DR ZULFIQAR ALI RIZVI CONSULTANT PSYCHIATRIST CONSULTANT PSYCHIATRIST PIMH LAHORE PIMH LAHORE.
Paul Cammell Consultant Psychiatrist, Flinders Medical Centre Lecturer, Flinders University.
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Transcript of Paul Cammell Consultant Psychiatrist, Flinders Medical Centre Lecturer, Flinders University.
Paul CammellConsultant Psychiatrist, Flinders Medical Centre
Lecturer, Flinders University
1. Discussion of cultural context: Australian 1. Discussion of cultural context: Australian psychotherapeutic culture (psychiatric and other)psychotherapeutic culture (psychiatric and other)
2. Discussion of psychodynamic theories – relevance to 2. Discussion of psychodynamic theories – relevance to your training and practice in generalyour training and practice in general
* * Toolbox of concepts Toolbox of concepts **Recommended ReadingsRecommended Readings
3. Three Lectures: Prof Kalucy, Dr Paul Cammell and Dr 3. Three Lectures: Prof Kalucy, Dr Paul Cammell and Dr Robin ChesterRobin Chester
Psychodynamically informed practice
Psychoanalytic Psychotherapy:Psychoanalytic Psychotherapy:-processes: transference, interpretation,
resistance, enactment, etc-analytic triangles
Malan--of person/conflict-models: classical, object relations, self psychology, ego
psychology, relational, interpersonal, intersubjective, attachment orientation, mentalization, Lacanian, etc
-training (theoretical, clinical supervision, training analysis, infant observation)
Ranges of modalities adopted by psychiatrists:Ranges of modalities adopted by psychiatrists:Formal psychoanalysis, psychoanalytic psychotherapy, psychodynamic psychotherapy, insight-oriented psychotherapy, psychodynamically-informed psychiatric management
Conflicts with the era of managed care, health insurance funds, evidence based medicine, health management, time-limited, cost efficient approaches
Role of Psychotherapy Outcomes Research
Universal Techniques• Focus on affect and expression of emotion• Exploration of attempts to avoid
distressing thoughts and feelings• Identification of recurring themes and
patterns• Developmental focus – exploration of past
experiences• Focus on interpersonal relations• Focus on the therapeutic relationship• Exploration of wishes and fantasies
Classical Freudian Technique
• Transference Interpretation
• Dreams, Parapraxes
• Conflict and Defence
• Remembering, repeating, working through… Nachtraglichkeit
Transference
• Freud, S. (1912). The Dynamics of Transference. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 97-108.
• Freud, S. (1914). Remembering, Repeating and Working-Through (Further Recommendations on the Technique of Psycho-Analysis II). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 145-156.
• Klein, M. (1952). The Origins of Transference. Int. J. Psycho-Anal., 33:433-438.
• Strachey, J. (1969). The Nature of the Therapeutic Action of Psychoanalysis. Int. J. Psycho-Anal., 50:275-292
• Winnicott, D.W. (1956). On Transference. Int. J. Psycho-Anal., 37:386-388
Object Relations and British Independent or Middle Tradition• Klein: pre-Oedipal development, the
paranoid-schizoid and depressive positions, envy, mourning
• Bion: containment and alpha-beta function, psychotic personality
• Winnicott, holding, transitional phenomena, false self
• Balint, Fairbairn etc
Ego Psychology, Neofreudian approaches
• Ego defenses
• Countertransference• Heimann
, P. (1950). On Counter-Transference. Int. J. Psycho-Anal., 31:81-84
• Bion, W. R. (1967b), Notes on memory and desire, Psychoanalytic Forum, 2, 271-286
• Sandler, J. (1976). Countertransference and Role-Responsiveness. Int. R. Psycho-Anal., 3:43-47
ERIKSON’S EIGHT STAGES OF THE LIFE CYCLEERIKSON’S EIGHT STAGES OF THE LIFE CYCLE
Trust versus MistrustTrust versus Mistrust (Birth to Approximately 18 Months) (Birth to Approximately 18 Months)
Autonomy versus Shame and DoubtAutonomy versus Shame and Doubt (Approximately 18 Months (Approximately 18 Months to Approximately 3 Years)to Approximately 3 Years)
Initiative versus GuiltInitiative versus Guilt (Approximately 3 Years to Approximately 5 (Approximately 3 Years to Approximately 5 Years)Years)
Industry versus InferiorityIndustry versus Inferiority (Approximately 5 Years to (Approximately 5 Years to Approximately 13 Years)Approximately 13 Years)
Identity versus Role ConfusionIdentity versus Role Confusion (Approximately 13 Years to (Approximately 13 Years to Approximately 21 Years)Approximately 21 Years)
Intimacy versus IsolationIntimacy versus Isolation (Approximately 21 Years to (Approximately 21 Years to Approximately 40 Years)Approximately 40 Years)
Generativity versus StagnationGenerativity versus Stagnation (Approximately 40 Years to (Approximately 40 Years to Approximately 60 Years)Approximately 60 Years)
Integrity versus DespairIntegrity versus Despair (Approximately 60 Years to Death) (Approximately 60 Years to Death)
Narcissistic-Psychotic DefensesNarcissistic-Psychotic DefensesProjectionProjectionDenialDenialDistortionDistortionSplittingSplitting
Immature DefensesImmature DefensesActing outActing outBlockingBlockingHypochondriasisHypochondriasisIntrojectionIntrojectionPassive-aggressive behaviorPassive-aggressive behaviorProjectionProjectionRegressionRegressionSchizoid fantasySchizoid fantasySomatizationSomatization
Adapted from Vaillant GE. Adaptation to Life. Boston: Little Brown; 1977; Semrad E. The operation of ego defenses in object loss. In: Moriarity DM, ed. The Loss of Loved Ones. Springfield, IL: Charles C Thomas; 1967; and Bibring GL, Dwyer TF, Huntington DS, Valenstein AA. A study of the psychological principles in pregnancy and of the earliest mother–child relationship: Methodological considerations. Psychoanal Stud Child. 1961;16:25.
Defense Mechanisms
Neurotic DefensesNeurotic DefensesControllingControllingDisplacementDisplacementDissociationDissociationExternalizationExternalizationInhibitionInhibitionIntellectualizationIntellectualizationIsolationIsolationRationalizationRationalizationReaction formationReaction formationRepressionRepressionSexualizationSexualization
Mature DefensesMature DefensesAltruismAltruismAnticipationAnticipationAsceticismAsceticismHumorHumorSublimationSublimationSuppressionSuppression
Adapted from Vaillant GE. Adaptation to Life. Boston: Little Brown; 1977; Semrad E. The operation of ego defenses in object loss. In: Moriarity DM, ed. The Loss of Loved Ones. Springfield, IL: Charles C Thomas; 1967; and Bibring GL, Dwyer TF, Huntington DS, Valenstein AA. A study of the psychological principles in pregnancy and of the earliest mother–child relationship: Methodological considerations. Psychoanal Stud Child. 1961;16:25.
Defense mechanisms
Attachment Theory
Bowlby: Attachment and Loss Trilogy
Evolutionary science, Ethology
Grief, Privation, Deprivation
(Maternal) attachment figure and security
Internal Working Models
Attachment (Proximity seeking)
Separation (Anxiety, Anger)
Loss (Sadness, Depression)
Questions ?Questions ?
Recommended ReadingsRecommended Readings
Self Psychology• Heinz Kohut
• Narcissism, Self pathology
• Self cohesion, shame, mirror/twin and other transferences
Kernberg•Ego Psychology and Object Relations
•Borderline Personality
•Transference Focussed Psychotherapy and the Evidence-Based Paradigm
Interpersonal, Relational Approaches
• Ogden, Sullivan, Mitchell, Aron, Stolorow, Orange, Bromberg
• The authority of the patient, co-construction and the analytic third
• Context, prejudice, the return of dissociation, focus on trauma, existential, humanistic and hermeneutic approaches
Lacan
• The French and Latin-American psychotherapy cultures
• Theory, Philosophy and Psychotherapy
• The Three Orders, Linguistics, Structuralism
Borderline Personality Disorder
“The Problem Patient of Our Time”
Borderline Personality and developmental neuroscience
Giovanni Liotti:Disorganized Attachment and Borderline PD
Peter Fonagy et al.:Mentalization as a core construct
Russell Meares:Memory, frontal/pre-frontal function
Glen Gabbard:Mind-body interactions
– HPA axis, hippocampal volume, hemispheric lateralization
Allan Schore:Right Brain Development and affective regulation
Borderline Syndromes – History1. Psychoanalysis
– 1930s-1950s Stern, Knight– 1960s-1970s Kernberg, (Winnicott, Khan, Bergeret)
2. Psychiatry• 1940s-1960s Ambulatory Schizophrenia (Zilboorg),
“Preschizophrenia” (Rapaport), “latent schizophrenia” (Federn), “pseudoneurotic schizophrenia” (Hoch and polatin), “schizotypal disorder” (Rado)
• Late 1960s “Borderline states” (Knight), “Borderline Syndrome” (Grinker)
• Mid 1970s “Borderline Personality” (Gunderson et al.)• 1980 DSM III “Borderline Personality Disorder”
3. Modern “evidence-based” psychotherapy– 1970s-1990s Object Relations BasedTransference Focussed
Psychotherapy (Kernberg, Clarkin)– 1990s Dialectical behaviour Therapy (Linehan); “Mentalization-based
treatment” (Fonagy, Bateman, Target) – 1990s-present Cognitive Analytic Therapy (Ryle), Conversational
Model (Meares), Supportive Psychoanalytic Psychotherapy (Appelbaum), Schema-Focused Therapy and Systems Training for Emotional Predictability and Problem Solving (or “STEPPS”, Blum)
Modern Therapeutic Approaches
• Pharmacotherapy– HPA axis sensitization and anxiolytic medication (eg
atypical antipsychotic medications)– Serotonergic agents
• Psychotherapy– Dialectical Behaviour Therapy (Linehan)– Psychodynamic psychotherapy
• Mentalization-based (Fonagy, Bateman, Target et al.), • Object-Relations based (Kernberg)• Self-Psychology based (Meares)
– Otherstructured, crisis plans, patient responsive, limit setting,
team-based
Mentalization
• Theory of mind (Fonagy, Bateman, Target et al.), social biofeedback theory, “mentalized affectivity”
• Borderline Personality Disorder— psychic equivalence and pretend modes; splitting and dissociation; disorganized trauma responses; affect dysregulation
Giovanni Liotti and Attachment Disorders
• Ethology/evolutionary research: motivational systems (and IWM’s)– eg care-seeking, care-giving, sexual—pair bonding, ranking—
dominance/submission, egalitarian/altruistic, intersubjective
• Attachment Disorganization and psychopathology– borderline and antisocial PD, conduct disorder, emotional
dysregulation and impulse control problems (HPA Hyperresponsiveness)
• Transgenerational transmission– The Adult Attachment Interview
Mentalization
• Theory of mind (Fonagy, Bateman, Target et al.), social biofeedback theory, “mentalized affectivity”
• Borderline Personality Disorder— psychic equivalence and pretend modes; splitting and dissociation; disorganized trauma responses; affect dysregulation
Borderline Personality and “abuse” or “trauma”
Judith Herman:
Complex PTSD “sexual abuse”
ERS Nijenhuis, Onno van der Hart:
Psychotraumatology and
Dissociative Disorder
Questions ?Questions ?
Case for Next WeekCase for Next Week
Recommended ReadingsRecommended Readings
Recommended Readings:Recommended Readings:General texts, including evidence based reviews:General texts, including evidence based reviews:New Oxford Textbook of Psychotherapy New Oxford Textbook of Psychotherapy (Gabbard, Beck, (Gabbard, Beck, Holmes)Holmes)What works for whomWhat works for whom, Roth & Fonagy, Roth & FonagyStandards and Guidelines for the PsychotherapiesStandards and Guidelines for the Psychotherapies (Paul (Paul Cameron, Jon Ennis & John Deadman Eds) eg Chapter 3Cameron, Jon Ennis & John Deadman Eds) eg Chapter 3
Basic Approaches to Psychodynamic PsychotherapyBasic Approaches to Psychodynamic Psychotherapy:: David Malan (David Malan (Individual Psychotherapy and the Science of Individual Psychotherapy and the Science of PsychodynamicsPsychodynamics), Glen Gabbard (), Glen Gabbard (Psychodynamic Psychodynamic PsychiatryPsychiatry), Nancy McWilliams (), Nancy McWilliams (Psychoanalytic Psychoanalytic Psychotherapy: A Practitioner’s Guide), Psychodynamic Psychotherapy: A Practitioner’s Guide), Psychodynamic Diagnostic and Statistical ManualDiagnostic and Statistical Manual
Models and Theories:Models and Theories: Comprehensive Textbook of PsychiatryComprehensive Textbook of Psychiatry (Kaplan & (Kaplan & Sadock), Chapters 6 and 30Sadock), Chapters 6 and 30