Psychodynamic Psychotherapies

Between the couch

and the intersubjective world

Jörn von Wietersheim – Department of Psychosomatic Medicine and

Psychotherapy,
Ulm University Medical Center, Germany
Introductory Lectures on Psycho-Analysis, G.W. Bd 1 | Freud 1915

„Ladies and gentlemen, I

cannot tell how much
knowledge about psycho-
analysis each one of you has
already acquired from what
you
„Hierhave
kannread or from
ein Zitat oder ein
hearsay.
Kommentar Butplatziert
the wording
werdenof
oderprospectus
my was auch sonst noch
–‘Elementary
wichtig ist.“ to Psycho-
Introduction
Analysis‘- obliges me to treat
you as though you knew
nothing and stood in need of
some preliminary
information.“

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Psychodynamics | Laplanche & Pontalis, The language of Psycho-Analysis

According to
psychodynamics,
psychological forces result
from a lively interplay of
inner drives, impulses, fears
and inhibitions.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Psychodynamics | Mentzos, neurotic conflict processing

Psychodynamics describes the

dynamics of inner psychological
tendencies and processes, their
interplay and interaction. A
differentiated and effective
study of psychodynamics goes
beyond the mere descriptive
and conscient, and is
unthinkable without
consideration of the
unconscious processes.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

First topographical model | Freud, The Interpretation of Dreams 1900

Conscious

Preconscious

Unconscious
Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy
First topographical model | Freud, The Interpretation of Dreams 1900

Conscious

Das Vorbewusste

Unconscious
Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy
Conflict | Laplanche & Pontalis, The language of Psycho-Analysis

In psychoanalysis, conflict is the

arousal of two or more strong
motives that cannot be solved
together. The conflict can be
obvious (e.g. between a desire
and a moral demand or between
two opposing emotions), or
manifest itself through
symptoms, behavioral
disorders, personality disorders,
etc.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

 Environment
Person

Sense of morality SUPER-EGO

Demands Values and norms
Obligations
Prohibitions

EGO
Reality principle Critical mind
Control Delay and
Reactions
renunciation of
gratifications

Pleasure principle ID
Demands Needs
Stimuli
Libido
Destrudo
Drive theory | Freud

desire and rejection

different parts:
Conflicts between: superego and id
superego and ego
ego and id

different drives

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Drive theory | Freud

desire and rejection

different parts:
Conflicts between: superego and id
superego and ego
ego and id

different drives

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Drive theory | Freud

desire and rejection

different parts:
Conflicts between: superego and id
superego and ego
ego and id

different drives

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Conflict | Operational Psychodynamic Diagnostic (OPD)
Arbeitskreis OPD (Hg.): OPD-2 - Operationalisierte Psychodynamische Diagnostik, Das Manual für Diagnostik und
Therapieplanung. Verlag Hans Huber / Hograefe

individuation versus dependency

submission versus control

self-perception versus object perception

self-worth and guilt conflicts

oedipal sexual conflicts

identity conflicts

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Defense

The totality of attempts to avoid

fear is what we call defense. Strictly
speaking, defense means the
attempts to avoid all events that are
unpleasant for the ego, not just fear.
That is why one refers to defense
against grief, depression, insult,
getting hurt, etc.

Hoffmann & Hochapfel,

Introduction to the study of
neuroses and psychosomatic
medicine

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Ego psychology | Anna Freud, 1936

Repression
Denial
Projection
Reaction formation
Intellectualization
Rationalization
Isolation
Displacement
Turning against the self
Identification with the aggressor
Regression
Introjection
Splitting
Projective identification
Psychosocial defense

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Object relations theory | Melanie Klein, William R.D. Fairbairn 1941

The object
relations
theory
discusses the
active
repetition of
previous
relationships,
and how they
were
perceived and
internalized.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Object relations theory | Melanie Klein, William R.D. Fairbairn 1941

„How did the self perceive and

internalize the relations with
others in their environment?“

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Object relations theory | Melanie Klein, William R.D. Fairbairn 1941

„What kinds of connections are

there between the internal
objects and the actual, external
objects? “

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Structure | Heinz Kohut, Otto Kernberg, Gerd Rudolf

The availability of
psychological functions,
that are required for the
organisation of the self
and its relations with
internal and external
objects

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Structure | Operationalized Psychodynamic Diagnostics (OPD)
Arbeitskreis OPD (Hg.): OPD-2 - Operationalisierte Psychodynamische Diagnostik, Das Manual für Diagnostik und
Therapieplanung. Verlag Hans Huber / Hograefe

Self-perception
Self reflexion,
Self image

Sense of identity
Affect differentiation

Self-regulation
Affect tolerance
Regulation of self-esteem

Impulse control
Anticipation

Defense
Internal versus
Interpersonal defense

Flexibility of defense

Self-object-differentiation

Object perception
Empathy

Whole (holistic) object perception

Realistic object perception

Communication
Experiencing affect
Communicating affect
Establishing contact

Reciprocity

Bonding
Internalization
of attachment

Detaching from relationships

Variability of attachment

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Therapeutic technique

Insight therapy
Emphasis on interpretation

Sigmund Freud (1937):

Constructions in Analysis.
GW Bd 16, S 41-56

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Therapeutic technique

Insight therapy The corrective emotional

Emphasis on interpretation experience

Franz Alexander and

Thomas M. French (1946):
Psychoanalytic therapy.
Sigmund Freud (1937): Principles and
Constructions in Analysis. Applications. New York,
GW Bd 16, S 41-56 Ronald.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Fundamental rule | Laplanche & Pontalis, The language of Psycho-Analysis

The fundamental rule of The patient is asked to

free association express in words all
thoughts and feelings,
without reservation, as
they spontaneously occur.
In following the rule, he or
she must often overcome
conscious feelings of
embarrassment, fear,
Dream shame, and guilt.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Interventions

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Interventions

Clarification
?

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Interventions

Clarification
!
Confrontation

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Interventions

Clarification
Remember

Confrontation

Biographical reconstruction .

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Interventions

Clarification
… because …

Confrontation

Biographical reconstruction .

Interpretation

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Interventions

Clarification
Remember
Repeat
Work through
Confrontation

Biographical reconstruction .

Interpretation

Working through
Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy
Resistance | Laplanche & Pontalis, The language of Psycho-Analysis

During psychoanalytic therapy, „resistance“ is every oppositional

behavior that inhibits the revelation of any repressed information
from within the unconscious mind.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Transference

The repetition of the patient‘s - In psychoanalysis, transference

mostly infantile- attitudes from is the redirection of
the past, in the specific unconsciously retained feelings
analyst/patient relationship.
and desires, developed within a
particular relationship with an
object from the past, toward a
new object. In the
transference, infantile
prototypes re-emerge and are
experienced with a strong
sensation of immediacy.

Hoffmann & Hochapfel, Introduction

to the study of neuroses and Laplanche & Pontalis, The language
psychosomatic medicine of Psycho-Analysis

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Countertransference | Paula Heimann

All (unconscious) behavioral responses of the therapist to the patient

in therapy, and specifically to the transference of the patient.

Paula Heimann: On countertransference. In: International Journal of Psychoanalysis.

Bd.31, 1950, S.81-84.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Countertransference | Heinrich Racker

Concordant countertransference:
An emotional reaction similar to the one experienced by the patient.

Complementary countertransference:
An emotional reaction, opposed to the one experienced by the
patient, and similar to the experience of a person related to the
patient.

Heinrich Racker: Transference and Countertransference. Ernst Reinhardt, München

1970.

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Analytical psychotherapy | Framework

Frequency:
2-3 therapy sessions / week (periodically 4)

Therapy setting:
Patient lying on a couch, analyst out of sight
Patient sitting, analyst diagonally opposite

Amount of therapy sessions paid by health insurance:

160 – 300

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Psychodynamic psychotherapy | Framework

Frequency:
1 therapy session / week (periodically 2; periodically longer breaks in between)

Therapy setting:
Patient sitting, analyst diagonally opposite

Amount of therapy sessions paid by health insurance:

Short-term psychotherapy 12 - 24
Long-term psychotherapy 60 - 100

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

fMRI study | Buchheim et al. 2012

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

fMRI study | Buchheim et al. 2012

Major Depressive Disorder according to DSM-IV criteria (N = 16)

prior unsuccessful psychopharmacotherapy

Control group based on sex, age and educational attainment level (N = 17)

2-4 analysis sessions / week during 15 months (90 – 210 sessions; avg = 129)

fMRI at beginning of treatment and after 15 months

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

fMRI study | Buchheim et al. 2012

Adult Attachment Projective

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

fMRI study | Buchheim et al. 2012

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Meta-analysis | Leichsenring, Rabung

2008; 300(13):1551-1565

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Munich Psychotherapy Study | Huber et al., TUM

Psychodynamic Psychotherapies | Nikolai Köppelmann| Department of Psychosomatic Medicine and Psychotherapy

Please don’t hesitate,
ladies and gentlemen,
to ask questions!