SP63923 Therapy

28 March 2013

Overview

• Freud’s aim in therapy

• Freud’s method of therapy

• Kleinian & Post-Kleinian therapy

• Evaluating psychoanalytic therapy

• Psychoanalytic therapy and cognitive behaviour therapy (CBT)

• Relational psychoanalysis

• Mentalization-based therapy

Freud’s aim in therapyFreud (1895, SE2:305)Aims to transform the patient’s ‘hysterical misery into commonunhappiness’ 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)

Freud’s method of therapyFreud (1912, SE12:111-20,115) Warns against the counter-transference – recommends ‘therapists, like surgeons, to adopt a stance ofemotional 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 patient’s 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 catchthe drift of the patient’s 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 patient’s response interpretationsmay 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 Isaacs’s (IJPA, 1952) Kleinian theory of ‘phantasy’

• Post-Kleinian attention to the counter-transference (e.g. Heimann, IJPA, 1950, 31:81-4; Bion’s 1967 book, Second Thoughts)

• See also

• Hinshelwood (1989) A Dictionary of Kleinian Thought

• Sayers (2007) Klein and Bion chapters in Freud’s 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 Eysenck‘s 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 Freud’s 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/patient’s 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 client’s/patient’s mentalization about relationships that have relatively low levels of involvement

• (8) only gradually focusing on the client’s/patient’s 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• Freud’s aim in therapy

• Freud’s method of therapy

• Kleinian & Post-Kleinian therapy

• Evaluating psychoanalytic therapy

• Psychoanalytic therapy and cognitive behaviour therapy (CBT)

• Relational psychoanalysis

• Mentalization-based therapy

READJ. Shedler (2010) The efficacy of psychodynamic psychotherapy.

American Psychologist, 65(2):98-109 (available on Moodle)

WRITE DOWNOne essential ingredient, according to Shedler (2010), of effective

psychoanalytic or non-psychoanalytic therapy

ESSAY TITLEEvaluate 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 patient’s experience; linking the patient’s 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 Freud’s 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 one’s 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 Leader’s recent books