic attempt to regain the affection that her father had never given
(i.e., if she had been more attractive, more appealing, perhaps he would
not have abandoned the family). A fear of abandonment pervaded her
relationships.
In one particularly significant session, Ellen was exploring her feelings
about her marriage. She discussed imagining herself leaving the
relationship or having an affair. She recalled being at a convention and
considering having a brief affair with a man who approached her there.
Feeling tempted but overwhelmed by the impulse, she went to her hotel
room to lie down briefly and consider the matter further. Moments later,
a panic attack ensued. Several things seemed to connect in this
session—sexual impulses, fears of loss, strivings for autonomy and self-
esteem, and the feeling of panic.
Making Analytic Interpretations
 Analysts want clients--gain insight into unconscious conflicts, but
they don’t want--overwhelm them with potentially frightening
material before they are ready--handle it.
 Through questions and comments about--client’s behavior, free
associations, dreams, and the like, the analyst guides--process of
self-exploration.
 client shows resistance--seeing the potential meaning of some
event, the therapist not only points out the resistance but also
offers an interpretation of what is going on.
 interpretive process--tentative and continuous, a constant
encouragement of clients--consider alternative views, to reject
obvious explanations, to search--deeper meanings
 Emotional understanding will liberate--client to deal with life--
more realistic and satisfying manner than before.
As Ellen continued in psychoanalysis, she and the therapist
began to feel that they better understood many of the complex emotional
currents that defined Ellen’s relationships. Ellen developed insight into
her unconscious concern that her husband’s activities “with the guys”
foreshadowed his abandonment of the marriage, and she became less
worried about his leaving. She recognized that her husband was
fundamentally different from her “dashing” but uncommitted Father
 Her panic attacks were less frequent but not entirely absent. Her
relationship with her mother improved after they were able to have
some candid conversations about her father (who had since died).
Gradually, however, Ellen began to feel that her therapist was
becoming less interested in working with her, though she did not
verbalize these feeling
After Ellen missed an appointment—she said that work
required her attention— the therapist explored with Ellen whether her
feelings about therapy had changed. She admitted that she had been
thinking that maybe she had gone as far as she could go in therapy.
Together, she and her analyst explored the possibility of termination.
The analyst did not advise it, as he felt that they were working through
some important material and talk of termination might be a form of
resistance. However, he said that he would support her decision if she
chose to terminate.
Ellen missed the next session—again, claiming work
commitments. Days later, at the next session, she was cheerful and
provocatively dressed but also reported that she had experienced another
panic attack. When the therapist commented on her cheerful demeanor
and manner of dress, Ellen became angry with him. She felt he did not
appreciate her attempts to cheer herself up or to make their interaction
more pleasant. She accused him of secretly wanting to terminate the
relationship, of probably being bored and uninterested in her “case” any
more
This and the sessions that followed were especially productive
because they represented opportunities to analyze Ellen’s resistance
(suggesting termination, missing appointments) as well as the
transference. The therapist suggested that Ellen’s feeling that she was
about to be abandoned, that the therapist really did not care about her,
were a reflection of how she had felt about her husband and about her
father. Her attempts to prevent this abandonment by being more
attractive, perhaps even seductive (but emotionally inauthentic), and
then feeling angry, were also reflections of a historical pattern for her
 Psychodynamic
Psychotherapy
Psychoanalytically Oriented Psychotherapy
Franz Alexander
 Therapists whose psychoanalytic procedures depart only slightly
from--guidelines set down by Freud--said--employ
psychoanalytically oriented psychotherapy
Individual Psychology
Alfred Adler
 His treatment methods focused--exploring and altering
misconceptions (or maladaptive lifestyles)
 Adlerian therapists use modeling, homework assignments, and
other techniques--help patients become aware--lifestyle and to
prompt them--change.
 Adlerians focus more--social and relational aspects of
psychopathology and less on its intrapsychic aspects
Analytical Psychology
Carl Jung
 viewed--unconscious not so much as a cauldron of conflicts
threatening--boil over with anxiety, but also as a source of
creativity and growth.
 Jungian therapists focus more--how clients create meaning and
construct a life story than on discovering--unconscious meaning of
symptoms
Otto Rank
 Rank’s emphasis--will, creativity, and relationship
Sandor Ferenczi
 Ferenczi stressed--importance of the therapeutic relationship and
the curative power of empathy
Ego Psychology
 Freud’s preoccupation with sexual and aggressive instincts (the
id)--basis--behavior and behavior disorder--too narrow.
 Behavior--determined to a large extent by the ego, can function
not just--combat id impulses or to referee conflicts but also--
promote learning and creativity.
 Heinz Hartmann, David Rapaport, Erik Erikson , and Anna Freud
use psychoanalytic techniques--explore patients’ adaptive ego
functions
 Ego-analytic therapists focus less--working through early
childhood experiences and more--working through current
problems.
 Therapists assess and attempt--bolster the client’s ego strengths,
which include reality testing, impulse control, judgment, and the
use of more “mature” defense mechanisms--sublimation.
Object Relations and Self-Psychology
 Fairbairn, Donald Winnicott, Melanie Klein, Margaret Mahler,
Otto Kernberg and Heinz Kohut
 Object relations theories, and therapies based on them, focus--
nature of interpersonal relationships--built from very early infant–
caregiver interactions
 Object relations theorists view--therapeutic relationship not as
transference--analyzed but as a “second chance”--client to obtain
in a close relationship the gratification--was absent during infancy
 Kohut’s self-psychology focuses--self or self-concept but, like
object relations approaches, views--analyst’s task as providing--
type of empathic responding and nurturing--client is assumed--
have missed as an infant.
Relational Psychodynamic Psychotherapy
 relational psychodynamic approaches blend several theories,
including elements from traditional psychoanalysis, ego
psychology, object relations theory, self-psychology, Sullivan’s
interpersonal therapy, and humanistic, person-centered, and
phenomenological approaches
 Relational theorists stress--importance of early relationships as
templates--later ones
 point out--relationships have an objective dimension (events--
actually happen) and a subjective dimension (way the relationship
is mentally represented, or perceived, by the persons involved).
 Harry Stack Sullivan believed--therapists should use--observations
of the client’s current and past interpersonal relationships to
clarify--them how their typical cognitions and behaviors interfere
with successful living
Short-Term Psychodynamic Psychotherapy
 Short-term dynamic psychotherapy approaches emphasize
pragmatic goals--obtained in relatively few sessions, typically 20
or less.
 Therapists using this approach focus--helping clients cope with a
current crisis or problem rather than--helping them work through
early relationships or reconstruct--personality.
 Short-term dynamic therapists stress forming a working
therapeutic alliance as quickly as possible and then helping clients
adopt coping strategies within specific domains.
Common Features and Key Variations in Psychodynamic Therapies
a. Similarities:
a) intrapsychic conflict
b) unconscious processes,
c) early relationships
d) ego functioning
e) the client–therapist relationship
 Classical psychoanalysis and its variants also differ--length of
treatment
 Another dimension--differentiates the psychodynamic therapies--
degree of emotional support offered by the therapist.
 Psychoanalysts offer support, but focus more--exploration of
emotionally difficult material, hoping--clients will develop insight.
 Psychodynamic psychotherapists practice interventions--range
from these analytical and interpretive ones--more supportive and
educational interventions stressed by interpersonal and relational
approaches.
The Current Status of Psychodynamic Psychotherapy
 psychodynamic approach--second most common one, after--
cognitive approach, among faculties at accredited graduate and
professional schools in clinical psychology.
 Psychodynamically oriented research publications--rise, too,
though critics argue--case studies that still dominate--
psychodynamic psychotherapy research literature lack scientific
rigor
 Recent large-scale reviews and meta-analyses have found--some
forms of psychodynamic psychotherapy produce results--
comparable to those of therapies identified as empirically
supported.
 appears--most psychodynamically oriented clinicians--becoming
less ideological in practice.