Week 1: Lay-out of the course and the history of psychotherapy.
Psychotherapy is a set of techniques believed to cure or to help solve behavioural and
other psychological problems in humans. Usual techniques involve talking therapies
where somebody listens to you and is friendly / empathic.
Web lecture ; a brief history of psychotherapy
Psychotherapies history
Since about 250 years the helping of other people became scientific (or at least more
than it used to be).
Russel (~1750)
Drinking and bathing in seawater supposed to be good for your health. This was the
state of mental helping at the time…
Mesmer (from the verb mesmerizing!)
Mesmer’s Theory: nervous symptoms were related to a blockade of magnetic forces in
the body. Therefore he experimented with placing magnets on people’s bodies while
trying to lift the blockade. (which “worked” because he patient had a disorder that we
still cannot explain; unexplained disorders). After a while he discovered that he didn’t
need the magnets for the same result and concluded that he had developed a personal
magnetism in his own hands (lol… ). But he was one of the first that developed group
therapy for neurotic problems by using his magnetic powers.
The king then ordered to investigate this form of treatment and found that there was no
effect (first investigation on psychotherapy), but there were people who were highly
responsive. These highly responsive clients couldn’t get the right response when it’s
randomized. So imagination without magnetism lead to convulsions (the result of all
Mesmer’s treatments) and that magnetism without imagination (believing in it) leads to
nothing.
The strong effects that can be observed in group treatments result from: touching,
imagination and mechanical imitation of behaviour observed in others. There are
reasons to believe that imagination is the strongest of these tree.
➔ Mesmer’s legacy
- Effects of imagination on behaviour
o Expectancies
o Placebo effect
- Nowadays it is seen as an early version of hypnotherapy
- Rapport between therapist and patient
Freud
He started to experiment with the effects of cocaine on the body (and he was a user
himself). Later he went to see Charcot, which was a guy who performed hypnosis on
woman with hysteria. But Freud wasn’t happy with using hypnosis, because there is a
development of (mutual) feelings with your patients.
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,Development in Freudian theory
1. Neurosis is the result of recent trauma (modern term: burn-out)
2. Neurosis is the result of childhood trauma (Seduction theory)
3. Neurosis is the result of imagined trauma (Psychoanalysis: like the Oedipus
complex)
Psychoanalysis
Psychoanalysis has been very dominant in the psychiatry and clinical psychology
(mainly in the united states and Europe), until around 1980. We still don’t know quite
sure if it works or not, because the treatment take around 5 years and so it’s hard to
compare the results and claim if it works or not. (That’s why there are still 500 people
practicing this way of therapy in the Netherlands even though it’s not included in the
basic health insurance coverage since 2010).
Skinner & Watson :Cognitive behavior domain
Think about little albert and the fear conditioning.
Evaluation of psychotherapy
Eysenck: It used to be assumed that treatment of neurotic disorders by psychoanalysis
or psychotherapy was instrumental in producing cure, however there is a strong
spontaneous remission effect. An analysis of reported effects of psychoanalysis, and
spontaneous remission shows that the different varieties of treatment fail to show any
better results than that produced by spontaneous remission.
Later studies concluded that the typical therapy client is better of than 75% of untreated
individuals. So there is a stronger effect related to the treatment, but the control
condition was based on a wait-list (that means that you compare psychotherapy with
nothing and might even be demotivating and interfere with natural recovering). They
also didn’t see any differences between all the schools of therapy! This is a result that
has been found often! There are recent studies that deny this result by focusing on a
specific disorder and comparing the results (no placebo-control but a medication
control).
The dodo bird verdict: Everyone has won and all must have prizes, see week 6
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,Week 2: Psychoanalysis in a nutshell: some pivotal concepts relevant for (psychodynamic)
psychotherapies today
Psychoanalysis and its position in the field of psychotherapies
There are too many psychotherapies, which is a disaster for the field. All these therapies
have some common roots: psychoanalysis, CBT, client centered therapy, and (family)
systems therapy.
Psychoanalytic models
Motivation Main concepts Psycho-pathology
Id-psychology Trauma drive (un)- Damming up of drives
gratification consciousness
Ego-psychology Drive verses Ego, id and Conflict and compromise
superego / superego formation
society
Object-relations Finding an Self- and object- Maladaptive relationships
theory object representations
Self-psychology Maintaining Self-esteem Pathological narcissism:
positive self- grandiose / vulnerable
esteem
Attachment theory Sense of safety: Internal working Insecure attachment:
affect regulation model diminished capacity to
mentalize; epistemic trust
There are a lot of theories but have a lot in common:
- There is a primary focus on subjective experiences
- Originally the theory and practice is founded on clinical experience and subsequent
theory building
- Psychic functioning is the result of genetic predisposition (biology!), learning
history and the ability to reflect
- All feelings, including adaptive and maladaptive, are co-determined by unconscious
processes
- Humans strive for feeling untroubled and stress free. The way to do this is by using
coping(conscious and external) and defense mechanisms (automatic unconscious
and internal)
- Humans are relational being, earlier experiences guide future relationships
(transference and countertransference
What is psychoanalysis
It started with Sigmund Freud and the main questions that has to be answered are: Why
do people what they do and why do they feel thing and what motivates people.
Psychoanalysis tries to explain the logic in illogical behavior.
Furthermore it’s also about what is helpful for people in medical care, while they need
support (and the patient) in difficult situations.
3
,Modern psychoanalysis is not only Freudian psychology, he still means a lot for the
theories and practice of it but it’s not all of it. Because psychoanalysis is about
homeostasis, affect regulation and unconscious mechanisms that steer the
homeostasis.
Id-psychology
This is the theory of Sigmund Freud, he got a lot of inspiration from the evolution theory
of Charles Darwin, which states that sexuality is important for the surviving of a species.
He copied this statement and thought it was the key-factor of mental health.
Furthermore, both Darwin and Freud claimed that the result of something was the
interaction between biology and the environment.
Psychopathologenesis according to Freud
Conflict / drive theory: clinical symptoms sometimes due to overwhelming traumatic
experiences (such as sexual abuse). But more often it’s the result of unconscious
conflicts between internalized restrictions from society (superego) and impulses from
(infantile) sexual instincts (=id). The therapy focusses on making the unconscious /
repressed conscious.
Basic assumptions of psychoanalysis
Behavior, thinking and feeling are determined by unconscious forces.
Conscious and unconscious functioning
The non-dynamic unconscious (UCS) functions conform biological laws and laws of
conditioning. Where the psychodynamic unconsciousness concerns those memories,
thoughts, feelings, desires, fantasies, that we try to keep out of awareness because they
are too painful. This psychodynamic unconsciousness functions according the primary
process principles. Primary process thinking is illogical, such as emotional
associations, events and reasoning have no logic connection in time and space. It is
driven by internal / emotional life. “magic, animistic, anthropomorphistic”
Contrary the conscious functioning functions according to the secondary process
principles. Secondary process thinking is logical thinking, which is about causality,
events and reasoning have a logic connection in time and space. It has a strong
connection with external life and reality.
When you function properly there is a equilibrium between the primary and secondary
process functioning. When the primary processes are “in service” (less) of the secondary
processes this leads to creativity, but when the primary processes flood the secondary
process (when you are stressed, fatigued) this could lead to Freudian slips, nightmares
and so called “encumbered mentalizations” which is an unhealthy way to think about
yourself and others.
4
,When secondary process is in service of primary processes one might get delusions,
they see something logical and they “make up” an illogical reasoning.
Side note: closed question strengthen secondary processes, but they must be reality
driven and only works when people are stressed. In contrary, asking open questions,
results in a more intimate way of thinking (?)…
Freudian slips
Saying something that you weren’t supposed to say and the source can be explained by
emotions. It gives us a little bit information about the unconscious process thinking of
others.
Ego-psychology
Conflict theory: clinical symptoms are the results of warded off feelings, thoughts,
fantasies, desires, but also by defense mechanisms such as adaptive (humor,
anticipation), neurotic (repression, rationalization) and primitive (denial, idealization)
ways. This is also called the ego-psychological model, which is basically the id-model,
but with defense mechanisms. Therapy that uses this model try to make someone aware
of the defense mechanisms they use.
Defense mechanisms
According to the ego-psychology people have different kind of defense mechanisms in
stressful situations. There are primitive defense mechanisms, such as denial,
idealization and devaluation. These mechanisms are mainly seen in clients with
borderline. Furthermore there are neurotic defense mechanisms, such as repressing,
rationalization, intellectualization, and isolation of affect. And lastly there are adaptive
defense mechanism, such as suppression, sublimation or humor.
5
,Conflict triangle
A: Anxiety
and
inhibiting
feelings
Conflict
triangle
I: Sexual and D: specific
agressive defense
impulses* mechanisms
1: *(activating, painful or otherwise unacceptable feelings)
Compromise formation
You can defend against some drives, but it always pops up at some time. So basically
there are always drives present, but you can control them to some manner
Object-relation theory
A theory created by Anna Freud, she was an ego-psychologist herself. She came to the
conclusion that psychopathology is not always the result of unconscious conflicts, but
could be due to the following facts (the so called “deficit-theory”):
- Deficits in parental care and affection
- Resulting in inadequate impulse control and emotion regulation, and persistence of
primitive defense mechanisms
- Therapy according to this theory would be to reinforce ego-functions (such as
impulse control or frustration tolerance).
Furthermore Marianne Klein created the object relation theory. She claims that we have
experiences with other people and this interaction affects the self and the other. So
interactions are associated with feelings including an impression of the important other.
All these events together build up your sense of self and others (others are always
referred to as object).
The object relational model (what is described above, and which you can compare
with schemes!) states that what we ‘see’ is only that what our ‘blue print’ (=scheme)
facilitates to us. Which makes sense because you can only describe somebody with the
knowledge you have.
So key features in the past are very important for creating these blueprints. So they
influence how we act towards others, but also for the relation one has with the therapist.
6
,Sometimes a subjective transference can happen during therapy. This happens when a
client projects his unconscious feelings about a certain person onto their therapist.
Whereas a therapist can feel a countertransference, which basically is the redirection
of the feelings toward a patient or the emotional entanglement with them. For a therapist
it’s important to both understand transference and countertransference because it gives
important information about the client’s feelings and or struggles.
Attachment theory
It’s the Harlow guy with the monkeys and mother figures (mothers warmth is important
for a child). Conclusion of his study is that the innate tendency to seek warmth and
safety is fundamental for all other emotional function (in opposite of Freud that said sex
is essential and belonging is just a side-effect). In other words, affectionate bonds with
parents, with other adults, and with peers are of supreme importance for the
development of a normal sexual and parental behavior.
Bowlby states that the set goal is to feel security (affect regulation) and children from 3
years old already have internal working models. The attachment is the inborn tendency
to seek for protection and comfort with specific persons when one feels vulnerable.
Further, the development of specific attachment styles is the result of the interaction
between biological constitution and early interferences in development.
Development of attachment styles
1. Basic attachment system (phylogenetically on hand)
Primary attachment behaviors, level of reflexes and present at birth
2. Procedural level (ontogenetically formed)
Implicit affective ‘models’ (the internal working models) and starts at the end of the
1st year
3. Level of cognitive representation (ontogenetically formed)
Declarative knowledge of attachment (learning through observation and asking)and
starts at the end of 2nd
The attachment style is either secure or insecure and depends on the reaction of the
parents. When the parent reacts to the needs of their child the attachment will be secure.
Model of self
Positive Negative
Model of
Positive Secure: comfortable with Pre-occupied: preoccupied with
other
intimacy and autonomy relationships
Negative Avoidant: dismissing of Anxious-avoidant: fearful of
intimacy counter-dependent intimacy and socially avoidant
Around 60% of the children have a secure attachment. A insecure attachment style does
not necessarily mean that one has psychopathology, but it is associated with lesser
degree of stress regulation skills, primitive defense mechanisms, heightened stress
reactivity and failing to trust.
The therapy focuses on enhancing mentalizing capacities.
7
,The essential principle of psychodynamic therapies
- Humans are riven (partly) by unconscious motivations
- Personality is composed by nature (temperament) and (early) experiences
- Symptoms and signs are the result of inadequate affect regulation
- Humans are ambivalent about changing (resistance) and probably are limited in their
capacities to dos so (by conditioning)
- (psychodynamic) therapy facilitates:
o Awareness of unconscious motivations to increase choices
o Exploring ways in which we avoid painful experiences
Practices of psychodynamic
Psychoanalysis
“On the couch”-therapy: it’s open ended, which means there is no “finish date” of the
therapy. The client would meet up with the therapist between 3 and 5 times a week.
Psychoanalytic = psychodynamic psychotherapy
Psychodynamic psychotherapy is either open ended or time limited, which depend on
the client’s wishes. The therapy can be supportive and confronting at the same time,
while it’s either for short of long term.
Psychodynamic therapists have their senses open for what seems illogical, but what
makes sense from an emotional point of view. You could state that they are trying to see
the equilibrium between primary and secondary process functioning.
There are some general working mechanisms they use to get to their goals: empathy,
unconditional acceptance, behavior and affect congruent, generating hope, treatment
and single sessions are well structured, and maintaining a good working alliance.
But there are also more specific working mechanisms such as: technical neutrality (=
not giving your own opinions about something the client asks), if necessary support and
limit setting, and clarification, confrontation and interpretation. While deconditioning
and modeling are implicit working mechanisms.
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,Week 3: Client centered therapy
The client is always right about his own emotions or perspective, even though this might
mismatch the reality. The client always knows what is the best way to be cured, the
therapist would just support them growing in their own way.
Rational stance = when people don’t feel many emotions, but they feel the pain of
stress in their body (somatized).
Humanistic psychology
It started in 1942 with Rogers with Abraham Maslow and called it the “third force”
(besides psychoanalysis and behaviorism). The most important part of humanistic
psychology is growth, every human being has the desire to grow. More specifically an
actualization tendency, which states that human development (including development
that is facilitated by the support of a therapist or your parents / teachers) is towards
increasing self-government, self-regulation, autonomy, and away for heteronymous
control, or control by external forces. Also that every human being strives for
autonomy, everyone is unique and has their own stories / feelings, an optimistic human
image (=people always act out of goodness), emphasis on subjective experiences, and
free will / personal responsibilities.
Carl Rogers
Is one of the main founders of humanistic psychology and got a shitload of awards.
Further, he used to be the chairman of the APA. He himself was an introvert with a
positive mindset.
Rogers fundamental postulates
People in general heave a need for self-actualization (see the link with Maslow here!).
The fully functioning person (=one that has succeeded in therapy / life) has an internal
locus of control and operates on the basis of own personal values, instead of conforming
to dictates of others or society in general. Further on he stated that persons are in
continuous dialogue with themselves as well as their environments (The phenomenal
field (that thing we experience at all times) = the continuous flow of experience). People
are also in need of “positive regard” by other people, leading to “positive self-regard”
and in need to be loved or valued by others. Contrary to positive regard, there are so
called “conditions of worth”, internal rules that let’s others and yourself see that you
are worthy (be kind, be the best version of yourself …). These conditions can lead to
“incongruencies”, which are the differences between on one hand the idea of ourselves
and our self-experience (Feeling ashamed about oneself, because how you acted is not
in line with what you want to be in life). Basically it’s a disbalance (tensions) between
who we are and what we experience.
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, Rogers Freud
Empathy
Unconditional positive regard Client’s knowledge is insignificant
Client knows best Therapist knows best
Reflective listening Advice, persuasion and teaching
Non-diagnosis Unconscious drives
Congruent whole personality Personality divided
Person focused Problem focused
Client centered Therapy
Client centered therapies started in 1942, with “nondirective counseling” by Rogers.
He stated that it was important to not give any directions as a therapist, because he
thought that the client himself knows what was important to cure themselves. So the
role of a therapist is to facilitate the client in his or her needs.
Conditions for person centered therapy:
1. A relationships exists between the client and therapist (=mutual confidence)
2. Client is in a state of incongruence (see above for meaning)
3. Therapist is congruent
4. Therapist experiences unconditional positive regard for the client
5. Therapist experiences and attempts to express an empathic understanding of the
client’s internal frame of reference
6. Therapist’s unconditional positive regard, empathic understanding, and congruence
must be perceived by the client.
Furthermore Rogers emphasized that facilitative conditions are fundamental, meaning
that the therapist is showing: Acceptance and unconditional positive regard, empathic
understanding, and genuineness (congruence). He also state that the necessary and
sufficient conditions for personality change: offering the facilitative conditions in a
genuine relationship is necessary and sufficient for bringing therapeutic change.
Congruence
Being real with one and another; There is no difference between the therapist and the
client (based on “level”), which means that that you are not a doctor for the client, but
more a person.
There must be no façade, self-awareness and sometimes deliberate self-disclosure.
Unconditional positive regard
Always prizing, accept and trust the client. When you prize and accept the other the
client might prize and accept themselves more. It’s not always easy when for example
you have a prisoner as a client or you dislike them in general. This might be contrary to
genuineness, but you might be able to overcome that by seeing it’s just his or her
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